title: Influence of Titration of Neurohormonal Antagonists and Blood Pressure Reduction on Renal Function and Decongestion in Decompensated Heart Failure.
abstract: BACKGROUND
  Reduction in systolic blood pressure (SBP reduction) during the treatment of acute decompensated heart failure is strongly and independently associated with worsening renal function. Our objective was to determine whether SBP reduction or titration of oral neurohormonal antagonists during acute decompensated heart failure treatment negatively influences diuresis and decongestion.
  
  
  RESULTS
  SBP reduction was evaluated from admission to discharge in consecutive acute decompensated heart failure admissions (n=656). Diuresis and decongestion were examined across a range of parameters, such as diuretic efficiency, fluid output, hemoconcentration, and diuretic dose. The average reduction in SBP was 14.4 ± 19.4 mm Hg, and 77.6% of the population had discharge SBP lower than admission. SBP reduction was strongly associated with worsening renal function (odds ratio, 1.9; 95% confidence interval, 1.2-2.9; P=0.004), a finding that persisted after adjusting for parameters of diuresis and decongestion (odds ratio, 2.0; 95% confidence interval, 1.3-3.2; P=0.002). However, SBP reduction did not negatively affect diuresis or decongestion (P ≥ 0.25 for all parameters). Uptitration of neurohormonal antagonists occurred in >50% of admissions and was associated with a modest additional reduction in blood pressure (≤ 5.6 mm Hg). Notably, worsening renal function was not increased, and diuretic efficiency was significantly improved with the uptitration of neurohormonal antagonists.
  
  
  CONCLUSIONS
  Despite a higher rate of worsening renal function, blood pressure reduction was not associated with worsening of diuresis or decongestion. Furthermore, titration of oral neurohormonal antagonists was actually associated with improved diuresis in this cohort. These results provide reassurance that the guideline-recommended titration of chronic oral medication during acute decompensated heart failure hospitalization may not be antagonistic to the short-term goal of decongestion.
authors.affiliation: Program of Applied Translational Research, Yale University.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Kula
authors.affiliation: Program of Applied Translational Research, Yale University.
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Hanberg
authors.affiliation: Program of Applied Translational Research, Yale University.|Department of Medicine, Yale University.
authors.forename: F Perry
authors.initials: FP
authors.lastname: Wilson
authors.affiliation: Department of Medicine, Medical University of South Carolina.
authors.forename: Meredith A
authors.initials: MA
authors.lastname: Brisco
authors.affiliation: Department of Medicine, Yale University.
authors.forename: Lavanya
authors.initials: L
authors.lastname: Bellumkonda
authors.affiliation: Department of Medicine, Yale University.
authors.forename: Daniel
authors.initials: D
authors.lastname: Jacoby
authors.affiliation: Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Steven G
authors.initials: SG
authors.lastname: Coca
authors.affiliation: Program of Applied Translational Research, Yale University.|Department of Medicine, Yale University.
authors.forename: Chirag R
authors.initials: CR
authors.lastname: Parikh
authors.affiliation: Section of Heart Failure and Transplantation, The Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: W H Wilson
authors.initials: WHW
authors.lastname: Tang
authors.affiliation: Program of Applied Translational Research, Yale University.|Department of Medicine, Yale University.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Testani
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000959:Antihypertensive Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001794:Blood Pressure / Q000187:drug effects*; D004231:Diuresis / Q000187:drug effects*; D004232:Diuretics / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D006727:Hormone Antagonists / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D007668:Kidney / Q000187:drug effects* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D010343:Patient Admission; D010351:Patient Discharge; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000959:Antihypertensive Agents; D004232:Diuretics; D006727:Hormone Antagonists
keywords: blood pressure; diuresis; diuretics; heart failure; hospitalization