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Hypotension during hospitalization for acute heart failure is independently associated with 30-day mortality: findings from ASCEND-HF.

Author(s): Patel PA(1), Heizer G(2), O'Connor CM(2), Schulte PJ(2), Dickstein K(2), Ezekowitz JA(2), Armstrong PW(2), Hasselblad V(2), Mills RM(2), McMurray JJ(2), Starling RC(2), Tang WH(2), Califf RM(2), Hernandez AF(2).

Affiliation(s): Author information: (1)From the Duke Clinical Research Institute, Durham, NC (P.A.P., G.H., C.M.O., P.J.S., V.H., R.M.C., A.F.H.); Duke University Medical Center, Durham, NC (C.M.O., R.M.C., A.F.H.); Central Hospital Cardiology Division, Stavanger, Norway (K.D.); Division of Cardiology, Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Canada (J.A.E., P.W.A.); Janssen Research & Development, LLC, Raritan, NJ (R.M.M.); Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Cleveland Clinic Foundation, OH (R.C.S., W.H.W.T.). priyesh.patel@dm.duke.edu. (2)From the Duke Clinical Research Institute, Durham, NC (P.A.P., G.H., C.M.O., P.J.S., V.H., R.M.C., A.F.H.); Duke University Medical Center, Durham, NC (C.M.O., R.M.C., A.F.H.); Central Hospital Cardiology Division, Stavanger, Norway (K.D.); Division of Cardiology, Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Canada (J.A.E., P.W.A.); Janssen Research & Development, LLC, Raritan, NJ (R.M.M.); Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Cleveland Clinic Foundation, OH (R.C.S., W.H.W.T.).

Publication date & source: 2014, Circ Heart Fail. , 7(6):918-25

BACKGROUND: Outcomes associated with episodes of hypotension while hospitalized with acute decompensated heart failure are not well understood. METHODS AND RESULTS: Using data from Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF), we assessed factors associated with in-hospital hypotension and subsequent 30-day outcomes. Patients were classified as having symptomatic or asymptomatic hypotension. Multivariable logistic regression was used to determine factors associated with in-hospital hypotension, and Cox proportional hazards models were used to assess the association between hypotension and 30-day outcomes. We also tested for treatment interaction with nesiritide on 30-day outcomes and the association between in-hospital hypotension and renal function at hospital discharge. Overall, 1555 of 7141 (21.8%) patients had an episode of hypotension, of which 73.1% were asymptomatic and 26.9% were symptomatic. Factors strongly associated with in-hospital hypotension included randomization to nesiritide (odds ratio, 1.98; 95% confidence interval [CI], 1.76-2.23; P<0.001), chronic metolazone therapy (odds ratio, 1.74; 95% CI, 1.17-2.60; P<0.001), and baseline orthopnea (odds ratio, 1.31; 95% CI, 1.13-1.52; P=0.001) or S3 gallop (odds ratio, 1.21; 95% CI, 1.06-1.40; P=0.006). In-hospital hypotension was associated with increased hazard of 30-day mortality (hazard ratio, 2.03; 95% CI, 1.57-2.61; P<0.001), 30-day heart failure hospitalization or mortality (hazard ratio, 1.58; 95% CI, 1.34-1.86; P<0.001), and 30-day all-cause hospitalization or mortality (hazard ratio, 1.40; 95% CI, 1.22-1.61; P<0.001). Nesiritide had no interaction on the relationship between hypotension and 30-day outcomes (interaction P=0.874 for death, P=0.908 for death/heart failure hospitalization, P=0.238 death/all-cause hospitalization). CONCLUSIONS: Hypotension while hospitalized for acute decompensated heart failure is an independent risk factor for adverse 30-day outcomes, and its occurrence highlights the need for modified treatment strategies. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00475852.

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