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Chapter 71: Evaluation and Management of Acute Heart Failure

Which of the following is true about outcomes of acute heart failure (AHF)?

A. In-hospital mortality is greater for patients with heart failure with reduced ejection fraction (HFrEF) than for patients with heart failure with preserved ejection fraction (HFpEF)

B. About 25% of patients are readmitted within 30 days of hospital discharge

C. About 30% of patients die within 6 months of hospitalization

D. After an initial hospitalization, subsequent hospitalizations tend to be shorter

E. None of the above

The answer is B. (Hurst’s The Heart, 14th Edition, Chap. 71) AHF is a harbinger of poor outcomes and is associated with significant mortality after discharge. Recent trends suggest in-hospital mortality rates range from 2% to 5% and are similar when comparing HFpEF to HFrEF (option A).1,2 Postdischarge mortality for these two groups approaches 10% at 90-day follow-up,3 whereas approximately 30% of patients die within 1 year of hospitalization (option C).2,4 Despite concerted efforts to reduce rehospitalizations for AHF, nearly 25% of patients are readmitted within 30 days of discharge, and 50% are readmitted by 6 months (option B).5,6 Each subsequent hospitalization following the index stay is associated with increasing risk of death (option D).

Which of the following contributes to renal dysfunction in AHF?

A. Elevated right-sided pressures

B. Diminished cardiac output

C. Renin-angiotensin-aldosterone system (RAAS) activation

D. Sympathetic nervous system (SNS) activation

E. All of the above

The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 71) While historically worsening renal function (WRF) in AHF was considered a consequence of reduced cardiac output (“underperfusion”), it has become increasingly apparent that right-sided congestion (eg, right atrial pressure) plays an important role. Multiple studies have failed to show a correlation between cardiac output and WRF in AHF, with the exception of extreme reductions in output (option B).7-10 In contrast, several studies show a correlation between elevated right atrial pressure and intra-abdominal pressure with WRF (option A).7-9,11 Neurohormonal activation plays a critical role in WRF in the setting of decompensation. The downstream effects of RAAS and SNS activation include angiotensin II and catecholamine-induced renal efferent arteriolar constriction, which increases glomerular filtration at the expense of renal blood flow (options C and D). Additionally, the stimulation of aldosterone secretion increases sodium resorption and exacerbates volume overload and congestion, which in turn ...

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