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CLINICAL RESEARCH: HEART FAILURE

Cardiorenal Interactions

Insights From the ESCAPE Trial

Anju Nohria, MD^_*, Vic Hasselblad, PhD, Amanda Stebbins, PhD, Daniel F. Pauly, MD, PhD, Gregg C. Fonarow, MD, Monica Shah, MD, Clyde W. Yancy, MD^¶, Robert M. Califf, MD, Lynne W. Stevenson, MD^_* and James A. Hill, MD^,_*

^_* Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
Duke University Medical Center, Durham, North Carolina
University of Florida College of Medicine, Gainesville, Florida
Ahmanson-UCLA Cardiomyopathy Center, UCLA Division of Cardiology, Los Angeles, California
^¶ UT Southwestern Medical School, Dallas, Texas.

Manuscript received May 30, 2007; revised manuscript received August 9, 2007, accepted August 13, 2007.

^_* Reprint requests and correspondence: Dr. James A. Hill, Heart Failure/Transplantation Program, University of Florida College of Medicine, 1600 Archer Road, Box 100277, Gainesville, Florida 32610. (Email: hillja{at}medicine.ufl.edu).

Objectives: We examined the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) database to understand the impact and pathophysiology of renal dysfunction in patients hospitalized with advanced decompensated heart failure (HF).

Background: Baseline renal insufficiency (RI) (estimated glomerular filtration rate [eGFR] <60 ml/min) and worsening renal function (WRF) ( serum creatinine [SCr] 0.3 mg/dl) during treatment of decompensated HF are associated with adverse outcomes.

Methods: We used a Cox proportional hazards model to evaluate the impact of renal function on 6-month outcomes. Renal parameters were correlated with hemodynamic measurements. The impact of a strategy using pulmonary artery catheter (PAC) guidance on WRF and outcomes in patients with baseline RI was compared with treatment based on clinical assessment alone.

Results: Baseline and discharge RI, but not WRF, were associated with an increased risk of death and death or rehospitalization. Among the hemodynamic parameters measured in patients randomized to the PAC arm (n = 194), only right atrial pressure correlated weakly with baseline SCr (r = 0.165, p = 0.03). There was no correlation between baseline hemodynamics or change in hemodynamics and WRF. A PAC-guided strategy was associated with less average increase in creatinine but did not decrease the incidence of defined WRF during hospitalization or affect renal function after discharge relative to clinical assessment alone.

Conclusions: Among patients with advanced decompensated HF, baseline RI impacts outcomes more than WRF. Poor forward flow alone does not appear to account for the development of RI or WRF in these patients. The addition of hemodynamic monitoring to clinical assessment does not prevent WRF or improve renal function after discharge. (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization; NCT00000619).

Abbreviations and Acronyms   CLIN = clinical assessment–guided treatment strategy   CrCl = creatinine clearance   eGFR = estimated glomerular filtration rate   PAC = pulmonary artery catheter–guided treatment strategy   PCWP = pulmonary capillary wedge pressure   RAP = right atrial pressure   SCr = serum creatinine

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