Author + information
- Received April 3, 2014
- Revision received August 25, 2014
- Accepted September 5, 2014
- Published online February 1, 2015.
- Behnood Bikdeli, MD∗,†,
- Kelly M. Strait, MS∗,
- Kumar Dharmarajan, MD, MBA∗,‡,
- Shu-Xia Li, PhD∗,
- Purav Mody, MBBS∗,§,
- Chohreh Partovian, MD, PhD¶,
- Steven G. Coca, DO, MS‖,
- Nancy Kim, MD, PhD∗,¶,
- Leora I. Horwitz, MD, MHS∗,¶,
- Jeffrey M. Testani, MD, MTR† and
- Harlan M. Krumholz, MD, SM∗,†,#∗∗∗ ()
- ∗Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
- †Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- ‡Division of Cardiology, Columbia University Medical Center, New York, New York
- §Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- ‖Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- ¶Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- #Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- ∗∗Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- ↵∗Reprint requests and correspondence:
Dr. Harlan Krumholz, Center for Outcomes Research and Evaluation, 1 Church Street, Suite 200, New Haven, Connecticut 06510.
Objectives This study sought to determine the use of intravenous fluids in the early care of patients with acute decompensated heart failure (HF) who are treated with loop diuretics.
Background Intravenous fluids are routinely provided to many hospitalized patients.
Methods We conducted a retrospective cohort study of patients admitted with HF to 346 hospitals from 2009 to 2010. We assessed the use of intravenous fluids during the first 2 days of hospitalization. We determined the frequency of adverse in-hospital outcomes. We assessed variation in the use of intravenous fluids across hospitals and patient groups.
Results Among 131,430 hospitalizations for HF, 13,806 (11%) were in patients treated with intravenous fluids during the first 2 days. The median volume of administered fluid was 1,000 ml (interquartile range: 1,000 to 2,000 ml), and the most commonly used fluids were normal saline (80%) and half-normal saline (12%). Demographic characteristics and comorbidities were similar in hospitalizations in which patients did and did not receive fluids. Patients who were treated with intravenous fluids had higher rates of subsequent critical care admission (5.7% vs. 3.8%; p < 0.0001), intubation (1.4% vs. 1.0%; p = 0.0012), renal replacement therapy (0.6% vs. 0.3%; p < 0.0001), and hospital death (3.3% vs. 1.8%; p < 0.0001) compared with those who received only diuretics. The proportion of hospitalizations that used fluid treatment varied widely across hospitals (range: 0% to 71%; median: 12.5%).
Conclusions Many patients who are hospitalized with HF and receive diuretics also receive intravenous fluids during their early inpatient care, and the proportion varies among hospitals. Such practice is associated with worse outcomes and warrants further investigation.
During the time the work was conducted, Drs. Bikdeli and Mody were post-doctoral associates, Dr. Dharmarajan was a post-doctoral fellow, and Dr. Partovian was an instructor in the Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine in New Haven, Connecticut. This study was supported by grant DF10-301 from the Patrick and Catherine Weldon Donaghue Medical Research Foundation in West Hartford, Connecticut and by grant UL1 RR024139-06S1 from the National Center for Advancing Translational Sciences in Bethesda, Maryland. This study was also funded, in part, by grant U01 HL105270-05 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute in Bethesda, Maryland. The content is solely the responsibility of the authors and does not necessarily represent the official views of the sponsors. Dr. Bikdeli is now a PGY-2 Internal Medicine Resident at Yale University and Yale–New Haven Hospital. Dr. Mody is a PGY-3 Internal Medicine Resident at the University of Texas Southwestern Medical Center. Dr. Dharmarajan is an Assistant Professor of Medicine at Yale University School of Medicine. Dr. Krumholz is the recipient of research agreements from Medtronic and from Johnson & Johnson, through Yale University, to develop methods of clinical trial data sharing; and he chairs a cardiac scientific advisory board for United Healthcare. Dr. Dharmarajan is supported by grant HL007854 from the National Heart, Lung, and Blood Institute; and is supported as a Centers of Excellence Scholar in Geriatric Medicine at Yale University by the John A. Hartford Foundation and the American Federation for Aging Research. Dr. Horwitz is supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 3, 2014.
- Revision received August 25, 2014.
- Accepted September 5, 2014.
- American College of Cardiology Foundation