Clinical profiles, pharmacotherapies and prognosis in acute heart failure : Focus on vasoactive medications

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Sammanfattning

Acute heart failure (AHF), one of the most common reasons for hospitalizations, is associated with high mortality. Its management is challenging and should be tailored according to different clinical manifestations that range from less severe hypertensive AHF to the most severe form, cardiogenic shock (CS), with its extremely poor prognosis. Acute coronary syndrome (ACS) precipitates over one-third of AHF (ACS-AHF) cases. The aim of this thesis is to analyze current real-life AHF management, with emphasis on vasoactive therapies, in relation to different AHF clinical presentations and specifically CS. In addition, the study targets for characterization two poorly described clinical pictures: 1) ACS-AHF and 2) CS complicated by acute kidney injury (AKI), a common organ injury in the critically ill. Data from two independent prospectively collected patient cohorts in this thesis comprise the FINN-AKVA (Finnish Acute Heart Failure) study, which is a national multicenter study including 620 patients hospitalized for AHF, and the European multicenter CardShock study including 219 patients with CS. Furosemide was the most common therapy for AHF regardless of clinical presentation, often administered even during the initial CS phase. Other intravenous medications and non-invasive ventilation varied according to the AHF clinical picture of AHF. Systolic blood pressure (SBP) was one of the main predictors of AHF-therapy utilization. Considering previous and current European guideline recommendations, use of nitrates was rather low, especially in hypertensive AHF. Compared with AHF patients without concomitant ACS (nACS-AHF), ACS-AHF manifested as a more severe clinical presentation and more frequently as de novo AHF. Guideline-recommended AHF therapies and invasive coronary procedures were more frequent in ACS-AHF. However, angiography (35%) and revascularization (percutaneous coronary intervention 16% and coronary artery bypass graft surgery 10%) rates were low. ACS-AHF was associated with higher 30-day mortality than was AHF without concomitant ACS (13% vs 8%). Use of vasopressors and inotropes was rather frequent in patients without shock, especially in pulmonary edema, and in ACS-AHF as well. They were used almost invariably in CS, noradrenaline being the most common vasopressor and dobutamine the inotrope of choice. Adrenaline was associated not only with excessive cardiac but also with 90-day mortality. In turn, noradrenaline combined with either dobutamine or levosimendan was associated with a more positive prognosis; these two combinations appeared to be alternatives with equivalent outcomes. Patients with CS frequently developed AKI during their first 48 hours of shock, but incidence varied by definition. The AKI definition based on urine output (UO) seemed rather liberal compared with one based on creatinine or on cystatin C (CysC). In addition, creatinine- and CysC-defined AKIs were independently related to higher 90-day mortality, whereas the UO-based AKI definition was not. A stricter cutoff of
Originalspråkengelska
UtgivningsortHelsinki
Förlag
Tryckta ISBN978-951-51-3803-3
Elektroniska ISBN978-951-51-3804-0
StatusPublicerad - 2017
MoE-publikationstypG5 Doktorsavhandling (artikel)

Vetenskapsgrenar

  • 3121 Allmänmedicin, inre medicin och annan klinisk medicin

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