Fluid therapy in non-septic, refractory acute decompensated heart failure patients - The cautious role of central venous pressure

Purpose: Fluid therapy in congestive acute decompensated heart failure (ADHF) patients might be inappropriate and worsening the prognosis. The aim of our study was to analyze the effect of fluid administration on mortality in non-septic, ADHF patients with reduced ejection fraction. Material and methods: We analyzed 41 ADHF consecutive 'cold-wet' patients (mean age 69.3 +/- 14.9 years, 27 men, LVEF 22.8 +/- 11.1%, lactates 2.2 +/- 1.6 mmol/L) without sepsis. At admission central venous pressure (CVP) was measured (17.6 +/- 7.2 cm H2O), and ultrasound examination of inferior vena cava (IVC) was performed (IVC min. 18.6 +/- 7.3mm and IVC max. 24.6 +/- 4.3 mm). Moreover, the groups were compared (survivors vs. non-survivors as well as 1st and 4th quartile of CVP). Results: Altogether 17 (41%) patients died: 16 (39%) during a mean of 11.2 +/- 7.8 days of hospitalization and 1 during a 30-day follow up. Patients in the lowest CVP quartile (< 13 cm H2O) had significantly worse in-hospital survival as compared to patients in the highest quartile (> 24 cm H2O), P = 0.012. Higher intravenous fluid volumes within the first 24 h were infused in patients in the lowest CVP quartile as compared to the highest CVP quartile (1791.7 +/- 1357.8 mL vs. 754.5 +/- 631.4 mL, P = 0.046). Moreover, more fluids were infused in a group of patients who died during a hospital stay and at 30-day follow up (1362.8 +/- 752.7 mL vs. 722.7 +/- 1046.5 mL, P = 0.004; 1348.8 +/- 731.0 mL vs. 703.6 +/- 1068.4 mL, P = 0.002, respectively). Conclusions: CVP-guided intravenous fluid therapy is a common practice which in high risk ADHF 'cold-wet' patients might be harmful and should rather be avoided. Lower CVP seems to be related with worse prognosis.