Pro-Adrenomedullin may guide decongestive therapy in acute heart failure patients

Benedikt N. Beer (Hamburg)1, S. Keshtkaran (Hamburg)1, C. Kellner (Hamburg)1, L. C. Besch (Hamburg)1, J. Sundermeyer (Hamburg)1, A. Dettling (Hamburg)1, C. Kondziella (Hamburg)1, P. Kirchhof (Hamburg)1, S. Blankenberg (Hamburg)1, C. Magnussen (Hamburg)1, B. Schrage (Hamburg)1

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.

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