1Universitätsklinikum Hamburg-Eppendorf Klinik für Kardiologie Hamburg, Deutschland
Background: Congestion is a major determinant of outcomes in acute heart failure. Its assessment is complex, rendering sufficient decongestive therapy a challenge. Consequently, residual congestion is frequent at discharge, increasing the risk of re-hospitalisation and death. Mid-regional pro-adrenomedullin mirrors vascular integrity and may therefore be an objective marker to quantify congestion and to guide decongestive therapies in patients with acute heart failure.
Methods: Observational, prospective, single centre study in unselected patients presenting with acute heart failure. This study aimed to assess the potential capability of mid-regional pro-adrenomedullin in guiding decongestion therapy. Congestion was assessed applying clinical scores. Baseline pro-adrenomedullin concentrations were related to in-hospital (all-cause) death and in-hospital worsening heart failure. Discharge pro-adrenomedullin concentrations were related to post-discharge (all-cause) mortality. Worsening heart failure was defined by the RELAX-AHF-2 trial criteria. Cox and logistic regression models with adjustment for clinical features were fitted.
Results: Overall, 233 patients were analysed (median age 77 years, 148 male (63.5%)). Ischaemic cardiomyopathy was the most common cause of heart failure affecting 85 patients (40.5%). The present hospitalisation was the first heart failure event in 47 patients (20.9%). Frequent presumed triggers were tachyarrhythmia (68 patients, 29.4%), hypertensive crisis (60 patients, 26.4%), infections (52 patients, 22.6%) and acute myocardial infarction (30 patients, 12.9%). Median NT-proBNP concentration was 7,332 ng/l (IQR 3,425, 14,854) and pro-adrenomedullin 2.0 nmol/l (1.4, 2.9). Overall, 8 patients (3.5%) died in hospital, 100 (44.1%) experienced in-hospital worsening heart failure and 60 patients (36.6%) died after discharge over a median follow-up of 1.92 years. Pro-adrenomedullin concentrations (logarithmised) were significantly associated with congestion, both at baseline as well as during the hospital stay (Figure 1). Baseline pro-adrenomedullin was associated with in-hospital worsening heart failure (OR 4.23, 95% Confidence Interval 1.87, 9.58; p<0.001), pro-adrenomedullin at discharge with post-discharge death (HR 3.93, 95% CI 1.86, 8.67; p<0.001) (Figure 2).
Conclusion: In patients admitted with decompensated heart failure, elevated pro-adrenomedullin is associated with congestion, in-hospital worsening heart failure and with death during follow-up. Pending external validation, these results identify pro-adrenomedullin as a promising biomarker to quantify cardiac congestion.