MONITORING OF FLUID AND DIURETIC ADMINISTRATION ACCORDING TO THE ECHOCARDIOGRAPHIC EVALUATION OF VOLUME STATUS IN PATIENTS WITH DECOMPENSATED CHRONIC CONGESTIVE HEART FAILURE (MONET)
Urgência / Cuidados Intermédios e Doente Crítico - Comunicação
Congresso ID: CO131 - Resumo ID: 299
1 – Internal Medicine IV Department, Fernando Fonseca Hospital; 2 – Cardiology Department, Fernando Fonseca Hospital
Joana Azevedo Duarte1, Filipe Paula1, Célia Coelho Henriques1, Raquel Maia1, Frederico Batista1, Luís Melo1, João Bicho Augusto2, Marisa Neves1, José Delgado Alves1
Introduction: Decompensated chronic heart failure (CHF) remains the most frequent cause of hospital admission in patients older than 65 years. The administration of large doses of loop diuretics, along with fluid restriction, is common during the first days after presentation. However, the application of this regimen according to clinical judgment alone, without an objective measurement of the volume status, can have deleterious consequences, namely acute kidney injury. Furthermore, guiding therapy by serial assessments of the patient’s volume status may lead to a better optimization of the hemodynamic profile. Ultrasound measurement of the inferior vena cava (IVC) diameter and its collapsibility index, which correlates with central venous pressure, is a non-invasive bedside method to determine patient intravascular volume status which is readily available in Internal Medicine wards.
Aim: To ascertain whether determining patient intravascular volume status through echocardiographic estimation of right atrial pressure (RAP) is superior to best clinical judgement on the management of decompensated CHF in hospitalized patients.
Methods: In this randomized, controlled, double-blinded interventional clinical trial, 55 patients admitted to an Internal Medicine ward due to decompensated CHF were randomly assigned to Group 1 (diuretic and fluid management according to RAP estimation by transthoracic echocardiography) or Group 2 (therapy management according to clinical judgment). The primary objective was to determine the difference regarding efficacy (reduction of Killip class, peripheral oedema and oxygen fraction of inspired air, acute lung oedema occurrence, hospital length of stay) and safety (variation of serum potassium and renal function) between both groups. Secondary objectives included assessment of differences in the hemodynamic profile and in pharmacological therapy.
Results: Patients from group 1 presented with a better hemodynamic profile during the study, allowing earlier optimization of angiotensin converting enzyme inhibitors dosages, administration of lower dosages of furosemide and a higher volume of crystalloids. Altogether it resulted in a lower serum creatinine both 72 hours after admission and during the whole hospital stay (p=0,012). There were no differences in all the efficacy outcomes, including hospital length of stay, 6-month mortality and 6-month hospital readmission rates.
Conclusion: Management of decompensated CHF guided by the echocardiographic estimation of RAP results in similar efficacy with less adverse effects (mainly reduced kidney injury) when compared to clinical assessment alone. This study shifts the focus away from intensive correction of fluid overload and towards improvement of the hemodynamic profile as a better approach to manage decompensated CHF.
Aim: To ascertain whether determining patient intravascular volume status through echocardiographic estimation of right atrial pressure (RAP) is superior to best clinical judgement on the management of decompensated CHF in hospitalized patients.
Methods: In this randomized, controlled, double-blinded interventional clinical trial, 55 patients admitted to an Internal Medicine ward due to decompensated CHF were randomly assigned to Group 1 (diuretic and fluid management according to RAP estimation by transthoracic echocardiography) or Group 2 (therapy management according to clinical judgment). The primary objective was to determine the difference regarding efficacy (reduction of Killip class, peripheral oedema and oxygen fraction of inspired air, acute lung oedema occurrence, hospital length of stay) and safety (variation of serum potassium and renal function) between both groups. Secondary objectives included assessment of differences in the hemodynamic profile and in pharmacological therapy.
Results: Patients from group 1 presented with a better hemodynamic profile during the study, allowing earlier optimization of angiotensin converting enzyme inhibitors dosages, administration of lower dosages of furosemide and a higher volume of crystalloids. Altogether it resulted in a lower serum creatinine both 72 hours after admission and during the whole hospital stay (p=0,012). There were no differences in all the efficacy outcomes, including hospital length of stay, 6-month mortality and 6-month hospital readmission rates.
Conclusion: Management of decompensated CHF guided by the echocardiographic estimation of RAP results in similar efficacy with less adverse effects (mainly reduced kidney injury) when compared to clinical assessment alone. This study shifts the focus away from intensive correction of fluid overload and towards improvement of the hemodynamic profile as a better approach to manage decompensated CHF.