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Published on: June 10, 2025
Prognostic impact of serum chloride concentrations in acute heart failure patients: A systematic Rreview and
Fengchao Wu1, Qingsu Lan2, Li Yan1
1Cardiology Department, Shaanxi Provincial People's Hospital, Xi'an, China.
Insights
Hypochloremia, or low chloride levels, is present in 17% of acute heart failure patients and significantly increases the risk of death. Persistent hypochloremia indicates a particularly poor prognosis in acute heart failure management.
Area of Science:
- Cardiology
- Nephrology
- Internal Medicine
Background:
- Acute heart failure (AHF) is a prevalent condition in emergency departments.
- Electrolyte imbalances frequently accompany AHF, yet chloride levels often receive limited attention.
- Emerging research links hypochloremia to adverse outcomes in AHF patients.
Purpose of the Study:
- To determine the incidence of hypochloremia in patients with acute heart failure.
- To evaluate the impact of reduced serum chloride levels on the prognosis of AHF.
- To assess the association between hypochloremia and mortality risk in AHF.
Main Methods:
- A systematic literature search was conducted across major databases (Cochrane Library, Web of Science, PubMed, Embase) up to December 29, 2021.
- Seven studies comprising 6787 AHF patients were included in the meta-analysis.
- Data were independently screened and extracted, with study quality assessed using the Newcastle-Ottawa Scale (NOS).
Main Results:
- The incidence of hypochloremia upon admission for AHF was found to be 17%.
- A 1 mmol/L decrease in serum chloride was associated with a 6% increased risk of all-cause mortality in AHF patients.
- Hypochloremia significantly elevated the risk of all-cause death (RR=1.71), with progressive (HR=2.24) and persistent (HR=2.80) hypochloremia showing even higher risks.
Conclusions:
- Reduced serum chloride levels at admission are linked to a poorer prognosis in AHF.
- Persistent hypochloremia presents a significantly worse prognosis compared to non-hypochloremic or progressive hypochloremic states.
- Findings for progressive and persistent hypochloremia should be interpreted cautiously due to the limited number of studies (n=2).
Objective:
Acute heart failure (AHF) is a common disease in the emergency departments. Its occurrence is often accompanied by electrolyte disorders, but little attention is paid to chloride ion. Recent studies have shown that hypochloremia was associated with poor prognosis of AHF. Therefore, this meta-analysis aimed to assess the incidence of hypochloremia and the impact of the reduction of serum chloride on the prognosis of AHF patients.
Methods:
We searched Cochrane Library, Web of science, PubMed, Embase databases and searched the relevant studies on chloride ion and AHF prognosis. The search time is from the establishment of the database to December 29, 2021. Two researchers screened the literature and extracted data independently. The quality of the included literature was evaluated using Newcastle-Ottawa Scale (NOS) scale. The effect amount is expressed as hazard ratio (HR) or relative risk (RR) and 95% confidence interval (CI). Review Manager 5.4.1 software for was used to perform the meta-analysis.
Results:
Seven studies involving 6787 AHF patients were included in meta-analysis. Meta-analysis revealed that the incidence of hypochloremia in AHF patients at admission was 17% (95% CI: 0.11-0.22); One mmol /L decrease in serum chloride at admission was associated with 6% increased risk of all-cause death of AHF patients (HR = 1.06, 95% CI: 1.04-1.08, P < 0.00001); Compared with the non-hypochloremia group, the risk of all-cause death in the hypochloremia group increased by 1.71 times (RR = 1.71, 95% CI: 1.45-2.02, P < 0.00001), the risk of all-cause death in the progressive hypochloremia(development of hypochloremia after admission) group increased by 2.24 times (HR = 2.24, 95% CI: 1.72-2.92, P < 0.00001), and the risk of all-cause death in the persistent hypochloremia (hypochloremia both on admission and at discharge) group increased by 2.80 times (HR = 2.80, 95% CI: 2.10-3.72, P < 0.00001).
Conclusion:
The available evidence shows that the decrease of chloride ion at admission is associated with poor prognosis of AHF patients, and the prognosis of persistent hypochloremia is worse.Some outcome indicators(progressive hypochloremia, persistent hypochloremia, and composite of death + HF hospitalization)are as few as 2 studies in the literature, and the results should be interpreted carefully.
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