This document provides information about a continuing medical education (CME) activity on cardio-renal syndromes (CRS). It begins with a declaration of disclosure stating the National Kidney Foundation's policy to ensure independence and manage any conflicts of interest among activity planners and faculty. The document then outlines the learning objectives, agenda, and pre-program questions. It also includes an overview of CRS, defining the different subtypes and discussing the bidirectional relationship between cardiac and renal dysfunction. Two case studies are presented to illustrate examples of acute cardiorenal syndrome type 1 and acute renocardiac syndrome type 3.
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
Cardio renal care-An integated best Practice Approch
1.
2. Declaration of Disclosure
It is the policy of the National Kidney Foundation to ensure
balance, independence, objectivity, and scientific rigor in all
CME/CE activities. Any individuals who have control over CME
content are required to disclose to learners any relevant
financial relationship(s) they may have with commercial
interests supporting this activity or whose products or devices
are discussed in this activity. If, on the basis of information
disclosed a conflict exists, resolution will be achieved based on
established policy by the NKF.
4. Learning Objectives
Distinguish among the different cardio-renal syndromes (CRS) to make an
accurate diagnosis in high risk patients
Evaluate strategies to facilitate organ protection in patients with CRS and
patients at risk for CRS
Incorporate a best practice approach to cardio-renal care in high risk
patients to improve patient outcomes
5. Agenda
Welcome and Introduction
Case Study Presentation
Overview of Cardiorenal Syndromes (CRS)
- Definition, Pathophysiology, and Epidemiology
Identifying and Reducing Risk for Developing CRS
Medical Management
Case Study Discussion
Closing Remarks and Evaluation
6. Pre-program Questions to Consider
What is cardio-renal syndrome?
Which patients are at risk of developing cardio-renal
syndrome?
What are treatment strategies for cardio-renal
syndrome?
8. Case Presentation
CC:
65-year-old male admitted with 3 weeks of increasing shortness of
breath, for consideration of MVR and CABG
HPI
49 year h/o type 1 DM, 20 yr of htn, and first MI 21 years ago.
Chronic kidney disease, stage 5, not on dialysis, dx 5 years ago with
nephrotic range proteinuria.
Known congestive heart failure with mitral regurgitation.
3 weeks prior to admission he developed increasing shortness of
breath and was unable to walk any distance or climbs stairs. At that
time BNP was elevated and he was sent to the emergency room for
admission.
9. Case Presentation
PMH
Type 1 diabetes diagnosed 1962,MI 1980,Hypertension
1980,Nephrotic syndrome 2005,Diabetic nephropathy 2005
with the first indication of renal failure, Congestive heart
failure 2005. Last cardiac cath in 2008 (due to new LBBB)–
diffuse 3 VD, no intervention, EF 35 – 45%.
Family history and social history noncontributory
No allergies
Review of systems notable only for significant shortness of
breath with no hemoptysis, no chest pain, no lower extremity
edema or weakness
11. Case Presentation
Admission Exam:
Afebrile, BP 120/60, HR reg @60
alert and oriented x3 in no significant distress
JVP to 15 cm
Cor: inferolaterally displaced PMI no heave, RRR, + apical
S3, III/VI holosystolic murmur at the apex
pulm: Decreased breath sounds at the bases with adjacent
rales, speaking in full sentences, no tachypnea, no accessory
muscle use
abdomen soft, nt, nondistended , + liver edge
femoral pulses 2+, trace edema at the ankles
12. Case Presentation
141 | 115 | 90
--------------------< 230 Ca: 8.6 P: 4.5 Mg: 1.6 [09/08 @ 14:51]
6.6 | 20 | 4.5
WBC: 5.6 / Hb: 10.6 / Hct: 31.2 / Plt: 125
PT: 11.1 / PTT: 28.2 / INR: 1.1
Troponin: 1.06
EKG: NSR @ 84, left bundle branch block, new from ‘08 but unchanged
from previous
Echo from < 1 month ago: LV dilated distal anteroseptal wall and apex
akinetic, inferior wall contracts normally, and all other wall hypokinetic,
EF 35 -40%, left atrium dilated 4.9 cm,3+ MR (TEE suggested 4+ MR)
13. Defining CRS
Because it has long been recognized that severe cardiac and renal dysfunction rarely
occur in isolation, the concept of cardiorenal syndrome has emerged. But CRS has been
very difficult to define because it encompasses many complex physiological, biochemical,
and hormonal abnormalities.1
In 2004, the National Heart, Lung, and Blood Institute defined CRS as only one syndrome
in which “… therapy to relieve congestive symptoms of heart failure is limited by further
worsening renal function (WRF).”2
However, a reciprocal relationship exists between cardiac and kidney disease --kidney
function declines in the presence of cardiac disease, and, conversely, CKD is considered
an independent risk factor for developing cardiovascular disease.3
Therefore, definitions have been formulated to also “….stress the complex and
bidirectional nature of pathophysiological interactions between the failing heart and
kidneys.”4
1. Bock J.S., Gottlieb S.S. Circulation 2010;121:2592-2600.
2. NHLBI Working Group. NHLBI web site. http://www.nhlbi.nih.gov/meetings/workshops/cardiorenal-hg-hd.htm.
3. House A.A., et al. Am J Kid Dis 2010;56:759-773.
4. Acute Dialysis Quality Initiative (ADQI) Consensus Group. Eur Heart J 2010;31:703-711.
14. Defining CRSThe Cardiorenal Connection, an extension of
Guyton’s hemodynamic model, represents
the cyclical nature of CRS.
Guyton’s Hemodynamic Model illustrates the
regulation of extracellular volume, cardiac
output, and mean arterial pressure through
feedback mechanisms between the heart and
kidney.3
The Cardiorenal Connection emphasizes these
pathophysiologic changes during heart or
kidney failure:
- NO-ROS (nitric oxide-reactive oxygen species)
imbalance
- sympathetic nervous system activation
- renin-angiotensin system activation, and
inflammation.
When one of these “connectors” become
deranged, the others do too, leading to heart
and kidney dysfunction, and, structural
damage. This ongoing cycle results in severe
CRS.
Bongartz L G et al. Eur Heart J 2005;26:11-17
15. Defining CRS
There is an urgent need to correctly define CRS in order to improve
medical management of a very sick population. Though debate continues
over the best definition(s), the following was developed in 2008 at the 7th
Acute Dialysis Quality Initiative (ADQI) Consensus Conference on Cardio-
Renal syndromes:
“Cardiorenal syndromes are disorders of the heart and kidneys whereby
acute or chronic dysfunction in one organ may induce acute or chronic
dysfunction of the other.”
The ADQI also established a classification of CRS subtypes that
distinguishes primary organ dysfunction (cardiac vs. renal) and acute vs.
chronic timeframe. A patient may exhibit one, several, or all of the
subtypes during the course of illness.
Acute Dialysis Quality Initiative (ADQI) Consensus Group. Eur Heart J 2010;31:703-711.
16. CRS Subtypes: Acute Cardiorenal Syndrome Type 1
McCullough P.A. Int J Neph 2010;2011:1-10.
17. CRS Subtypes: Acute Cardiorenal Syndrome, Type 1
Type 1 is common, with 27-40% of patients hospitalized for ADHF (acute
decompensated heart failure) appearing to develop AKI (acute kidney
injury).1
The incidence estimates for AKI associated with ADHF and ACS (acute
coronary syndrome) have ranged between 24-45% to 9-19%, respectively.
The broad ranges are related to varying definitions of WRF, differences in the
observed time-at-risk, and the heterogeneity of selected populations being
studied.2
The ESCAPE trial fulfills the criteria for acute cardiorenal syndrome (type 1)
with a presenting diagnosis of ADHF, and demonstrates the following cardio-
renal interactions2
:
1. Acute Dialysis Quality Initiative (ADQI) Consensus Group. Eur Heart J 2010;31:703-711.
2. Cruz D.N. and Bagshaw S.M. Int J Neph 2010;2011:1-11.
18. Acute Heart Failure causing AKI
Cardiogenic shock - >70% have AKI
Acute anterior wall MI
Mitral valve papillary muscle rupture
MI, endocarditis
Acute aortic regurgitation
Endocarditis
Acute decompensation of chronic heart failure
Flash pulmonary Edema
Hypertensive emergency
Predominantly preserved LVF/LVH
Predominant RV failure
19. Cardiorenal Interactions in the ESCAPE Trial
Nohria, A. et al. JACC 2008;51:1268-1274
-The risk of death and death or rehospitalization
at 6 months increased with increasing SCr and decreasing
eGFR.
-Baseline renal function appeared more predictive of long-
term outcomes than WRF during hospitalization.
20. Characteristics of pts with WRF from ESCAPE trial
No difference in PAC –derived hemodynamic parameters
in pts who had improved or worsening RF.
Those with WRF:
↑SBP, ↑ prevalence of HTN, ↑suspicion of ascites, ↑use
of thiazides, ↑weight loss and rate of weight loss.
RF did not worsen when treatment was PAC directed to
lower CVP and PCWP
Whereas it did when guided by clinical assessment alone
Testoni et al. Am J Cardiol 2010;106:1763-69
Binanay et al. JAMA 2005;294:1625-33
21. CRS Subtypes: Chronic Cardiorenal Syndrome, Type 2
McCullough P.A. Int J Neph 2010;2011:1-10.
22. CRS Subtypes: Chronic Cardiorenal Syndrome, Type 2
Type 2 is common and has been reported in 63% of patients hospitalized
with congestive heart failure.4
Of 118,465 admissions in the ADHERE trial, 27.4, 43.5, and 13.1% of
patients were found to have mild, moderate, and severe kidney
dysfunction at the time of hospital admission, respectively.2
The ADHERE registry used a classification and regression tree (CART) to
determine predictors of mortality, and found high BUN to be the best
predictor of mortality, with additional risk conferred by low systolic blood
pressure, and then even further by high creatinine.2
1. Acute Dialysis Quality Initiative (ADQI) Consensus Group. Eur Heart J 2010;31:703-711.
2. Heywood H, Fonarow GC, Costanzo MR, et al. High prevalence of renal dysfunction and its impact on outcome in 118,465 patients
hospitalized with acute decompensated heart failure: a report from the ADHERE database. J Cardiac Failure 2007;13:422-430.
23. Journal of Cardiac Failure Vol. 13 No. 6 August 2007
Findings from the ADHERE Database
25. Case #2
72 year old woman, who presents for evaluation of
possible MVR and CABG.
Flew directly from the Kuwait for opinion.
PMH:
1) Ischemic Heart Disease: NSTEMI 2003,
2) HTN on multiple meds, h/o hypertensive emergency
(flash pulmonary edema) in 2/11
3) HL on atorvastatin
4) DM2
5) Hypothyroidism on synthroid
6) Morbid obesity with obesity hypoventilation syndrome on
nighttime O2
7) CRI (b/l Cr 1.6)
26. Case # 2
Meds:
Candesartan 16 mg daily, Carvedilol 6.25 mg BID, ISMN 60 mg
daily, Plavix 75 mg daily, Levothyroxine 50 mcg daily, Norvasc 10
mg daily, Lipitor 20 mg daily, Lasix 40 mg BID, Nexium 40 mg
daily, Allopurinol 300 mg daily, ASA 81 mg, Novomix Insulin
70/30, Pregabalin 75 mg daily, Prazosin 2 mg TID
Exam:
Gen: morbidly obese, NAD
Neck: supple, no JVD, no LAD
Cardiac: diffuse enlarged PMI, 6th IC space, RRR, nl S1/S2, loud
cresc/decresc murmur at RUSB radiating to R neck, HSM at apex,
NoS3
Pulm: shallow inspiratory effort, decreased b/l lung bases
Abdomen: protuberant, obese, non-tender, +bs
Ext: no pitting edema, 2+ pulses
27. Case # 2
Initial labs stable : BUN/Creat 70/1.8
Lasix held in preparation for cath
Cardiac cath revealed no change in anatomy from
2007 and only 1+ MR, low filling pressures and RV
pressures.
Approx 70% stenosis of the right RA only
Tolerated procedure well, but complained of
abdominal pain afterwards. No evidence of bleeding,
and hemodynamics stable for the next 48 hours.
Blood pressure relatively low and meds DC’d over the
next few days
28. Hospital Course:
Over the next few days:
Acute renal failure developed BUN/Creat 104/5.48,
Na 117, K 6.1, HCO3 16, oliguria but never anuria
Initially fluid status OK, but CHF developed
BP low 100/60, never needed pressors, but off ALL meds
Junctional escape rhythm requiriring emergent TPM
CVVH initiated, only necessary for 12 hrs.
UOP began to increase, creat down to 1.67 over the next
10 days. Meds resumed.
During renal recovery, episode of flash pulm edema
with BP 190/110, required BiPap and IV nitro.
30. CRS Subtypes: Acute Renocardiac Syndrome, Type 3
Due to heterogeneity in the causes and definitions of AKI, as
well as variable risk for developing CVD among individuals,
and many clinical studies not reporting the occurrence of
acute cardiac dysfunction as outcomes, incidence estimates
are mostly context and disease-specific.
Patients suffering AKI secondary to contrast were almost
twice as likely to suffer downstream adverse events, including
cardiovascular events, in the year following contrast exposure.
Acute Dialysis Quality Initiative (ADQI) Consensus Group. Eur Heart J 2010;31:703-711.
32. Go, et al., 2004
1.0
1.4
2.0
2.8
3.4
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
≥ 60 45-59 30-44 15-29 < 15
AdjustedHazardRatio
eGFR
Adjusted hazard ratio for CVD events
- The retrospective study by Go, et al fulfills criteria for chronic renocardiac
syndrome, type 4.
- Go found graded increases in the prevalence of CVD and HF, along with higher
risk of subsequent cardiac events during follow-up associated with the degree
of decline in eGFR < 60 mL/min/1.73m2.
Go AS, Chertow GM, Fan D, et al. N Engl J Med. 2004 Sep 23;351(13):1296-1305.
37. Shastri S, Sarnak MJ. Cardiovascular Disease and CKD: Core Curriculum 2010. Am J Kidney Dis 2010;56:399-417.
38. Kidney Failure Is a
Rapidly Growing Problem
Numberofpatients(inthousands)
USRDS, 2000
98,953
372,407
661,330
172,667
Prevalence
Incidence
39. 39
Incident Counts and
Adjusted Rates, by Primary
Diagnosis
U.S. Renal Data System 2009 ADR
Incident ESRD patients; rates
adjusted for age, gender, & race.
40. Diabetes: The Most CommonDiabetes: The Most Common
Cause of ESRDCause of ESRD
Primary Diagnosis for Patients Who Start Dialysis
Diabetes
50.1%
Hypertension
27%
Glomerulonephritis
13%
Other
10%
United States Renal Data System. Annual Data Report. 2000.
No. of patients
Projection
95% CI
1984 1988 1992 1996 2000 2004 2008
0
100
200
300
400
500
600
700
r2
=99.8%
243,524
281,355
520,240
No.ofdialysispatients(thousands)
41. Stages and Prevalence of CKD
(Age ≥ 20 Years)
GFRGFR Prevalence*Prevalence*
StageStage DescriptionDescription (mL/min/1.73 m(mL/min/1.73 m22
)) n (1000s)n (1000s) %%
1
Kidney damage with
normal or elevated
GFR
≥ 90 5900 3.3
2
Kidney damage with
mild decreased GFR
60-89 5300 3.0
3
Moderate decreased
GFR
30-59 7600 4.3
4 Severe decreased GFR 15-29 400 0.2
5 Kidney failure <15 (or dialysis) 300 0.1
*Population of 177 million people ≥ 20 years
Adapted from NHANES III
42. Stage 5
Stage 4
Stage 3
Stage 2
Stage 1 n=5,900,000
n=5,300,000
n=7,600,000
n=400,000
n=400,000
At risk population
Total = 20 million
NHANES III
43.
44. CKD Patients Are More Likely To Die
Than Progress To Kidney Failure
5-Year Mortality Rate
RRT = renal replacement therapy
Keith D, et al. Arch Int Med 2004;164:659-663
14.9%
74.8%
10.2%
16.2%
63.3%
19.5%
10.3%
64.2%
24.3%
45.7%
19.9%
27.8%
6.6%
1.0%
1.2%
49. Slow CKD progression
Treat to target BP <130/801
ACEI and/or ARB are first line therapies for hypertension with albuminuria or
proteinuria
Control blood sugar in diabetes, target HbA1C <7%
Refer to dietitian for food choices appropriate for this patient
Modify all CVD risk factors
Control dyslipidemia
Weight control and smoking cessation
Anemia management
Control hyperphosphatemia, hyperparathyroidism and vitamin D deficiency
Minimize further kidney injury
Avoid nephrotoxins such as NSAIDs, aminoglycosides, IV and intra-arterial
contrast etc
Adjust dosages of renally excreted medications; avoid metformin if GFR<60
NKF. KDOQI guidelines.
50. Challenge of Managing CRS
The treatment of heart failure often depends on large
doses of diuretics and afterload reduction in order to
optimize preload and afterload.7
As a result of volume depletion, renal function worsens.7
Conversely, treatment with volume to preserve renal
function leads to pulmonary and systemic congestion and
worsening heart failure.7
Chan EJ, Dellsperger KC. Cardiorenal syndrome: the clinical cardiologists’ perspective. Cardiorenal Med 2011;1:13-22.
51. Diuretic Resistance
Reduced natriuretic response to a given dose of
diuretic
Escalating doses of loop and non-loop diuretics at the
expense of renal function
Often seen as the response to the “prerenal state”
neurohormonal up-regulation, via AT II, aldosterone Na
retention, ↑ vasopressin H2O resorption
renin release @ macula densa -> direct Na resorption and
intrarenal vasoconstriction -> ↓ GFR-> ↓ filtered load of Na
and H20 -> Kidney respond w/ vasoconstriction @ afferent
arterioles -> ↓ RBF -> ↑ neurohormonal cascade again
↑ CVP, ↑ renal venous pressure -> ↑ intracapsular pressure -
> ↓ GFR
52. Ultrafiltration: UNLOAD Study
At 48h, weight loss greater in UF group than
diuretic group
At 48h, dyspnea scores similar between groups
At 90 d, 44% reduction in percentage of pts
rehospitalized for HF in UF group compared to
diuretic group
No difference in Cr between groups at 48h or at
90 days
Baseline diuretic dose was not doubled in the
standard care arm within the first 24 hrs. as
mandated by the trial, and so this group may
have received less effective treatment,
decongestion, and weight loss.
Costanzo, MR et al. J Am Coll Cardiol 2007;49:675.
53. UNLOAD
“Early use of UF may allow more control of the
circulating mass with effective neurohormonal
purification and of all the inflammatory mediators”
Claudio Ronco. Heart Fail Rev 2010
But…
Do we risk putting patients on anticoagulation to achieve
diuresis and natriuresis?
Must consider the risk of acute kidney injury with UF.
Cost—$14,000 per device and over $900 per filter, which
needs to be replaced every 24h
Further trials may show that the cost-benefit when
taking into account HF hospitalizations, ED visits, etc.
favors UF
For now, we use UF as a last resort. No conclusive data
to demonstrate improvement in CHF outcomes.
54. RECOMMENDATION FOR USE OF UF IN HEART FAILURE
Class IIa recommendation from the ACC/AHA: Ultrafiltration is reasonable
for patients with refractory congestion not responding to medical therapy.
(Level of evidence: B)
If volume overload is confirmed, the dose of loop diuretic should be first
increased to ensure that adequate drug levels reach the kidney.
If this is inadequate, a second type of diuretic, usually a thiazide or
spironolactone can be added.
A third option to consider is continuous infusion of the loop diuretic.
If all diuretic strategies are unsuccessful, UF or another renal replacement
modality may be reasonable.
Consultation with a kidney specialist may be appropriate before selecting any
mechanical modality to affect diuresis.
2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and
Management of Heart Failure in Adults. Circulation 2009;119:1977-
55. Management: CRS Type 1
Vasodilators and loop diuretics are
widely recommended in cases of ADHF
and CRS type 1. However, loop
diuretics predispose to electrolyte
imbalances and hypovolemia leading to
neurohumoral activation, reduced renal
glomerular flow with further rises in
serum creatinine.
Vasodilators such as nesiritide may also
affect kidney function and even
exacerbate kidney injury.
Vasopressin 2 antagonists can improve
hyponatremia, but without
improvement in survival.
If congestion occurs with low blood
pressure, inotropic agents should be
considered.
Extracorporeal ultrafiltration may be
helpful in ADHF associated with
diuretic resistance.
Depending on the cause and setting,
left ventricular assist devices as a
bridge to transplant or surgery may be
appropriate.
Overtreatment with loop diuretics,
ACEi, and/or spironolactone may
induce AKI.
Acute Dialysis Quality Initiative (ADQI) Consensus Group. Eur Heart J 2010;31:703-711.
56. • Meta-analysis of RCTs to
assess risk of worsening
renal function with
nesiritide
– Increase in serum Cr
>0.5mg/dL
• 5 RCTs, 1269 pts
• Results = Nesiritide
significantly increased
risk of worsening renal
function compared with
non-inotrope based
controls and all controls
at all infusion rates
A and B = Nesiritide < 0.03 ug/kg/m
C and D = Nesiritide < 0.015 ug/kg/m
E and F = Nesiritide < 0.06 ug/kg/m
57. ASCEND-HF
7,000 pts, 300 centers
Nesiritide vs placebo, with standard of care (including IV
nitro and diuretics) w/in 24hrs of admission.
1 – 7 days Rx, ave. 40 hours
No significant difference in 30 day readmission or death
Only 4.7% mortality, 10% total endpoints
Slight ↓in SOB at 6 hrs. and 24 hrs – no statistical sig.
NO DECLINE in renal function
Confirmed the safety of nesiritide but no definitive word
on usefulness so far.
Need subgroup analysis
O’Connor, et al. N Engl J Med 2011; 365:32-43.
58. Vasopressin Antagonists
V1 receptors: in vasculature mediates VC
V2 receptors: in distal nephron mediates H2O
resorption
Antagonism of V1a rec:
↑CO
↓PVR
↓MAP
↓AVP mediated cardiomyocyte hypertrophy
Antagonism of V2 rec:
Aquaresis/free water clearance
↓ urine osm
↑ serum Na
Lemmens-Gruber, Kamyar, Cell Mol Life Sci 2006;63:1766-79
59. Vasopressin Antagonists
Tolvaptan:
Approved for treating hyponatremia, and is an option not routinely used
Initial studies very promising
↑ UOP
↓ urine osm
↓ urine Na conc
No change in renal fn or BP
↓ furosemide use
↓ body weight
BUT…EVEREST trial
> 4000 pts and All of above achieved
You see early benefit in dyspnea on day 1 and edema/weight on day 7,
but no benefit on heart failure hospitalization or mortality. The cost
for 30 days is close to $6000.
NO overall benefit (need sub-group analyses and more trials)
? Timing, ? Length of Rx, ? Dose
Most useful in pts with high
Copeptin levels?
Gheorghiade et al. Circ 2003;107:2690-96
Gheorghiade et al. JAMA 2004;291(16):1963-71
Gheorghiade et al. JAMA 2007 (12):1332-43
60. Management: CRS Type 2
Therapy of CHF with concomitant
renal impairment is not evidence-
based, as these patients are usually
excluded from CHF trials.
Patients are usually hypervolemic, and
more intensive diuretic treatment is
needed.
Loop diuretics are preferred, but
thiazides may improve diuresis during
diuretic resistance.8
Diuretic infusions may be more
effective than bolus doses, and can be
combined with amiloride, aldosterone
antagonists, or metolazone.
Increasing doses of diuretics associated
with worse outcomes.
In refractory cases, renal replacement
therapy may be needed.
ACEi and ARB initiation may cause
deterioration in renal function, which is
usually transient and reversible.
Patients with CKD or renal artery
stenosis are at higher risk and need
careful monitoring. Hyperkalemia may
occur and dietary restriction of
potassium may be needed.
Anemia is often present and correction
may improve symptoms.
Acute Dialysis Quality Initiative (ADQI) Consensus Group. Eur Heart J 2010;31:703-711.
61. High CVP: Poor Prognosticator for Worsening
Renal Failure in CHF
High CVP on admission and
after intense medical therapy
was associated with WRF and
overall outcome
WRF occurred less when CVP
of < 8 achieved
Ability of CVP to stratify risk
was independent of HR,
PCWP, SBP, CI and SPAP
Baseline CI was actually
better in those who
developed WRF
“Congestive Kidney Failure”?
Mullins et al. JACC 2009; 53:589-96
Damman et al. JACC 2009; 53:582-88
CVP CI
SBP PCWP
62. High vs low dose IV furosemide From ADHERE registry:
< 160 mg/day of IV
furosemide -> ↓ hospital
mortality, ↓ instances of
WRF, ↓ ICU utilization,
and shorter hospitalization
then patient's treated with
high-dose IV loop
diuretics.
Initiation of dialysis occurred
less often in low-dose
admissions although did not
exceed 2% in any cohort
63. Furosemide in ADHF:
Bolus Dose vs Continuous Infusion
8 randomized controlled trials, 254 patients
Urine output greater with continuous infusion
(+271cc/24h, p<0.01)
Electrolyte disturbances not significantly different
between the two groups (p=0.5)
Less adverse effects (tinnitus, hearing loss) with
continuous infusion (p=0.005)
Hospital stay shortened by 3.1d (p<0.0001) and cardiac
mortality reduced (p<0.0001) with continuous infusion
based on single study
All-cause mortality reduced based on 2 studies (p<0.0001)
Cochrane Database Syst Rev 2004;1:CD003178..
65. Management: CRS Type 4
Cardioprotection for patients with CKD by using ACEi and/or
beta blockers, including those on dialysis
Maintenance of fluid and sodium balance in order to prevent
volume overload
Correct anemia
Minimize vascular calcification
Acute Dialysis Quality Initiative (ADQI) Consensus Group. Eur Heart J 2010;31:703-711.
66. ACEI/ARB/Renin Inhibitors
Inclination is to stop them with renal
insufficiency/failure
Most troublesome in the setting of
“overdiuresis” or poor renal perfusion
elderly
Hyperkalemia
In the setting of contrast agents
Allow for 30% increase in creatinine
67. ACEI/ARB/Renin Inhibitors
Reverse vasoconstriction, intraglomerular pressure↓ and reduce
aldosterone mediated sodium retention – therefore should be
ideal.
Well established role of renoprotective effects in DM2
Most CHF trials are underpowered to assess and/or do not have
enough info on renal function or outcome
Minnesota Heart Study (2000)
2009 - restrospective look at ACE/ARB
If GFR < 15 ml/min, pts were far less likely to get them (50%
vs 65% if GFR > 90)
OR of 1 year mortality 0.72 if DC’d on one
OR of 30 day mortality 0.45 if given in hospital
Berger, et al. Am Heart J 2007;153:1064-73
68. β-Blockers
SNS:
β1 – myocardial VC, ↑ renin release
Β2 – RV vasodilation
α1 - systemic and RV VC
CKD and CHF overstimulation of SNS
Still underutilization w/ CKD
Carvedilol – better tolerated due to vasodilating properties from α
blockade, and nonselective β blockade
Again…most large studies excluded pts with significant renal
disease, when used, show ↓in CV events, ↓ in albuminuria
Avoid in decompensated HF, but otherwise push to high doses
69. Anemia Prevalence by CKD Stage
69
*NHANES participants aged ≥20 y with anemia as defined by WHO criteria: hemoglobin (Hgb)
<12 g/dL for women, and Hgb <13 g/dL for men.
USRDS 2004 Annual Data Report. The data reported here have been supplied by the USRDS. The interpretation and reporting of
these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S.
government. Available at: www.usrds.org. Accessed 3/28/05.
PatientsWithAnemia*(%)
NHANES III
NHANES 1999-2000
CKD Stage
71. Major Trials of Statins
Early trials which began to show benefit of statins
Scandinavian Simvastatin Survival Study (4S) supported the use of
statins in secondary prevention for cardiovascular disease (Lancet
1994)
Pts with elevated LDLs and h/o CAD with LDL reduction from
simvastatin had reduced recurrent cardiovascular events
The Heart Protection Study (HPS), which showed preventative
effects of statin use in specific risk groups, such as DM, CAD, other
vascular disease, showed reduction in mortality w simvastatin
(Lancet 2002)
Most recently the JUPITER trial (NEJM 11/20/08) showed in
patients with LDL less than 130 and only elevated CRP, reduction in
rates of mi, stroke, or combined endpoint of MI, stroke and death
And many others which examine the role of statin for primary and
secondary prevention as well as post MI
72. Major Statin Trials in CKD?
Many of these trials tend to exclude patients w
CKD and transplant patients, despite the fact that
~50% of transplant patients are on statins
Subgroup analysis of the Heart Protection Study
and Anglo Scandinavian Cardiac Outcomes Trial-
Lipid Lowering Arm (ASCOT-LLA) and
Cholesterol and Recurrent Events (CARE) study,
did show mortality benefit in patients w mild
renal insufficiency
But can this data be applied to CKD and
transplant patients for secondary and even
primary prevention?
81. New Strategies for Management
Biomarkers 1
B-type Natriuretic Peptides
(BNP and NT-proBNP)
Copeptin
Fibroblast Growth Factor 23 (FGF – 23)
Neutrophil Gelatinase-associated
Lipocalin (NGAL):
Cystatin C
Kidney Injury Molecule-1 (KIM-1)
N-acetyl-B-(D)glucosaminidase
Interleukin-18 (IL-18)
Bioimpedance Vector Analysis (BIVA)
Imaging
Treatments 1,2,3
Furosemide and hypertonic
saline (HTS)
Vasopressin antagonists
Adenosine receptor antagonists
Cardiac resynchronization with
AICD
Ultrafiltration
1. Acute Dialysis Quality Initiative (ADQI) Consensus Group. Eur Heart J 2010;31:703-711.
2. House AA, et al. Am J Kid Dis 2010;56:759-773.
3. Chan EJ, Dellsperger KC. Cardiorenal syndrome: the clinical cardiologists’ perspective. Cardiorenal Med 2011;1:13-22.
82. BNP-guided treatment of CHF
Trials are small and
Underpowered
Still not recommended
in CHF guidelines
83. BNP in renal failure
Maisel, et al, ADQI consensus group. Nephrol Dial Transplant 2010. Editorial Review
84. Cardiac Biomarkers
in CRS
Van Kimmenade R, et al. JACC 2006;48:1621
• ICON study: NT-pro BNP > 4,647
(mean) and GFR < 60:
best predictor of mortality
– OR 3.46, accounted for vast
majority of deaths
– Those with GFR <60, but ↓NT-
proBNP had 60-day outcomes
comparable to those without
renal insufficiency
– Those with creat rise: had
increase risk if NT-pro BNP
levels were above the mean
– Is NT-pBNP better marker of
“cardio-renal syndrome”?
85. Copeptin (CT-proAVP)
Copeptin (C-terminal pro-vasopressin)
Stable in serum or plasma, therefore easily measured
Is it a better marker for mortality and morbidity in pts
with acute HF after AMI?
Stronger predictor t of M&M than BNP and NT-
proBNP
Higher in pts with decreasing renal fn
Voors, et al. Eur Heart J 2009;30:1187-94
Morgenthaler. Cong Heart Fail 2010;16(4) (suppl 1)s37-44
Can levels guide therapy…? VP antagonists
86. Copeptin in Heart Failure
AVP contributes to LV
dysfunction
Aggravates LV wall
stress
Stimulates LVH
Worsens remodeling
Strong correlation btwn
Copeptin levels and
mortality
Copeptin & BNP added
to risk stratification Neuhold, et al JACC. 2008;52:26672
87. Cystatin C
Cysteine protease inhibitor
Levels not affected by age, gender, race, diet, muscle mass
Better measure of glomerular function than creatinine
Correlates well with NT-pro BNP levels
Tn T, NT-pro BNP and cysC give complementary
prognostic information in acute HF
Detects decline in renal fn within 48 hours
Rise of > 0.3mg/L longer hospitalization, higher
in-house mortality, independent predictor of
survival during follow-up
Manzano-Fernandez et al. Am J Cardiol 2009;103: 1753-9
Linzbach S, et al. Am J Cardiol 2009;103:1128-33
88. Cystatin C
FINN-AKVA Study
CRS type 1 patients
>0.3mg/L rise in cysC
occurred w/in 48 hrs in
16%
Extended
hospitalization 3 days
OR 4 for in-house death
OR 2.8 for 90 day
mortality
Lassus J, et al. Eur Heart J 2010;31:2791-98
CysC
>0.1mg/L
CysC >0.3mg/L
CysC > 0.5mg/L
89. Cystatin C and Creatinine
With 0.2 mg/dL rise in creat and 0.3mg/L rise in
cysC, mortality 44.8% at 90d
91. Furosemide and HTS
Theory:
Offsets the counterproductive neurohormonal up-
regulation
transiently improves hemodynamics
promotes renal Na extraction with accompanied net
water loss and preservation of renal function
Seems counterintuitive, but in a way, it is “giving the
body the very sodium it is trying so hard to retain”
Liszowski, Curr Heart Fail Rep. 2010;7:134-39
92. Furosemide and Hypertonic Saline
↑ natriuresis and diuresis
Results maintained over time , when continuing PO
diuretic therapy and low Na (but not restricted) diet
Better survival at 48 months (55 vs 13%)
Allows more rapid attainment of dry weight
Faster ↓ in BNP ( BNP maintained with higher Na↓
diet)
Lower LOS and 30 day readmission rate.
Improvement in renal fn
No adverse cardiac events
US and Brazil w/ ongoing
large studies now
Paterna, et al. Eur. J Heart Fail 2000;2:305-13
Paterna et al. Clin Drug Interact; 25:165-174
Paterna et al.JACC 2005;45:1887-2003
Licata et al. Am Heart J 2003;145;459-66
93. Adenosine Receptor Antagonists
A1, A2 and A3 receptors
Ado levels are increase in HF
Ado activity is mediated by neurohormonal systems, renal nervous
system, and Ado can alter levels of NO and vasodilators
A1 Receptor activation ↓eGFR glomerular arteriolar VC ↑ Na
reabsorption in prox and distal tubules (TG feedback) ↓ Renin
secretion
A2 Receptor ActivationVasodilation renal medullar blood flow↑
Ideal therefore to have A1 Receptor blockade and allow A2 activity ↑
UOP and preservation of eGFR
Nodari. Heart Fail Rev. online 12/7/10
Vallon et al.Physiol Rev. 2006;86:901-40
Marraccini et al.Cardiovasc Res. 1996;32:949-53
Kuan et al.J Cardiovasc Pharmachol.1993;21:822-28
94. CRT with Impaired Renal Function
Initial cohort data suggests that pts w/significant reverse
remodeling after CRT showed improved renal fn. and ↑
survival
In only 85 pts though…those w/ no significant reverse
remodeling had higher baseline eGFR
Fung, Int J Cardiol 2007;122:10-16
MIRACLE substudy:
all groups (eGFR 30–60, 60–90 and > 90) derived benefit
from CRT
↑ EF and ↓ LV volumes
Again… ↓ in LVESV best in patients w/ eGFR > 90, and worst
in GFR 30 – 60.
Boerrigter, J Card Failure 2008;14:539-46
95. CRT with Impaired Renal Function
Feb. 2011 JACC: 490 pts
undergoing CRT
CHF pts with mod –
severely reduced renal fn
(eGFR< 60) as compared
to those with normal or
mildly reduced renal fn
(eGFR > 60), showed
worse response to CRT Van Bommel, et al. JACC 211: 57;549-555
96. CRT with Impaired Renal Function
GFR < 60 had higher mortality
than if GRF 60 – 90, or > 90
Only 43% in low GFR group
were responders
eGFR remained a very strong
predictor of survival after
CRT
CRT responders had higher
baseline GFR
CRT responders also had
preservation of renal fn,
nonresponders had slight
decline (only a subset of 133
pts).
97. CRT with Impaired Renal Function
Can this data help us determine who will respond to
CRT or if CRT is indicated?
With or without AICD?
If high venous pressures cause renal dysfunction– then
can we prevent renal failure with improvement in LV
synchrony?
Or…does the high CVP override the benefit?
Impaired renal fn is associated with more MR, lower EF
Improvement in renal fn is likely due to ↑EF, ↓MR, ↓ SBP,
↓CVP
Were “non-responders” actually “responders” as their
renal fn could have declined without CRT?
98. Integrated Strategies for Both Cardiology
and Nephrology
Recognize the cardiorenal syndrome
Treat the whole patient
Treat for the long-term
Optimize heart failure therapy so that renal function is preserved
Consider new approaches to diuretic infusion or combination therapy that
may reduce the degree of renal dysfunction
Consider vasodilators for use in the appropriate setting to improve
transrenal blood flow while protecting renal function
Consider newer approaches such as ultrafiltration, vasopressin antagonists
and adenosine receptor blockade for improving volume regulation while
preserving renal and cardiac function
Harbir KR, Gupta RS, Singh SR. Challenge of renal protection in acute decompensated heart failure. http://www.apicon2011.org/HTMLPages/12.htm.
last accessed November 1, 2011.
99. Post-program Questions to Consider
What is cardio-renal syndrome?
Which patients are at risk of developing cardio-renal
syndrome?
What are treatment strategies for cardio-renal
syndrome?
The “cardiorenal connection” describes the effects of neurohormonal abnormalities of CRS on hemodynamic regulation.
The plural (cardiorenal syndromes) is used in the definition to indicate that there is more than one syndrome.
The classification also was considered necessary for standardizing epidemiologic and diagnostic criteria.
This subtype is an acute worsening of heart function leading to kidney injury and/or dysfunction. The worsening renal function (WRF) further complicates acute heart failure (AHF) and/or acute coronary syndrome (ACS)
Impaired renal fn is consistently found as a risk factor for 1 yr mortality
ESCAPE (Evaluation study of CHF and PAC effectiveness) trial was designed to assess the efficacy of PAC assisted treatment in decompensated HF in 433 pts – all had EF &lt; 30%, used &gt; 160mg lasix, s/sx of CHF.
Excluded – creat &gt; 3.5, dopamine use, mirinone use.
PAC’s provided little info regarding who would have renal failure
PAC directed therapy however resulted in patients having no change in renal fn, whereas those with only clinically guided therapy had worsening renal fn.
This subtype describes chronic abnormalities in heart function leading to chronic kidney injury or dysfunction that can then further complicate heart disease.
attempted to develop and validate a practical, user-friendly method of risk stratification for in-hospital mortality among pts admitted with ADHF. Data taken from ADHERE registry: Acute Decompensated HF national REgistry (contains data on pts hospitalized with ADHF in 263 community, tertiary, and academic centers from all regions of US. ADHF=New onset decompensated heart failure or decompensation of chronic established HF with sx sufficient to warrant hospitalization. Med records reviewed by trained abstractors).
Overall mortality 4.1%, but 10-fold variation depending on certain predictors
CART – classification and regression tree
Best single predictor of mortality = High BUN
Then Low SBP
Then High Cr – in an additive manner
Obviously those pts judged to be at higher risk may receive higher level monitoring and treatment, while those at lower risk may be reassured and managed less intensively - between high and low risk OR 12.9
Subtype 3 describes worsening of kidney function leading to heart injury and/or dysfunction – abnormalities in cardiac function are secondary to acute kidney injury (AKI).
Acidemia is a probable cause of heart failure and electrolyte abnormalities are strongly related to arrhythmias
AKI is found in 35% of ICU patients
This subtype describes chronic kidney disease (CKD) leading to heart injury, disease, and/or dysfunction – cardiac dysfunction is secondary to CKD.
Subtype 5 describes how systemic conditions such as sepsis can lead to simultaneous injury and/or dysfunction of both the heart and kidneys.
There are limited data for the pathophysiology or epidemiology of this subtype, and the epidemiology is mostly disease and context-specific.
This graphic illustrates the common risk factors for both CKD and CVD and how they continually converge and eventually lead to organ failure.
It is clear that intervention at the earliest stages of this progression is paramount. Controlling modifiable risk factors, or even reducing the risk of developing them in the first place is where integrated care should actually begin.
Risk factors for cardiovascular disease include the traditional risk factors as defined in the Framingham Heart Study, as well as nontraditional risk factors specific to kidney disease and those found in the general population.
Rates of kidney failure have been almost doubling each decade and are projected to reach over half-a-million (661,330,000) by 2010.
These data were adapted from the National Health and Nutrition Examination Survey III (NHANES III) From 1988-1994.
Nearly 20 million people in the United States have chronic kidney disease (CKD).
Of that number, 18 million – the majority – have early chronic kidney disease (stage 1, 2, 3). So there is a great opportunity here for health care professionals to intervene at the early stages and stop the progression of chronic kidney disease (CKD).
This is a very important point. If you look at stage 3, you will notice that there are 7.6 million patients with stage 3 nephropathy. But if you look at stage 4, there are only 400,000. Again, there are 7.6 million people in stage 3; but 400,000 in stage four. Why is the prevalence nearly 200 times greater in stage 3 than stage 4? Because the majority of patients with stage 3 nephropathy will die of a cardiovascular event before reaching dialysis. The “lucky ones” will end up on dialysis. So, again, there is a great need to treat patients in the early stages.
Let us consider two important outcomes in CKD – progression to kidney failure and mortality. How do these two outcomes compare to one another in terms of their risk? The percent of patients who die is greater than the percent of patients who progress to kidney failure. So, once again, this speaks to the importance of strategies to modulate cardiovascular risk in patients with CKD.
Key:
It is important to note that for CKD stages 1 through 4, more patients die than reach renal replacement therapy (RRT).
Cardiovascular disease (CVD) claims about as many lives as the next 5 leading causes of death––cancer, chronic lower respiratory disease, accidents, diabetes mellitus, and pneumonia/influenza; according to Centers for Disease Control and Prevention (CDC) data, CVD accounted for 927,448 deaths in the United States, compared with 557,271 deaths caused by cancer, followed by 124,816 for chronic lower respiratory disease, 106,742 for accidents, 73,249 for diabetes, and 65,984 for influenza and pneumonia.1,2
Based on data from the Third National Health and Nutrition Examination Survey (NHANES III), 70 million Americans have 1 or more types of CVD, including coronary heart disease (CHD), congestive heart failure (CHF), myocardial ischemia, angina, hypertension, stroke, peripheral vascular disease, and dyslipidemia.2
Nearly 2600 Americans die from CVD daily, an average of 1 death every 34 seconds. Every minute someone dies of a heart attack, and every 3 minutes someone has a fatal stroke.2
In North America, 370,000 deaths are due to higher than optimal blood pressure (BP), and 350,000 deaths are due to higher than optimal cholesterol annually. Statistics show that 58% of CVD burden is due to higher than optimal BP and cholesterol levels.3
Transition: In today’s presentation, we will focus on CV risk in hypertensive patients with additional risk factors.
Central to reducing risk for both CVD and CKD is weight management. Obesity or overweight is oftentimes the first insult that triggers the development of both CVD and CKD risk factors, including hypertension, diabetes, dyslipidemia, albuminuria, and reduced kidney function.
These interventions for risk reduction can be recommended and reinforced by either the nephrologist or cardiologist, and should be address with an integrated team approach.
Risk management specific to chronic kidney disease.
AT II and aldosterone -&gt; Na retention
Vasopressin -&gt; free water retention
Renin is released from the macula densa, causes direct Na resporption across the proximal tubular epithelium
The UNLOAD study was a prospective, randomized study of 200 pts looking at early UF vs IV diuresis for ADHF
Patients required 2 of the following:
2+ or greater peripheral edema
JVD ≥ 7cm
Radiographic pulmonary edema or effusion
Enlarged liver/ascites
Pulmonary rales, PND, or orthopnea
Randomized within 24h of hospitalization
IV diuretics at least 2x daily home PO dose
Ultrafiltration rate up to 500cc/h, at discretion of doc (no diuretics first 48h)
As we know, Cr is an important prognostic factor for patients with ADHF
At least the makers of nesiritide could take comfort in the fact that this did not necessarily translate into increased rates of death
Acute study of clinical effectiveness of nesiritide in decompensated HF
In 2001, Nesiritide was approved and took off, but with the safety concerns,
IN VMAC – there was an arm with IV nitro – here it could be used as appropriate
Excellent background meds. None excluded X milrinone and levosementan
It will be interesting to see if a specific subgroup still does better with nesiritide when optimally treated,
Response to tolvaptan was not better in patients with higher baseline AVP levels, but this may be because AVP is so unstable in serum, and clears so quickly. Measuring Copepin levels may be of use here.
Copeptin (C-terminal pro-vasopressin)
Stable in serum or plasma, therefore easily measured
Better marker for mortality and morbidity in pts with acute HF after AMI
Stronger than BNP and NT-proBNP
Higher in pts with decreasing renal fn
Confirms data that suggests that improving cardiac output without relieving venous congestion may not avert WRF -and that inotropes may not relieve or prevent WRF.
142 consecutive pts admitted with ADHF, PAC guided. Mean EF 20%
Baseline CVP, not CI predicted WRF. If severe RI at baseline, 60% developed WRF
Detrimental effect of high CVP was worse with preserved CI. 2.0 vs 1.8 L/min/m2
CVP remained a predictor despite controlling for DM, blood pressure or baseline renal fn. CVP as predictor of WRF held true even for those with baseline GFR &gt; 30, (17 vs 12) but CI were similar.
After Rx, CVP (11 vs 8) and CI (2.7 vs 2.4) remained higher in those who developed WRF.
Specifically, CVP &gt; 8 after Rx was associated with WRF, and discharge CVP also related.
-Challenges the assumption that WRF is due to low-output or hypotension causing impaired renal “pre-load”.
-“congestive kidney failure” – caused by increased renal pressure from venous congestion (increased renal AL), and increased renal interstitial pressure (intrinsic renal disease) might be an underappreciated mechanism for the development of WRF.
Clearly the HDD group was sicker at baseline, but these findings were after risk and propensity adjustments – age, BUN, SBP, DBP, Na+, HR, creat and dyspnea at rest. (P .014 before and 0.036 after)
IV Loop diuretics High dose (&gt; 160mg) vs low dose (&lt; 160mg)
High dose - were older, had DM and renal insufficiency, asthma, COPD, afib, CAD, PAD, and HTN at baseline
Low dose – more women and older
ARB’s – reno-protective effect in DM2 w/ early and late nephropathy
IRMA-2: irbesartan
IDNT-irbesartan vs amlodipine
RENAAL - losartan
MARVAAL – valsartan vs amlodipine
ATII inhibitors dec. TGF beta, dec renal hypertrophy, dec periubular interstitial fibrosis
One of the complications that occur as CKD progresses is anemia.
As eGFR falls below 60 mL/min/1.73 m2 (CKD stage 3), the prevalence of anemia increases to approximately 10% of adult patients.
In CKD stages 4 and 5, when eGFR falls below 30 mL/min/1.73 m2, anemia prevalence is very high, affecting the majority of patients.
Comparing the NHANES III and the subsequent NHANES 1999-2000 study, the prevalence of anemia has marginally declined, according to the USRDS.
Cut points for the diagnosis of CHF have been adjusted in some trials –ie. Breathing Not Properly trial BNP as high as 300 was not associated with CHF – may need to adjust 2 – 4 fold, but should not be higher than 400.
NT-pro BNP levels can also vary depending on age – higher levels as people age
BNP may more specific than pro-BNP in predicting HF in the setting of renal failure
ICON - international collaborative on NT-pro BNP
In this study, the combination of the NT-proBNP &gt; 4500 and Creat &lt; 60 revealed best predictor of mortality
Those with a rise in creat of &gt; 0.3 with BNP &gt; mean did the worst. No relationship btwn change in creat and outcome if BNP level was below the mean
AVP or anti-diurestic hormone - levels in serm are unstable and quickly cleared
Copeptin association to mortality seen in all levels of CHF, but most in Class II and III
If Copeptin &lt; 5.75 – 24 month mortality 12%
If Copeptin &gt; 21.7 Mortality &gt; 50%
FINN-AKVA – prospective observational study in Finland
Definition of AKI is rise of creat of &gt; 3mg/dL within 48hrs
49% women, Ave age 75.4
On DC 84% on BB and 73% on ACE/ARB
In hospital mortality 5.1%, 12 month 29.1%
Only 9% with inc creat by 0.3 mg.dL at 48 hrs and 4% w/ 50% increase in creat
All pts above had increase in creat of &gt; 0.2 mg/dL. Only red line also had rise in cysC
NT-proBNP did not predict in hospital or 30 day mortality but did at 12 months
AKI cysC increased both short and long term mortality risk with BNP values below the mean.
If NT-proBNP values were above the mean, AKIcysC increased 90 day mortality but not 12 month – although trends are seen
Paterna’s group:
Diuretic resistant pts, excluded those with creat &gt; 2, BUN &gt; 60.
IV furosemide 500 – 1000mg/day
HTS = 150 mL of 1.4–4.6% NaCl
Fluid restriction to 1000 cc/day
2.8gm Na diet better than 1.8 gm diet (licata)
These were 2 small studies that began to look at renal function and CRT – could it help more? Or was renal failure a reason NOT to give CRT?
2 small subsets of larger studies:
MIRACLE: multicenter In-Sync Randomized Clinical Evaluation
LVESV decreases: &gt;90 GFR : 53 ml, 60 – 90 GFR : 40 ml, and 30 – 60 GFR: 30 ml
Definition of response to CRT: in LV-ESV at 6 months of 15%
Long term primary endpoint: all cause mortality
Overall, 54% responded favorably to CRT
GFR 74 26 ml/min/1.73m2 vs 64 28 in responders
54% overall responded to CRT
Results similar to MIRACLE
GFR was a stronger predictor of survival than etiology of HF, MR grade, gender, meds, functional class, QRS duration, LV volumes