Efficacy and safety of high dose versus low dose furosemide with or without dopamine infusion: the Dopamine in Acute Decompensated Heart Failure II (DAD-HF II) trial

2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure

Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.

Differential Response to Low-Dose Dopamine or Low-Dose Nesiritide in Acute Heart Failure With Reduced or Preserved Ejection Fraction: Results From the ROSE AHF Trial (Renal Optimization Strategies Evaluation in Acute Heart Failure)

BACKGROUND

The ROSE AHF trial (Renal Optimization Strategies Evaluation in Acute Heart Failure) found that when compared with placebo, neither low-dose dopamine (2 µg/kg per minute) nor low-dose nesiritide (0.005 μg/kg per minute without bolus) enhanced decongestion or preserved renal function in AHF patients with renal dysfunction. However, there may be differential responses to vasoactive agents in AHF patients with reduced versus preserved ejection fraction (EF). This post hoc analysis examined potential interaction between treatment effect and EF (EF ≤40% versus >40%) on the ROSE AHF end points.

METHODS AND RESULTS

ROSE AHF enrolled AHF patients (n=360; any EF) with renal dysfunction. The coprimary end points were cumulative urine volume and the change in serum cystatin-C in 72 hours. The effect of dopamine (interaction P=0.001) and nesiritide (interaction P=0.039) on urine volume varied by EF group. In heart failure with reduced EF, urine volume was higher with active treatment versus placebo, whereas in heart failure with preserved EF, urine volume was lower with active treatment. The effect of dopamine and nesiritide on weight change, sodium excretion, and incidence of AHF treatment failure also varied by EF group (interaction P<0.05 for all). There was no interaction between vasoactive treatment's effect and EF on change in cystatin-C. Compared with placebo, dopamine was associated with improved clinical outcomes in heart failure with reduced EF and worse clinical outcomes in heart failure with preserved EF. With nesiritide, there were no differences in clinical outcomes when compared with placebo in both heart failure with reduced EF and heart failure with preserved EF.

CONCLUSIONS

In this post hoc analysis of ROSE AHF, the response to vasoactive therapies differed in patients with heart failure with reduced EF and heart failure with preserved EF. Investigations of AHF therapies should assess the potential for differential responses in AHF with preserved versus reduced EF.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01132846.

Advances in chemical pharmacotherapy for managing acute decompensated heart failure

INTRODUCTION

Acute decompensated heart failure (ADHF) contributes largely to the burden of heart failure and is associated with a poorer prognosis. Although numerous clinical trials evaluated the benefit of newer medications for ADHF, most of them were not successful. Areas covered: This review focusses on the updates on recent developments in chemical pharmacotherapy for the management of ADHF. A MEDLINE search for relevant review articles and original investigations on newer drugs for ADHF provided us with necessary literature. Expert opinion: Currently, popular therapies like diuretics, vasodilators, and inotropes offer symptomatic relief but do not provide survival benefit. Although multiple medications targeting novel pathways in ADHF were studied extensively, they failed to show either symptomatic or mortality benefit in available randomized trials. Improving our understanding of the complex pathophysiology of ADHF along with designing studies which include patients who are more representative of the real-world heart failure population, standardizing methods for endpoint assessment, and evaluating the role on novel biomarkers of organ dysfunction is important to improve ADHF research. Enhancing preventive strategies like improving baseline therapy in chronic heart failure patients and developing strategies for early identification of ADHF are important as our quest for innovative ADHF pharmacotherapy continues.

Treating Diuretic Resistance: An Overview

Loop diuretics are central to the management of fluid overload in acute decompensated heart failure. However, a variance in the response to loop diuretics can alter a patient's clinical course and has an adverse effect on clinical outcomes. Thus, a diminished response to loop diuretics is an important clinical issue. Factors thought to contribute to diuretic resistance include erratic oral absorption in congested states and postdiuretic sodium retention. Further contributing to diuretic resistance in patients with advanced heart failure are decreases in renal perfusion and alterations in sodium handling that occur in an attempt to maintain circulatory homeostasis. Several pharmacologic interventions have been used to improve diuretic response. Intravenous diuretic administration, increasing diuretic doses, or changing diuretic agents can potentially overcome pharmacokinetic obstacles which contribute to drug resistance. Combination diuretic therapy may be useful to overcome increased sodium retention, dopamine may improve renal perfusion, and hypertonic saline may transiently increase intravascular volume and improve sodium delivery to the tubules of the nephron. Despite the prevalence of diuretic resistance, there remains a paucity of clinical trial evidence to help guide therapy in these patients.

Management of Congestion and Diuretic Resistance in Heart Failure

We present the case of a patient with heart failure and severe congestion who was responding poorly to diuretic therapy. We discuss the key problems concerning the pathophysiology and bedside therapeutic approach to congestion and fluid overload in this clinical setting, and we give practical suggestions to overcome congestion, especially in the setting of diuretic resistance and worsening renal function. We conclude that the application of key pharmacokinetic and pharmacodynamic principles of diuretic therapy, along with in-depth knowledge of the pathophysiology of heart failure, still represent the cornerstones for a correct approach to decongestive therapy in these patients.

A meta-analysis of low-dose dopamine in heart failure

BACKGROUND

Heart failure (HF) is a major health problem worldwide with no proven therapy. Low-dose dopamine (LDD) has been applied to patients with HF to enhance diuresis and preserve renal function since the last century. However, the efficacy of LDD in HF has been questioned by several studies recently. The purpose of this meta-analysis is to appraise the effects of the LDD to HF.

METHODS

Relative trials were identified in the PubMed, The Web of Science, OVID EBM Reviews and Cochrane databases, and the relevant papers were examined. Pooled mean difference (MD) and 95% confidence interval (95% CI) were estimated by random effects models. The primary endpoints in our meta-analysis were renal function, determined by blood urea, creatinine levels, eGFR and urine output. Secondary endpoints were rates of all-cause mortality and readmission after treatment.

RESULTS

Six randomized controlled trials (RCTs) and one retrospective study involving 587 patients were included in this analysis. LDD enhanced eGFR (MD, 7.44; 95% CI, 1.92-12.95; P=0.008), urine output (SMD, 0.58; 95% CI, 0.15-1.01; P=0.008) and decrease creatinine levels (MD, -0.36; 95% CI, -0.64/-0.08; P=0.004), blood urea (MD, -6.97; 95% CI, -13.12/-0.81; P=0.03). No statistically significant differences in the rates of mortality (RR, 0.86; 95% CI, 0.62-1.20, P=0.37) and readmission (RR: 0.86; 95% CI 0.47-1.56, P=0.62) were noted.

CONCLUSIONS

LDD indeed brought benefits in terms of promoting diuresis and preserving renal function for HF patients. It did not demonstrate statistical significance in rates of readmission nor mortality. The efficacy of LDD to HF patients should be confirmed by further large, high quality clinical trials.

Acute decompensated heart failure (ADHF): A comprehensive contemporary review on preventing early readmissions and postdischarge death

Heart failure (HF) is an increasingly prevalent syndrome and a leading cause of both first hospitalization and readmissions. Strikingly, up to 25% of the patients are readmitted within 30 to 60-days, accounting for HF as the primary cause for readmission in the adult population. Given its poor prognosis, one could describe it as a "malignant condition". Acute decompensation is intrinsically related to increased right heart tele-diastolic pressures and often related to congestive symptoms. In-hospital strategies to adequately compensate and timely discharge patients are limited. Conversely, the fragile early postdischarge phase is a vulnerable period when one could potentially intervene cost-effectively to improve survival and to reduce morbidity. Promising transitional hospital-to-home programs may have a broader role in the near future, namely for selected higher risk patients. However, identifying patients at risk for hospital readmission has been challenging. Novel approaches, such as ferric carboxymaltose and valsartan/sacubitril, and reemerging drugs, particularly digoxin, may reduce hospitalizations. Despite this, optimizing the use of "older" therapies is still warranted. Right heart pressures monitoring may provide novel insights into promptly outpatient management. Unfortunately, randomized trials in the specific ADHF population are scarce. A novel paradigmatic approach is needed in order to suitably improve the currently poor prognosis of ADHF. Both improving survival and reducing hospitalizations are, therefore, primordial therapy goals. Lastly, no single drug has consistently proved to improve survival in HF with preserved ejection fraction (HFpEF); yet, some approaches may efficiently reduce hospitalizations. Awareness on HFpEF management beyond the failing heart is imperative.

A Clinical Approach to the Acute Cardiorenal Syndrome

Acute kidney injury is a frequent complication of acute heart failure syndromes, portending an adverse prognosis. Acute cardiorenal syndrome represents a unique form of acute kidney injury specific to acute heart failure syndromes. The pathophysiology of acute cardiorenal syndrome involves renal venous congestion, ineffective forward flow, and impaired renal autoregulation caused by neurohormonal activation. Biomarkers reflecting different aspects of acute cardiorenal syndrome pathophysiology may allow patient phenotyping to inform prognosis and treatment. Adjunctive vasoactive, neurohormonal, and diuretic therapies may relieve congestive symptoms and/or improve renal function, but no single therapy has been proved to reduce mortality in acute cardiorenal syndrome.

Decongestion: Diuretics and other therapies for hospitalized heart failure

Acute heart failure (AHF) is a potentially life-threatening clinical syndrome, usually requiring hospital admission. Often the syndrome is characterized by congestion, and is associated with long hospital admissions and high risk of readmission and further healthcare expenditure. Despite a limited evidence-base, diuretics remain the first-line treatment for congestion. Loop diuretics are typically the first-line diuretic strategy with some evidence that initial treatment with continuous infusion or boluses of high-dose loop diuretic is superior to an initial lower dose strategy. In patients who have impaired responsiveness to diuretics, the addition of an oral thiazide or thiazide-like diuretic to induce sequential nephron blockade can be beneficial. The use of intravenous low-dose dopamine is no longer supported in heart failure patients with preserved systolic blood pressure and its use to assist diuresis in patients with low systolic blood pressures requires further study. Mechanical ultrafiltration has been used to treat patients with heart failure and fluid retention, but the evidence-base is not robust, and its place in clinical practice is yet to be established. Several novel pharmacological agents remain under investigation.

Diagnosis and management of acute heart failure

Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an 'aged' population.As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department,intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.

Effects of ventriculoarterial coupling changes on renal function, echocardiographic indices and energy efficiency in patients with acute decompensated systolic heart failure under furosemide and dopamine treatment: a comparison of three therapeutic protocols

BACKGROUND

Ventriculoarterial coupling (VAC) status relates to tissue perfusion and its optimization may improve organ function and energy efficiency (EE) of the cardiovascular system. The effects of non-invasively calculated VAC improvement on echocardiographic parameters, renal function indices and EE improvement in patients with acute decompensated systolic heart failure were studied. Furthermore, effects of different treatment modalities on VAC, renal function and echocardiographic parameters were compared.

METHODS

Systolic heart failure patients with ejection fraction <50% were studied, who, at the treating physician's discretion, received 8-hour infusions of: high dose furosemide (20mg/h), low dose furosemide (5mg/h) or dopamine (5μg/kg/min) combined with furosemide (5mg/h). Echocardiographic assessments were performed at 0 and 24h. Renal function was evaluated using serum creatinine and creatinine clearance. VAC and EE were assessed noninvasively, by echocardiography.

RESULTS

Significant correlations were noted between VAC improvement and improvements in EE and serum creatinine (rho=0.96, p<0.001, rho=0.32, p=0.04 respectively). Dopamine-furosemide combination had a borderline effect on creatinine (p=0.08) and led to significant improvements in e', E/e' ratio (p=0.015 and p=0.009 respectively) and VAC (value closer to 1).

CONCLUSION

VAC improvement correlated with EE and creatinine improvement, regardless of treatment, supporting a potential role for VAC status assessment and improvement in acute decompensated systolic heart failure. Dopamine and furosemide combination seemed to improve VAC and diastolic function but only had a borderline effect on renal function.

The acute cardiorenal syndrome type I: considerations on physiology, epidemiology, and therapy

Acute cardiorenal syndrome, also known as cardiorenal syndrome type 1, is defined as an abrupt worsening of cardiac function that occurs in at least 30 % of patients with acute decompensated heart failure and can lead to the development of acute kidney injury. The changes in renal function that occur in this setting have variable prognostic implications, as both poorer and better outcomes have been reported when renal function worsens during treatment of heart failure decompensation. Furthermore, it remains unclear when worsening renal function is actually a manifestation of true acute kidney injury or simply an indicator of hemoconcentration. Given these gaps in the understanding of the significance of renal function changes in the setting of decompensated heart failure, it is not surprising that studies on the effects of available therapies, including diuretics, vasoactive drugs, and mechanical fluid removal have yielded inconsistent results. The purpose of this review is to analyze critically the current knowledge on the pathophysiology, epidemiology, prognosis, and treatment of acute cardiorenal syndrome.

ROSE-AHF and lessons learned

Nesiritide and dopamine have been recognized for some time as potential renal adjunct therapies in the management of patients with acute heart failure (AHF). Several studies have yielded conflicting evidence of the efficacy of both medications in enhancing the renal function of patients with AHF. The Renal Optimization Strategies Evaluation (ROSE) study was a multicenter double-blind placebo controlled trial designed to assess the potential renoprotective effects of low-dose nesiritide and dopamine in AHF patients with renal dysfunction. This article will focus on previous research, summary of results, and lessons learned from the ROSE-AHF trial as well as future directions for clinical research and applications.

Diuretic response in acute heart failure-pathophysiology, evaluation, and therapy

The administration of loop diuretics to achieve decongestion is the cornerstone of therapy for acute heart failure. Unfortunately, impaired response to diuretics is common in these patients and associated with adverse outcomes. Diuretic resistance is thought to result from a complex interplay between cardiac and renal dysfunction, and specific renal adaptation and escape mechanisms, such as neurohormonal activation and the braking phenomenon. However, our understanding of diuretic response in patients with acute heart failure is still limited and a uniform definition is lacking. Three objective methods to evaluate diuretic response have been introduced, which all suggest that diuretic response should be determined based on the effect of diuretic dose administered. Several strategies have been proposed to overcome diuretic resistance, including combination therapy and ultrafiltration, but prospective studies in patients who are truly unresponsive to diuretics are lacking. An enhanced understanding of diuretic response should ultimately lead to an improved, individualized approach to treating patients with acute heart failure.

Pharmacotherapy Update on the Use of Vasopressors and Inotropes in the Intensive Care Unit

This paper summarizes the pharmacologic properties of vasoactive medications used in the treatment of shock, including the inotropes and vasopressors. The clinical application of these therapies is discussed and recent studies describing their use and associated outcomes are also reported. Comprehension of hemodynamic principles and adrenergic and non-adrenergic receptor mechanisms are salient to the appropriate therapeutic utility of vasoactive medications for shock. Vasoactive medications can be classified based on their direct effects on vascular tone (vasoconstriction or vasodilation) and on the heart (presence or absence of positive inotropic effects). This classification highlights key similarities and differences with respect to pharmacology and hemodynamic effects. Vasopressors include pure vasoconstrictors (phenylephrine and vasopressin) and inoconstrictors (dopamine, norepinephrine, and epinephrine). Each of these medications acts as vasopressors to increase mean arterial pressure by augmenting vascular tone. Inotropes include inodilators (dobutamine and milrinone) and the aforementioned inoconstrictors. These medications act as inotropes by enhancing cardiac output through enhanced contractility. The inodilators also reduce afterload from systemic vasodilation. The relative hemodynamic effect of each agent varies depending on the dose administered, but is particularly apparent with dopamine. Recent large-scale clinical trials have evaluated vasopressors and determined that norepinephrine may be preferred as a first-line therapy for a broad range of shock states, most notably septic shock. Consequently, careful selection of vasoactive medications based on desired pharmacologic effects that are matched to the patient's underlying pathophysiology of shock may optimize hemodynamics while reducing the potential for adverse effects.

Editor's Choice-Recent therapeutic trials on fluid removal and vasodilation in acute heart failure

Recent therapeutic trials regarding the management of acute heart failure (AHF) failed to demonstrate the efficacy of newer therapeutic modalities and agents. Low- versus high-dose and continuous administration of furosemide were shown not to matter. Ultrafiltration was not found to be more efficacious than sophisticated diuretic therapy including dose-adjusted intravenous furosemide and metolazone. Dopamine and nesiritide were not shown to be superior to current therapy. Tezosentan and tovalptan had no effect on mortality. The development of rolofylline was terminated due to adverse effect (seizures). Lastly, preliminary experience with serelaxin indicates a mortality improvement at six months that remains to be confirmed. The disappointing findings of these recent trials may reflect the lack of efficacy of newer therapeutic modalities and agents. Alternatively the disappointing findings of these recent trials may be in part due to methodological issues. The AHF syndrome is complex with many clinical phenotypes. Failure to match clinical phenotypes and therapeutic modalities is likely to be partly responsible for the disappointing findings of recent AHF trials.

Newest additions to heart failure treatment

INTRODUCTION

Despite the improvement in heart failure (HF) therapy in the last 30 years, this condition remains a major public health concern with high hospitalization and mortality rates, and related costs. Recently, new pharmacological approaches are under evaluation.

AREAS COVERED

For chronic HF with reduced ejection fraction (EF) direct renin inhibitors, neprilysin-angiotensin II receptor inhibitors and aldosterone synthase inhibitors have been tested. For HF with preserved EF, no therapy has been demonstrated up to now to be able to improve patients' outcomes and it remains a substantial unmet need. In acute HF (AHF) new inotropes and vasodilators have been developed and are currently investigated in trials. In this review, mechanism of action and clinical efficacy of new pharmacological approaches on acute and chronic HF will be discussed.

EXPERT OPINION

In patients with HF, some unmet needs remain to be challenged in the near future. For patients with chronic HF, the management of comorbidities, a better definition and treatment of patients with preserved EF are the major issues to be solved. The treatment of patients admitted for AHF is even more compelling. Several hypotheses of research focused on these issues are tested in ongoing trials.