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Implications of Serum Chloride Homeostasis in Acute Heart Failure (from ROSE-AHF)
Justin L Grodin1, Jie-Lena Sun2, Kevin J Anstrom2
1Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
Insights
Lower serum chloride levels in acute heart failure patients are linked to poorer outcomes and reduced diuretic response. While chloride changes reflect decongestion, they don't directly predict clinical results.
Area of Science:
- Cardiology
- Nephrology
- Internal Medicine
Background:
- Lower serum chloride (Cl) levels are linked to increased mortality in acute heart failure (AHF).
- The clinical significance of serum Cl levels during AHF treatment remains unclear.
Purpose of the Study:
- To investigate the association between serum Cl levels and short-term clinical response in AHF patients.
- To evaluate the impact of serum Cl levels on postdischarge outcomes, including death and rehospitalization.
Main Methods:
- Serum Cl levels were measured at randomization in 358 AHF patients from the Renal Optimization Strategies Evaluation in Acute Heart Failure trial.
- Outcomes assessed included diuretic response, renal function, death, and rehospitalization at various time points.
- Patients were stratified into baseline Cl tertiles (84-98, 99-102, 103-117 meq/l).
Main Results:
- Baseline serum Cl was associated with diuretic efficiency but not cystatin C changes at 72 hours.
- Lower baseline Cl levels correlated with increased 60-day and 180-day mortality, and 60-day death/rehospitalization.
- These associations were diminished after adjusting for loop diuretic dose.
- Chloride changes correlated with weight, cystatin C, and sodium excretion changes, indicating decongestion, but not clinical outcomes.
Conclusions:
- Serum chloride levels in AHF are inversely associated with loop diuretic response and carry prognostic value.
- Changes in serum chloride reflect decongestion but are not directly linked to clinical outcomes.
- Further research may clarify the role of chloride in AHF management.
Abstract:
Lower serum chloride (Cl) levels are strongly associated with increased long-term mortality after admission for acute heart failure (AHF). However, the therapeutic implications of serum Cl levels during AHF are unknown. We sought to determine the short-term clinical response and postdischarge outcomes associated with serum Cl levels in AHF. Serum Cl was measured at randomization (n = 358) and during hospitalization from patients with AHF in the Renal Optimization Strategies Evaluation in Acute Heart Failure trial. Outcomes included diuretic response and renal function at 72 hours and death and rehospitalization at 60 and 180 days. Baseline Cl tertiles were 84 to 98; 99 to 102; and 103 to 117 meq/l. Baseline Cl level was associated with diuretic efficiency (p <0.001) but not change in cystatin C (p = 0.30) at 72 hours and was associated with 60-day death (hazard ratio [HR] 0.86, p = 0.029), 60-day death and rehospitalization (HR 0.90, p = 0.01), and 180-day death (HR 0.91, p = 0.049). These associations were attenuated with additional adjustment for loop diuretic dose (p >0.05). Chloride change correlated with weight change (ρ 0.18, p = 0.001), cystatin C change (ρ -0.35, p <0.001), and cumulative sodium excretion (ρ -0.21, p <0.001) but was not associated with any clinical outcomes (p >0.05 for all). In conclusion, serum Cl levels in AHF were inversely associated with loop diuretic response and were prognostic. However, changes in Cl levels were associated with parameters of decongestion but not with clinical outcomes.