Got a tough Get With The Guidelines question? Send it to guidelineinfo@heart.org to get an answer. Selected questions will be answered here by members of our Steering Committee or staff.
April 27, 2007
Q: Is there any information/literature for the use of ACE-I or ARBs in patients who have heart failure but also have end-stage renal disease on dialysis?
A: From the ACC/AHA guidelines for Heart Failure:
6. PATIENTS WITH HF WHO HAVE CONCOMITANT DISORDERS
RECOMMENDATIONS
Class I
1. All other recommendations should apply to patients with concomitant disorders unless there are specific exceptions. (Level of Evidence C)
6.2.1. Patients With Renal Insufficiency
Patients with HF frequently have impaired renal function as a result of poor renal perfusion, intrinsic renal disease, or drugs used to treat HF. Patients with renal hypoperfusion or intrinsic renal disease show an impaired response to diuretics and ACEIs (161, 634) and are at increased risk of adverse effects during treatment with digitalis (304). Renal function may worsen during treatment with diuretics or ACEIs (160, 488), although the changes produced by these drugs are frequently short-lived, generally asymptomatic, and reversible. Persistent or progressive renal functional impairment often reflects deterioration of the underlying renal disease process and is associated with a poor prognosis (19, 635). The symptoms of HF in patients with end-stage renal disease may be exacerbated by an increase in loading conditions produced both by anemia (636) and by fistulas implanted to permit dialysis. In addition, toxic metabolites and abnormalities of phosphate, thyroid, and parathyroid metabolism associated with chronic renal insufficiency can depress myocardial function.
Despite the potential for these adverse interactions, most patients with HF tolerate mild to moderate degrees of functional renal impairment without difficulty. In these individuals, changes in blood urea nitrogen and serum creatinine are generally clinically insignificant and can usually be managed without the withdrawal of drugs needed to slow the progression of HF. However, if the serum creatinine increases to more than 3 mg per dL, the presence of renal insufficiency can severely limit the efficacy and enhance the toxicity of established treatments (161, 304, 634). In patients with a serum creatinine greater than 5 mg per dL, hemofiltration or dialysis may be needed to control fluid retention, minimize the risk of uremia, and allow the patient to respond to and tolerate the drugs routinely used for the management of HF (490, 637).
— Gregg C. Fonarow, M.D., FACC, FACP
April 3, 2007
Q: Does GWTG provide comparative data. If so, is it severity adjusted? Thanks – Kayla
A: GWTG provides comparative data on each performance and quality measure that is benchmarked to similar, regional and national hospital data. Any timeframe of interest since the start of each GWTG module can be analyzed. While case mix adjustment for performance measures is of potential interest, it has not been standard to do so in national registries or in JCAHO/CMS/Hospital Compare reports. It is still debated among health service researchers whether case mix adjustment is necessary for performance measures. We have begun to explore methods for case mix adjustment within GWTG and the influence such adjustment has on hospital rankings. If validated methodology were developed for performance measure this is something that we would integrate.
— Gregg C. Fonarow, M.D., FACC, FACP
Q: Our hospital is already doing GWTG–CAD. We are considering doing GWTG–Stroke. Can you tell me what ICD-9 diagnosis codes are used to identify stroke patients?
A: A list of ICD-9 codes used to identify stroke patients can be found here.
