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Chapter 71: Evaluation and Management of Acute Heart Failure

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

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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)

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

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

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

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E. None of the above

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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).

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Which of the following contributes to renal dysfunction in AHF?

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A. Elevated right-sided pressures

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B. Diminished cardiac output

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

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D. Sympathetic nervous system (SNS) activation

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E. All of the above

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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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