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Rafique Z, Weir MR, Onuigbo M, Pitt B, Lafayette R, Butler J, Lopes M, Farnum C, Peacock WF. Expert Panel Recommendations for the Identification and Management of Hyperkalemia and Role of Patiromer in Patients with Chronic Kidney Disease and Heart Failure. J Manag Care Spec Pharm 2017; 23:S10-S19. [PMID: 28485203 PMCID: PMC10408402 DOI: 10.18553/jmcp.2017.23.4-a.s10] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Virtual panel meetings were conducted among 7 physicians, all of whom are independent experts, including 3 nephrologists, 2 cardiologists, and 2 emergency medicine physicians (the panel). The panel met with the purpose of discussing the current treatment landscape, treatment challenges, economic impact, and gaps in care for patients with hyperkalemia that is associated with heart failure and chronic kidney disease. The stated goal of the panel discussion was to develop practical solutions in the identification and management of hyperkalemia in this patient population. The panel noted that hyperkalemia is a serious condition that can lead to life-threatening complications, yet the treatment paradigm for hyperkalemia has remained without major advances for approximately 50 years, until the approval of patiromer. A number of issues still exist in the management of this patient population, including the lack of uniform treatment guidelines and consensus regarding the approach to treatment. As part of its effort, the panel developed an algorithm, the Proposed Diagnostic Algorithm for Hyperkalemia Treatment in the Acute Care Setting/Chronic Care. The panel agreed that patiromer appears to be a viable option for the management of hyperkalemia in patients with chronic kidney disease and/or heart failure and in patients who experience chronic hyperkalemia. DISCLOSURES This panel discussion was funded by Relypsa and facilitated by Magellan Rx Management. Rafique is a principal investigator for Relypsa and serves as a consultant for Instrumentation Laboratory, Magellan Health, Relypsa, and ZS-Pharma. Butler serves as consultant for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, CardioCell, Janssen, Merck, Novartis, Relypsa, and ZS-Pharma. Lopes and Farnum are employed by Magellan Rx Management. Rafique designed the management protocol for this panel discussion and contributed to the writing and editing of this report document. The other authors report no conflicting interests. Relypsa is the manufacturer of Veltassa (patiromer).
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Affiliation(s)
- Zubaid Rafique
- 1 Baylor College of Medicine, Texas Medical Center, Houston
| | | | - Macaulay Onuigbo
- 3 Mayo Clinic Health System, Eau Claire, Wisconsin, and Mayo Clinic, Rochester, Minnesota
| | - Bertram Pitt
- 4 University of Michigan School of Medicine, Ann Arbor
| | | | | | - Maria Lopes
- 7 Magellan Rx Management, Newport, Rhode Island
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Tseng WC, Liu JS, Hung SC, Kuo KL, Chen YH, Tarng DC, Hsu CC. Effect of spironolactone on the risks of mortality and hospitalization for heart failure in pre-dialysis advanced chronic kidney disease: A nationwide population-based study. Int J Cardiol 2017; 238:72-78. [PMID: 28363684 DOI: 10.1016/j.ijcard.2017.03.080] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 01/05/2017] [Accepted: 03/16/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Spironolactone has been shown to reduce cardiovascular death in patients with mild-to-moderate chronic kidney disease (CKD), but its risks and benefits in advanced CKD remain unsettled. We aimed to assess whether spironolactone reduces cardiovascular mortality and morbidity in pre-dialysis stage 5 CKD patients. METHODS Using Taiwan's National Health Insurance Research Database from January 2000 to June 2009, we enrolled 27,213 pre-dialysis stage 5 CKD adult patients, in whom 1363 patients were treated with spironolactone (user) and 25,850 were not (nonuser). Outcomes were all-cause mortality, hospitalization for heart failure (HHF) and major adverse cardiac event (MACE, the composite of acute myocardial infarction and ischemic stroke). Patients were followed up till December 31, 2009. RESULTS Over 85,758 person-years of follow-up, spironolactone users had higher incidence for all-cause mortality (24.7/100 person-years vs. 10.6/100 person-years), infection-related death (4.4/100 person-years vs. 1.7/100 person-years) and HHF (4.0/100 person-years vs. 1.4/100 person-years). Multivariable Cox hazards model showed that spironolactone users were associated with higher risks of all-cause mortality (adjusted hazard ratio [aHR] 1.35, 95% confidence interval [CI] 1.24-1.46), infection-related death (aHR 1.42, CI 1.16-1.73) and HHF (aHR 1.35, CI 1.08-1.67) as compared to nonusers. The risks for cardiovascular mortality, MACE and hyperkalemia-associated hospitalization were similar between two groups. After matching users and nonusers (1:3 ratio) by propensity scores, the results were consistent in matched cohort and across subgroups. CONCLUSIONS Spironolactone may be associated with higher risks for all-cause and infection-related mortality and HHF in pre-dialysis stage 5 CKD patients. Spironolactone should be used with caution in advanced CKD patients.
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Affiliation(s)
- Wei-Cheng Tseng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jia-Sin Liu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Szu-Chun Hung
- Division of Nephrology, Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Taipei, Taiwan
| | - Ko-Lin Kuo
- Division of Nephrology, Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Taipei, Taiwan
| | - Yu-Hsin Chen
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan; Department and Institute of Physiology, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Chih-Cheng Hsu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan; Department of Health Services Administration, China Medical University, Taichung, Taiwan.
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Yaprak M. ELECTROCARDIOGRAPHIC MANIFESTATIONS OF SEVERE HYPERKALEMIA: A CASE REPORT. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2017. [DOI: 10.17944/mkutfd.307015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Schmidt M, Mansfield KE, Bhaskaran K, Nitsch D, Sørensen HT, Smeeth L, Tomlinson LA. Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin-angiotensin system blockade: a UK general practice-based cohort study. BMJ Open 2017; 7:e012818. [PMID: 28069618 PMCID: PMC5223644 DOI: 10.1136/bmjopen-2016-012818] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To examine adherence to serum creatinine and potassium monitoring and discontinuation guidelines following initiation of treatment with ACE inhibitors (ACEI) or angiotensin receptor blockers (ARBs); and whether high-risk patients are monitored. DESIGN A general practice-based cohort study using electronic health records from the UK Clinical Practice Research Datalink and Hospital Episode Statistics. SETTING UK primary care, 2004-2014. SUBJECTS 223 814 new ACEI/ARB users. MAIN OUTCOME MEASURES Proportion of patients with renal function monitoring before and after ACEI/ARB initiation; creatinine increase ≥30% or potassium levels >6 mmol/L at first follow-up monitoring; and treatment discontinuation after such changes. Using logistic regression models, we also examined patient characteristics associated with these biochemical changes, and with follow-up monitoring within the guideline recommendation of 2 weeks after treatment initiation. RESULTS 10% of patients had neither baseline nor follow-up monitoring of creatinine within 12 months before and 2 months after initiation of an ACEI/ARB, 28% had monitoring only at baseline, 15% only at follow-up, and 47% both at baseline and follow-up. The median period between the most recent baseline monitoring and drug initiation was 40 days (IQR 12-125 days). 34% of patients had baseline creatinine monitoring within 1 month before initiating therapy, but <10% also had the guideline-recommended follow-up test recorded within 2 weeks. Among patients experiencing a creatinine increase ≥30% (n=567, 1.2%) or potassium level >6 mmol/L (n=191, 0.4%), 80% continued treatment. Although patients with prior myocardial infarction, hypertension or baseline potassium >5 mmol/L were at high risk of ≥30% increase in creatinine after ACEI/ARB initiation, there was no evidence that they were more frequently monitored. CONCLUSIONS Only one-tenth of patients initiating ACEI/ARB therapy receive the guideline-recommended creatinine monitoring. Moreover, the vast majority of the patients fulfilling postinitiation discontinuation criteria for creatinine and potassium increases continue on treatment.
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Affiliation(s)
- Morten Schmidt
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Internal Medicine, Regional Hospital of Randers, Denmark
| | - Kathryn E Mansfield
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Krishnan Bhaskaran
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Laurie A Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Kim HL, Kim MA, Choi DJ, Han S, Jeon ES, Cho MC, Kim JJ, Yoo BS, Shin MS, Seong IW, Ahn Y, Kang SM, Kim YJ, Kim HS, Chae SC, Oh BH, Lee MM, Ryu KH. Gender Difference in the Prognostic Value of N-Terminal Pro-B Type Natriuretic Peptide in Patients With Heart Failure ― A Report From the Korean Heart Failure Registry (KorHF) ―. Circ J 2017; 81:1329-1336. [DOI: 10.1253/circj.cj-16-1345] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hack-Lyoung Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Boramae Medical Center
| | - Myung-A Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Boramae Medical Center
| | - Dong-Ju Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Bundang Hospital
| | - Seongwoo Han
- Department of Cardiovascular Medicine, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University
| | - Eun-Seok Jeon
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Samsung Medical Center
| | - Myeong-Chan Cho
- Department of Internal Medicine, Chungbuk National University College of Medicine
| | - Jae-Joong Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center
| | - Byung-Su Yoo
- Department of Internal Medicine, Yonsei University Wonju Christian Hospital
| | - Mi-Seung Shin
- Department of Internal Medicine, Gachon University Gil Hospital
| | - In-Whan Seong
- Department of Internal Medicine, Chungnam National University College of Medicine
| | - Youngkeun Ahn
- Department of Internal Medicine, Chonnam National University College of Medicine
| | - Seok-Min Kang
- Department of Internal Medicine, Yonsei University Severance Hospital
| | - Young-Jo Kim
- Department of Internal Medicine, Yeungnam University College of Medicine
| | - Hyung Seop Kim
- Department of Internal Medicine, Keimyung University College of Medicine
| | - Shung Chull Chae
- Department of Internal Medicine, Kyungpook National University College of Medicine
| | - Byung-Hee Oh
- Department of Internal Medicine, Seoul National University College of Medicine
| | | | - Kyu-Hyung Ryu
- Department of Cardiovascular Medicine, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University
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Li L, Harrison SD, Cope MJ, Park C, Lee L, Salaymeh F, Madsen D, Benton WW, Berman L, Buysse J. Mechanism of Action and Pharmacology of Patiromer, a Nonabsorbed Cross-Linked Polymer That Lowers Serum Potassium Concentration in Patients With Hyperkalemia. J Cardiovasc Pharmacol Ther 2016; 21:456-65. [PMID: 26856345 PMCID: PMC4976659 DOI: 10.1177/1074248416629549] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 12/18/2015] [Indexed: 12/15/2022]
Abstract
Hyperkalemia is a potentially life-threatening condition, and patients who have chronic kidney disease, who are diabetic, or who are taking renin-angiotensin-aldosterone system inhibitors are at increased risk. Therapeutic options for hyperkalemia tend to have limited effectiveness and can be associated with serious side effects. Colonic potassium secretion can increase to compensate when urinary potassium excretion decreases in patients with renal impairment, but this adaptation is insufficient and hyperkalemia still results. Patiromer is a novel, spherical, nonabsorbed polymer designed to bind and remove potassium, primarily in the colon, thereby decreasing serum potassium in patients with hyperkalemia. Patiromer has been found to decrease serum potassium in patients with hyperkalemia having chronic kidney disease who were on renin-angiotensin-aldosterone system inhibitors. Results of nonclinical studies and an early phase clinical study are reported here. Two studies with radiolabeled drug, one in rats and the other in dogs, confirmed that patiromer was not absorbed into the systemic circulation. Results of an in vitro study showed that patiromer was able to bind 8.5 to 8.8 mEq of potassium per gram of polymer at a pH similar to that found in the colon and had a much higher potassium-binding capacity compared with other resins, including polystyrene sulfonate. In a study in hyperkalemic rats, a decrease in serum potassium was observed via an increase in fecal potassium excretion. In a clinical study in healthy adult volunteers, a significant increase in fecal potassium excretion and a significant decrease in urinary potassium excretion were observed. Overall, patiromer is a high-capacity potassium binder, and the chemical and physical characteristics of patiromer may lead to good clinical efficacy, tolerability, and patient acceptance.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Jerry Buysse
- Tricida, Inc, South San Francisco, CA, USA Guest Editor: Sharon L. Hale
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New Agents in Treatment of Hyperkalemia: an Opportunity to Optimize Use of RAAS Inhibitors for Blood Pressure Control and Organ Protection in Patients with Chronic Kidney Disease. Curr Hypertens Rep 2016; 18:55. [DOI: 10.1007/s11906-016-0663-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Martín-Pérez M, Ruigómez A, Michel A, García Rodríguez LA. Impact of hyperkalaemia definition on incidence assessment: implications for epidemiological research based on a large cohort study in newly diagnosed heart failure patients in primary care. BMC FAMILY PRACTICE 2016; 17:51. [PMID: 27145981 PMCID: PMC4857380 DOI: 10.1186/s12875-016-0448-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 04/22/2016] [Indexed: 01/06/2023]
Abstract
Background Various definitions of hyperkalaemia have been used in clinical research, and data from routine clinical practice on its incidence are sparse. We aimed to establish the incidence of hyperkalaemia in patients with newly diagnosed heart failure in the UK general population using different definitions for the condition. Methods We conducted a large retrospective cohort study using data from The Health Improvement Network primary care database. Patients with newly diagnosed heart failure (N = 19,194) were identified and followed until the first occurrence of hyperkalaemia. Different serum potassium (K+) thresholds were evaluated as possible definitions for hyperkalaemia, and incidence rates (IRs) calculated using a final operational definition both overall and among patient sub-groups. Results IRs of hyperkalaemia ranged from 0.92–7.93 per 100 person-years according to the definition. Based on considerable differences in the serum K+ normal range used between practices, 2176 (11.3 %) individuals were identified with a record of hyperkalaemia using our operational definition of a proportional increase of ≥10 % above the upper bound of the normal range: IR 2.90 per 100 person-years (95 % CI 2.78–3.02) over a mean follow-up of 3.91 years. Incidence rates were higher in older patients, and in those with diabetes or renal impairment. Conclusions Hyperkalaemia is a common finding in heart failure patients in primary care, but its incidence can vary nearly ten-fold depending on its definition. Since assessment of hyperkalaemia risk is essential for therapeutic decision making in heart failure patients, this finding warrants consideration in future epidemiological studies.
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Affiliation(s)
- Mar Martín-Pérez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain
| | - Ana Ruigómez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain
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Chang AR, Sang Y, Leddy J, Yahya T, Kirchner HL, Inker LA, Matsushita K, Ballew SH, Coresh J, Grams ME. Antihypertensive Medications and the Prevalence of Hyperkalemia in a Large Health System. Hypertension 2016; 67:1181-8. [PMID: 27067721 DOI: 10.1161/hypertensionaha.116.07363] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 03/11/2016] [Indexed: 01/13/2023]
Abstract
Little is known about the frequency and patterns of hyperkalemia in clinical settings. We evaluated the association between baseline antihypertensive medications that may affect potassium levels (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, loop/thiazide diuretics, and potassium-sparing diuretics) and hyperkalemia, defined by potassium >5 mEq/L and >5.5 mEq/L, over a 3-year time period in 194 456 outpatients in the Geisinger Health System, as well as actions taken after an episode of hyperkalemia. The proportions of patients with 0, <2, 2 to 4, and ≥4 potassium measurements per year were 20%, 58%, 16%, and 6%. Potassium levels >5 mEq/L and >5.5 mEq/L occurred in 10.8% and 2.3% of all patients over the 3-year period; among patients with ≥4 measurements per year, corresponding values were 39.4% and 14.6%. Most cases of hyperkalemia occurred only once during follow-up. The antihypertensive medication class most strongly associated with hyperkalemia was angiotensin-converting enzyme inhibitors. Among patients with a measurement of potassium >5.5 mEq/L, only 24% were seen by a nephrologist and 5.2% were seen by a dietician during the 3-year period. Short-term actions after a potassium measurement >5.5 mEq/L included emergency room visit (3.1% within 7 days), remeasurement of potassium (44.3% with 14 days), and change in a potassium-altering medication (26.4% within 60 days). The most common medication changes were discontinuation/dose reduction of an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or potassium-sparing diuretic, which occurred in 29.1% and 49.6% of people taking these medications, respectively. In conclusion, hyperkalemia is common. Future research may enable optimal renin-angiotensin-aldosterone system inhibitor use with improved management of hyperkalemia.
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Affiliation(s)
- Alex R Chang
- From the Division of Nephrology, Geisinger Health System, Danville, PA (A.R.C., J.L., T.Y.); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD (Y.S., K.M., S.H.B., J.C., M.E.G.); Geisinger Health System, Biomedical and Translational Informatics, Danville, PA (H.L.K.); Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.); and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD (M.E.G.).
| | - Yingying Sang
- From the Division of Nephrology, Geisinger Health System, Danville, PA (A.R.C., J.L., T.Y.); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD (Y.S., K.M., S.H.B., J.C., M.E.G.); Geisinger Health System, Biomedical and Translational Informatics, Danville, PA (H.L.K.); Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.); and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD (M.E.G.)
| | - Julia Leddy
- From the Division of Nephrology, Geisinger Health System, Danville, PA (A.R.C., J.L., T.Y.); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD (Y.S., K.M., S.H.B., J.C., M.E.G.); Geisinger Health System, Biomedical and Translational Informatics, Danville, PA (H.L.K.); Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.); and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD (M.E.G.)
| | - Taher Yahya
- From the Division of Nephrology, Geisinger Health System, Danville, PA (A.R.C., J.L., T.Y.); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD (Y.S., K.M., S.H.B., J.C., M.E.G.); Geisinger Health System, Biomedical and Translational Informatics, Danville, PA (H.L.K.); Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.); and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD (M.E.G.)
| | - H Lester Kirchner
- From the Division of Nephrology, Geisinger Health System, Danville, PA (A.R.C., J.L., T.Y.); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD (Y.S., K.M., S.H.B., J.C., M.E.G.); Geisinger Health System, Biomedical and Translational Informatics, Danville, PA (H.L.K.); Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.); and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD (M.E.G.)
| | - Lesley A Inker
- From the Division of Nephrology, Geisinger Health System, Danville, PA (A.R.C., J.L., T.Y.); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD (Y.S., K.M., S.H.B., J.C., M.E.G.); Geisinger Health System, Biomedical and Translational Informatics, Danville, PA (H.L.K.); Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.); and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD (M.E.G.)
| | - Kunihiro Matsushita
- From the Division of Nephrology, Geisinger Health System, Danville, PA (A.R.C., J.L., T.Y.); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD (Y.S., K.M., S.H.B., J.C., M.E.G.); Geisinger Health System, Biomedical and Translational Informatics, Danville, PA (H.L.K.); Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.); and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD (M.E.G.)
| | - Shoshana H Ballew
- From the Division of Nephrology, Geisinger Health System, Danville, PA (A.R.C., J.L., T.Y.); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD (Y.S., K.M., S.H.B., J.C., M.E.G.); Geisinger Health System, Biomedical and Translational Informatics, Danville, PA (H.L.K.); Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.); and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD (M.E.G.)
| | - Josef Coresh
- From the Division of Nephrology, Geisinger Health System, Danville, PA (A.R.C., J.L., T.Y.); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD (Y.S., K.M., S.H.B., J.C., M.E.G.); Geisinger Health System, Biomedical and Translational Informatics, Danville, PA (H.L.K.); Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.); and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD (M.E.G.)
| | - Morgan E Grams
- From the Division of Nephrology, Geisinger Health System, Danville, PA (A.R.C., J.L., T.Y.); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD (Y.S., K.M., S.H.B., J.C., M.E.G.); Geisinger Health System, Biomedical and Translational Informatics, Danville, PA (H.L.K.); Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.); and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD (M.E.G.)
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Garimella PS, Jaber BL. Patiromer for Hyperkalemia in Diabetic CKD: A New Kid on the Block. Am J Kidney Dis 2016; 67:545-7. [PMID: 26806002 DOI: 10.1053/j.ajkd.2016.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 01/05/2016] [Indexed: 11/11/2022]
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Abbas S, Ihle P, Harder S, Schubert I. Risk of hyperkalemia and combined use of spironolactone and long-term ACE inhibitor/angiotensin receptor blocker therapy in heart failure using real-life data: a population- and insurance-based cohort. Pharmacoepidemiol Drug Saf 2015; 24:406-13. [PMID: 25683504 DOI: 10.1002/pds.3748] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 11/24/2014] [Accepted: 12/08/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Clinical trials and few observational studies report increased hyperkalemia risks in heart failure patients receiving aldosterone blockers in addition to standard therapy. The aim of this study is to assess the hyperkalemia risk and combined use of spironolactone and long-term ACE (angiotensin-converting enzyme) inhibitor/angiotensin receptor blocker (ARB) therapy for heart failure in a real-life setting of a heterogeneous population. METHODS Using claims data of the statutory health insurance fund AOK, covering 30% of the German population, we performed a nested case-control study in a cohort of heart failure patients receiving continuous ACE/ARB therapy (n = 1,491,894). Hyperkalemia risk associated with concurrent use of spironolactone and ACE/ARB was calculated by conditional logistic regression in 1062 cases and 10,620 risk-set-sampling-matched controls. RESULTS Risk of hyperkalemia in heart failure patients was significantly associated with spironolactone use (odds ratio (OR) (95% confidence interval (CI)) = 13.59 (11.63-15.88) in all and 11.05 (8.67-14.08) in those with information on New York Heart Association (NYHA) stage of disease). In the NYHA subpopulation, higher risk estimates were observed in short-term as compared with long-term users (OR (95%CI) = 13.00 (9.82-17.21) and 9.12 (6.78-12.26), respectively). Moreover, the association was stronger in older (≥70 years of age) as compared with younger patients (<70 years of age) (OR (95%CI) = 12.32 (9.35-16.23) and 8.73 (5.05-15.08), respectively), although interaction was not significant (pinteraction = 0.07). CONCLUSIONS Hyperkalemia risk associated with combined use of spironolactone and ACE/ARB is much stronger in real-life practice than observed in clinical trials. Careful potassium level monitoring in concomitant users of spironolactone and ACE/ARB is necessary.
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Affiliation(s)
- Sascha Abbas
- PMV Research Group at the Department of Child and Adolescent Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
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Bezalel S, Mahlab-Guri K, Asher I, Werner B, Sthoeger ZM. Angiotensin-converting enzyme inhibitor-induced angioedema. Am J Med 2015; 128:120-5. [PMID: 25058867 DOI: 10.1016/j.amjmed.2014.07.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 07/13/2014] [Accepted: 07/14/2014] [Indexed: 01/13/2023]
Abstract
Angiotensin-converting enzyme inhibitors (ACE-I) are widely used, effective, and well-tolerated antihypertensive agents. The mechanisms by which those agents act can cause side effects such as decreased blood pressure, hyperkalemia, and impaired renal function. ACE-I can induce cough in 5%-35% and angioedema in up to 0.7% of treated patients. Because cough and angioedema are considered class adverse effects, switching treatment to other ACE-I agents is not recommended. Angioedema due to ACE-I has a low fatality rate, although deaths have been reported when the angioedema involves the airways. Here, we review the role of bradykinin in the development of angioedema in patients treated with ACE-I, as well as the incidence, risk factors, clinical presentation, and available treatments for ACE-I-induced angioedema. We also discuss the risk for recurrence of angioedema after switching from ACE-I to angiotensin receptor blockers treatment.
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Affiliation(s)
- Shira Bezalel
- Departments of Medicine B, Clinical Immunology Allergy and AIDS, Kaplan Medical Center, Rehovot, Israel
| | - Keren Mahlab-Guri
- Departments of Medicine B, Clinical Immunology Allergy and AIDS, Kaplan Medical Center, Rehovot, Israel
| | - Ilan Asher
- Departments of Medicine B, Clinical Immunology Allergy and AIDS, Kaplan Medical Center, Rehovot, Israel
| | - Ben Werner
- Departments of Medicine B, Clinical Immunology Allergy and AIDS, Kaplan Medical Center, Rehovot, Israel
| | - Zev Moshe Sthoeger
- Departments of Medicine B, Clinical Immunology Allergy and AIDS, Kaplan Medical Center, Rehovot, Israel.
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Panhwar AH, Kazi TG, Afridi HI, Arain SA, Arain MS, Brahman KD, Ullah N, Ali J, Arain SS. Comparative evaluation of essential and toxic elements in the blood of kidney failure patients and healthy referents. ENVIRONMENTAL MONITORING AND ASSESSMENT 2015; 187:37. [PMID: 25632899 DOI: 10.1007/s10661-014-4246-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/29/2014] [Indexed: 06/04/2023]
Abstract
The aim of the present study was to evaluate the comparative distribution, correlation, and apportionment of selected elements-aluminum (Al), calcium (Ca), cadmium (Cd), potassium (K), magnesium (Mg), sodium (Na), and lead (Pb)-in the blood samples of male kidney failure patients (KFP) and healthy subjects of age ranged 30-60 years. The blood samples were digested with nitric acid and perchloric acid mixture (2:1), followed by the quantification of elements by atomic absorption spectrometry. The concentration of essential elements in blood samples of KFP were found in the range of Ca (97-125), Mg (18-36), Na (2971-3685), and K (177-270) mg/L while, the levels of Al, Cd, and Pb were found in the range of (475-1275), (0.9-9.9), and (211-623) μg/L, respectively. In the healthy referents, concentration of electrolytes in blood samples was lower than KFP, but difference was not significant (p > 0.05). While the levels of toxic elements in blood samples of referents were three- to sixfold lower than KFP (p < 0.01). Principal component analysis (PCA) and cluster analysis (CA) of the element data manifested diverse apportionment of the selected elements in the blood sample of the KFP compared with the healthy counterparts.
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Affiliation(s)
- Abdul Haleem Panhwar
- National Center of Excellence in Analytical Chemistry, University of Sindh, Jamshoro, 76080, Pakistan,
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Michel A, Martín-Pérez M, Ruigómez A, García Rodríguez LA. Risk factors for hyperkalaemia in a cohort of patients with newly diagnosed heart failure: a nested case-control study in UK general practice. Eur J Heart Fail 2015; 17:205-13. [PMID: 25581138 DOI: 10.1002/ejhf.226] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/09/2014] [Accepted: 12/12/2014] [Indexed: 12/22/2022] Open
Abstract
AIMS The aim of this study was to identify risk factors for hyperkalaemia in a cohort of patients with newly diagnosed heart failure in the UK. METHODS AND RESULTS A nested case-control study was conducted using data from The Health Improvement Network primary care database. A cohort of 19 194 patients aged 1-89 years between January 2000 and December 2005 with newly diagnosed heart failure was followed up and cases of hyperkalaemia identified. Cases were frequency matched to controls by age, sex, and calendar year, and information on demographics, co-morbidities, co-medications, and lifestyle factors was extracted from the database. Using unconditional logistic regression models, odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to identify potential risk factors. In total, 2176 hyperkalaemia cases were identified over a mean follow-up of 3.9 years. Significant risk factors for hyperkalaemia were: renal failure (OR 3.81; 95% CI 3.29-4.42), type II diabetes (OR 1.52; 95% CI 1.31-1.75), valvular heart disease (OR 1.28; 95% CI 1.06-1.54), and current use of potassium-sparing diuretics (OR 3.01; 95% CI 2.61-3.48), ACE inhibitors (OR 1.70; 95% CI 1.41-2.04), trimethoprim (OR 2.82; 95% CI 1.88-4.23), non-steroidal anti-inflammatory drugs (OR 1.41; 95% CI 1.11-1.79), and several drug combinations. The risk was highest within the first month of medication use and decreased thereafter. CONCLUSION Our findings may help to better identify patients with heart failure most likely to benefit from careful monitoring of serum potassium levels. Particular vigilance is needed during the start of treatment with certain medications.
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Characterization and Prediction of Adverse Events From Intensive Chronic Heart Failure Management and Effect on Quality of Life: Results From the Pro-B-Type Natriuretic Peptide Outpatient-Tailored Chronic Heart Failure Therapy (PROTECT) Study. J Card Fail 2015; 21:9-15. [DOI: 10.1016/j.cardfail.2014.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 10/01/2014] [Accepted: 10/13/2014] [Indexed: 11/23/2022]
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Pfeffer MA, Claggett B, Assmann SF, Boineau R, Anand IS, Clausell N, Desai AS, Diaz R, Fleg JL, Gordeev I, Heitner JF, Lewis EF, O'Meara E, Rouleau JL, Probstfield JL, Shaburishvili T, Shah SJ, Solomon SD, Sweitzer NK, McKinlay SM, Pitt B. Regional variation in patients and outcomes in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) trial. Circulation 2014; 131:34-42. [PMID: 25406305 DOI: 10.1161/circulationaha.114.013255] [Citation(s) in RCA: 689] [Impact Index Per Article: 68.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) patients with heart failure and preserved left ventricular ejection fraction assigned to spironolactone did not achieve a significant reduction in the primary composite outcome (time to cardiovascular death, aborted cardiac arrest, or hospitalization for management of heart failure) compared with patients receiving placebo. In a post hoc analysis, an ≈4-fold difference was identified in this composite event rate between the 1678 patients randomized from Russia and Georgia compared with the 1767 enrolled from the United States, Canada, Brazil, and Argentina (the Americas). METHODS AND RESULTS To better understand this regional difference in clinical outcomes, demographic characteristics of these populations and their responses to spironolactone were explored. Patients from Russia/Georgia were younger, had less atrial fibrillation and diabetes mellitus, but were more likely to have had prior myocardial infarction or a hospitalization for heart failure. Russia/Georgia patients also had lower left ventricular ejection fraction and creatinine but higher diastolic blood pressure (all P<0.001). Hyperkalemia and doubling of creatinine were more likely and hypokalemia was less likely in patients receiving spironolactone in the Americas with no significant treatment effects in Russia/Georgia. All clinical event rates were markedly lower in Russia/Georgia, and there was no detectable impact of spironolactone on any outcomes. In contrast, in the Americas, the rates of the primary outcome, cardiovascular death, and hospitalization for heart failure were significantly reduced by spironolactone. CONCLUSIONS This post hoc analysis demonstrated greater potassium and creatinine changes and possible clinical benefits with spironolactone in patients with heart failure and preserved ejection fraction from the Americas. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00094302.
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Affiliation(s)
- Marc A Pfeffer
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.).
| | - Brian Claggett
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Susan F Assmann
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Robin Boineau
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Inder S Anand
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Nadine Clausell
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Akshay S Desai
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Rafael Diaz
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Jerome L Fleg
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Ivan Gordeev
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - John F Heitner
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Eldrin F Lewis
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Eileen O'Meara
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Jean-Lucien Rouleau
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Jeffrey L Probstfield
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Tamaz Shaburishvili
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Sanjiv J Shah
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Scott D Solomon
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Nancy K Sweitzer
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Sonja M McKinlay
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Bertram Pitt
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
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Fralick M, Macdonald EM, Gomes T, Antoniou T, Hollands S, Mamdani MM, Juurlink DN. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population based study. BMJ 2014; 349:g6196. [PMID: 25359996 PMCID: PMC4214638 DOI: 10.1136/bmj.g6196] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To determine whether the prescription of co-trimoxazole with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker is associated with sudden death. DESIGN Population based nested case-control study. SETTING Ontario, Canada, from 1 April 1994 to 1 January 2012. PARTICIPANTS Ontario residents aged 66 years or older treated with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker. Cases were those who died suddenly shortly after receiving an outpatient prescription for one of co-trimoxazole, amoxicillin, ciprofloxacin, norfloxacin, or nitrofurantoin. Each case was matched with up to four controls on age, sex, chronic kidney disease, and diabetes. MAIN OUTCOME MEASURE Odds ratio for the association between sudden death and exposure to each antibiotic relative to amoxicillin, after adjustment for predictors of sudden death according to a disease risk index. RESULTS Of 39,879 sudden deaths, 1027 occurred within seven days of exposure to an antibiotic and were matched to 3733 controls. Relative to amoxicillin, co-trimoxazole was associated with an increased risk of sudden death (adjusted odds ratio 1.38, 95% confidence interval 1.09 to 1.76). The risk was marginally higher at 14 days (adjusted odds ratio 1.54, 1.29 to 1.84). This corresponds to approximately three sudden deaths within 14 days per 1000 co-trimoxazole prescriptions. Ciprofloxacin (a known cause of QT interval prolongation) was also associated with an increased risk of sudden death (adjusted odds ratio 1.29, 1.03 to 1.62), but no such risk was observed with nitrofurantoin or norfloxacin. CONCLUSIONS In older patients receiving angiotensin converting enzyme inhibitors or angiotensin receptor blockers, co-trimoxazole is associated with an increased risk of sudden death. Unrecognized severe hyperkalemia may underlie this finding. When appropriate, alternative antibiotics should be considered in such patients.
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Affiliation(s)
- Michael Fralick
- Department of Internal Medicine, University of Toronto, Toronto, ON, Canada, M5G 2C4
| | - Erin M Macdonald
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, M5N 4M5
| | - Tara Gomes
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, M5N 4M5 Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada, M5B 1W8 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada, M5T 3M7
| | - Tony Antoniou
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, M5N 4M5 Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada, M5B 1W8 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada, M5T 3M7 Department of Family and Community Medicine, St Michael's Hospital, Toronto
| | - Simon Hollands
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, M5N 4M5
| | - Muhammad M Mamdani
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, M5N 4M5 Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada, M5B 1W8 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada, M5T 3M7 Applied Health Research Centre, St Michael's Hospital, Toronto King Saud University, Riyadh, Saudi Arabia
| | - David N Juurlink
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, M5N 4M5 Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada, M5B 1W8 Sunnybrook Research Institute, Toronto, ON, Canada, M4N 3M5 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada, M5T 3M7
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Thomason JD, Rapoport G, Fallaw T, Calvert CA. The influence of enalapril and spironolactone on electrolyte concentrations in Doberman pinschers with dilated cardiomyopathy. Vet J 2014; 202:573-7. [PMID: 25257351 DOI: 10.1016/j.tvjl.2014.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 09/03/2014] [Accepted: 09/05/2014] [Indexed: 11/26/2022]
Abstract
The combination of an angiotensin-converting enzyme inhibitor (ACEI) with an aldosterone receptor antagonist can increase serum potassium and magnesium and lower serum sodium concentrations. The objective of this study was to retrospectively determine whether an ACEI and spironolactone can be co-administered to Doberman pinschers with occult dilated cardiomyopathy without serious adverse influences on serum electrolyte concentrations. Between 2001 and 2007, 26 client-owned Doberman pinschers were given enalapril, spironolactone, and carvedilol and followed for at least 6 months. Most dogs had been prescribed mexiletine for ventricular tachyarrhythmia suppression. Dogs were treated with pimobendan when congestive heart failure was imminent. Baseline and follow-up (3-10 visits) color-flow Doppler echocardiograms, serum urea nitrogen (SUN), creatinine, sodium, potassium, and magnesium concentration data were tabulated. Compared to baseline data, there were no significant changes in serum sodium or serum creatinine concentrations. Serum magnesium (P = 0.003), serum potassium (P = 0.0001), and SUN (P = 0.0001) concentrations increased significantly with time. Although the combination of ACEI and spironolactone was associated with significant increases in magnesium, potassium, and SUN concentrations, these changes were of no apparent clinical relevance. At the dosages used in this study, this combination of drugs appears safe.
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Affiliation(s)
- J D Thomason
- Department of Veterinary Clinical Sciences, Veterinary Health Center, Kansas State University, 1800 Dension Ave., Manhattan, KS 66506, USA.
| | - G Rapoport
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, 501 DW Brooks Dr., Athens, GA 30602, USA
| | - T Fallaw
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, 501 DW Brooks Dr., Athens, GA 30602, USA
| | - C A Calvert
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, 501 DW Brooks Dr., Athens, GA 30602, USA
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Rossignol P, Dobre D, Gregory D, Massaro J, Kiernan M, Konstam M, Zannad F. Incident hyperkalemia may be an independent therapeutic target in low ejection fraction heart failure patients: Insights from the HEAAL study. Int J Cardiol 2014; 173:380-7. [DOI: 10.1016/j.ijcard.2014.02.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 11/25/2013] [Accepted: 02/22/2014] [Indexed: 10/25/2022]
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71
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Current Evidence on Treatment of Patients With Chronic Systolic Heart Failure and Renal Insufficiency. J Am Coll Cardiol 2014; 63:853-71. [DOI: 10.1016/j.jacc.2013.11.031] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 11/18/2013] [Accepted: 11/19/2013] [Indexed: 01/23/2023]
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72
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Pitt B, Latini R, Maggioni AP, Solomon SD, Smith BA, Wright M, Prescott MF, McMurray JJ. Neurohumoral effects of aliskiren in patients with symptomatic heart failure receiving a mineralocorticoid receptor antagonist: the Aliskiren Observation of Heart Failure Treatment study. Eur J Heart Fail 2014; 13:755-64. [DOI: 10.1093/eurjhf/hfr034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Roberto Latini
- Department of Cardiovascular Research; Istituto di Ricerche Farmacologiche Mario Negri; Milan Italy
| | | | | | | | | | | | - John J.V. McMurray
- Brigham & Women's Hospital; Boston MA USA
- British Heart Foundation Cardiovascular and Research Centre; University of Glasgow; 126 University Place Glasgow G12 8TA UK
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Kiernan MS, Wentworth D, Francis G, Martinez FA, Dickstein K, Komajda M, Zannad F, Neaton JD, Konstam MA. Predicting adverse events during angiotensin receptor blocker treatment in heart failure: results from the HEAAL trial. Eur J Heart Fail 2014. [DOI: 10.1093/eurjhf/hfs145] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Michael S. Kiernan
- Tufts Medical Center; Tufts University School of Medicine; Boston MA USA
| | - Deborah Wentworth
- University of Minnesota; School of Public Health; Minneapolis MN USA
| | - Gary Francis
- xx; University of Minnesota School of Medicine; Minneapolis MN USA
| | - Felipe A. Martinez
- Cordoba National University; Rusculleda Foundation for Clinical Research; Cordoba Argentina
| | | | - Michel Komajda
- Universite Pierre et Marie Curie-Paris 6; Pitie-Salpetriere Hospital; Paris France
| | - Faiez Zannad
- Henri Poincare University of Nancy; Nancy France
| | - James D. Neaton
- University of Minnesota; School of Public Health; Minneapolis MN USA
| | - Marvin A. Konstam
- Tufts Medical Center; Tufts University School of Medicine; Boston MA USA
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Tomey MI, Winston JA. Cardiovascular pathophysiology in chronic kidney disease: opportunities to transition from disease to health. Ann Glob Health 2013; 80:69-76. [PMID: 24751567 DOI: 10.1016/j.aogh.2013.12.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/01/2013] [Accepted: 12/19/2013] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is common, and is associated with a high burden of cardiovascular disease. This cardiovascular risk is incompletely explained by traditional risk factors, calling attention to a need to better understand the pathways in CKD contributing to adverse cardiovascular outcomes. FINDINGS Pathophysiological derangements associated with CKD, including disordered sodium, potassium, and water homeostasis, renin-angiotensin-aldosterone and sympathetic activity, anemia, bone and mineral metabolism, uremia, and toxin accumulation may contribute directly to progression of cardiovascular disease and adverse outcomes. CONCLUSION Improving cardiovascular health in patients with CKD requires improved understanding of renocardiac pathophysiology. Ultimately, the most successful strategy may be prevention of incident CKD itself.
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Affiliation(s)
- Matthew I Tomey
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Jonathan A Winston
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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75
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Mathieson L, Severn A, Guthrie B. Monitoring and adverse events in relation to ACE inhibitor/angiotensin receptor blocker initiation in people with diabetes in general practice: a population database study. Scott Med J 2013; 58:69-76. [PMID: 23728750 DOI: 10.1177/0036933013482634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIM To determine whether angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) initiation in people with diabetes is monitored as recommended by recent guidelines and the incidence of associated adverse renal events. DESIGN Retrospective population database analysis of 4056 people in Tayside, Scotland with type 2 diabetes prescribed an ACEI/ARB between 1 January 2005 and 31 December 2009. METHOD Measurement of urea and electrolytes (U&Es) before and after ACEI/ARB initiation and renal adverse events; defined as a ≥30% rise in serum creatinine and post-initiation potassium of ≥5.6 mmol/L. Associations of adverse events with patient demographics or co-prescription of drugs with known renal effects were examined. RESULTS Overall, 89% of initiations were with an ACE inhibitor. A total of 18.84% (CI 95% 18.82-18.86) of patients initiating ACE inhibitor or ARB had U&Es measured in the 90 days before initiation and within 5-14 days after initiation. Only 1.7% of patients had an adverse renal event. Patients prescribed with an ARB were less likely to be monitored than those prescribed with an ACE inhibitor, but no less likely to suffer harm. CONCLUSIONS Current clinical practice of biochemical monitoring of ACE inhibitor/ARB is poor, but adverse events are rare. Further studies with serial U&Es are needed to establish the critical time window for adverse renal events and evaluate whether intensive biochemical monitoring recommended is required in low-risk groups.
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Rossignol P, Dobre D, McMurray JJV, Swedberg K, Krum H, van Veldhuisen DJ, Shi H, Messig M, Vincent J, Girerd N, Bakris G, Pitt B, Zannad F. Incidence, determinants, and prognostic significance of hyperkalemia and worsening renal function in patients with heart failure receiving the mineralocorticoid receptor antagonist eplerenone or placebo in addition to optimal medical therapy: results from the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF). Circ Heart Fail 2013; 7:51-8. [PMID: 24297687 DOI: 10.1161/circheartfailure.113.000792] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists improve outcomes in patients with systolic heart failure but may induce worsening of renal function (WRF) and hyperkalemia (HK). We assessed the risk factors for mineralocorticoid receptor antagonist-related WRF and for HK, as well as the association between HK and WRF with clinical outcomes in the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF). METHODS AND RESULTS Serial changes in estimated glomerular filtration rate and in serum potassium were available in 2737 patients during a median 21-month follow-up. HK variably defined as serum K>4.5, 5, or 5.5 mmol/L occurred in 74.7%, 32.5%, and 8.9% patients enrolled in EMPHASIS-HF, respectively. WRF defined as a decrease in estimated glomerular filtration rate>20% or >30% from baseline occurred in 27% and 14% of patients, respectively. Patients assigned eplerenone displayed modest and early but significant and persistent (1) rise in serum potassium and (2) reduction in estimated glomerular filtration rate when compared with those assigned placebo. In multivariate analyses, eplerenone was associated with a higher incidence of WRF and HK, which were interrelated and also associated with baseline patient characteristics (eg, age≥75 years, hypertension, diabetes mellitus, nonwhite race, ejection fraction<30%, and treatment with an antiarrythmics drug or loop diuretic). Eplerenone retained its survival benefits without any significant interaction with the association between HK>5.5 mmol/L only and WRF and worse outcomes. CONCLUSIONS In patients with heart failure receiving optimal therapy, WRF and HK were more frequent when eplerenone was added, but their occurrence did not eliminate the survival benefit of eplerenone. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00232180.
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Affiliation(s)
- Patrick Rossignol
- Inserm, Centre d'Investigations Cliniques- 9501, and Inserm U1116, Nancy, France
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Heerspink HJL, Gao P, Zeeuw DD, Clase C, Dagenais GR, Sleight P, Lonn E, Teo KT, Yusuf S, Mann JF. The effect of ramipril and telmisartan on serum potassium and its association with cardiovascular and renal events: Results from the ONTARGET trial. Eur J Prev Cardiol 2013; 21:299-309. [DOI: 10.1177/2047487313510678] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Hiddo J Lambers Heerspink
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peggy Gao
- Population Health Research Institute, McMaster University, Canada
| | - Dick de Zeeuw
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Catherine Clase
- Population Health Research Institute, McMaster University, Canada
| | - Gilles R Dagenais
- Department of Cardiology and Pneumologie, University of Montreal, Montreal, Quebec, Canada
| | | | - Eva Lonn
- Population Health Research Institute, McMaster University, Canada
| | - Koon T Teo
- Population Health Research Institute, McMaster University, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Canada
| | - Johannes F Mann
- Munich General Hospitals, Munich and Friedrich Alexander University, Germany
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Ritz E, Pitt B. Mineralocorticoid receptor blockade-a novel approach to fight hyperkalaemia in chronic kidney disease. Clin Kidney J 2013; 6:464-8. [PMID: 26120440 PMCID: PMC4438399 DOI: 10.1093/ckj/sft084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 06/28/2013] [Indexed: 01/06/2023] Open
Abstract
Hyperkalaemia continues to be a major hazard of mineralocorticoid receptor blockade in an effort to retard the progression of chronic kidney disease (CKD). In cardiac patients on mineralocorticoid receptor blockade, RLY-5016 which captures K+ in the colon has been effective in reducing the risk of hyperkalaemia. This compound might be useful in CKD as well.
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Affiliation(s)
- E Ritz
- Nierenzentrum , University of Heidelberg , Heidelberg , Germany
| | - B Pitt
- Internal Medicine and Cardiovascular Disease , University of Michigan Medical School , Ann Arbor, MI , USA
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79
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Howlett JG, MacFadyen JC. Traitement du diabète chez les personnes atteintes d'insuffisance cardiaque. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Valika AA, Gheorghiade M. Ace inhibitor therapy for heart failure in patients with impaired renal function: a review of the literature. Heart Fail Rev 2013; 18:135-40. [PMID: 22213014 DOI: 10.1007/s10741-011-9295-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Heart failure syndromes are often associated with multi-organ dysfunction, and concomitant liver, renal, and neurologic involvement is very common. Neuro-hormonal antagonism plays a key role in the management of this syndrome, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are one of the cornerstones of therapy. Cardiorenal physiology is becoming more recognized in these patients with advanced heart failure, and the role of neuro-hormonal blockade in this setting is vaguely defined in the literature. Often, angiotensin-converting enzyme inhibitors are decreased or even withheld in these circumstances. The purpose of this article is to review the role and pathophysiology of ace inhibition and angiotensin receptor blockade in patients with acute and chronic heart failure syndromes and concomitant cardiorenal physiology.
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Affiliation(s)
- Ali A Valika
- Cardiology, Northwestern University Feinberg School of Medicine, 675 N. St. Clair, Galter Pavilion, Suite#11-120, Chicago, IL 60601, USA.
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Garg N, Thomas G, Jackson G, Rickard J, Nally JV, Tang WW, Navaneethan SD. Cardiac resynchronization therapy in CKD: a systematic review. Clin J Am Soc Nephrol 2013; 8:1293-303. [PMID: 23660183 PMCID: PMC3731896 DOI: 10.2215/cjn.00750113] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 03/27/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) confers morbidity and mortality benefits to selected patients with heart failure. This systematic review examined effects of CRT in CKD patients (estimated GFR [eGFR] <60 ml/min per 1.73 m(2)). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS MEDLINE and Scopus (from 1990 to December 2012) and conference proceedings abstracts were searched for relevant observational studies and randomized controlled trials (RCTs). Studies comparing the following outcomes were included: (1) CKD patients with and without CRT and (2) CKD patients with CRT to non-CKD patients with CRT. Mortality, eGFR, and left ventricular ejection fraction data were extracted and pooled when appropriate using a random-effects model. RESULTS Eighteen studies (14 observational studies and 4 RCTs) were included. There was a modest improvement in eGFR with CRT among CKD patients (mean difference 2.30 ml/min per 1.73m(2); 95% confidence interval, 0.33 to 4.27). Similarly, there was a significant improvement in left ventricular ejection with CRT in CKD patients (mean difference 6.24%; 95% confidence interval, 3.46 to 9.07). Subgroup analysis of three RCTs reported lower rates of death or hospitalization for heart failure with CRT (versus other therapy) in the CKD population. Survival outcomes of CKD patients (compared with the non-CKD population) with CRT differed among observational studies and RCTs. CONCLUSIONS CRT improves left ventricular and renal function in the CKD population with heart failure. Given the increasing use of cardiac devices, further studies examining the effects of CRT on mortality in CKD patients, particularly those with advanced kidney disease, are warranted.
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Affiliation(s)
- Neha Garg
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - George Thomas
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gregory Jackson
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Rickard
- Department of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Joseph V. Nally
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - W.H. Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; and
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Sankar D. Navaneethan
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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Lefebvre HP, Ollivier E, Atkins CE, Combes B, Concordet D, Kaltsatos V, Baduel L. Safety of spironolactone in dogs with chronic heart failure because of degenerative valvular disease: a population-based, longitudinal study. J Vet Intern Med 2013; 27:1083-91. [PMID: 23869534 DOI: 10.1111/jvim.12141] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 04/10/2013] [Accepted: 06/04/2013] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Spironolactone treatment in humans is associated with an increased risk of hyperkalemia and renal dysfunction. HYPOTHESIS Dogs with cardiac disease treated with spironolactone, in addition to conventional therapy, are not at higher risk for adverse events (AEs) than those receiving solely conventional therapy. ANIMALS One hundred and ninety-six client-owned dogs with naturally occurring myxomatous mitral valve disease. METHODS Prospective, double-blinded field study with dogs randomized to receive either spironolactone (2 mg/kg once a day) or placebo in addition to conventional therapy (angiotensin-converting enzyme inhibitor, plus furosemide and digoxin if needed). Safety was compared between treatment groups, using the frequency of AEs, death caused by cardiac disease, renal disease, or both, and variations in serum sodium, potassium, urea, and creatinine concentrations. For the latter, population-specific reference intervals were established and out of range values (ORV) analyzed. RESULTS The number of AEs was similar in the spironolactone and reference groups (188 and 208, respectively), when followed for median duration of 217 days (range [2-1,333]). At each study time point, the percentage of dogs showing ORV was similar between groups. There were a higher number of deaths because of cardiac disease, renal disease or both in the reference group (30.7% versus 13.7%) (P = .0043). CONCLUSIONS AND CLINICAL IMPORTANCE Dogs with heart failure receiving spironolactone in addition to conventional treatment are not at a higher risk for AEs, death caused by cardiac disease, renal disease, or both, hyperkalemia, or azotemia.
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Affiliation(s)
- H P Lefebvre
- INP, Ecole Nationale Vétérinaire de Toulouse, Unité de Recherche Clinique & Département des Sciences Cliniques, Université de Toulouse, Toulouse, France
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Haas CS, Pohlenz I, Lindner U, Muck PM, Arand J, Suefke S, Lehnert H. Renal tubular acidosis type IV in hyperkalaemic patients--a fairy tale or reality? Clin Endocrinol (Oxf) 2013; 78:706-11. [PMID: 22891694 DOI: 10.1111/j.1365-2265.2012.04446.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 02/15/2012] [Accepted: 04/21/2012] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Hyperkalaemia is a common feature in hospitalized patients and often attributed to drugs antagonizing the renin-angiotensin-aldosterone system (RAAS) and/or acute kidney injury (AKI), despite significantly preserved glomerular filtration rate (GFR). The objective of this study was to determine the prevalence and role of renal tubular acidosis type IV (RTA IV) in the development of significant hyperkalaemia. DESIGN A single-centre retrospective study. PATIENTS Patients admitted to a University Hospital over 12 months. MEASUREMENTS Patients with a potassium value > 6·0 mm were identified. Clinical and laboratory data were revisited, and patients with a normal anion gap metabolic acidosis were evaluated for the existence of RTA IV. RESULTS A total of 57 patients having significant hyperkalaemia (>6·0 mm) were identified. Twelve patients had end-stage renal disease, while 21 patients had solely AKI or progressive chronic renal failure. RTA IV was present in 24 patients (42%), of whom 71% had pre-existing renal insufficiency because of diabetic nephropathy or tubulointerstitial nephritis. All hyperkalaemic patients with urinary/serum electrolytes suggestive of RTA IV had evidence of AKI, but creatinine levels were significantly lower (P < 0·05), while the number of drugs antagonizing the RAAS was comparable. CONCLUSION We demonstrated that RTA IV (i) is very common in patients with hyperkalaemia; (ii) should always be suspected in hyperkalaemic patients with only moderately impaired GFR; and (iii) may result in significant hyperkalaemia in the presence of both AKI and drugs antagonizing the RAAS.
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Affiliation(s)
- Christian S Haas
- Department of Medicine I, University of Luebeck, Ratzeburger Allee 160, Luebeck, Germany.
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Electrolyte abnormalities and laboratory findings in patients with out-of-hospital cardiac arrest who have kidney disease. Am J Emerg Med 2013; 31:487-93. [DOI: 10.1016/j.ajem.2012.09.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 09/21/2012] [Accepted: 09/24/2012] [Indexed: 11/24/2022] Open
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Abstract
Hyperkalaemia is well recognized as a medical emergency. However, with the publication of trials showing benefit with renin-aldosterone axis suppression in heart failure, the epidemiology of patients presenting with hyperkalaemia has changed. The reported incidence of rate of serious hyperkalaemia (>6.0 mEq/l of potassium) ranges from 6 to 12% in patients on spironolactone with congestive cardiac failure (CCF). A rational choice of therapy based on present evidence is different from the traditionally used algorithm, given our understanding of the physiology relevant to this patient group. This article discusses the changing face of hyperkalaemia and the present evidence and discusses options in treatment of hyperkalaemia.
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Affiliation(s)
- A Chapagain
- Department of Renal Medicine and Transplantation, St Bartholomew's and the Royal London Hospital, London E1 1BB, UK.
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87
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Management of hyperkalaemia consequent to mineralocorticoid-receptor antagonist therapy. Nat Rev Nephrol 2012; 8:691-9. [DOI: 10.1038/nrneph.2012.217] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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KURIACHAN VIKAS, TEDROW USHA, ANTMAN ELLIOTT, EPSTEIN LAURENCEM. Acute Hyperkalemia Detected by Alert from Implantable Cardioverter-Defibrillator. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:e276-9. [DOI: 10.1111/j.1540-8159.2012.03471.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jain N, Kotla S, Little BB, Weideman RA, Brilakis ES, Reilly RF, Banerjee S. Predictors of hyperkalemia and death in patients with cardiac and renal disease. Am J Cardiol 2012; 109:1510-3. [PMID: 22342847 DOI: 10.1016/j.amjcard.2012.01.367] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 01/10/2012] [Accepted: 01/10/2012] [Indexed: 01/21/2023]
Abstract
Predictors of hyperkalemia in patients with cardiovascular disease (CVD; defined as patients with hypertension and heart failure) and associated chronic kidney disease (CKD) are not well established. The aim of this study was to ascertain risk factors of hyperkalemia (defined as serum potassium concentration >5.0 mEq/L) and associated all-cause mortality in patients with CVD treated with antihypertensive drugs that impair potassium homeostasis. In a retrospective analysis using a logistic regression model, risk factors for hyperkalemia and all-cause mortality were analyzed in 15,803 patients with CVD treated with antihypertensive drugs. The mean estimated glomerular filtration rate and mean serum potassium concentration were 55.55 ml/min/1.73 m(2) and 4.06 mEq/L, respectively. Hyperkalemia was observed in 24.5% of study patients and 1.7% of total hospital admissions. Compared to patients with normokalemia, those with hyperkalemia had a higher percentage of death (6.25% vs 2.92%, p = 0.0001) and admissions (7.80% vs 5.04%, p = 0.0001). Predictors of hyperkalemia were CKD stage (odds ratio [OR] 2.14, 95% confidence interval [CI] 2.02 to 2.28), diabetes mellitus (OR 1.59, 95% CI 1.47 to 1.72), coronary artery disease (OR 1.32, 95% CI 1.21 to 1.43), and peripheral vascular disease (OR 1.55, 95% CI 1.36 to 1.77). Predictors of all-cause mortality were CKD stage (OR 1.26, 95% CI 1.12 to 1.43), hyperkalemic event (OR 1.56, 95% CI 1.30 to 1.88), age (OR 1.04, 95% CI 1.03 to 1.05), and hospitalization (OR 1.04, 95% CI 1.04 to 1.05). In conclusion, hyperkalemia is encountered frequently in patients with established CVD who are taking antihypertensive drugs and is associated with increases in all-cause mortality and hospitalizations. Advanced CKD, diabetes mellitus, coronary artery disease, and peripheral vascular disease are independent predictors of hyperkalemia.
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Frequency and predictors of hyperkalemia in patients ≥60 years of age with heart failure undergoing intense medical therapy. Am J Cardiol 2012; 109:693-8. [PMID: 22152974 DOI: 10.1016/j.amjcard.2011.10.027] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 10/25/2011] [Accepted: 10/25/2011] [Indexed: 11/24/2022]
Abstract
Hyperkalemia is a concern in heart failure (HF), especially in older patients with co-morbidities. Previous studies addressing this issue have focused mainly on younger patients. This study was aimed at determining the frequency and predictors of hyperkalemia in older patients with HF undergoing intense medical therapy. Frequency and predictors of hyperkalemia were defined in patients (n = 566) participating in the Trial of Intensified versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure, in which patients ≥60 years of age were randomized to a standard versus an intensified N-terminal brain natriuretic peptide-guided HF therapy. During an 18-month follow-up 76 patients (13.4%) had hyperkalemia (≥5.5 mmol/L) and 28 (4.9%) had severe hyperkalemia (≥6.0 mmol/L). Higher baseline serum potassium (odds ratio [OR] 2.92 per mmol/L), baseline creatinine (OR 1.11 per 10 μmol/L), gout (OR 2.56), New York Heart Association (NYHA) class (compared to NYHA class II, IV OR 3.08), higher dosage of spironolactone at baseline (OR 1.20 per 12.5 mg/day), and higher dose changes of spironolactone (compared to no dose change: 12.5 mg, OR 1.45; 25 mg, OR 2.52; >25 mg, OR 3.24) were independent predictors for development of hyperkalemia (p <0.05 for all comparisons). In conclusion, hyperkalemia is common in patients ≥60 years of age with HF undergoing intense medical therapy. Risk is increased in patients treated with spironolactone, in addition to patient-specific risk factors such as chronic kidney disease, higher serum potassium, advanced NYHA class, and gout. Careful surveillance of serum potassium and cautious use of spironolactone in patients at risk may help to decrease the incidence of potentially hazardous complications caused by hyperkalemia.
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92
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Cernes R, Mashavi M, Zimlichman R. Differential clinical profile of candesartan compared to other angiotensin receptor blockers. Vasc Health Risk Manag 2011; 7:749-59. [PMID: 22241949 PMCID: PMC3253768 DOI: 10.2147/vhrm.s22591] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The advantages of blood pressure (BP) control on the risks of heart failure and stroke are well established. The renin-angiotensin system plays an important role in volume homeostasis and BP regulation and is a target for several groups of antihypertensive drugs. Angiotensin II receptor blockers represent a major class of antihypertensive compounds. Candesartan cilexetil is an angiotensin II type 1 (AT[1]) receptor antagonist (angiotensin receptor blocker [ARB]) that inhibits the actions of angiotensin II on the renin-angiotensin-aldosterone system. Oral candesartan 8–32 mg once daily is recommended for the treatment of adult patients with hypertension. Clinical trials have demonstrated that candesartan cilexetil is an effective agent in reducing the risk of cardiovascular mortality, stroke, heart failure, arterial stiffness, renal failure, retinopathy, and migraine in different populations of adult patients including patients with coexisting type 2 diabetes, metabolic syndrome, or kidney impairment. Clinical evidence confirmed that candesartan cilexetil provides better antihypertensive efficacy than losartan and is at least as effective as telmisartan and valsartan. Candesartan cilexetil, one of the current market leaders in BP treatment, is a highly selective compound with high potency, a long duration of action, and a tolerability profile similar to placebo. The most important and recent data from clinical trials regarding candesartan cilexetil will be reviewed in this article.
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Affiliation(s)
- Relu Cernes
- The Brunner Institute for Cardiovascular Research, Wolfson Medical Center and Tel Aviv University, Tel Aviv, Israel
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93
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Chang TI, Chertow GM. Chronic kidney disease and cardiovascular therapeutics: time to close the evidence gaps. J Am Coll Cardiol 2011; 58:1162-4. [PMID: 21884955 DOI: 10.1016/j.jacc.2011.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 06/07/2011] [Accepted: 06/14/2011] [Indexed: 11/16/2022]
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Bootsma JEM, Warlé-van Herwaarden MF, Verbeek ALM, Füssenich P, De Smet PAGM, Olde Rikkert MG, Kramers C. Adherence to biochemical monitoring recommendations in patients starting with renin angiotensin system inhibitors: a retrospective cohort study in the Netherlands. Drug Saf 2011; 34:605-14. [PMID: 21663336 DOI: 10.2165/11587250-000000000-00000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Renin angiotensin system inhibitors (RASIs) are frequently involved in serious adverse events. These events principally occur in high-risk patients and often arise within the first days after treatment initiation; therefore, guidelines recommend biochemical monitoring within 3 weeks after the start of therapy with RASIs. OBJECTIVE The purpose of this study was to examine the level of biochemical monitoring directly after treatment initiation with RASIs in patients with different risk profiles and to study the attitudes of the physicians involved towards biochemical monitoring. METHODS We carried out a retrospective analysis of 202 patients who started RASI therapy in 2006 in Groesbeek, the Netherlands. We determined the rate of serum creatinine and potassium monitoring within 3 weeks after the start of therapy. In addition, we studied the intentions and attitudes towards biochemical monitoring during RASI therapy among 68 general practitioners and medical specialists by way of a brief questionnaire. RESULTS Serum creatinine and potassium monitoring after treatment initiation was performed in 34% and 28% of patients, respectively. Of all the patients, 29% had two or more additional risk factors for renal function deterioration. In these high-risk patients, creatinine was significantly less often monitored compared with low-risk patients (22% vs 39%). In contrast to these findings, the prescribing physicians claimed to check serum creatinine within 2 weeks after treatment initiation in 85% of their patients. Most of the prescribing physicians (88%) rated this monitoring as (very) important. CONCLUSIONS We demonstrated that, despite positive intentions of physicians, the biochemical monitoring recommendation in patients treated with RASIs is poorly met. In addition, serum creatinine monitoring was significantly less often performed in high-risk patients compared with low-risk patients.
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Affiliation(s)
- Janet E M Bootsma
- Department of Pharmacology-Toxicology, Radboud University Nijmegen Medical Centre, the Netherlands.
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95
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Shah AM, Shin SH, Takeuchi M, Skali H, Desai AS, Køber L, Maggioni AP, Rouleau JL, Kelly RY, Hester A, Keefe D, McMurray JJV, Pfeffer MA, Solomon SD. Left ventricular systolic and diastolic function, remodelling, and clinical outcomes among patients with diabetes following myocardial infarction and the influence of direct renin inhibition with aliskiren. Eur J Heart Fail 2011; 14:185-92. [PMID: 21965526 DOI: 10.1093/eurjhf/hfr125] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
AIMS We assessed the relationship between diabetes and cardiac structure and function following myocardial infarction (MI) and whether diabetes influences the effect of direct renin inhibition on change in left ventricular (LV) size. METHODS AND RESULTS The ASPIRE trial enrolled 820 patients 2-8 weeks after MI with ejection fraction ≤ 45% and randomized them to the direct renin inhibitor aliskiren (n= 423) or placebo (n = 397) added to standard medical therapy. Echocardiography was performed at baseline and after 36 weeks in 672 patients with evaluable paired studies. Compared with non-diabetic patients, diabetic patients (n = 214) were at higher risk for a composite of cardiovascular (CV) death, heart failure hospitalization, recurrent MI, stroke, or aborted sudden death (14 vs. 7%; adjusted hazard ratio 1.63, 95% confidence interval 1.01-2.64, P= 0.045), despite similar left ventricular ejection fraction (37.9 ± 5.3 vs. 37.6 ± 5.2%, P= 0.48) and end-systolic volume (ESV) (84 ± 25 vs. 82 ± 28 mL, P= 0.46). Diabetic patients demonstrated greater concentric remodelling (relative wall thickness 0.38 ± 0.07 vs. 0.36 ± 0.07, P= 0.0002) and evidence of higher LV filling pressure (E/E' 11.1 ± 5.3 vs. 9.1 ± 4.3, P= 0.0011). At 36 weeks, diabetic patients experienced similar per cent reduction in ESV overall (-4.9 ± 17.9 vs. -5.5 ± 16.9, P= 0.67) but tended to experience greater reduction in ESV than non-diabetic patients when treated with aliskiren (interaction P = 0.08). CONCLUSIONS Compared with non-diabetic patients, diabetic patients are at increased risk of CV events post-MI despite no greater LV enlargement or reduction in systolic function. Diabetic patients demonstrate greater concentric remodelling and evidence of higher LV filling pressure, suggesting diastolic dysfunction as a potential mechanism for the higher risk observed among these patients.
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Affiliation(s)
- Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02445, USA.
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Antoniou T, Gomes T, Mamdani MM, Yao Z, Hellings C, Garg AX, Weir MA, Juurlink DN. Trimethoprim-sulfamethoxazole induced hyperkalaemia in elderly patients receiving spironolactone: nested case-control study. BMJ 2011; 343:d5228. [PMID: 21911446 PMCID: PMC3171211 DOI: 10.1136/bmj.d5228] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To characterise the risk of admission to hospital for hyperkalaemia in elderly patients treated with trimethoprim-sulfamethoxazole in combination with spironolactone. DESIGN Population based nested case-control study. SETTING Ontario, Canada, from 1 April 1992 to 1 March 2010. PARTICIPANTS Cases were residents of Ontario aged 66 years or above receiving chronic treatment with spironolactone and admitted to hospital with hyperkalaemia within 14 days of receiving a prescription for either trimethoprim-sulfamethoxazole, amoxicillin, norfloxacin, or nitrofurantoin. Up to four controls for each case were identified from the same cohort, matched on age, sex, and presence or absence of chronic kidney disease and diabetes, and required to have received one of the study antibiotics within 14 days before the case's index date. MAIN OUTCOME MEASURES Odds ratio for association between admission to hospital with hyperkalaemia and receipt of a study antibiotic in the preceding 14 days, adjusted for conditions and drugs that may influence risk of hyperkalaemia. RESULTS During the 18 year study period, 6903 admissions for hyperkalaemia were identified, 306 of which occurred within 14 days of antibiotic use. Of these, 248 (81%) cases were matched to 783 controls. 10.8% (17,859/165,754) of spironolactone users received at least one prescription for trimethoprim-sulfamethoxazole. Compared with amoxicillin, prescription of trimethoprim-sulfamethoxazole was associated with a marked increase in the risk of admission to hospital for hyperkalaemia (adjusted odds ratio 12.4, 95% confidence interval 7.1 to 21.6). The population attributable fraction was 59.7%, suggesting that approximately 60% of all cases of hyperkalaemia in older patients taking spironolactone and treated with an antibiotic for a urinary tract infection could be avoided if trimethoprim-sulfamethoxazole was not prescribed. Treatment with nitrofurantoin was also associated with an increase in the risk of hyperkalaemia (adjusted odds ratio 2.4, 1.3 to 4.6), but no such risk was found with norfloxacin (adjusted odds ratio 1.6, 0.8 to 3.4) CONCLUSIONS Among older patients receiving spironolactone, treatment with trimethoprim-sulfamethoxazole was associated with a major increase in the risk of admission to hospital for hyperkalaemia. This drug combination should be avoided when possible.
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Nishida Y, Takahashi Y, Nakayama T, Soma M, Asai S. Comparative effect of olmesartan and candesartan on lipid metabolism and renal function in patients with hypertension: a retrospective observational study. Cardiovasc Diabetol 2011; 10:74. [PMID: 21827713 PMCID: PMC3163179 DOI: 10.1186/1475-2840-10-74] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 08/10/2011] [Indexed: 01/01/2023] Open
Abstract
Background Angiotensin II receptor blockers (ARBs), including olmesartan and candesartan, are widely used antihypertensive agents. Many clinical studies have demonstrated that ARBs have organ-protecting effects, e.g., cardioprotection, vasculoprotection and renoprotection. However, the effect of prolonged olmesartan monotherapy on lipid metabolism in patients with hypertension is less well studied. We performed a retrospective observational study to compare the effects of olmesartan with those of candesartan, focusing on lipid metabolism and renal function. Methods We used data from the Clinical Data Warehouse of Nihon University School of Medicine obtained between Nov 1, 2004 and Feb 28, 2011, to identify cohorts of new olmesartan users (n = 168) and candesartan users (n = 266). We used propensity-score weighting to adjust for differences in all covariates (age, sex, comorbid diseases, previous drugs) between olmesartan and candesartan users, and compared serum chemical data including serum triglyceride (TG), LDL-cholesterol (LDL-C), total cholesterol (TC), potassium, creatinine and urea nitrogen. The mean exposure of olmesartan and candesartan users was 126.1 and 122.8 days, respectively. Results After adjustment, there were no statistically significant differences in all covariates between olmesartan and candesartan users. The mean age was 60.7 and 61.0 years, and 33.4% and 33.7% of olmesartan and candesartan users were women, respectively. There were no statistically significant differences in mean values for all laboratory tests between baseline and during the exposure period in both olmesartan and candesartan users. In olmesartan users, the reduction of serum TG level was significant in comparison with that in candesartan users. Other parameters of lipid profile and renal function showed no statistically significant difference in the change from baseline to during the exposure period between olmesartan and candesartan users. Conclusions In this study, we observed a more beneficial effect on lipid metabolism, a reduction of serum TG, with olmesartan monotherapy than with candesartan monotherapy. However, there were no clinically significant changes in the levels of all test parameters between baseline and during the exposure period with both drugs. These results suggest that the influence of olmesartan or candesartan monotherapy on lipid metabolism and renal function is small, and that they can be safely used in patients with hypertension.
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Affiliation(s)
- Yayoi Nishida
- Division of Genomic Epidemiology and Clinical Trials, Advanced Medical Research Center, Nihon University School of Medicine, 30-1 Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
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Bielecka-Dabrowa A, Rysz J, Mikhailidis DP, Banach M. What is the risk of hyperkalaemia in heart failure? Expert Opin Pharmacother 2011; 12:2329-38. [PMID: 21770818 DOI: 10.1517/14656566.2011.601743] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Chronic heart failure (CHF) is the only major cardiovascular disease whose prevalence and incidence are thought to be increasing. Potassium balance may be lost both through the neurohormonal mechanisms involved in cardiovascular diseases and through the drugs used in their treatment. Avoiding both hypo- and hyperkalemia is difficult but beneficial in CHF. AREAS COVERED Aldosterone production is decreased in the elderly, diabetic patients, and those receiving drugs that block the production or action of renin and angiotensin II. As a result, these groups, as well as those with already impaired potassium excretion due to progressive age or disease-related decline in glomerular filtration rate, are particularly vulnerable to the development of hyperkalemia. EXPERT OPINION Evidence from several studies suggests that, in patients with CHF, serum potassium should be maintained between 4.0 and 5.5 mEq/L. To gain the maximum benefit from aldosterone antagonists it is necessary to individualize their use; it is also necessary to carefully monitor electrolytes.
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Affiliation(s)
- Agata Bielecka-Dabrowa
- Medical University of Lodz, WAM University Hospital in Lodz, Department of Hypertension, Zeromskiego 113, 90-549 Lodz, Poland
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Tobe SW, Clase CM, Gao P, McQueen M, Grosshennig A, Wang X, Teo KK, Yusuf S, Mann JFE. Cardiovascular and renal outcomes with telmisartan, ramipril, or both in people at high renal risk: results from the ONTARGET and TRANSCEND studies. Circulation 2011; 123:1098-107. [PMID: 21357827 DOI: 10.1161/circulationaha.110.964171] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial (ONTARGET), dual therapy did not reduce cardiovascular or renal outcomes compared with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers alone. Previous controlled trials with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers have demonstrated greater cardiovascular and renal benefit in people with renal risk. We hypothesized that dual therapy would be more effective than monotherapy in patients with low glomerular filtration rate and elevated albuminuria. METHODS AND RESULTS Post hoc analysis was performed of renal subgroups of dual therapy versus monotherapy for the ONTARGET study and angiotensin receptor blocker versus placebo for the Telmisartan Randomized Assessment Study in ACE Intolerant Subjects With Cardiovascular Disease (TRANSCEND). The studies featured hazard ratios by subgroups and Cox regression models with factors for treatment, subgroup, and interactions. The main cardiovascular outcome was the composite of cardiovascular death, myocardial infarction, stroke, or hospitalization for heart failure, and the main renal outcome was the composite of chronic dialysis or doubling of creatinine. In ONTARGET, there was no cardiovascular or renal benefit from dual over monotherapy in any subgroup, even with low glomerular filtration rate and/or elevated albuminuria. In TRANSCEND, in the comparison of angiotensin receptor blocker with placebo, there was a significant interaction for the main renal outcome (P = 0.01) in the direction of harm for patients with normoalbuminuria (0.37 versus 0.16 events per 100 patient-years; hazard ratio, 2.35; confidence interval, 1.33 to 4.15) but a trend to benefit with microalbuminuria (0.52 versus 0.89 events per 100 patient-years; hazard ratio, 0.60; confidence interval, 0.25 to 1.46) and macroalbuminuria (1.57 versus 2.60 events per 100 patient-years; hazard ratio, 0.71; confidence interval, 0.21 to 2.44). CONCLUSIONS This post hoc analysis does not support dual therapy over monotherapy in high-vascular risk patients with low glomerular filtration rate or albuminuria. This observation is a post hoc comparison and should be interpreted appropriately. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov Identifier: NCT00153101.
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Affiliation(s)
- Sheldon W Tobe
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Edelmann F, Wachter R, Düngen HD, Störk S, Richter A, Stahrenberg R, Neumann T, Lüers C, Angermann CE, Mehrhof F, Gelbrich G, Pieske B. Heart failure therapy in diabetic patients-comparison with the recent ESC/EASD guideline. Cardiovasc Diabetol 2011; 10:15. [PMID: 21303531 PMCID: PMC3045292 DOI: 10.1186/1475-2840-10-15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 02/08/2011] [Indexed: 01/20/2023] Open
Abstract
Background To assess heart failure therapies in diabetic patients with preserved as compared to impaired systolic ventricular function. Methods 3304 patients with heart failure from 9 different studies were included (mean age 63 ± 14 years); out of these, 711 subjects had preserved left ventricular ejection fraction (≥ 50%) and 994 patients in the whole cohort suffered from diabetes. Results The majority (>90%) of heart failure patients with reduced ejection fraction (SHF) and diabetes were treated with an ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB) or with beta-blockers. By contrast, patients with diabetes and preserved ejection fraction (HFNEF) were less likely to receive these substance classes (p < 0.001) and had a worse blood pressure control (p < 0.001). In comparison to patients without diabetes, the probability to receive these therapies was increased in diabetic HFNEF patients (p < 0.001), but not in diabetic SHF patients. Aldosterone receptor blockers were given more often to diabetic patients with reduced ejection fraction (p < 0.001), and the presence and severity of diabetes decreased the probability to receive this substance class, irrespective of renal function. Conclusions Diabetic patients with HFNEF received less heart failure medication and showed a poorer control of blood pressure as compared to diabetic patients with SHF. SHF patients with diabetes were less likely to receive aldosterone receptor blocker therapy, irrespective of renal function.
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Affiliation(s)
- Frank Edelmann
- Department of Cardiology and Pneumology, University of Göttingen, Göttingen, Germany.
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