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Lee YW, Huang LH, Ku CH. Use of dietary sodium intervention effect on neurohormonal and fluid overload in heart failure patients: Review of select research based literature. Appl Nurs Res 2018; 42:17-21. [PMID: 30029710 DOI: 10.1016/j.apnr.2018.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 04/14/2018] [Accepted: 04/18/2018] [Indexed: 11/15/2022]
Abstract
AIM This literature review analyzed ten articles investigating the effects of low dietary sodium intake on neurohormonal and fluid overload on heart failure (HF). BACKGROUND Recommendations for low dietary sodium to HF patients has been debated in the past one to two decades. METHODS This report presents a literature review of interventional studies from 2006 to 2015 investigating adult HF patients. RESULTS The results of the neurohormonal outcome variables seem to be the primary consideration for recommending a low sodium diet to patients with HF. Most of articles in this review reported that 2.6-3 g/day of dietary sodium is effective for decreased BNP, renin, and aldosterone (neurohormonal) plasma levels in patients with HF. CONCLUSIONS We have to provide the reason, effect, and amount of dietary sodium when providing dietary sodium recommendations to patients.
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Affiliation(s)
- Yi-Wen Lee
- College of Nursing, Chang Gung University of Science and Technology, 261, Wen-Hwa 1st Rd., Kwei-Shan, Taoyuan City 33303, Taiwan.
| | - Lian-Hua Huang
- Nursing Department, China Medical University Health Care System, 2, Yude Road, North District, Taichung, 40447, Taiwan.
| | - Chieh-Hsio Ku
- College of Nursing, Chang Gung University of Science and Technology, 261, Wen-Hwa 1st Rd., Kwei-Shan, Taoyuan City 33303, Taiwan.
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Aronow WS, Shamliyan TA. Dietary Sodium Interventions to Prevent Hospitalization and Readmission in Adults with Congestive Heart Failure. Am J Med 2018; 131:365-370.e1. [PMID: 29307539 DOI: 10.1016/j.amjmed.2017.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/08/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Wilbert S Aronow
- Westchester Medical Center, New York Medical College, Valhalla, NY
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Urinary composition predicts diuretic efficiency of hypertonic saline solution with furosemide therapy and heart failure prognosis. Heart Vessels 2018; 33:1029-1036. [PMID: 29556693 DOI: 10.1007/s00380-018-1156-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 03/16/2018] [Indexed: 10/17/2022]
Abstract
Recently, we and other group have reported that furosemide administration along with hypertonic saline solution enhanced diuretic efficiency of furosemide. However, little is known about factors which associated with high diuretic efficiency by hypertonic saline solution with furosemide therapy. To identify predictors of diuretic efficiency in the hypertonic saline solution with furosemide therapy, we recruited 30 consecutive hospitalized heart failure (HF) patients with volume overload (77 ± 10 years, systolic blood pressure > 90 mmHg, and estimated glomerular filtration rate > 15 ml/min/1.73 m2). Hypertonic saline with furosemide solution, consisting of 500 ml of 1.7% hypertonic saline solution with 40 mg of furosemide, was administered continuously over 24 h. The patients were divided into two groups on the basis of 24-h urine volume (UV) after initiation of diuretic treatment ≥ 2000 ml (high urine volume: HUV) and < 2000 ml (low urine volume: LUV). The basal clinical characteristics of both groups were analyzed and the predictors of HUV after receiving the treatment were identified. There were not significant differences between two groups in baseline clinical characteristics and medication. Univariate logistic analysis revealed that blood urea nitrogen/creatinine ratio, urine urea nitrogen/creatinine ratio (UUN/UCre), fractional excretion of sodium, and tricuspid annular plane systolic excursion positively associated with HUV. Multivariate logistic regression analysis revealed that UUN/UCre at baseline was independently associated with HUV, and UUN/UCre best predicts HUV by the therapy with a cut-off value of 6.16 g/dl/g Cre (AUC 0.910, 95% CI 0.696-0.999, sensitivity 80%, specificity 87%). The Kaplan-Meier curves revealed significant difference for HF rehospitalization and death rate at 180 days between patients with UUN/UCre ≥ 6.16 g/dl/g Cre and those with UUN/UCre < 6.16 g/dl/g Cre (log-rank P = 0.0489). UUN/UCre at baseline strongly predicted of diuretic efficiency in the hypertonic saline solution with furosemide therapy, and was associated with HF prognosis.
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The Art and Science of Using Diuretics in the Treatment of Heart Failure in Diverse Clinical Settings. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018. [PMID: 29500794 DOI: 10.1007/5584_2018_182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
It is important to understand the rationale for appropriate use of different diuretics, alone or in combination, in different heart failure patients, under diverse clinical settings. Clinicians and nurses engaged in heart failure care, must be familiar with different diuretics, their appropriate doses, methods of administration, monitoring of the responses, and the side-effects. Inappropriate use of diuretics, both under-treatment and overtreatment, and poor follow-up can lead to failures, and adverse outcomes. Adequate treatment of congestion, with rather aggressive use of diuretics, is necessary, even if that may worsen renal function temporarily in some patients. Diuretic treatment should later be titrated down, by early recognition of the euvolemic sate, which can be assessed by clinical examination, measurement of the natriuretic peptides, and when possible, echocardiographic estimation of the left ventricular filling pressure. You need to treat patients, who are truly resistant to the loop diuretics, by administering the diuretics as intravenous bolus injection followed by continuous infusion, and/or by sequential nephron blockade by adding the thiazide diuretics. You need to use the diuretics based on a sound understanding of the pathophysiology of the disease process, the pharmacokinetics and pharmacodynamics of the diuretics, even when strong evidences for your choices might be lacking. Some patients may benefit from injection of loop diuretics together with hypertonic saline, and others from injection of loop diuretics with albumin. Patient education, and regular follow up of the treatment of heart failure patients, in out-patient settings are important for reducing the rates of complications, and for reducing the needs for urgent hospitalizations.
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Lafrenière G, Béliveau P, Bégin JY, Simonyan D, Côté S, Gaudreault V, Israeli Z, Lavi S, Bagur R. Effects of hypertonic saline solution on body weight and serum creatinine in patients with acute decompensated heart failure. World J Cardiol 2017; 9:685-692. [PMID: 28932357 PMCID: PMC5583541 DOI: 10.4330/wjc.v9.i8.685] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 02/20/2017] [Accepted: 06/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To test the safety and effectiveness of hypertonic saline solution (HSS + F) as a strategy for weight loss and prevention of further deterioration of renal function.
METHODS Patients admitted with acute decompensated heart failure (ADHF) who received HSS + F were included in the study. After a period of a standard ADHF treatment, our patients received an intravenous infusion of furosemide (250 mg) combined with HSS (150 mL of 3% NaCl) twice a day for a mean duration of 2.3 d. Our primary outcomes were weight loss and a change in serum creatinine per day of treatment. The parameters of the period prior to treatment with HSS + F were compared with those of the period with HSS + F.
RESULTS A total of 47 patients were included. The mean creatinine on admission was 155 μmol/L ± 65 μmol/L, the ejection fraction was 40% ± 17%. The experimental treatment (HSS + F) resulted in greater weight loss per day of treatment than the standard treatment (-1.4 kg/d ± 1.4 kg/d vs -0.4 kg/d ± 1.0 kg/d, P = 0.0168). Importantly, the change in creatinine was not significantly different.
CONCLUSION This study supports the effectiveness of HSS + F on weight loss in patients with ADHF. The safety profile, particularly with regard to renal function, leads us to believe that HSS + F may be a valuable option for those patients presenting with ADHF who do not respond to conventional treatment with intravenous furosemide alone.
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Affiliation(s)
- Gabrielle Lafrenière
- Division of Cardiology, Department of Medicine, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC G1R 2J6, Canada
| | - Patrick Béliveau
- Division of Cardiology, Department of Medicine, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC G1R 2J6, Canada
| | - Jean-Yves Bégin
- Department of Psychoeducation, Université du Québec à Trois-Rivières, Trois-Rivières, QC G9A 5H7, Canada
| | - David Simonyan
- Clinical Research Platform, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC G1R 2J6, Canada
| | - Sylvain Côté
- Department of Pharmacy, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC G1R 2J6, Canada
| | - Valérie Gaudreault
- Division of Cardiology, Department of Medicine, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC G1R 2J6, Canada
| | - Zeev Israeli
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, London, ON N6A5A5, Canada
| | - Shahar Lavi
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, London, ON N6A5A5, Canada
| | - Rodrigo Bagur
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, London, ON N6A5A5, Canada
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Pfortmueller CA, Schefold JC. Hypertonic saline in critical illness - A systematic review. J Crit Care 2017; 42:168-177. [PMID: 28746899 DOI: 10.1016/j.jcrc.2017.06.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/29/2017] [Accepted: 06/17/2017] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The optimal approach to fluid management in critically ill patients is highly debated. Fluid resuscitation using hypertonic saline was used in the past for more than thirty years, but has recently disappeared from clinical practice. Here we provide an overview on the currently available literature on effects of hypertonic saline infusion for fluid resuscitation in the critically ill. METHODS Systematic analysis of reports of clinical trials comparing effects of hypertonic saline as resuscitation fluid to other available crystalloid solutions. A literature search of MEDLINE and the Cochrane Controlled Clinical trials register (CENTRAL) was conducted to identify suitable studies. RESULTS The applied search strategy produced 2284 potential publications. After eliminating doubles, 855 titles and abstracts were screened and 40 references retrieved for full text analysis. At total of 25 scientific studies meet the prespecified inclusion criteria for this study. CONCLUSION Fluid resuscitation using hypertonic saline results in volume expansion and less total infusion volume. This may be of interest in oedematous patients with intravascular volume depletion. When such strategies are employed, renal effects may differ markedly according to prior intravascular volume status. Hypertonic saline induced changes in serum osmolality and electrolytes return to baseline within a limited period in time. Sparse evidence indicates that resuscitation with hypertonic saline results in less perioperative complications, ICU days and mortality in selected patients. In conclusion, the use of hypertonic saline may have beneficial features in selected critically ill patients when carefully chosen. Further clinical studies assessing relevant clinical outcomes are warranted.
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Affiliation(s)
- Carmen Andrea Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
| | - Joerg C Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
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Abstract
Loop diuretics are central to the management of fluid overload in acute decompensated heart failure. However, a variance in the response to loop diuretics can alter a patient's clinical course and has an adverse effect on clinical outcomes. Thus, a diminished response to loop diuretics is an important clinical issue. Factors thought to contribute to diuretic resistance include erratic oral absorption in congested states and postdiuretic sodium retention. Further contributing to diuretic resistance in patients with advanced heart failure are decreases in renal perfusion and alterations in sodium handling that occur in an attempt to maintain circulatory homeostasis. Several pharmacologic interventions have been used to improve diuretic response. Intravenous diuretic administration, increasing diuretic doses, or changing diuretic agents can potentially overcome pharmacokinetic obstacles which contribute to drug resistance. Combination diuretic therapy may be useful to overcome increased sodium retention, dopamine may improve renal perfusion, and hypertonic saline may transiently increase intravascular volume and improve sodium delivery to the tubules of the nephron. Despite the prevalence of diuretic resistance, there remains a paucity of clinical trial evidence to help guide therapy in these patients.
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Wan Y, Li L, Niu H, Ma X, Yang J, Yuan C, Mu G, Zhang J. Impact of Compound Hypertonic Saline Solution on Decompensated Heart Failure. Int Heart J 2017; 58:601-607. [DOI: 10.1536/ihj.16-313] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yanfang Wan
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University
| | - Lei Li
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University
| | - Heping Niu
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University
| | - Xiaoli Ma
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University
| | - Jing Yang
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University
| | - Chen Yuan
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University
| | - Guichen Mu
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University
| | - Jun Zhang
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University
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Abstract
We present the case of a patient with heart failure and severe congestion who was responding poorly to diuretic therapy. We discuss the key problems concerning the pathophysiology and bedside therapeutic approach to congestion and fluid overload in this clinical setting, and we give practical suggestions to overcome congestion, especially in the setting of diuretic resistance and worsening renal function. We conclude that the application of key pharmacokinetic and pharmacodynamic principles of diuretic therapy, along with in-depth knowledge of the pathophysiology of heart failure, still represent the cornerstones for a correct approach to decongestive therapy in these patients.
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Abstract
PURPOSE OF REVIEW Recognizing the relevance of sodium balance in heart failure, it has been presumed that patients with heart failure benefit from a low-sodium diet, though its efficacy and safety are unclear. The purpose of this review is to provide insight into the currently available evidence base for the effects of dietary sodium restriction in patients with chronic heart failure. RECENT FINDINGS There has been an increasing body of evidence on the effects of sodium restriction in heart failure; however, both observational and experimental studies have shown mixed results. Recent randomized controlled trial data has even suggested that sodium restriction may have detrimental effects in patients with heart failure. Only a few randomized controlled trials have included clinical outcomes as a primary endpoint. These have been either unpowered to test the association between reduced sodium intake and outcomes, or conducted in the context of an aggressive diuretic treatment and fluid restriction. SUMMARY The effects of a low-sodium diet on clinical outcomes in patients with heart failure remain unclear. Ongoing research into the effects of lowering sodium for patients with chronic or acute heart failure will shed light on the importance of holistic self-care and dietary strategies in heart failure.
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Doukky R, Avery E, Mangla A, Collado FM, Ibrahim Z, Poulin MF, Richardson D, Powell LH. Impact of Dietary Sodium Restriction on Heart Failure Outcomes. JACC-HEART FAILURE 2016; 4:24-35. [PMID: 26738949 DOI: 10.1016/j.jchf.2015.08.007] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 08/06/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVES This study sought to evaluate the impact of sodium restriction on heart failure (HF) outcomes. BACKGROUND Although sodium restriction is advised for patients with HF, data on sodium restriction and HF outcomes are inconsistent. METHODS We analyzed data from the multihospital HF Adherence and Retention Trial, which enrolled 902 New York Heart Association functional class II/III HF patients and followed them up for a median of 36 months. Sodium intake was serially assessed by a food frequency questionnaire. Based on the mean daily sodium intake prior to the first event of death or HF hospitalization, patients were classified into sodium restricted (<2,500 mg/d) and unrestricted (≥2,500 mg/d) groups. Study groups were propensity score matched according to plausible baseline confounders. The primary outcome was a composite of death or HF hospitalization. The secondary outcomes were cardiac death and HF hospitalization. RESULTS Sodium intake data were available for 833 subjects (145 sodium restricted, 688 sodium unrestricted), of whom 260 were propensity matched into sodium restricted (n = 130) and sodium unrestricted (n = 130) groups. Sodium restriction was associated with significantly higher risk of death or HF hospitalization (42.3% vs. 26.2%; hazard ratio [HR]: 1.85; 95% confidence interval [CI]: 1.21 to 2.84; p = 0.004), derived from an increase in the rate of HF hospitalization (32.3% vs. 20.0%; HR: 1.82; 95% CI: 1.11 to 2.96; p = 0.015) and a nonsignificant increase in the rate of cardiac death (HR: 1.62; 95% CI: 0.70 to 3.73; p = 0.257) and all-cause mortality (p = 0.074). Exploratory subgroup analyses suggested that sodium restriction was associated with increased risk of death or HF hospitalization in patients not receiving angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (HR: 5.78; 95% CI: 1.93 to 17.27; p = 0.002). CONCLUSIONS In symptomatic patients with chronic HF, sodium restriction may have a detrimental impact on outcome. A randomized clinical trial is needed to definitively address the role of sodium restriction in HF management. (A Self-management Intervention for Mild to Moderate Heart Failure [HART]; NCT00018005).
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Affiliation(s)
- Rami Doukky
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois; Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois; Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Rush Center for Urban Health Equity, Rush University Medical Center, Chicago, Illinois.
| | - Elizabeth Avery
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois; Rush Center for Urban Health Equity, Rush University Medical Center, Chicago, Illinois
| | - Ashvarya Mangla
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois; Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Rush Center for Urban Health Equity, Rush University Medical Center, Chicago, Illinois
| | - Fareed M Collado
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Zeina Ibrahim
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois
| | | | - DeJuran Richardson
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois; Rush Center for Urban Health Equity, Rush University Medical Center, Chicago, Illinois; Department of Mathematics and Computer Science, Lake Forest College, Lake Forest, Illinois
| | - Lynda H Powell
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois; Rush Center for Urban Health Equity, Rush University Medical Center, Chicago, Illinois
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Dietary Sodium Restriction in Heart Failure: A Recommendation Worth its Salt? JACC-HEART FAILURE 2016; 4:36-8. [PMID: 26738950 DOI: 10.1016/j.jchf.2015.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 10/12/2015] [Indexed: 12/25/2022]
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Abstract
Acute kidney injury is a frequent complication of acute heart failure syndromes, portending an adverse prognosis. Acute cardiorenal syndrome represents a unique form of acute kidney injury specific to acute heart failure syndromes. The pathophysiology of acute cardiorenal syndrome involves renal venous congestion, ineffective forward flow, and impaired renal autoregulation caused by neurohormonal activation. Biomarkers reflecting different aspects of acute cardiorenal syndrome pathophysiology may allow patient phenotyping to inform prognosis and treatment. Adjunctive vasoactive, neurohormonal, and diuretic therapies may relieve congestive symptoms and/or improve renal function, but no single therapy has been proved to reduce mortality in acute cardiorenal syndrome.
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Affiliation(s)
- Jacob C Jentzer
- Department of Critical Care Medicine, UPMC Presbyterian Hospital, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Lakhmir S Chawla
- Division of Intensive Care Medicine, Department of Medicine, Washington DC Veterans Affairs Medical Center, 50 Irving Street, Washington, DC 20422, USA; Division of Nephrology, Department of Medicine, Washington DC Veterans Affairs Medical Center, 50 Irving Street, Washington, DC 20422, USA.
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Vazir A, Cowie MR. Decongestion: Diuretics and other therapies for hospitalized heart failure. Indian Heart J 2016; 68 Suppl 1:S61-8. [PMID: 27056656 PMCID: PMC4824339 DOI: 10.1016/j.ihj.2015.10.386] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/30/2015] [Indexed: 01/11/2023] Open
Abstract
Acute heart failure (AHF) is a potentially life-threatening clinical syndrome, usually requiring hospital admission. Often the syndrome is characterized by congestion, and is associated with long hospital admissions and high risk of readmission and further healthcare expenditure. Despite a limited evidence-base, diuretics remain the first-line treatment for congestion. Loop diuretics are typically the first-line diuretic strategy with some evidence that initial treatment with continuous infusion or boluses of high-dose loop diuretic is superior to an initial lower dose strategy. In patients who have impaired responsiveness to diuretics, the addition of an oral thiazide or thiazide-like diuretic to induce sequential nephron blockade can be beneficial. The use of intravenous low-dose dopamine is no longer supported in heart failure patients with preserved systolic blood pressure and its use to assist diuresis in patients with low systolic blood pressures requires further study. Mechanical ultrafiltration has been used to treat patients with heart failure and fluid retention, but the evidence-base is not robust, and its place in clinical practice is yet to be established. Several novel pharmacological agents remain under investigation.
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Affiliation(s)
- Ali Vazir
- Consultant in Cardiology and Critical Care (HDU), Royal Brompton Hospital, United Kingdom; Honorary Clinical Senior Lecturer, National Heart and Lung Institute, Imperial College London, United Kingdom.
| | - Martin R Cowie
- Professor of Cardiology, Imperial College London (Royal Brompton Hospital), United Kingdom.
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Abstract
There is growing awareness of the role of diet in both health and disease management. Much data are available on the cardioprotective diet in the primary and secondary prevention of CVD. However, there is limited information on the role of diet in the management of heart failure (HF). Animal models of HF have provided interesting insight and potential mechanisms by which dietary manipulation may improve cardiac performance and delay the progression of the disease, and small-scale human studies have highlighted beneficial diet patterns. The aim of this review is to summarise the current data available on the role of diet in the management of human HF and to demonstrate that dietary manipulation needs to progress further than the simple recommendation of salt and fluid restriction.
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66
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Yancy CW. The Uncertainty of Sodium Restriction in Heart Failure. JACC-HEART FAILURE 2016; 4:39-41. [DOI: 10.1016/j.jchf.2015.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 11/07/2015] [Indexed: 11/16/2022]
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Miller WL, Borgeson DD, Grantham JA, Luchner A, Redfield MM, Burnett JC. Dietary sodium modulation of aldosterone activation and renal function during the progression of experimental heart failure. Eur J Heart Fail 2015; 17:144-50. [PMID: 25823360 DOI: 10.1002/ejhf.212] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS Aldosterone activation is central to the sodium–fluid retention that marks the progression of heart failure (HF). The actions of dietary sodium restriction, a mainstay in HF management, on cardiorenal and neuroendocrine adaptations during the progression of HF are poorly understood. The study aim was to assess the role of dietary sodium during the progression of experimental HF. METHODS AND RESULTS Experimental HF was produced in a canine model by rapid right ventricular pacing which evolves from early mild HF to overt, severe HF. Dogs were fed one of three diets: (i) high sodium [250 mEq (5.8 g) per day, n =6]; (ii) standard sodium [58 mEq (1.3 g) per day, n =6]; and (iii) sodium restriction [11 mEq (0.25 g) per day, n =6]. During the 38-day study, haemodynamics, renal function, plasma renin activity (PRA), and aldosterone were measured. Changes in haemodynamics at 38 days were similar in all three groups, as were changes in renal function. Aldosterone activation was demonstrated in all three groups; however, dietary sodium restriction, in contrast to high sodium, resulted in early (10 days) activation of PRA and aldosterone. High sodium demonstrated significant suppression of aldosterone activation over the course of HF progression. CONCLUSIONS Excessive dietary sodium restriction particularly in early stage HF results in early aldosterone activation, while normal and excess sodium intake are associated with delayed or suppressed activation. These findings warrant evaluation in humans to determine if dietary sodium manipulation, particularly during early stage HF, may have a significant impact on neuroendocrine disease progression.
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Rationale and Design of the "Safety and Efficacy of the Combination of Loop with Thiazide-type Diuretics in Patients with Decompensated Heart Failure (CLOROTIC) Trial:" A Double-Blind, Randomized, Placebo-Controlled Study to Determine the Effect of Combined Diuretic Therapy (Loop Diuretics With Thiazide-Type Diuretics) Among Patients With Decompensated Heart Failure. J Card Fail 2015; 22:529-36. [PMID: 26576715 DOI: 10.1016/j.cardfail.2015.11.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 11/03/2015] [Accepted: 11/09/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Fluid overload refractory to loop diuretic therapy can complicate acute or chronic heart failure (HF) management. The Safety and Efficacy of the Combination of Loop with Thiazide-type Diuretics in Patients with Decompensated Heart Failure (CLOROTIC) trial (Clinicaltrials.gov identifier NCT01647932) will test the hypothesis that blocking distal tubule sodium reabsorption with hydrochlorothiazide can antagonize the renal adaptation to chronic loop diuretic therapy and improve diuretic resistance. METHODS CLOROTIC is a randomized, placebo-controlled, double-blind, multicenter study. Three hundred and four patients with decompensated HF will be randomly assigned to receive hydrochlorothiazide or placebo in addition to a furosemide regimen. The main inclusion criteria are: age ≥18 years, history of chronic HF (irrespective of etiology and/or ejection fraction), admission for acute decompensation, and previous treatment with an oral loop diuretic for at least 1 month before randomization. The 2 coprimary endpoints are changes in body weight and changes in patient-reported dyspnea during hospital admission. Morbidity, mortality, and safety aspects will also be addressed. CONCLUSIONS CLOROTIC is the first large-scale trial to evaluate whether the addition of a thiazide diuretic (hydrochlorothiazide) to a loop diuretic (furosemide) is a safe and effective strategy for improving congestive symptoms resulting from HF. This trial will provide important information and will therefore have a major impact on treatment strategies and future trials in these patients.
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Comparison of three diuretic treatment strategies for patients with acute decompensated heart failure. Herz 2015; 40:1115-20. [PMID: 26135463 DOI: 10.1007/s00059-015-4327-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 05/14/2015] [Accepted: 05/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are few prospective data available for establishing a standard diuretic administration regimen for patients with acute decompensated heart failure (ADHF). We aimed to assess the safety and efficacy of three regimens of furosemide administration in patients with ADHF with regard to diuresis, renal functions, and in-hospital outcomes. METHODS A total of 43 patients who presented with ADHF were randomized into three groups: (a) continuous infusion (cIV) of 160 mg furosemide for 16 h/day (n = 15); (b) bolus injections (bI) of 80 mg furosemide twice a day (n = 14); (c) and administration of 160 mg furosemide plus hypertonic saline solution (HSS) as an infusion for 30 min once a day (n = 14). All regimens were continued for 48 h. Study endpoints were negative fluid balance assessed by loss of body weight, change in the serum creatinine (baseline to 48 h and baseline to compensated state), and length of hospitalization. RESULTS There was no significant difference in the mean change in serum creatinine level at the end of 48 h between groups (p = 0.08). There was also no significant difference among groups regarding loss of body weight (p = 0.66). A significantly shorter hospitalization was observed in patients treated with HSS compared with the other groups (cIV group 6.6 ± 3.4 days vs. bI group 7.9 ± 4.1 days vs. HSS group 3.7 ± 1.3 days; p < 0.01). CONCLUSION All three furosemide regimens have similar renal safety and efficacy measures. However, administration of furosemide plus HSS may be the preferred diuretic strategy because of its shorter hospital stay.
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Butler J, Papadimitriou L, Georgiopoulou V, Skopicki H, Dunbar S, Kalogeropoulos A. Comparing Sodium Intake Strategies in Heart Failure: Rationale and Design of the Prevent Adverse Outcomes in Heart Failure by Limiting Sodium (PROHIBIT) Study. Circ Heart Fail 2015; 8:636-45. [PMID: 25991806 PMCID: PMC4441040 DOI: 10.1161/circheartfailure.114.001700] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 02/10/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Javed Butler
- From the Department of Medicine, Division of Cardiology, Stony Brook University, NY (J.B., L.P., H.S.); and Department of Medicine, Division of Cardiology (V.G., A.K.) and Nell Hodgson Woodruff School of Nursing (S.D.), Emory University, Atlanta, GA.
| | - Lampros Papadimitriou
- From the Department of Medicine, Division of Cardiology, Stony Brook University, NY (J.B., L.P., H.S.); and Department of Medicine, Division of Cardiology (V.G., A.K.) and Nell Hodgson Woodruff School of Nursing (S.D.), Emory University, Atlanta, GA
| | - Vasiliki Georgiopoulou
- From the Department of Medicine, Division of Cardiology, Stony Brook University, NY (J.B., L.P., H.S.); and Department of Medicine, Division of Cardiology (V.G., A.K.) and Nell Hodgson Woodruff School of Nursing (S.D.), Emory University, Atlanta, GA
| | - Hal Skopicki
- From the Department of Medicine, Division of Cardiology, Stony Brook University, NY (J.B., L.P., H.S.); and Department of Medicine, Division of Cardiology (V.G., A.K.) and Nell Hodgson Woodruff School of Nursing (S.D.), Emory University, Atlanta, GA
| | - Sandra Dunbar
- From the Department of Medicine, Division of Cardiology, Stony Brook University, NY (J.B., L.P., H.S.); and Department of Medicine, Division of Cardiology (V.G., A.K.) and Nell Hodgson Woodruff School of Nursing (S.D.), Emory University, Atlanta, GA
| | - Andreas Kalogeropoulos
- From the Department of Medicine, Division of Cardiology, Stony Brook University, NY (J.B., L.P., H.S.); and Department of Medicine, Division of Cardiology (V.G., A.K.) and Nell Hodgson Woodruff School of Nursing (S.D.), Emory University, Atlanta, GA
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Kırat T, Köse N. Response to the letter by Akinori Sairaku et al.: Different mechanisms=synergic effect. Int J Cardiol 2015; 186:148. [DOI: 10.1016/j.ijcard.2015.03.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/17/2015] [Indexed: 11/17/2022]
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Hyponatremia in Acute Decompensated Heart Failure. J Am Coll Cardiol 2015; 65:480-92. [DOI: 10.1016/j.jacc.2014.12.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 11/30/2014] [Accepted: 12/02/2014] [Indexed: 01/11/2023]
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Abstract
The administration of loop diuretics to achieve decongestion is the cornerstone of therapy for acute heart failure. Unfortunately, impaired response to diuretics is common in these patients and associated with adverse outcomes. Diuretic resistance is thought to result from a complex interplay between cardiac and renal dysfunction, and specific renal adaptation and escape mechanisms, such as neurohormonal activation and the braking phenomenon. However, our understanding of diuretic response in patients with acute heart failure is still limited and a uniform definition is lacking. Three objective methods to evaluate diuretic response have been introduced, which all suggest that diuretic response should be determined based on the effect of diuretic dose administered. Several strategies have been proposed to overcome diuretic resistance, including combination therapy and ultrafiltration, but prospective studies in patients who are truly unresponsive to diuretics are lacking. An enhanced understanding of diuretic response should ultimately lead to an improved, individualized approach to treating patients with acute heart failure.
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Abstract
The use of diuretics is common in patients with heart failure (HF), to relieve the congestive symptoms of HF. Although they are widely used, there are limited data on their ability to modulate HF-related morbidity and mortality. Diuretic efficacy may be limited by adverse neurohormonal activation and by 'congestion-like' symptoms. Diuretics are an extremely useful and varied class of agent for the management of hypervolaemic states. This review summarises the basic features of diuretics, including their mechanism of action, indications and adverse effects in heart failure.
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DiNicolantonio JJ, Lucan SC. The wrong white crystals: not salt but sugar as aetiological in hypertension and cardiometabolic disease. Open Heart 2014; 1:e000167. [PMID: 25717381 PMCID: PMC4336865 DOI: 10.1136/openhrt-2014-000167] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 08/28/2014] [Accepted: 10/01/2014] [Indexed: 01/09/2023] Open
Abstract
Cardiovascular disease is the leading cause of premature mortality in the developed world, and hypertension is its most important risk factor. Controlling hypertension is a major focus of public health initiatives, and dietary approaches have historically focused on sodium. While the potential benefits of sodium-reduction strategies are debatable, one fact about which there is little debate is that the predominant sources of sodium in the diet are industrially processed foods. Processed foods also happen to be generally high in added sugars, the consumption of which might be more strongly and directly associated with hypertension and cardiometabolic risk. Evidence from epidemiological studies and experimental trials in animals and humans suggests that added sugars, particularly fructose, may increase blood pressure and blood pressure variability, increase heart rate and myocardial oxygen demand, and contribute to inflammation, insulin resistance and broader metabolic dysfunction. Thus, while there is no argument that recommendations to reduce consumption of processed foods are highly appropriate and advisable, the arguments in this review are that the benefits of such recommendations might have less to do with sodium-minimally related to blood pressure and perhaps even inversely related to cardiovascular risk-and more to do with highly-refined carbohydrates. It is time for guideline committees to shift focus away from salt and focus greater attention to the likely more-consequential food additive: sugar. A reduction in the intake of added sugars, particularly fructose, and specifically in the quantities and context of industrially-manufactured consumables, would help not only curb hypertension rates, but might also help address broader problems related to cardiometabolic disease.
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Affiliation(s)
- James J DiNicolantonio
- Department of Preventive Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Sean C Lucan
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, USA
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Smyth A, O’Donnell MJ, Yusuf S, Clase CM, Teo KK, Canavan M, Reddan DN, Mann JFE. Sodium intake and renal outcomes: a systematic review. Am J Hypertens 2014; 27:1277-84. [PMID: 24510182 DOI: 10.1093/ajh/hpt294] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Sodium intake is an important determinant of blood pressure; therefore, reduction of intake may be an attractive population-based target for chronic kidney disease (CKD) prevention. Most guidelines recommend sodium intake of < 2.3 g/day, based on limited evidence. We reviewed the association between sodium intake and renal outcomes. METHODS We reviewed cohort studies and clinical trials, which were retrieved by searching electronic databases, that evaluated the association between sodium intake/excretion and measures of renal function, proteinuria, or new need for dialysis. RESULTS Of 4,337 reviewed citations, seven (n = 8,129) were eligible, including six cohort studies (n = 7,942) and one clinical trial (n = 187). Four studies (n = 1,787) included patients with CKD. All four cohort studies reported that high intake (> 4.6 g/day) was associated with adverse outcomes (vs. moderate/low), while none reported an increased risk with moderate intake (vs. low). Three studies (n = 6,342) included patients without CKD. Two cohort studies (n = 6,155) reported opposing directions of association between low (vs. moderate) sodium intake and renal outcomes, and one clinical trial (n = 187) reported a benefit from low intake (vs. moderate) on proteinuria but an adverse effect on serum creatinine. CONCLUSIONS Available, but limited, evidence supports an association between high sodium intake (> 4.6g/day) and adverse outcomes. However, the association with low intake (vs. moderate) is uncertain, with inconsistent findings from cohort studies. There is urgent need to clarify the long-term efficacy and safety of currently recommended low sodium intake in patients with CKD.
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Affiliation(s)
- Andrew Smyth
- Department of Nephrology, Galway University Hospitals, Galway, Ireland
- Health Research Board Clinical Research Facility, National University of Ireland, Galway, Ireland
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Martin J. O’Donnell
- Health Research Board Clinical Research Facility, National University of Ireland, Galway, Ireland
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Catherine M. Clase
- Department of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Koon K. Teo
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Michelle Canavan
- Health Research Board Clinical Research Facility, National University of Ireland, Galway, Ireland
| | - Donal N. Reddan
- Department of Nephrology, Galway University Hospitals, Galway, Ireland
| | - Johannes F. E. Mann
- Population Health Research Institute, Hamilton, Ontario, Canada
- Friedrich Alexander University of Erlangen, Germany
- Department of Nephrology, Hypertension & Rheumatology, Munich General Hospitals, Munich, Germany
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DiNicolantonio JJ, O'Keefe JH, Lucan SC. An unsavory truth: sugar, more than salt, predisposes to hypertension and chronic disease. Am J Cardiol 2014; 114:1126-8. [PMID: 25212553 DOI: 10.1016/j.amjcard.2014.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 07/08/2014] [Indexed: 11/29/2022]
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Gandhi S, Mosleh W, Myers RB. Reply: Comments on hypertonic saline with furosemide for the treatment of acute congestive heart failure: A systematic review and meta-analysis. Int J Cardiol 2014; 176:1153. [DOI: 10.1016/j.ijcard.2014.07.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 07/27/2014] [Indexed: 11/26/2022]
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Managing therapeutic competition in patients with heart failure, lower urinary tract symptoms and incontinence. Drugs Aging 2014; 31:93-101. [PMID: 24357134 PMCID: PMC3907694 DOI: 10.1007/s40266-013-0145-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Up to 50 % of heart failure patients suffer from lower urinary tract symptoms. Urinary incontinence has been associated with worse functional status in patients with heart failure, occurring three times more frequently in patients with New York Heart Association Class III and IV symptoms compared with those with milder disease. The association between heart failure and urinary symptoms may be directly attributable to worsening heart failure pathophysiology; however, medications used to treat heart failure may also indirectly provoke or exacerbate urinary symptoms. This type of drug–disease interaction, in which the treatment for heart failure precipitates incontinence, and removal of medications to relieve incontinence worsens heart failure, can be termed therapeutic competition. The mechanisms by which heart failure medication such as diuretics, angiotensin-converting enzyme (ACE) inhibitors and β-blockers aggravate lower urinary tract symptoms are discussed. Initiation of a prescribing cascade, whereby antimuscarinic agents or β3-agonists are added to treat symptoms of urinary urgency and incontinence, is best avoided. Recommendations and practical tips are provided that outline more judicious management of heart failure patients with lower urinary tract symptoms. Compelling strategies to improve urinary outcomes include titrating diuretics, switching ACE inhibitors, treating lower urinary tract infections, appropriate fluid management, daily weighing, and uptake of pelvic floor muscle exercises.
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Comments on hypertonic saline with furosemide for the treatment of acute congestive heart failure: A systematic review and meta-analysis. Int J Cardiol 2014; 176:288. [DOI: 10.1016/j.ijcard.2014.06.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 06/29/2014] [Indexed: 11/21/2022]
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DiNicolantonio JJ, Lucan SC, Lavie CJ, O'Keefe JH. Dietary sodium restriction: still searching for the grains of truth. The reply. Am J Med 2014; 127:e17. [PMID: 24856325 DOI: 10.1016/j.amjmed.2014.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 02/20/2014] [Accepted: 02/20/2014] [Indexed: 11/25/2022]
Affiliation(s)
| | - Sean C Lucan
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, La; Pennington Biomedical Research Center, Baton Rouge, La
| | - James H O'Keefe
- Mid America Heart Institute at Saint Luke's Hospital, Kansas City, Mo; University of Missouri-Kansas City, Kansas City, Mo
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82
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DiNicolantonio JJ, Lucan SC, O'Keefe JH. Letter by DiNicolantonio et al regarding article, "reducing sodium intake to prevent stroke: time for action, not hesitation". Stroke 2014; 45:e106-7. [PMID: 24803597 DOI: 10.1161/strokeaha.114.005067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Sean C Lucan
- Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - James H O'Keefe
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine
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De Vecchis R, Esposito C, Ariano C, Cantatrione S. Hypertonic saline plus i.v. furosemide improve renal safety profile and clinical outcomes in acute decompensated heart failure. Herz 2014; 40:423-35. [DOI: 10.1007/s00059-013-4041-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 11/27/2013] [Accepted: 12/16/2013] [Indexed: 11/25/2022]
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84
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Gandhi S, Mosleh W, Myers RBH. Hypertonic saline with furosemide for the treatment of acute congestive heart failure: a systematic review and meta-analysis. Int J Cardiol 2014; 173:139-45. [PMID: 24679680 DOI: 10.1016/j.ijcard.2014.03.020] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 02/22/2014] [Accepted: 03/09/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Advanced congestive heart failure (CHF) therapies include intravenous inotropic agents, change in class of diuretics, and venous ultrafiltration or hemodialysis. These modalities have not been associated with improved prognosis and are limited by availability and cost. Compared to high-dose furosemide alone, concomitant hypertonic saline solution (HSS) administration has demonstrated improved clinical outcomes with good safety profile. METHODS A literature search was conducted for randomized controlled trials that investigated the use of HSS in patients admitted to hospital with acute CHF. RESULTS 1032 patients treated with HSS and 1032 controls, demonstrated decreased all-cause mortality in patients treat with HSS with RR of 0.56 (95% CI 0.41-0.76,p=0.0003). 1012 patients treated with HSS and 1020 controls, demonstrated decreased heart failure hospital readmission with RR of 0.50 (95% CI 0.33-0.76,p=0.001). Patients treated with HSS also demonstrated decreased hospital length of stay (p=0.0002), greater weight loss (p<0.00001), and preservation of renal function (p<0.00001). CONCLUSION The results of this meta-analysis demonstrate that in patients with advanced CHF concomitant hypertonic saline administration improved weight loss, preserved renal function, and decreased length of hospitalization, mortality and heart failure rehospitalization. A future adequately powered, multi-centre, placebo controlled, randomized, double dummy, blinded trial is needed to assess the benefit of hypertonic saline in patients with renal dysfunction, in diverse patient populations, as well using a patient population on optimal current heart failure treatment. Pending further validation, there is promise for hypertonic saline as an advanced therapy for the management of acute advanced CHF.
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Affiliation(s)
- Sumeet Gandhi
- McMaster University, Division of Cardiology, Hamilton, ON, Canada; Sunnybrook Health Sciences Centre, Division of Cardiology, University of Toronto, ON, Canada.
| | | | - Robert B H Myers
- Sunnybrook Health Sciences Centre, Division of Cardiology, University of Toronto, ON, Canada
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85
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DiNicolantonio JJ, O'Keefe JH, Lucan SC. Population-wide sodium reduction: reasons to resist. Mayo Clin Proc 2014; 89:426-7. [PMID: 24582202 DOI: 10.1016/j.mayocp.2014.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/20/2013] [Accepted: 01/03/2014] [Indexed: 10/25/2022]
Affiliation(s)
| | - James H O'Keefe
- Mid America Heart Institute, Saint Luke's Hospital, Kansas City, MO
| | - Sean C Lucan
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
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Konerman MC, Hummel SL. Sodium restriction in heart failure: benefit or harm? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:286. [PMID: 24398803 DOI: 10.1007/s11936-013-0286-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Current guidelines vary in the recommended amount of dietary sodium intake for heart failure (HF) patients. Observational studies and the hypertension literature support the concept that sodium restriction improves HF outcomes. In contrast, several randomized controlled trials imply that dietary sodium restriction can cause harm through hypovolemia and increased neurohormonal activation. Data from hypertensive animal models and humans suggest that dietary sodium intake may need to be individually tailored based on HF severity and the physiologic response to sodium loading. Future studies must assess interactions between sodium intake, fluid intake, and diuretics to match clinical practice and improve safety. More information is needed in multiple areas, including accurate measurement of sodium intake, implementation of dietary changes in HF patients, and establishment of biomarkers that predict response to changes in sodium intake. Additional research is urgently needed to determine the true impact of the most commonly recommended self-care strategy in HF.
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Affiliation(s)
- Matthew C Konerman
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
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Graziani G, Pini D, Oldani S, Cucchiari D, Podestà MA, Badalamenti S. Renal dysfunction in acute congestive heart failure: a common problem for cardiologists and nephrologists. Heart Fail Rev 2013; 19:699-708. [DOI: 10.1007/s10741-013-9416-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Givertz MM, Teerlink JR, Albert NM, Westlake Canary CA, Collins SP, Colvin-Adams M, Ezekowitz JA, Fang JC, Hernandez AF, Katz SD, Krishnamani R, Stough WG, Walsh MN, Butler J, Carson PE, Dimarco JP, Hershberger RE, Rogers JG, Spertus JA, Stevenson WG, Sweitzer NK, Tang WHW, Starling RC. Acute decompensated heart failure: update on new and emerging evidence and directions for future research. J Card Fail 2013; 19:371-89. [PMID: 23743486 DOI: 10.1016/j.cardfail.2013.04.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 04/17/2013] [Indexed: 01/10/2023]
Abstract
Acute decompensated heart failure (ADHF) is a complex clinical event associated with excess morbidity and mortality. Managing ADHF patients is challenging because of the lack of effective treatments that both reduce symptoms and improve clinical outcomes. Existing guideline recommendations are largely based on expert opinion, but several recently published trials have yielded important data to inform both current clinical practice and future research directions. New insight has been gained regarding volume management, including dosing strategies for intravenous loop diuretics and the role of ultrafiltration in patients with heart failure and renal dysfunction. Although the largest ADHF trial to date (ASCEND-HF, using nesiritide) was neutral, promising results with other investigational agents have been reported. If these findings are confirmed in phase III trials, novel compounds, such as relaxin, omecamtiv mecarbil, and ularitide, among others, may become therapeutic options. Translation of research findings into quality clinical care can not be overemphasized. Although many gaps in knowledge exist, ongoing studies will address issues around delivery of evidence-based care to achieve the goal of improving the health status and clinical outcomes of patients with ADHF.
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Affiliation(s)
- Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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DiNicolantonio JJ, Niazi AK, Sadaf R, O' Keefe JH, Lucan SC, Lavie CJ. Dietary sodium restriction: take it with a grain of salt. Am J Med 2013; 126:951-5. [PMID: 24054177 DOI: 10.1016/j.amjmed.2013.05.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 05/15/2013] [Accepted: 05/15/2013] [Indexed: 11/18/2022]
Abstract
The American Heart Association recently strongly recommended a dietary sodium intake of <1500 mg/d for all Americans to achieve "Ideal Cardiovascular Health" by 2020. However, low sodium diets have not been shown to reduce cardiovascular events in normotensive individuals or in individuals with pre-hypertension or hypertension. Moreover, there is evidence that a low sodium diet may lead to a worse cardiovascular prognosis in patients with cardiometabolic risk and established cardiovascular disease. Low sodium diets may adversely affect insulin resistance, serum lipids, and neurohormonal pathways, leading to increases in the incidence of new cardiometabolic disease, the severity of existing cardiometabolic disease, and greater cardiovascular and all-cause mortality. Although a high sodium intake also may be deleterious, there is good reason to believe that sodium intake is regulated within such a tight physiologic range that there is little risk to leaving sodium intake to inherent biology as opposed to likely futile attempts at conscious control.
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90
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91
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Trullàs JC, Morales-Rull JL, Formiga F. [Diuretic therapy in heart failure]. Med Clin (Barc) 2013; 142:163-70. [PMID: 23768854 DOI: 10.1016/j.medcli.2013.04.027] [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: 03/05/2013] [Revised: 04/05/2013] [Accepted: 04/11/2013] [Indexed: 01/11/2023]
Abstract
Many of the primary clinical manifestations of heart failure (HF) are due to fluid retention, and treatments targeting congestion play a central role in HF management. Diuretic therapy remains the cornerstone of congestion treatment, and diuretics are prescribed to the majority of HF patients. Despite this ubiquitous use, there is limited evidence from prospective randomized studies to guide the use of diuretics. With the chronic use of diuretic and usually in advanced stages of HF, diuretics may fail to control salt and water retention. This review describes the mechanism of action of available diuretic classes, reviews their clinical use based on scientific evidence and discusses strategies to overcome diuretic resistance.
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Affiliation(s)
- Joan Carles Trullàs
- Servicio de Medicina Interna, Hospital Sant Jaume d'Olot, Universitat de Girona, Girona, España.
| | | | - Francesc Formiga
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España
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Felker GM, Mentz RJ. Diuretics and ultrafiltration in acute decompensated heart failure. J Am Coll Cardiol 2012; 59:2145-53. [PMID: 22676934 DOI: 10.1016/j.jacc.2011.10.910] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 10/11/2011] [Accepted: 10/17/2011] [Indexed: 01/11/2023]
Abstract
Congestion and volume overload are the hallmarks of acute decompensated heart failure (ADHF), and loop diuretics have historically been the cornerstone of treatment. The demonstrated efficacy of loop diuretics in managing congestion is balanced by the recognized limitations of diuretic resistance, neurohormonal activation, and worsening renal function. However, the recently published DOSE (Diuretic Optimization Strategies Evaluation) trial suggests that previous concerns about the safety of high-dose diuretics may not be valid. There has been a growing interest in alternative strategies to manage volume retention in ADHF with improved efficacy and safety profiles. Peripheral venovenous ultrafiltration (UF) represents a potentially promising approach to volume management in ADHF. Small studies suggest that UF may allow for more effective fluid removal compared with diuretics, with improved quality of life and reduced rehospitalization rates. However, further investigation is needed to completely define the role of UF in patients with ADHF. This review summarizes available data on the use of both diuretics and UF in ADHF patients and identifies challenges and unresolved questions for each approach.
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Affiliation(s)
- G Michael Felker
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
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Alderman MH, Cohen HW. Dietary sodium intake and cardiovascular mortality: controversy resolved? Am J Hypertens 2012; 25:727-34. [PMID: 22627176 DOI: 10.1038/ajh.2012.52] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Universal reduction in sodium intake has long been recommended, largely because of its proven ability to lower blood pressure for some. However, multiple randomized trials have also demonstrated that similar reductions in sodium increase plasma renin activity and aldosterone secretion, insulin resistance, sympathetic nerve activity, serum cholesterol, and triglyceride levels. Thus, the health consequences of reducing sodium cannot be predicted by its impact on any single physiologic characteristic but will reflect the net of conflicting effects. Some 23 observational studies (>360,000 subjects and >26,000 end points) linking sodium intake to cardiovascular outcomes have yielded conflicting results. In subjects with average sodium intakes of less than 4.5 g/day, most have found an inverse association of intake with outcome; in subjects with average intakes greater than 4.5 g/day, most reported direct associations. Finally, in two, a "J-shaped" relation was detected. In addition, three randomized trials have found that heart failure subjects allocated to 1.8 g of sodium have significantly increased morbidity and mortality compared with those at 2.8 g. At the same time, a randomized study in retired Taiwanese men found that allocation to an average intake of 3.8 g improved survival compared with 5.3 g. Taken together, these data provide strong support for a "J-shaped" relation of sodium to cardiovascular outcomes. Sodium intakes above and below the range of 2.5-6.0 g/day are associated with increased cardiovascular risk. This robust body of evidence does not support universal reduction of sodium intake.
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Affiliation(s)
| | - Hillel Cohen
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
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