Prognosis value of early albuminuria trajectory after acute heart failure

Introduction

The role of albuminuria has emerged as a cardiovascular risk factor and a potential marker of congestion. Its association with other biomarkers, such as NT-proBNP, is well established during acute heart failure (AHF). However, the trajectory of the urinary albumin-to-creatinine ratio (UACR) at discharge and at the first post-discharge visit (two weeks after) may serve as a prognostic indicator for long-term cardiovascular events.

Purpose

To assess how UACR changes after AHF admission and its impact in long-term outcomes.

Methods

Single center, prospective study that included all patients with AHF admitted to the Cardiology Department between February - June 2024. Patients were classified based on UACR levels at discharge and two weeks after: (1) normoalbuminuria at both time points; (2) microalbuminuria at discharge with a >50% reduction or normalization two weeks after; and (3) microalbuminuria at discharge with <50% reduction or any episode of macroalbuminuria in any both time.

Results

A total of 88 patients were included: 44.3% in group 1 (n=39), 14.8% in group 2 (n=13), and 40.9% in group 3 (n=36). Median follow-up was higher in group 1 (p=0.003). Patients in groups 2–3 had more comorbidities and worse prior UACR. No differences were found in HF etiology.

At baseline, patients in groups 2–3 showed a higher use of beta-blockers, SGLT2 inhibitors, mineralocorticoid receptor antagonists (MRA), and diuretics. At discharge, the treatment was similar except for higher dose of diuretics and thiazide diuretics in group 3.

Regarding echocardiographic parameters, patients in group 3 showed higher pulmonary artery pressure (PAPs), lower TAPSE/PAPs ratio and greater severity of valvular disease such as mitral (p=0.008) and tricuspid regurgitation (p=0.020). (Figure 1). No different was found in left ventricular ejection fraction.

Patients in groups 2–3 had a higher proportion of prior HF admission and worse clinical congestion scores (CCS).

Regarding laboratory data at discharge, patients in group 3 showed worse renal function, higher levels of NT-proBNP and alkaline phosphatase. At the two weeks follow-up, patient in group 3 had worse renal function, lower serum chloride levels, higher NT-proBNP and slighly lower urinary sodium and chloride levels.

During follow-up, patients (30.7%) were readmitted due to HF and ten patients (11.4%) died. All six HF-related deaths occurred in group 3. Five patients required renal replacement therapy, all from group 3. The composite outcome of all-cause mortality or HF readmission was significantly higher in group 3 (p = 0.013).

Conclusions

Persistent or worsening albuminuria after AHF discharge is associated with poorer prognosis, including higher HF readmissions, mortality and need for renal replacement therapy. Monitoring UACR trajectory in the early post-discharge period may help identify high-risk patients and guide closer follow-up.Clinical characteristics between groupsFor image description, please refer to the figure legend and surrounding text.Kaplan–Meier curve by UACR groupsFor image description, please refer to the figure legend and surrounding text.