title: Impact of changes in blood pressure during the treatment of acute decompensated heart failure on renal and clinical outcomes.
abstract: OBJECTIVE
  One of the primary determinants of blood flow in regional vascular beds is perfusion pressure. Our aim was to investigate if reduction in blood pressure during the treatment of decompensated heart failure would be associated with worsening renal function (WRF). Our secondary aim was to evaluate the prognostic significance of this potentially treatment-induced form of WRF.
  
  
  RESULTS
  Subjects included in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial limited data were studied (386 patients). Reduction in systolic blood pressure (SBP) was greater in patients experiencing WRF (-10.3 ± 18.5 vs. -2.8 ± 16.0 mmHg, P < 0.001) with larger reductions associated with greater odds for WRF (odds ratio = 1.3 per 10 mmHg reduction, P < 0.001). Systolic blood pressure reduction (relative change > median) was associated with greater doses of in-hospital oral vasodilators (P ≤ 0.017), thiazide diuretic use (P = 0.035), and greater weight reduction (P = 0.023). In patients with SBP-reduction, WRF was not associated with worsened survival [adjusted hazard ratio (HR) = 0.76, P = 0.58]. However, in patients without SBP-reduction, WRF was strongly associated with increased mortality (adjusted HR = 5.3, P < 0.001, P interaction = 0.001).
  
  
  CONCLUSIONS
  During the treatment of decompensated heart failure, significant blood pressure reduction is strongly associated with WRF. However, WRF that occurs in the setting of SBP-reduction is not associated with an adverse prognosis, whereas WRF in the absence of this provocation is strongly associated with increased mortality. These data suggest that WRF may represent the final common pathway of several mechanistically distinct processes, each with potentially different prognostic implications.
authors.affiliation: Department of Medicine, Cardiovascular Division, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. jeffrey.testani@uphs.upenn.edu
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Testani
authors.forename: Steven G
authors.initials: SG
authors.lastname: Coca
authors.forename: Brian D
authors.initials: BD
authors.lastname: McCauley
authors.forename: Richard P
authors.initials: RP
authors.lastname: Shannon
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Kimmel
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D001794:Blood Pressure / Q000187:drug effects*; D005260:Female; D005919:Glomerular Filtration Rate / Q000187:drug effects*; D006333:Heart Failure / Q000503:physiopathology* / Q000628:therapy*; D006801:Humans; D007668:Kidney / Q000098:blood supply / Q000187:drug effects / Q000503:physiopathology*; D007674:Kidney Diseases / Q000503:physiopathology*; D007677:Kidney Function Tests; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016896:Treatment Outcome