Acute Decompensated Heart Failure Complicated by Respiratory Failure
2019; Lippincott Williams & Wilkins; Volume: 12; Issue: 5 Linguagem: Inglês
10.1161/circheartfailure.119.006013
ISSN1941-3297
AutoresP. Elliott Miller, Sean van Diepen, Tariq Ahmad,
Tópico(s)Cardiac Arrest and Resuscitation
ResumoHomeCirculation: Heart FailureVol. 12, No. 5Acute Decompensated Heart Failure Complicated by Respiratory Failure Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBAcute Decompensated Heart Failure Complicated by Respiratory Failure P. Elliott Miller, MD, Sean van Diepen, MD, MSc and Tariq Ahmad, MD, MPH P. Elliott MillerP. Elliott Miller P. Elliott Miller, MD, Section of Cardiovascular Medicine, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510. Email E-mail Address: [email protected] Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (P.E.M., T.A.). , Sean van DiepenSean van Diepen Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.v.D.). and Tariq AhmadTariq Ahmad Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (P.E.M., T.A.). Originally published29 Apr 2019https://doi.org/10.1161/CIRCHEARTFAILURE.119.006013Circulation: Heart Failure. 2019;12:e006013Patients with acute decompensated heart failure (ADHF), admitted to the hospital, have become more medically complex, with an increasing number of noncardiac comorbidities.1 The increasing medical complexity and aging population have contributed to higher rates of respiratory failure, with a reported incidence ranging between 5.0% to 13.9% from registry and administrative data.2–4 However, there is limited data on the utilization of ideal respiratory support strategies, including invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV) in patients with cardiovascular dysfunction or how respiratory failure affects clinical outcomes. As a result, there is a paucity of evidence available to guide clinicians on how to manage this unique and critically ill group of patients.The management of respiratory support for patients with ADHF has mostly consisted of expert opinion and extrapolation from other patient populations (eg, acute respiratory distress syndrome and chronic obstructive pulmonary disease).5 However, given the unique cardiopulmonary interactions between positive pressure ventilation and ventricular dysfunction, there is reason to believe that respiratory strategies might impact this population differently. Further, patients with cardiovascular dysfunction have generally been excluded or poorly represented in clinical trials investigating essential elements of mechanical ventilation, such as sedation and ventilator strategies.6,7Respiratory Failure in ADHF Registries and Clinical TrialsThe Acute Decompensated Heart Failure National Registry was a multicenter registry including over 100 000 patients in the United States. Patient-level characteristics, outcomes, and procedures were collected to better define current HF demographics.2 In this study, a total of 5% of the total cohort and 23% of patients admitted to an intensive care unit (n=19 754) required IMV.2 Similarly, in the prospective, observational EuroHeart Failure Survey II (n=3580), 5.1% of patients with new-onset ADHF required IMV, and 13.9% required some form of ventilatory support (reported as either NIV or IMV).3 Unfortunately, more granular evidence such as ventilator strategy (IMV versus NIV), associated outcomes, and trends over time are limited.Compared with 5.0% to 13.9% of patients from national registries, the reported incidence of respiratory support utilization from ADHF clinical trials is substantially lower. Of the 25 664 patients included from ADHF studies over the past 17 years, only 59 (0.23%) patients have been reported to require respiratory support (Table). None of the studies differentiated IMV from NIV, and <25% of trials reported the incidence of respiratory failure or ventilator use. Among the 57 patients reported to require respiratory support, the associated clinical outcomes have only been described in 24 (0.09% of the total) patients.Table. Respiratory Support Details From Acute Heart Failure Clinical TrialsClinical TrialYearNo. of PatientsRespiratory Failure Data Collected*Related Exclusion CriteriaRespiratory Support OutcomesVMAC2002489Not specifiedMV at the time of enrollmentNot reportedLIDO2002203Not specifiedNoneNot reportedRUSSLAN2002504Not specifiedNoneNot reportedOPTIME-CHF2002951Not specifiedNoneUse of MV collected (n=24)RITZ-42003193Composite of worsening HF, including MV at 72 hPatients requiring MV at enrollmentNot reportedESCAPE†‡2005433Data sheet includes mechanical respiratory supportMV present or anticipatedNot reportedSURVIVE20071327Prespecified secondary outcome for requiring MVA specified inclusion criterion included dyspnea at rest or mechanical ventilationMV (n=24) not associated with survival at 180 dEVEREST20074133Not specifiedNoneNot reportedVERITAS I & II20071448Implementation of mechanical ventilatory (including CPAP) supportMechanical ventilatory support. Prior CPAP use was allowed if discontinued ≥2 h before study drug initiationNot reportedEMOTE2007201Not specifiedNoneNot reportedPROTECT20102033Not specifiedOngoing or planned mechanical support, including endotracheal intubationNot reportedASCEND-HF†20117141Use of MV or NIV collected per protocol. Included in composite secondary end point as persistent/worsening HFNoneRespiratory failure reported in supplement (n=11), but MV or NIV not specifiedDOSE AHF‡2011308Composite secondary end point of worsening/persistent HF at 72 h, which included respiratory supportNoneNot reportedCARRESS-HF‡2012188Data sheet includes mechanical respiratory supportNoneNot reportedROSE‡2013360Composite secondary end point of worsening/persistent HF at 72 h, which included respiratory supportNoneNot reportedREVIVE I & II2013100 and 600Not specifiedMV at the time of enrollmentWorsening pulmonary edema and dyspnea recorded without mention of respiratory supportRELAX-AHF20131161Not specifiedCurrent or planned mechanical ventilationNot reportedATOMIC-AHF2016606Not specifiedNoneNot reportedTACTICS-HF2017257Primary outcome of dyspnea. Secondary outcomes for rescue therapy included mechanical respiratory supportNoneTwo patients received either mechanical circulatory or respiratory supportSECRET of CHF2017250Primary outcome of dyspneaNoneNot reportedTRUE-AHF20172157The definition of persistent/worsening HF included NIV and MVAcute or chronic respiratory disorderNot reportedBLAST-AHF2017621Worsening HF definition included mechanical therapyMV at the time of screening or during the current hospitalization. CPAP/BiPAP discontinued <1 h before randomizationNot reportedASCEND-HF indicates Acute Study of Nesiritide in Decompensated Heart Failure; ATOMIC-AHF, Acute Treatment With Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure; BiPAP, bilevel positive airway pressure; BLAST-AHF, Biased Ligand of the Angiotensin Receptor Study in Acute Heart Failure; CARRESS-HF, Cardiorenal Rescue Study in Acute Decompensated Heart Failure; CPAP, continuous positive airway pressure; DOSE AHF, Diuretic Optimization Strategies Evaluation; EMOTE, Enoximone in Intravenous Inotrope-Dependent Subjects; ESCAPE, Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness; EVEREST, Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan; HF, heart failure; LIDO, Levosimendan Infusion Versus Dobutamine; MV, mechanical ventilation; NIV, noninvasive ventilation; OPTIME-CHF, Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure; PROTECT, Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized With Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function; RELAX-AHF, Relaxin in Acute Heart Failure; REVIVE, Randomized Evaluation of Intravenous Levosimendan Efficacy; RITZ-4, Randomized Intravenous Tezosentan Study; ROSE, Renal Optimization Strategies Evaluation; RUSSLAN, Randomised Study on Safety and Effectiveness of Levosimendan in Patients With Left Ventricular Failure due to an Acute Myocardial Infarct; SECRET of CHF, Study to Evaluate Challenging Responses to Therapy in Congestive Heart Failure; SURVIVE, Survival of Patients With Acute Heart Failure in Need of Intravenous Inotropic Support; TACTICS-HF, Targeting Acute Congestion With Tolvaptan in Congestive Heart Failure; TRUE-AHF, Trial of Ularitide Efficacy and Safety in Acute Heart Failure; VERITAS, Value of Endothelin Receptor Inhibition With Tezosentan in Acute Heart Failure Studies; and VMAC, Vasodilation in the Management of Acute CHF.*Obtained from data sheets, design publications, and supplemental materials.†Concurrent registry is available.‡Available from the National Institutes of Health Biologic Specimen and Data Repository Information Coordinating Center.NIV in Cardiogenic Pulmonary EdemaThe 3CPO trial (Three Interventions in Cardiogenic Pulmonary Oedema) is the largest (n=1069) study to compare standard oxygen therapy with NIV (either continuous positive airway pressure or bilevel positive airway pressure) in patients with cardiogenic pulmonary edema. Although NIV was associated with a greater improvement in patient-reported dyspnea, heart rate, acidosis, and hypercapnia, there was no difference in mortality (9.8% versus 9.5%; P=0.87) or intubation rates (2.8% versus 2.9%; P=0.90) between the oxygen and NIV groups.8 However, it should be noted that this study excluded critically ill patients, which likely contributed to the low incidence of intubation and mortality.9Several subsequent meta-analyses in patients with cardiogenic pulmonary edema, which include data from 3CPO, have reported a decrease in intubation rates and in-hospital mortality with NIV compared with oxygen therapy.10,11 In clinical practice, a majority of providers preferentially use NIV in patients with cardiogenic pulmonary edema. A recent multicenter, observational study of 1293 patients with cardiogenic pulmonary edema reported that nearly 80% of patients initially received NIV and 25% of patients initially started on oxygen therapy were switched to NIV for treatment failure.12Unanswered QuestionsIn addition to further defining for whom and when to initiate both NIV and IMV, as well as weaning from these therapies, numerous questions remain about ventilator strategies in patients with ADHF. Although potentially lifesaving, IMV can be a risk factor for hyperoxia, ventilator-associated pneumonia, and ventilator lung injury.13 Importantly, there is little evidence to guide the optimal mechanical ventilation settings in patients with ADHF, given this population has been excluded or poorly represented in critical care studies, including those examining tidal volumes.7 Recognizing the unique cardiopulmonary interactions in patients with left and right ventricular dysfunction, further research is needed to define oxygen targets and optimal positive end-expiratory pressures.5Although not unexpected that patients with ADHF who develop respiratory failure will have poorer outcomes, the scope of this problem has not been clearly delineated. How outcomes are affected by HF type (reduced versus preserved ejection fraction, left versus right ventricular dysfunction, and ischemic versus nonischemic) and concurrent illness (eg, cardiorenal syndrome) is also unknown. Further, given the deleterious effects associated with IMV (immobility, interruptions in nutrition, infection, and sedation-related complications), the impact of respiratory failure on discharge disposition, quality of life, readmissions, and subsequent frailty have not been studied in this complex population.A Path ForwardThere are several strategies that may help further our understanding of this critically ill patient population (Figure). In the near term, we suggest more detailed reporting of both NIV and IMV use, associated clinical outcomes, accompanying sedatives, and ventilator settings from ADHF clinical trials. When possible, an accompanying registry, such as those from the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) and the ASCEND-HF (Acute Study of Nesiritide in Decompensated Heart Failure),14,15 would help capture a sicker population and provide a greater number of patients with respiratory failure to study.Download figureDownload PowerPointFigure. Essential, ideal, and future data elements needed for patient-centered studies. BiPAP indicates bilevel positive airway pressure; CPAP, continuous positive airway pressure; EHR, electronic health record; ICU, intensive care unit; IMV, invasive mechanical ventilation; LV, left ventricle; NC, nasal cannula; NIV, noninvasive ventilation; PEEP, positive end-expiratory pressure; TV, tidal volume; and VAP, ventilator-associated pneumonia. *Left and right ventricular dysfunction, preserved vs reduced ejection fraction, ischemic vs nonischemic, and extracorporeal membrane oxygenation.In the future, pragmatic trials harnessing electronic health records may be a potential option to improve our knowledge of respiratory failure in ADHF. Additionally, trials embedded in the growing Critical Care Cardiology Trials Network offer a particularly exciting option for registry data, as well as randomized clinical trials in the cardiac intensive care unit.16 Finally, cross-specialty collaborations between HF and intensive care specialists would potentially lead to more robust data collection and future insights that help bridge the evidence gap for this complex, growing, but understudied population.AcknowledgmentsWe extend a special thanks to Dr Christopher Granger for his advice with this article.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.P. Elliott Miller, MD, Section of Cardiovascular Medicine, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510. Email elliott.[email protected]eduReferences1. Sharma A, Zhao X, Hammill BG, Hernandez AF, Fonarow GC, Felker GM, Yancy CW, Heidenreich PA, Ezekowitz JA, DeVore AD. 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Quien M, Thomas A, Ludmir J and Miller P (2022) Staffing models in the cardiac intensive care unit, Current Opinion in Critical Care, 10.1097/MCC.0000000000000958, Publish Ahead of Print Il'Giovine Z and Starling R (2021) Needing to vent: best to pitch the vent before heart transplant, European Heart Journal. Acute Cardiovascular Care, 10.1093/ehjacc/zuab081, 10:8, (852-854), Online publication date: 27-Oct-2021. Miller P, Mullan C, Chouairi F, Sen S, Clark K, Reinhardt S, Fuery M, Anwer M, Geirsson A, Formica R, Rogers J, Desai N and Ahmad T (2021) Mechanical ventilation at the time of heart transplantation and associations with clinical outcomes, European Heart Journal. Acute Cardiovascular Care, 10.1093/ehjacc/zuab063, 10:8, (843-851), Online publication date: 27-Oct-2021. 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Miller P, Thomas A, Breen T, Chouairi F, Kunitomo Y, Aslam F, Damluji A, Anavekar N, Murphy J, van Diepen S, Barsness G, Brennan J and Jentzer J (2021) Prevalence of Noncardiac Multimorbidity in Patients Admitted to Two Cardiac Intensive Care Units and Their Association with Mortality, The American Journal of Medicine, 10.1016/j.amjmed.2020.09.035, 134:5, (653-661.e5), Online publication date: 1-May-2021. 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Metkus T, Miller P, Alviar C, Baird-Zars V, Bohula E, Cremer P, Gerber D, Jentzer J, Keeley E, Kontos M, Menon V, Park J, Roswell R, Schulman S, Solomon M, van Diepen S, Katz J and Morrow D (2020)(2020) Advanced Respiratory Support in the Contemporary Cardiac ICU, Critical Care Explorations, 10.1097/CCE.0000000000000182, 2:9, (e0182) Miller P, Patel S, Saha A, Guha A, Pawar S, Poojary P, Ratnani P, Chan L, Kamholz S, Alviar C, van Diepen S, Nasir K, Ahmad T, Nadkarni G and Desai N (2019) National Trends in Incidence and Outcomes of Patients With Heart Failure Requiring Respiratory Support, The American Journal of Cardiology, 10.1016/j.amjcard.2019.08.033, 124:11, (1712-1719), Online publication date: 1-Dec-2019. Miller P, Caraballo C, Ravindra N, Mezzacappa C, McCullough M, Gruen J, Levin A, Reinhardt S, Ali A, Desai N and Ahmad T (2019) Clinical Implications of Respiratory Failure in Patients Receiving Durable Left Ventricular Assist Devices for End-Stage Heart Failure, Circulation: Heart Failure, 12:11, Online publication date: 1-Nov-2019. Metkus T, Stephens R, Schulman S, Hsu S, Morrow D and Eid S (2019) Utilization and outcomes of early respiratory support in 6.5 million acute heart failure hospitalizations, European Heart Journal - Quality of Care and Clinical Outcomes, 10.1093/ehjqcco/qcz030 May 2019Vol 12, Issue 5 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.119.006013PMID: 31030542 Originally publishedApril 29, 2019 Keywordsheart failureincidencerespiratory insufficiencymechanical ventilationnoninvasive ventilationPDF download Advertisement SubjectsClinical StudiesHeart Failure
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