From the Guidelines
European and British guidelines recommend measuring urinary albumin:creatinine ratio (uACR) in heart failure patients as part of comprehensive assessment, though it is not a routine first-line test. The European Society of Cardiology suggests uACR measurement particularly in patients with diabetes or hypertension who have heart failure, as albuminuria can indicate kidney dysfunction and vascular damage that may worsen heart failure outcomes 1.
Key Points to Consider
- The test should be performed on a spot morning urine sample, with values above 30 mg/g considered abnormal.
- For heart failure patients, elevated uACR may signal increased cardiovascular risk and potential need for more aggressive treatment of underlying conditions.
- The presence of albuminuria in heart failure patients has prognostic significance, as it reflects systemic endothelial dysfunction and neurohormonal activation that can contribute to heart failure progression.
- Clinicians should consider uACR testing especially when optimizing renin-angiotensin-aldosterone system inhibitors, as these medications can affect both heart failure outcomes and urinary albumin excretion.
- Regular monitoring of uACR may help guide therapy adjustments and risk stratification in heart failure management.
Monitoring Frequency
The NICE guidelines for chronic heart failure in adults recommend a minimum frequency of 6-monthly monitoring for patients with stable CHF, with increased frequency if changes are made to the drug regimen 1.
Important Considerations
- The risk of hyperkalaemia with aldosterone antagonists is emphasized, with renal function tests suggested postinitiation at 1 week, then at 1,2,3,6 months and then 6-monthly if stable.
- The guidance advises against use of these medications with baseline potassium >5 mmol l–1 and recommends discontinuation at ≥6 mmol l–1.
- Maximum permitted fall in renal function after ACEi/ARB initiation or titration is suggested to be 25% decrease in eGFR or 30% increase in creatinine from pretreatment levels.
Clinical Decision Making
In clinical practice, the decision to measure uACR in heart failure patients should be based on individual patient characteristics, such as the presence of diabetes or hypertension, and the potential benefits and risks of testing 1.
From the Research
European and British Guidelines for Urinary Albumin:Creatinine Ratio in Heart Failure Patients
- There are no specific European or British guidelines mentioned in the provided studies regarding the use of urinary albumin:creatinine ratio (UACR) for heart failure patients.
- However, the studies suggest that UACR is a significant predictor of worse outcomes in patients with heart failure 2, 3, 4, 5, 6.
- The studies also indicate that albuminuria is associated with increased cardiovascular mortality and morbidity in patients with heart failure, diabetes, hypertension, and chronic kidney disease 2, 3, 4, 5.
Association between UACR and Heart Failure
- Elevated UACR is associated with an increased risk of new-onset heart failure in patients with type 2 diabetes 4.
- UACR is an independent predictor of mortality and cardiovascular hospitalizations in patients with heart failure 2, 6.
- The relationship between UACR and heart failure is consistent across different subgroups, including sex, estimated glomerular filtration rate, systolic blood pressure, and glycosylated hemoglobin 4.
Clinical Implications
- The use of UACR as a biomarker may be useful for identifying and monitoring disease trajectory in patients with heart failure 3.
- The addition of UACR to established heart failure risk models may improve risk prediction efficacy 4.
- Further research is needed to determine the cost-effectiveness of screening and treating low-grade albuminuria in patients with heart failure 3.