What is the role of Albumin (Human Albumin) IV in the management of heart failure?

Role of Albumin IV in Heart Failure Management

Intravenous albumin is not recommended as a standard therapy in the management of heart failure as there is insufficient evidence supporting its routine use for improving mortality, morbidity, or quality of life outcomes.

Pathophysiological Considerations

Hypoalbuminemia is common in heart failure patients and is associated with:

• Poor prognosis and increased mortality 1
• Longer hospital stays 2
• Potential contribution to pulmonary congestion and edema
• Myocardial dysfunction
• Diuresis resistance and fluid retention 2

Evidence Analysis

Current Guidelines on Heart Failure Management

Heart failure management guidelines from both European Society of Cardiology 3 and American College of Cardiology/American Heart Association 3 do not include albumin administration as part of standard heart failure therapy. The cornerstone treatments emphasized in these guidelines include:

• ACE inhibitors/ARBs
• Beta-blockers
• Diuretics for fluid overload
• Aldosterone antagonists
• Cardiac glycosides in select patients

Research on Albumin in Heart Failure

Recent research provides mixed or negative findings regarding albumin use in heart failure:

• A 2022 retrospective cohort study found that albumin administration in hospitalized acute heart failure patients was not associated with either improved or worsened outcomes for the composite endpoint of intubation, emergency renal replacement therapy, or death 4

• The DOSE-AHF and ROSE-AHF trials analysis demonstrated that baseline serum albumin levels were not associated with short-term clinical outcomes for acute heart failure patients undergoing decongestive therapies 5

Clinical Decision Algorithm for Albumin Use in Heart Failure

1. First-line therapies (should be optimized before considering albumin):

   • Loop diuretics for fluid overload
   • ACE inhibitors/ARBs
   • Beta-blockers
   • Aldosterone antagonists when appropriate

2. Consider albumin only in specific scenarios:

   • Severe hypoalbuminemia (<3.0 g/dL) with diuretic resistance
   • Concurrent conditions where albumin has established benefit:
     • Large-volume paracentesis in patients with ascites
     • Spontaneous bacterial peritonitis
     • Hepatorenal syndrome 3

3. Monitor for complications if albumin is administered:

   • Pulmonary edema
   • Fluid overload
   • Heart failure exacerbation

Important Caveats and Pitfalls

• Targeting specific albumin levels may lead to complications: The Albumin to Prevent Infection in Chronic Liver Failure trial showed that targeting specific albumin levels may be associated with higher rates of pulmonary edema and fluid overload 3

• Diuretic management is critical: Diuretics should be used cautiously to avoid excessive preload reduction, which could reduce stroke volume and cardiac output 3

• Hypoalbuminemia as a prognostic marker: While hypoalbuminemia is associated with poor outcomes, current evidence does not support that correcting albumin levels with IV albumin improves outcomes 6

• Cost considerations: Albumin is an expensive blood product with limited evidence of benefit in heart failure

Conclusion

While hypoalbuminemia is associated with worse outcomes in heart failure patients, there is insufficient evidence that albumin administration improves clinical outcomes. Standard heart failure therapies (ACE inhibitors, beta-blockers, diuretics) should remain the cornerstone of treatment, with albumin reserved for specific scenarios where its benefit has been established.