Discordance between lactic acidemia and hemodynamics in patients with advanced heart failure
Narang N, Dela Cruz M, Imamura T, Chung B, Nguyen AB, Holzhauser L, Smith BA, Kalantari S, Raikhelkar J, Sarswat N, Kim GH, Jeevanandam V, Burkhoff D, Sayer G, Uriel N. Discordance between lactic acidemia and hemodynamics in patients with advanced heart failure. Clin Cardiol. 2021 Mar 18. doi: 10.1002/clc.23584. Epub ahead of print. PMID: 33734459
BACKGROUND: Elevated lactic acid (LA) levels carry a poor prognosis in patients with shock. Data are lacking on the significance of LA levels in patients with acute decompensated heart failure (ADHF).
HYPOTHESIS: This study assessed the relationship between LA levels, hemodynamics and clinical outcomes.
METHODS: This was a retrospective analysis of registry data of 100 advanced heart failure patients presenting for right heart catheterization (RHC) for concern of ADHF. LA levels (normal ≤2.1 mmol/L) were obtained prior to RHC; no significant changes in therapy were made between LA collection and RHC.
RESULTS: Median age was 58 (47.3, 64.8) years; 57% were receiving inotropes prior to RHC. Median pulmonary capillary wedge pressure (PCWP) and cardiac index (CI) were 28 (21, 35) mmHg and 2.0 (1.7, 2.5) L/min/m2 , respectively. Eighty patients had normal LA prior to RHC. There was no correlation between LA levels and PCWP (R = 0.09, p = .38); 63% of the normal LA group had a PCWP >24 mmHg. There was a moderate inverse correlation between LA and CI (R = - 0.40; p < .001); 58% of the normal LA group had a CI <2.2 L/min/m2 . Thirty-day survival free of death/hospice, inotrope dependence, progression to heart transplant/left-ventricular assist device implant was comparable between the normal and elevated LA groups (28% vs. 20%; p = .17).
CONCLUSION: In patients presenting with ADHF, normal LA levels do not exclude the presence of depressed CI (a hemodynamic criteria for cardiogenic shock) and may not offer accurate risk stratification. Invasive hemodynamics should not be delayed based on normal LA levels alone.