What is the risk of sudden cardiac death in congestive heart failure (CHF) patients given albumin?

From the Guidelines

Albumin administration in patients with congestive heart failure (CHF) should be avoided due to the risk of sudden cardiac death, and alternative treatments should be considered. The primary concern is that albumin infusion can increase intravascular volume, potentially worsening fluid overload and precipitating acute decompensated heart failure in already compromised cardiac patients 1. When considering the management of CHF, the focus should be on evidence-based treatments that improve morbidity, mortality, and quality of life, such as the use of beta blockers, ACEi-ARB, and ARNi, as recommended in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. Key points to consider in the management of CHF include:

• The importance of continuing oral guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF), unless contraindicated 1
• The benefits of beta blockers, ACEi-ARB, and ARNi in reducing mortality and morbidity in patients with HFrEF 1
• The need for careful consideration of volume status and renal function when initiating or adjusting GDMT 1
• The potential risks of sudden cardiac death associated with rapid volume expansion, particularly in patients with severe CHF (NYHA class III-IV), those with ejection fraction <30%, and patients with recent decompensation. In patients with CHF, the goal is to optimize volume status, reduce symptoms, and improve quality of life, while minimizing the risk of adverse events, including sudden cardiac death. Alternative volume expanders or addressing the underlying cause of hypoalbuminemia rather than treating the laboratory value itself should be considered whenever possible in CHF patients. The use of albumin in CHF patients should be reserved for specific situations where the benefits outweigh the risks, and close cardiac monitoring is essential to mitigate the risk of sudden cardiac death.

From the FDA Drug Label

CONTRAINDICATIONS Certain patients, e.g., those with a history of congestive cardiac failure, renal insufficiency or stabilized chronic anemia, are at special risk of developing circulatory overload. The FDA drug label does not answer the question.

From the Research

Sudden Cardiac Death in CHF Patients

• Sudden cardiac death (SCD) is a common mode of death in patients with congestive heart failure (CHF) 2.
• The risk of SCD in CHF patients can be predicted by factors such as left ventricular ejection fraction (LVEF) and estimated glomerular filtration rate (eGFR) 2.
• Roughly a quarter of SCD events occur within 3 months after discharge in patients with CHF 2.

Predictors of SCD in CHF Patients

• Advanced degree of left ventricular dysfunction and frequent or complex ventricular arrhythmias are major predictors of total and sudden mortality among patients with CHF 3.
• Electrolyte or autonomic nervous system imbalance, use of certain anti-arrhythmic drugs, or intermittent myocardial ischemia can also contribute to the development of cardiac arrhythmias and sudden death in CHF patients 3.
• The presence of ventricular tachycardia in patients with CHF increases the probability of dying, with a threefold increase in odds of dying over a 1 to 2 year follow-up period 4.

Mechanisms of SCD in CHF Patients

• Adverse left ventricular remodelling and fibrosis can create a fragile and vulnerable substrate, leading to sudden death in CHF patients 5.
• Self-organizing criticality within the ventricular myocardium can result in acute circulatory collapse, even in the absence of an identifiable triggering event 5.
• Anti-remodelling and antifibrotic interventions, such as neurohormonal antagonists and cardiac resynchronization, can reduce the risk of sudden death in patients with heart failure 5.

Treatment and Prevention of SCD in CHF Patients

• Implantable cardioverter-defibrillator (ICD) implantation is an established treatment for SCD prevention in CHF patients 2.
• Beta blockers can improve left ventricular function and symptoms of CHF, and may also reduce hospital readmission and decrease mortality 6.
• Correction of predisposing factors, such as electrolyte or autonomic nervous system imbalance, can reduce the risk of lethal ventricular arrhythmias in CHF patients 4.