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D'Amato A, Prosperi S, Severino P, Myftari V, Labbro Francia A, Cestiè C, Pierucci N, Marek-Iannucci S, Mariani MV, Germanò R, Fanisio F, Lavalle C, Maestrini V, Badagliacca R, Mancone M, Fedele F, Vizza CD. Current Approaches to Worsening Heart Failure: Pathophysiological and Molecular Insights. Int J Mol Sci 2024; 25:1574. [PMID: 38338853 PMCID: PMC10855688 DOI: 10.3390/ijms25031574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Worsening heart failure (WHF) is a severe and dynamic condition characterized by significant clinical and hemodynamic deterioration. It is characterized by worsening HF signs, symptoms and biomarkers, despite the achievement of an optimized medical therapy. It remains a significant challenge in cardiology, as it evolves into advanced and end-stage HF. The hyperactivation of the neurohormonal, adrenergic and renin-angiotensin-aldosterone system are well known pathophysiological pathways involved in HF. Several drugs have been developed to inhibit the latter, resulting in an improvement in life expectancy. Nevertheless, patients are exposed to a residual risk of adverse events, and the exploration of new molecular pathways and therapeutic targets is required. This review explores the current landscape of WHF, highlighting the complexities and factors contributing to this critical condition. Most recent medical advances have introduced cutting-edge pharmacological agents, such as guanylate cyclase stimulators and myosin activators. Regarding device-based therapies, invasive pulmonary pressure measurement and cardiac contractility modulation have emerged as promising tools to increase the quality of life and reduce hospitalizations due to HF exacerbations. Recent innovations in terms of WHF management emphasize the need for a multifaceted and patient-centric approach to address the complex HF syndrome.
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Affiliation(s)
- Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Vincenzo Myftari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Aurora Labbro Francia
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Claudia Cestiè
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Nicola Pierucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Stefanie Marek-Iannucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Rosanna Germanò
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
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102
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Nakamura M, Imamura T, Kinugawa K. Preliminary Report of Intravenous Tolvaptan Sodium Phosphate (Samtas ®) Treatment in Decompensated Heart Failure. J Clin Med 2024; 13:720. [PMID: 38337413 PMCID: PMC10856676 DOI: 10.3390/jcm13030720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Tolvaptan sodium phosphate (Samtas®; Otsuka Pharmaceutical, Tokyo, Japan) is a novel intravenous aquaretic diuretic aimed at individuals experiencing advanced congestion refractory to conventional diuretics and having difficulty with oral intake. Despite its potential, the true efficacy and practicality of this compound within real-world clinical settings remain obscure. Methods: A retrospective analysis of clinical data was conducted, examining trends among consecutive in-hospital patients diagnosed with congestive heart failure who underwent treatment with tolvaptan sodium phosphate at a prominent academic medical center between June 2022 and June 2023. Results: Twenty-one patients were enrolled (median age: 75 years, serum N-terminal pro B-type natriuretic peptide: 8941 pg/mL). Among them, 14 patients (67%) received non-invasive/invasive positive-pressure ventilation, and 17 patients (81%) concurrently received intravenous inotropes. Subsequent to the initiation of tolvaptan sodium phosphate treatment, a significant increase in urine volume was observed on the following day (p = 0.036). Urine osmolality decreased from 356 (318, 443) at baseline to 247 (176, 333) mOsm/kg after 4 h (p = 0.002). No occurrences of hypernatremia were recorded during the therapeutic period. Notably, two patients transitioned from tolvaptan sodium phosphate treatment to continuous hemodiafiltration due to insufficient efficacy. Conclusions: In routine clinical practice, intravenous tolvaptan sodium phosphate exhibits potential efficacy and practicability in the majority of congestive heart failure patients exhibiting refractory congestion, unstable hemodynamics, and challenges with oral intake.
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Affiliation(s)
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan; (M.N.); (K.K.)
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103
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Glargaard S, Thomsen JH, Løgstrup BB, Schou M, Iversen KK, Tuxen C, Nielsen OW, Bang CA, Lindholm MG, Seven E, Barasa A, Stride N, Vraa S, Tofterup M, Rasmussen RV, Høfsten DE, Rossing K, Køber L, Gustafsson F, Thune JJ. Thoracentesis to alleviate pleural effusion in acute heart failure: study protocol for the multicentre, open-label, randomised controlled TAP-IT trial. BMJ Open 2024; 14:e078155. [PMID: 38245015 PMCID: PMC10806591 DOI: 10.1136/bmjopen-2023-078155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/21/2023] [Indexed: 01/22/2024] Open
Abstract
INTRODUCTION Pleural effusion is present in half of the patients hospitalised with acute heart failure. The condition is treated with diuretics and/or therapeutic thoracentesis for larger effusions. No evidence from randomised trials or guidelines supports thoracentesis to alleviate pleural effusion due to acute heart failure. The Thoracentesis to Alleviate cardiac Pleural effusion Interventional Trial (TAP-IT) will investigate if a strategy of referring patients with acute heart failure and pleural effusion to up-front thoracentesis by pleural pigtail catheter insertion in addition to pharmacological therapy compared with pharmacological therapy alone can increase the number of days the participants are alive and not hospitalised during the 90 days following randomisation. METHODS AND ANALYSIS TAP-IT is a pragmatic, multicentre, open-label, randomised controlled trial aiming to include 126 adult patients with left ventricular ejection fraction ≤45% and a non-negligible pleural effusion due to heart failure. Participants will be randomised 1:1, stratified according to site and anticoagulant treatment, and assigned to referral to up-front ultrasound-guided pleural pigtail catheter thoracentesis in addition to standard pharmacological therapy or to standard pharmacological therapy only. Thoracentesis is performed according to local guidelines and can be performed in participants in the pharmacological treatment arm if their condition deteriorates or if no significant improvement is observed within 5 days. The primary endpoint is how many days participants are alive and not hospitalised within 90 days from randomisation and will be analysed in the intention-to-treat population. Key secondary outcomes include 90-day mortality, complications, readmissions, and quality of life. ETHICS AND DISSEMINATION The study has been approved by the Capital Region of Denmark Scientific Ethical Committee (H-20060817) and Knowledge Center for Data Reviews (P-2021-149). All participants will sign an informed consent form. Enrolment began in August 2021. Regardless of the nature, results will be published in a peer-reviewed medical journal. TRIAL REGISTRATION NUMBER NCT05017753.
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Affiliation(s)
- Signe Glargaard
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Jakob Hartvig Thomsen
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Brian Bridal Løgstrup
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Karmark Iversen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Tuxen
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Olav W Nielsen
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Axel Bang
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | | | - Ekim Seven
- Department of Cardiology, Copenhagen University Hospital-Amager and Hvidovre, Copenhagen, Denmark
| | - Anders Barasa
- Department of Cardiology, Copenhagen University Hospital-Glostrup, Glostrup, Denmark
| | - Nis Stride
- Department of Cardiology, Copenhagen University Hospital-North Zealand, Hilleroed, Denmark
| | - Søren Vraa
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Marlene Tofterup
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Rasmus Vedby Rasmussen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Dan Eik Høfsten
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kasper Rossing
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jens Jakob Thune
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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104
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Guzik M, Iwanek G, Fudim M, Zymliński R, Marciniak D, Ponikowski P, Biegus J. Spot urine sodium as a marker of urine dilution and decongestive abilities in acute heart failure. Sci Rep 2024; 14:1494. [PMID: 38233473 PMCID: PMC10794205 DOI: 10.1038/s41598-024-51744-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 01/09/2024] [Indexed: 01/19/2024] Open
Abstract
The decongestion ability in response to diuretic treatment plays a crucial role in the treatment of acute heart failure. This effectiveness is evaluated through the assessment of sodium concentration and urine volume, which are also treatment goals themselves. However, the bidirectional interconnection between these factors remains not fully understood. The objective of this study is to provide mechanistic insights into the correlation between spot urine sodium concentrations (UNa+) and urine dilution. This aims to better understand of the decongestive abilities in acute heart failure (AHF). The study was single-center, prospective, conducted on a group of 50 AHF patients. Each participant received a standardized furosemide dose of 1 mg per kg of body weight. Hourly diuresis was measured in the first 6 h of the study, and urine composition was assessed at predefined timepoints. The study group presented the exponential (rather than linear) pattern of relationship between UNa+ and 6-h urine volume, whereas relationship between eGFR and 6-h urine volume was linear (r = 0.61, p < 0.001). The relationship between UNa+ and all other analyzed indices of urine dilution, including the change from baseline in urine creatinine concentration, urine osmolarity, and urine osmolarity corrected for urine sodium, also exhibited an exponential relationship. Patients who were chronically exposed to furosemide demonstrated a significantly lower urine dilution (1.78 [1.18-3.54] vs 11.58 [3.9-17.88]; p < 0.001) in comparison to naïve individuals. In conclusion, it should be noted that in AHF higher UNa+ is associated with disproportionally higher urine dilution, and patients naïve to furosemide have significantly greater ability to dilute urine when compare to chronic furosemide users.
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Grants
- SUBZ.A460.23.055 Institute of Heart Diseases, Wroclaw Medical University, Poland.
- SUBZ.A460.23.055 Institute of Heart Diseases, Wroclaw Medical University, Poland.
- SUBZ.A460.23.055 Institute of Heart Diseases, Wroclaw Medical University, Poland.
- SUBZ.A460.23.055 Institute of Heart Diseases, Wroclaw Medical University, Poland.
- SUBZ.A460.23.055 Institute of Heart Diseases, Wroclaw Medical University, Poland.
- SUBZ.A460.23.055 Institute of Heart Diseases, Wroclaw Medical University, Poland.
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Affiliation(s)
- Mateusz Guzik
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.
| | - Gracjan Iwanek
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Marat Fudim
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Robert Zymliński
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Dominik Marciniak
- Department of Drugs Form Technology, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
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105
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Magaña Serrano JA, Cigarroa López JA, Chávez Mendoza A, Ivey-Miranda JB, Mendoza Zavala GH, Olmos Domínguez L, Chávez Leal SA, Pombo Bartelt JE, Herrera-Garza EH, Mercado Leal G, Parra Michel R, Aguilera Mora LF, Nuriulu Escobar PL. Vulnerable period in heart failure: a window of opportunity for the optimization of treatment - a statement by Mexican experts. Drugs Context 2024; 13:2023-8-1. [PMID: 38264402 PMCID: PMC10803129 DOI: 10.7573/dic.2023-8-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/14/2023] [Indexed: 01/25/2024] Open
Abstract
Acute heart failure (HF) is associated with poor prognosis. After the acute event, there is a vulnerable period during which the patient has a marked risk of readmission or death. Therefore, early optimization of treatment is mandatory during the vulnerable period. The objective of this article is to provide recommendations to address the management of patients with HF during the vulnerable period from a practical point of view. A group of Mexican experts met to prepare a consensus document. The vulnerable period, with a duration of up to 6 months after the acute event - either hospitalization, visit to the emergency department or the outpatient clinic/day hospital - represents a real window of opportunity to improve outcomes for these patients. To best individualize the recommendations, the management strategies were divided into three periods (early, intermediate and late vulnerable period), including not only therapeutic options but also evaluation and education. Importantly, the recommendations are addressed to the entire cardiology team, including physicians and nurses, but also other specialists implicated in the management of these patients. In conclusion, this document represents an opportunity to improve the management of this population at high risk, with the aim of reducing the burden of HF.
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Affiliation(s)
- José Antonio Magaña Serrano
- División de Insuficiencia Cardiaca y Trasplante, Hospital de Cardiología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - José Angel Cigarroa López
- Clínica de Insuficiencia Cardiaca Avanzada y Trasplantes de la UMAE Hospital de Cardiología, Centro Médico Nacional Siglo XXI, IMSS (Instituto Mexicano del Seguro Social), Ciudad de México, México
| | - Adolfo Chávez Mendoza
- Clínica de Insuficiencia Cardiaca y Hospital de Día, Hospital de Cardiología, Centro Médico Nacional SXXI, IMSS (Instituto Mexicano del Seguro Social), Instituto Nacional de Salud Pública, Ciudad de México, México
| | - Juan Betuel Ivey-Miranda
- Clínica de Insuficiencia Cardiaca Avanzada y Trasplantes de la UMAE Hospital de Cardiología, Centro Médico Nacional Siglo XXI, IMSS (Instituto Mexicano del Seguro Social), Ciudad de México, México
| | - Genaro Hiram Mendoza Zavala
- Clínica de Insuficiencia Cardiaca y Hospital de Día, Hospital de Cardiología, Centro Médico Nacional SXXI, IMSS (Instituto Mexicano del Seguro Social), Instituto Nacional de Salud Pública, Ciudad de México, México
| | - Luis Olmos Domínguez
- Clínica de Insuficiencia Cardiaca y Hospital de Día, Hospital de Cardiología, Centro Médico Nacional SXXI, IMSS (Instituto Mexicano del Seguro Social), Instituto Nacional de Salud Pública, Ciudad de México, México
| | | | | | - Eduardo Heberto Herrera-Garza
- Programa de Trasplante Cardiaco y Clínica de Insuficiencia Cardíaca, Hospital Christus Muguerza Alta Especialidad, Monterrey, México
| | - Gerardo Mercado Leal
- División de Cardiocirugía, Clínica de Insuficiencia Cardiaca, Trasplante Cardiaco y Hospital de Día, CMN 20 de Noviembre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Ciudad de México, México
| | - Rodolfo Parra Michel
- Unidad de Coronaria y Clínica de Insuficiencia Cardíaca Avanzada e Hipertensión Arterial Pulmonar. Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, México
| | - Luisa Fernanda Aguilera Mora
- Clínica de Insuficiencia Cardiaca, Instituto Cardiovascular de Mínima Invasión, Centro Médico Puerta de Hierro, Zapopan, México
| | - Patricia Lenny Nuriulu Escobar
- Unidad de Insuficiencia Cardiaca y Cardio-Oncología del Instituto Cardiovascular de Hidalgo, Pachuca de Soto Hidalgo, Fellow SIAC, Pachuca de Soto, México
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106
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Trullàs JC, Casado J. [Diuretic resistance in heart failure]. Med Clin (Barc) 2024; 162:19-21. [PMID: 37919121 DOI: 10.1016/j.medcli.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Joan Carles Trullàs
- Servicio de Medicina Interna, Hospital d'Olot i Comarcal de la Garrotxa, Girona, Catalunya, España; Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Barcelona, Catalunya, España; Grupo de Trabajo de Insuficiencia Cardiaca y Fibrilación Auricular de la Sociedad Española de Medicina Interna, Madrid, España.
| | - Jesús Casado
- Grupo de Trabajo de Insuficiencia Cardiaca y Fibrilación Auricular de la Sociedad Española de Medicina Interna, Madrid, España; Servicio de Medicina Interna, Hospital Universitario de Getafe, Madrid, España
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107
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Bilgeri V, Spitaler P, Puelacher C, Messner M, Adukauskaite A, Barbieri F, Bauer A, Senoner T, Dichtl W. Decongestion in Acute Heart Failure-Time to Rethink and Standardize Current Clinical Practice? J Clin Med 2024; 13:311. [PMID: 38256444 PMCID: PMC10816514 DOI: 10.3390/jcm13020311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/31/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Most episodes of acute heart failure (AHF) are characterized by increasing signs and symptoms of congestion, manifested by edema, pleura effusion and/or ascites. Immediately and repeatedly administered intravenous (IV) loop diuretics currently represent the mainstay of initial therapy aiming to achieve adequate diuresis/natriuresis and euvolemia. Despite these efforts, a significant proportion of patients have residual congestion at discharge, which is associated with a poor prognosis. Therefore, a standardized approach is needed. The door to diuretic time should not exceed 60 min. As a general rule, the starting IV dose is 20-40 mg furosemide equivalents in loop diuretic naïve patients or double the preexisting oral home dose to be administered via IV. Monitoring responses within the following first hours are key issues. (1) After 2 h, spot urinary sodium should be ≥50-70 mmol/L. (2) After 6 h, the urine output should be ≥100-150 mL/hour. If these target measures are not reached, the guidelines currently recommend a doubling of the original dose to a maximum of 400-600 mg furosemide per day and in patients with severely impaired kidney function up to 1000 mg per day. Continuous infusion of loop diuretics offers no benefit over intermittent boluses (DOSE trial). Emerging evidence by recent randomized trials (ADVOR, CLOROTIC) supports the concept of an early combination diuretic therapy, by adding either acetazolamide (500 mg IV once daily) or hydrochlorothiazide. Acetazolamide is particularly useful in the presence of a baseline bicarbonate level of ≥27 mmol/L and remains effective in the presence of preexisting/worsening renal dysfunction but should be used only in the first three days to prevent severe metabolic disturbances. Patients should not leave the hospital when they are still congested and/or before optimized long-term guideline-directed medical therapy has been initiated. Special attention should be paid to AHF patients during the vulnerable post-discharge period, with an early follow-up visit focusing on up-titrate treatments of recommended doses within 2 weeks (STRONG-HF).
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Affiliation(s)
- Valentin Bilgeri
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Philipp Spitaler
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Christian Puelacher
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Moritz Messner
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Agne Adukauskaite
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Fabian Barbieri
- Deutsches Herzzentrum der Charité, Hindenburgdamm 30, 12203 Berlin, Germany;
| | - Axel Bauer
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Thomas Senoner
- Department of Anesthesiology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
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108
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Song YJ, Xu JQ, Chen X, Hu YW, Xiong HDJ, Ou SJ, Zhou HL, Sun XL. Formulation and application of the "hospital-to-home + online-to-offline" treatment scheme in caring for and supporting vulnerable patients with chronic heart failure. Technol Health Care 2024; 32:191-200. [PMID: 37393446 DOI: 10.3233/thc-220693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2023]
Abstract
BACKGROUND Chronic heart failure (CHF) is the terminal stage of cardiovascular disease. OBJECTIVE In this study, the "hospital-to-home + online-to-offline" (H2H + O2O) care scheme was implemented for patients with CHF during vulnerable periods, and its effect was evaluated. METHODS Patients with CHF in the cardiovascular department of a Class III/Grade A hospital in Jiangxi Province from January to December 2020 were selected using a convenience sampling method and randomly divided into a control and intervention group (n= 100 each). The patients in the control group received routine in-hospital treatment and out-of-hospital follow-up, while in the intervention group, a multi-disciplinary cooperation team with CHF specialist nurses evaluated and stratified the patients before discharge and formulated individualized prescriptions and care plans. Based on the "Health & Happiness" chronic disease follow-up application designed for this study, the specialist nurses provided patients with one-to-one guidance. After three months, the cardiac function, heart failure knowledge, self-care behavior, and re-hospitalization rate of the patients were compared between the two groups. Cardiac function was evaluated by the serum B-type natriuretic peptide (BNP), the left ventricular ejection fraction (LVEF), and a six-minute walking test (6MWT). Heart failure knowledge and self-care behavior was assessed using specific questionaries. RESULTS The level of cardiac function in the intervention group was significantly higher than that in the control group, and the difference was statistically significant (P< 0.001). The mastery of heart failure knowledge and self-care behavior in the intervention group were significantly higher than those in the control group, and the differences were statistically significant (P< 0.05). The re-hospitalization rate due to CHF in the intervention group was 21.0%, which was lower than that in the control group (35.0%), and the difference was statistically significant (P< 0.05). CONCLUSION The H2H + O2O care scheme can be used for the transition of vulnerable patients with CHF from the hospital to family care to improve the patients' level of cardiac function, elevate their knowledge level and self-care abilities, and improve their overall health outcomes.
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109
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Khan MS, Paracha AA, Biegus J, Espriella RDL, Núñez J, Santos-Gallego CG, Yaranov D, Fudim M. Preload Reduction Therapies in Heart Failure. Heart Fail Clin 2024; 20:71-81. [PMID: 37953023 DOI: 10.1016/j.hfc.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Preload reserve represents an important concept in the normal physiologic responses of the body to meet the changing metabolic demands. The recruitment of preload in healthy patients leads to an increase in effective circulating blood volume with a concomitant increase in cardiac output. However, in the setting of heart failure (HF), preload augmentation may precipitate HF decompensation. In this review, we focus on the role of splanchnic nerve modulation and pharmacological therapeutic interventions to prevent HF decompensation through preload reduction. Furthermore, we explore the emerging device-based approaches for cardiac preload reduction while reviewing the ongoing clinical trials.
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Affiliation(s)
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Poland
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Fundación de Investigación INCLIVA, Valencia, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Fundación de Investigación INCLIVA, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Carlos G Santos-Gallego
- Cardiology Department, Mount Sinai Hospital, NYC; Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NYC
| | | | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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110
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Felker GM. Natriuresis-Guided Titration of Loop Diuretics in Heart Failure: Another Brick in the Wall. Circ Heart Fail 2024; 17:e011359. [PMID: 38179720 DOI: 10.1161/circheartfailure.123.011359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- G Michael Felker
- Duke Clinical Research Institute, Division of Cardiology, Duke University School of Medicine, Durham, NC
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111
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Shrestha S, Poudel A, Steadman KJ, Nissen LM. Deprescribing Tool for Older PeoPle with Limited-life Expectancy (De-TOPPLE) version 1: Development and validation using a modified Delphi technique. Basic Clin Pharmacol Toxicol 2024; 134:15-27. [PMID: 37264733 DOI: 10.1111/bcpt.13907] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 05/28/2023] [Accepted: 05/30/2023] [Indexed: 06/03/2023]
Abstract
Deprescribing decision making in older adults with limited life expectancy is often challenging for clinicians. We aimed to develop and validate a Deprescribing Tool for Older People with Limited-life Expectancy (De-TOPPLE). Modified Delphi technique was used to gain experts' consensus on the tool and further develop using their feedback. Experts [Round-1 (n = 13), Round-2 (n = 7)] had clinical and/or research background on geriatric medicine, geriatrics, family medicine or pharmacotherapy. Round-1 consensus was achieved on approach taken by the tool to evaluate risk and benefit; distinguishing medications as preventive, symptom control or dual-purpose; referring to established deprescribing process; stepwise approach to deprescribing; and the overall concept. Common feedback was to reflect upon harm-benefit analysis, distinguish medication types earlier, qualify adverse events, use time-to-benefit (TTB), prioritise symptom relief, monitor post-deprescribing, include shared decision making and define terms for clinical familiarisation. After tool update, Round-2 consensus was achieved on usability in clinical setting, flexibility of implicit judgement, ceasing preventive medication with inadequate TTB, ceasing symptom control medication with inadequate symptom relief, ceasing dual-purpose medication (DPM) with inadequate TTB and symptom relief, and continuing DPM with adequate TTB and symptom relief. De-TOPPLE version 1 was developed and validated through two rounds of the Delphi process. Clinical use of the tool needs final validation following the addition of contextual statements to the tool.
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Affiliation(s)
- Shakti Shrestha
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Arjun Poudel
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kathryn J Steadman
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa M Nissen
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
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112
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Samson R, Ennezat PV, Jemtel THL. Patient-Centered Heart Failure Therapy. Am J Med 2024; 137:23-29. [PMID: 37838238 DOI: 10.1016/j.amjmed.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/16/2023]
Abstract
Simultaneous initiation of quadruple therapy with angiotensin receptor-neprilysin inhibitor, beta-adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor aims at prompt improvement and prevention of readmission in patients hospitalized for heart failure with reduced ejection fraction. However, titration of quadruple therapy is time consuming. Lengthy up-titration of quadruple therapy may negate the benefit of early initiation. Quadruple therapy should start with a sodium glucose cotransporter 2 inhibition and a mineralocorticoid antagonist, as both enable safe decongestion and require minimal or no titration. Depending on the level of decongestion and clinical characteristics, patients receive an angiotensin receptor-neprilysin inhibitor or a beta-adrenergic receptor blocker to be titrated after hospital discharge. Outpatient addition of an angiotensin receptor-neprilysin inhibitor to a beta-adrenergic receptor blocker or vice versa completes the quadruple therapy scheme. By focusing on decongestion and matching intervention to patients' profile, the present therapeutic sequence allows rapid implementation of quadruple therapy at fully recommended doses.
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Affiliation(s)
- Rohan Samson
- Advanced Heart Failure Therapies Program, University of Louisville Health-Jewish Hospital, Ky
| | - Pierre V Ennezat
- Department of Cardiology, AP-HP Hopitaux Universitaires Henri Mondor, Créteil, France
| | - Thierry H Le Jemtel
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, La.
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113
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Convey V, Huh T, Achilles EJ, Massey LK, McKaba VF, Loughran KA, Kraus MS, Gelzer AR, Crooks AV, Oyama MA. Urine sodium concentration after intravenous furosemide in dogs with acute congestive heart failure and correlation with treatment efficacy. J Vet Intern Med 2024; 38:71-80. [PMID: 38038223 PMCID: PMC10800184 DOI: 10.1111/jvim.16955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/10/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Poor natriuresis is a potential marker of diuretic resistance in dogs with acute congestive heart failure (CHF) but little is known about the relationship between urine sodium concentration (uNa) and frequency of successful decongestion. Supplemental O2 is a common treatment in dogs with severe CHF. The time from start to discontinuation of supplemental O2 therapy (DCSO2 ) typically reflects the time course and ease of decongestion. HYPOTHESIS/OBJECTIVES Urine Na concentration after IV administration of furosemide will be correlated with duration of treatment with supplemental O2 (timeO2 ) and the cumulative frequency of successful DCSO2 during hospitalization. ANIMALS Fifty-one dogs with acute CHF. METHODS Retrospective observational single center study. RESULTS Dogs with low uNa had significantly longer mean timeO2 than dogs with high uNa (uNa <87 mmol/L, 24.2 ± 2.6 hours vs uNa ≥87 mmol/L, 16.6 ± 1.7 hours; P = .02). Low uNa was correlated with lower cumulative frequency of DCSO2 (12 hour, 28%; 24 hour, 42%; 36 hour, 73%) compared to high uNa (12 hour, 28%; 24 hour, 88%; 36 hour, 96%; P = .005). History of PO loop diuretics, low serum chloride concentration (sCl), and high PCV were associated with low uNa. Urine Na concentration outperformed other metrics of diuretic responsiveness including weight loss. CONCLUSIONS AND CLINICAL IMPORTANCE Urine Na concentration after IV furosemide predicted timeO2 and cumulative frequency of DCSO2 in dogs with acute CHF, which likely reflects important aspects of diuretic responsiveness. Urine Na can assess diuretic responsiveness and treatment efficacy in dogs with CHF.
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Affiliation(s)
- Victoria Convey
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Terry Huh
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Erin J. Achilles
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Laura K. Massey
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Victoria F. McKaba
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Kerry A. Loughran
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Marc S. Kraus
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Anna R. Gelzer
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Alexandra V. Crooks
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Mark A. Oyama
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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114
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Dauw J, Charaya K, Lelonek M, Zegri-Reiriz I, Nasr S, Paredes-Paucar CP, Borbély A, Erdal F, Benkouar R, Cobo-Marcos M, Barge-Caballero G, George V, Zara C, Ross NT, Barker D, Lekhakul A, Frea S, Ghazi AM, Knappe D, Doghmi N, Klincheva M, Fialho I, Bovolo V, Findeisen H, Alhaddad IA, Galluzzo A, de la Espriella R, Tabbalat R, Miró Ò, Singh JS, Nijst P, Dupont M, Martens P, Mullens W. Protocolized Natriuresis-Guided Decongestion Improves Diuretic Response: The Multicenter ENACT-HF Study. Circ Heart Fail 2024; 17:e011105. [PMID: 38179728 DOI: 10.1161/circheartfailure.123.011105] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/25/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND The use of urinary sodium to guide diuretics in acute heart failure is recommended by experts and the most recent European Society of Cardiology guidelines. However, there are limited data to support this recommendation. The ENACT-HF study (Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure) investigated the feasibility and efficacy of a standardized natriuresis-guided diuretic protocol in patients with acute heart failure and signs of volume overload. METHODS ENACT-HF was an international, multicenter, open-label, pragmatic, 2-phase study, comparing the current standard of care of each center with a standardized diuretic protocol, including urinary sodium to guide therapy. The primary end point was natriuresis after 1 day. Secondary end points included cumulative natriuresis and diuresis after 2 days of treatment, length of stay, and in-hospital mortality. All end points were adjusted for baseline differences between both treatment arms. RESULTS Four hundred one patients from 29 centers in 18 countries worldwide were included in the study. The natriuresis after 1 day was significantly higher in the protocol arm compared with the standard of care arm (282 versus 174 mmol; adjusted mean ratio, 1.64; P<0.001). After 2 days, the natriuresis remained higher in the protocol arm (538 versus 365 mmol; adjusted mean ratio, 1.52; P<0.001), with a significantly higher diuresis (5776 versus 4381 mL; adjusted mean ratio, 1.33; P<0.001). The protocol arm had a shorter length of stay (5.8 versus 7.0 days; adjusted mean ratio, 0.87; P=0.036). In-hospital mortality was low and did not significantly differ between the 2 arms (1.4% versus 2.0%; P=0.852). CONCLUSIONS A standardized natriuresis-guided diuretic protocol to guide decongestion in acute heart failure was feasible, safe, and resulted in higher natriuresis and diuresis, as well as a shorter length of stay.
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Affiliation(s)
- Jeroen Dauw
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium (J.D., P.N., M.D., P.M.)
- UHasselt, Doctoral School for Medicine and Life Sciences, LCRC, Diepenbeek, Belgium (J.D., W.M.)
| | - Kristina Charaya
- Department of Cardiology, Sonography and Functional Diagnostics, First Moscow State Medical University, Russia (K.C.)
| | - Małgorzata Lelonek
- Department of Noninvasive Cardiology, Medical University of Lodz, Poland (M.L.)
| | - Isabel Zegri-Reiriz
- Department of Cardiology, Heart Failure and Heart Transplant Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (I.Z.-R.)
| | - Samer Nasr
- Department of Cardiology, Mount Lebanon Hospital-Balamand University Medical Center, Hazmiyeh (S.N.)
| | | | - Attila Borbély
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Hungary (A.B.)
| | - Fatih Erdal
- Department of Cardiology, Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands (F.E.)
| | - Riad Benkouar
- Benyoucef Benkhedda Faculty of Medicine, Mustapha Pacha Hospital, University of Algiers, Algeria (R.B.)
| | - Marta Cobo-Marcos
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda (IDIPHISA), Madrid, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (M.C.-M.)
| | - Gonzalo Barge-Caballero
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Complexo Hospitalario Universitario A Coruña (CHUAC), Servicio Galego de Saúde (SERGAS), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain (G.B.-C.)
| | - Varghese George
- Pushpagiri Institute of Medical Sciences, Tiruvalla, India (V.G.)
| | | | - Noel T Ross
- Kuala Lumpur General Hospital, Malaysia (N.T.R.)
| | - Diane Barker
- University Hospitals of North Midlands, Stoke on Trent, United Kingdom (D.B.)
| | | | - Simone Frea
- Division of Cardiology, Città della Salute e della Scienza University Hospital of Torino, Turin, Italy (S.F.)
| | - Azmee M Ghazi
- National Heart Institute, Kuala Lumpur, Malaysia (A.M.G.)
| | - Dorit Knappe
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (D.K.)
| | - Nawal Doghmi
- Department of Cardiology, CHU Ibn Sina, Mohammed V University, Rabat, Morocco (N.D.)
| | | | - Inês Fialho
- Department of Cardiology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal (I.F.)
| | - Virginia Bovolo
- Department of Cardiology, Michele e Pietro Ferrero Hospital, Verduno, Italy (V.B.)
| | - Hajo Findeisen
- Department of Internal Medicine, Red Cross Hospital, Bremen, Germany (H.F.)
| | | | | | | | - Ramzi Tabbalat
- Department of Cardiology, Abdali Hospital, Amman, Jordan (R.T.)
| | - Òscar Miró
- Emergency Department, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Catalonia, Spain (Ò.M.)
| | - Jagdeep S Singh
- The Heart Centre, Royal Infirmary of Edinburgh, United Kingdom (J.S.S.)
| | - Petra Nijst
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium (J.D., P.N., M.D., P.M.)
| | - Matthias Dupont
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium (J.D., P.N., M.D., P.M.)
| | - Pieter Martens
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium (J.D., P.N., M.D., P.M.)
| | - Wilfried Mullens
- UHasselt, Doctoral School for Medicine and Life Sciences, LCRC, Diepenbeek, Belgium (J.D., W.M.)
- UHasselt, Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Diepenbeek, Belgium (W.M.)
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115
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Londoño JM, Betancur KJ, Fonseca L, Fonseca P, Cañas EM, Saldarriaga CI. Spot urinary sodium as a prognostic marker for mortality in patients with acute decompensated heart failure. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2023; 43:41-50. [PMID: 38207157 PMCID: PMC10941827 DOI: 10.7705/biomedica.6920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/20/2023] [Indexed: 01/13/2024]
Abstract
Introduction. Urinary sodium has been proposed as a prognostic marker and indicator of the diuretic response in patients with heart failure. However, study results are heterogeneous. Objective. To evaluate the spot urinary sodium level as a risk factor for mortality in patients with decompensated heart failure. Materials and methods. We conducted a case-control study nested in a prospective cohort of patients with decompensated heart failure. The primary outcome was mortality at 180 days. The risk factors associated with mortality were evaluated through a bivariate analysis. Differences in clinical variables between groups with urinary sodium greater than or lesser than 70 mEq/L were analyzed. Results. The study included 79 patients; 15 died at 180 days. Their mean age was 68.9 years (SD=± 13.8); 30 were women (38%), and 15 (18.9%) had urinary sodium <70 mEq/L. In the bivariate analysis, a significant association was found between mortality and past medical history of hospitalizations, SBP<90 mm Hg, the use of inotropes, and urinary sodium <70 mEq/L. Regarding clinical characteristics, patients with low urinary sodium level in the last year were hospitalized more frequently with hyponatremia and hypotension at admission. Conclusion. Patients with urinary sodium <70 mEq/L had more severe signs. In a bivariate analysis, urinary sodium was associated with mortality at 180 days.
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Affiliation(s)
- Jessica M Londoño
- Cardiología, Universidad Pontificia Bolivariana-Clínica Cardio VID, Medellín, Colombia.
| | - Kelly J Betancur
- Cardiología, Universidad Pontificia Bolivariana-Clínica Cardio VID, Medellín, Colombia.
| | - Lina Fonseca
- Cardiología, Clínica Cardio VID, Medellín, Colombia.
| | - Paula Fonseca
- Medicina Interna, Universidad Cooperativa de Colombia, Medellín, Colombia.
| | - Eliana M Cañas
- Cardiología, Universidad Pontificia Bolivariana-Clínica Cardio VID, Medellín, Colombia.
| | - Clara I Saldarriaga
- Cardiología, Universidad Pontificia Bolivariana-Clínica Cardio VID, Medellín, Colombia.
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116
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Emara AN, Wadie M, Mansour NO, Shams MEE. The clinical outcomes of dapagliflozin in patients with acute heart failure: A randomized controlled trial (DAPA-RESPONSE-AHF). Eur J Pharmacol 2023; 961:176179. [PMID: 37923161 DOI: 10.1016/j.ejphar.2023.176179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023]
Abstract
AIMS Dapagliflozin may confer additional decongestive and natriuretic benefits to patients with acute heart failure (AHF). Nonetheless, this hypothesis was not clinically examined. This study aimed primarily to investigate the effect of dapagliflozin on symptomatic relief in those patients. METHODS This was a randomized, double-blind study that included 87 patients with AHF presenting with dyspnea. Within 24 h of admission, patients were randomized to receive either dapagliflozin (10 mg/day, N = 45) or placebo (N = 42) for 30 days. The primary outcome was the difference between the two groups in the area under the curve (AUC) of visual analogue scale (VAS) dyspnea score over the first 4 days. Secondary endpoints included urinary sodium (Na) after 2 h of randomization, percent change in NT-proBNP, cumulative urine output (UOP), and differences in mortality and hospital readmission rates. RESULTS The results showed that dapagliflozin significantly reduced the AUC of VAS dyspnea score compared to placebo (3192.2 ± 1631.9 mm × h vs 4713.1 ± 1714.9 mm × h, P < 0.001). The relative change of NT-proBNP compared to its baseline was also larger with dapagliflozin (-34.89% vs -10.085%, P = 0.001). Additionally, higher cumulative UOP was found at day 4 (18600 ml in dapagliflozin vs 13700 in placebo, P = 0.031). Dapagliflozin decreased rehospitalization rates within 30 days after discharge, while it did not affect the spot urinary Na concentration, incidence of worsening of heart failure, or mortality rates. CONCLUSION Dapagliflozin may provide symptomatic relief and improve diuresis in patients with AHF. Further studies are needed to confirm these findings. https://clinicaltrials.gov/study/NCT05406505.
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Affiliation(s)
- Abdelrahman N Emara
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt.
| | - Moheb Wadie
- Cardiology Department, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt.
| | - Noha O Mansour
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt; Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura National University, Egypt.
| | - Mohamed E E Shams
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt.
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117
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Kaddour M, Burri H. Conduction System Pacing: Have We Finally Found the Holy Grail of Physiological Pacing? Heart Int 2023; 17:2-5. [PMID: 38419718 PMCID: PMC10919353 DOI: 10.17925/hi.2023.17.2.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/25/2023] [Indexed: 03/02/2024] Open
Abstract
The late fifties are considered a high point in the history of cardiac pacing, since this era is marked by the first pacemaker implantation, which has since evolved into life-saving therapy. Right ventricular apical and biventricular pacing are the classic techniques that are recommended as first-l ine approaches for most indications in current guidelines. However, conduction system pacing has emerged as being able to deliver a more physiological form of pacing and is becoming mainstream practice in a growing number of centres. In this review, we aim to compare traditional pacing methods with conduction system pacing.
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Affiliation(s)
- Myriam Kaddour
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
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118
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Barchitta A, Rossitto G, Ruzza L, Maio D, Scaparotta G, Bagordo D, Antonini Canterin F, Piovesana P, Seccia TM, Nalesso F, Calò L, Rossi GP. Coronary sinus diameter to estimate congestion and predict survival. IJC HEART & VASCULATURE 2023; 49:101294. [PMID: 38020054 PMCID: PMC10663896 DOI: 10.1016/j.ijcha.2023.101294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
Background Congestion predicts a poor prognosis, but its assessment is challenging in clinical practice and requires a multiparametric approach. We investigated if the coronary sinus (CS) diameter can predict mortality in a human model of rapid fluid unloading. Methods We measured by echocardiography the CS, and the inferior vena cava (IVC) for comparison, in 60 patients with end-stage chronic kidney disease (ESKD) immediately before and after hemodialysis (HD; age 76 [57-81] years, 40% female, left ventricular ejection fraction 57 [53-56]%). Patients were prospectively followed up for all-cause mortality. Results HD-induced decongestion decreased the maximum diameters of both CS and IVC (p ≤ 0.001 for all). The maximum diameter of the CS (CSmax) was as accurate as the IVC maximum diameter and collapsibility for the identification of congestion, defined as pre-hemodialysis status (AUROC CSmax = 0.902 vs IVC = 0.895, p = n.s.). A CSmax diameter after hemodialysis > 9 mm predicted all-cause mortality at 12 months (Log-rank Chi square = 11.49, p < 0.001). Conclusions A persistently dilated CS after hemodialysis is a marker of residual congestion and predicts death at one year in high-risk ESKD patients.
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Affiliation(s)
- Agatella Barchitta
- University of Padova, Emergency Medicine and Hypertension, University Hospital, Padova, Italy
| | - Giacomo Rossitto
- University of Padova, Emergency Medicine and Hypertension, University Hospital, Padova, Italy
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Luisa Ruzza
- University of Padova, Emergency Medicine and Hypertension, University Hospital, Padova, Italy
| | - Daniele Maio
- University of Ferrara, Cardiology, St Anna Hospital, Ferrara, Italy
| | | | - Domenico Bagordo
- University of Padova, Emergency Medicine and Hypertension, University Hospital, Padova, Italy
| | | | | | - Teresa Maria Seccia
- University of Padova, Emergency Medicine and Hypertension, University Hospital, Padova, Italy
| | - Federico Nalesso
- University of Padova, Nephrology, University Hospital, Padova, Italy
| | - Lorenzo Calò
- University of Padova, Nephrology, University Hospital, Padova, Italy
| | - Gian Paolo Rossi
- University of Padova, Emergency Medicine and Hypertension, University Hospital, Padova, Italy
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119
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Ayenew B, Kumar P, Hussein A, Gashaw Y, Girma M, Ayalew A, Tadesse B. Heart failure drug classes and 30-day unplanned hospital readmission among patients with heart failure in Ethiopia. J Pharm Health Care Sci 2023; 9:49. [PMID: 38012803 PMCID: PMC10680257 DOI: 10.1186/s40780-023-00320-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Drug therapy is a crucial aspect of heart failure management and has been shown to reduce morbidity and mortality in heart failure patients. However, the comparative effects of these drug classes on readmission rates have not been well studied. Therefore, the aim of this study was to examine the association between different classes of heart failure drugs and 30-day readmission rates in patients with heart failure. METHOD A multicenter, hospital-based retrospective cohort design was employed and 572 randomly selected patients with heart failure were included. Data were entered in Epi-data version 4.6 and analyzed with STATA version 17. Kaplan-Meier and log-rank tests were used to estimate and compare survival time. A Cox proportional hazard model was utilized, employing both bi-variable and multi-variable analyses, to examine the effect of predictors on the timing of unplanned hospital readmissions. The strength of the association was assessed using an adjusted hazard ratio (aHR), and statistical significance was declared for p-values < 0.05 and a 95% confidence interval (CI). RESULTS In this study, a total of 151 (26.40%) heart failure patients were readmitted within 30 days of discharge. In the multivariate cox proportional hazards analysis being an age (> 65 year) (AHR: 2.34, 95%CI: 1.63, 3.37), rural in residency (AHR: 1.85, 95%CI: 1.07, 3.20), hospital stays > 7 Days (AHR: 3.68, 95%CI: 2.51,5.39), discharge with Diuretics (AHR: 2.37, 95%CI: 1.45, 3.86), and discharge with Beta-Blocker (AHR: 0.48, 95%CI: 0 0.34, 0.69) were identified as independent predictors of unplanned hospital readmission. CONCLUSION Elderly patients, being in rural areas, longer hospital stays, and discharges of patients on diuretics and not on beta-blockers were independent predictors of unplanned hospital readmission. Therefore, working on these factors will help to reduce the hazard of unplanned hospital readmissions, improve patient outcomes, and increase the efficiency of heart failure management.
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Affiliation(s)
- Birhanu Ayenew
- Department of Adult Health Nursing, College of Health Science, Assosa University, Assosa, Ethiopia.
| | - Prem Kumar
- Department of Adult Health Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Adem Hussein
- Department of Adult Health Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Yegoraw Gashaw
- Department of Pediatric and Child Health Nursing, College of Health Science, Assosa University, Assosa, Ethiopia
| | - Mitaw Girma
- Department of Comprehensive Health Nursing, College of Medicine & Health Sciences, Wollo University, Dessie, Ethiopia
| | - Abdulmelik Ayalew
- Department of Adult Health Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Beza Tadesse
- Department of Adult Health Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
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Moreira GR, Villacorta H. A Personalized Approach to the Management of Congestion in Acute Heart Failure. Heart Int 2023; 17:35-42. [PMID: 38455673 PMCID: PMC10919353 DOI: 10.17925/hi.2023.17.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/18/2023] [Indexed: 03/09/2024] Open
Abstract
Heart failure (HF) is the common final pathway of several conditions and is characterized by hyperactivation of numerous neurohumoral pathways. Cardiorenal interaction plays an essential role in the progression of the disease, and the use of diuretics is a cornerstone in the treatment of hypervolemic patients, especially in acute decompensated HF (ADHF). The management of congestion is complex and, to avoid misinterpretations and errors, one must understand the interface between the heart and the kidneys in ADHF. Congestion itself may impair renal function and must be treated aggressively. Transitory elevations in serum creatinine during decongestion is not associated with worse outcomes and diuretics should be maintained in patients with clear hypervolemia. Monitoring urinary sodium after diuretic administration seems to improve the response to diuretics as it allows for adjustments in doses and a personalized approach. Adequate assessment of volemia and the introduction and titration of guideline-directed medical therapy are mandatory before discharge. An early visit after discharge is highly recommended, to assess for residual congestion and thus avoid readmissions.
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Affiliation(s)
- Gustavo R Moreira
- Cardiology Division, Fluminense Federal University, Niterói, Rio de Janeiro State, Brazil
| | - Humberto Villacorta
- Cardiology Division, Fluminense Federal University, Niterói, Rio de Janeiro State, Brazil
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121
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Meani P, Pagnoni M, Mondellini GM, Fiorenza S, Brunner-La Rocca HP. Impact of loop diuretic dosage in a population of patients with acute heart failure: a retrospective analysis. Front Cardiovasc Med 2023; 10:1267042. [PMID: 38075974 PMCID: PMC10701382 DOI: 10.3389/fcvm.2023.1267042] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/31/2023] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Loop diuretics are essential for managing congestion in acute heart failure (AHF) patients, but concerns exist about their dosing and administration. This study aims to explore the relationship between aggressive diuretic treatment and clinical outcomes in AHF patients. METHODS We randomly selected 370 AHF patients from admissions at Maastricht University Medical Center between January 2011 and March 2017. Patients were divided into four quartiles based on diuretic doses administrated during index hospitalization. The primary endpoint was a composite of cardiovascular (CV) rehospitalization or death at 1 year. RESULTS 42.4% of patients experimented the primary outcome The composite endpoint rates were 35.4%, 41.6%, 38.5%, and 54.9%, respectively, from lowest to highest dose quartiles (p = 0.033). In univariate analysis, the outcome was significantly lower in the first three quartiles as compared to the fourth quartile. One-year CV mortality was 9.1%, 10.1%, 20.9% and 27.2%, respectively (p = 0.002). After adjusting for confounders, the association between loop diuretic dosage disappeared for both the primary outcome and one-year CV mortality. Most secondary outcomes and endpoints at 3 months, including worsening renal function, showed no significant differences between groups, while hypokaliemia occurrence, length of hospital stay and weight loss at index admission were higher in the fourth quartile compared to the first one. CONCLUSIONS High loop diuretic doses are associated with poor outcomes in AHF patients, reflecting disease severity rather than harm from aggressive diuretic use. Furthermore, high diuretic doses do not seem to negatively affect kidney function.
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Affiliation(s)
- P. Meani
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht (MUMC), Maastricht, Netherlands
| | - M. Pagnoni
- Division of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - G. M. Mondellini
- Division of Cardiology, Università Degli Studi di Milano, Milan, Italy
| | - S. Fiorenza
- Division of Cardiology, Istituto Clinico Città Studi, Milan, Italy
| | - H. P. Brunner-La Rocca
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
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122
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Deniau B, Costanzo MR, Sliwa K, Asakage A, Mullens W, Mebazaa A. Acute heart failure: current pharmacological treatment and perspectives. Eur Heart J 2023; 44:4634-4649. [PMID: 37850661 DOI: 10.1093/eurheartj/ehad617] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 08/23/2023] [Accepted: 09/08/2023] [Indexed: 10/19/2023] Open
Abstract
Acute heart failure (AHF) represents the most frequent cause of unplanned hospital admission in patients older than 65 years. Symptoms and clinical signs of AHF (e.g. dyspnoea, orthopnoea, oedema, jugular vein distension, and variation of body weight) are mostly related to systemic venous congestion secondary to various mechanisms including extracellular fluids, increased ventricular filling pressures, and/or auto-transfusion of blood from the splanchnic into the pulmonary circulation. Thus, the initial management of AHF patients should be mostly based on decongestive therapies on admission followed, before discharge, by rapid implementation of guideline-directed oral medical therapies for heart failure. The therapeutic management of AHF requires the identification and rapid diagnosis of the disease, the diagnosis of the cause (or triggering factor), the evaluation of severity, the presence of comorbidities, and, finally, the initiation of a rapid treatment. The most recent guidelines from ESC and ACC/AHA/HFSA have provided updated recommendations on AHF management. Recommended pharmacological treatment for AHF includes diuretic therapy aiming to relieve congestion and achieve optimal fluid status, early and rapid initiation of oral therapies before discharge combined with a close follow-up. Non-pharmacological AHF management requires risk stratification in the emergency department and non-invasive ventilation in case of respiratory failure. Vasodilators should be considered as initial therapy in AHF precipitated by hypertension. On the background of recent large randomized clinical trials and international guidelines, this state-of-the-art review describes current pharmacological treatments and potential directions for future research in AHF.
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Affiliation(s)
- Benjamin Deniau
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, 2 rue Ambroise Paré, 75010 Paris, France
- UMR-S 942, INSERM, MASCOT, Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, France
| | | | - Karen Sliwa
- Cape Heart Institute, Department of Cardiology and Medicine, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, South Africa
| | - Ayu Asakage
- UMR-S 942, INSERM, MASCOT, Université de Paris Cité, Paris, France
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg A.V., Genk, Belgium
- Hasselt University, Diepenbeek/Hasselt, Belgium
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, 2 rue Ambroise Paré, 75010 Paris, France
- UMR-S 942, INSERM, MASCOT, Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, France
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123
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Hahn RT, Lawlor MK, Davidson CJ, Badhwar V, Sannino A, Spitzer E, Lurz P, Lindman BR, Topilsky Y, Baron SJ, Chadderdon S, Khalique OK, Tang GHL, Taramasso M, Grayburn PA, Badano L, Leipsic J, Lindenfeld J, Windecker S, Vemulapalli S, Redfors B, Alu MC, Cohen DJ, Rodés-Cabau J, Ailawadi G, Mack M, Ben-Yehuda O, Leon MB, Hausleiter J. Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints. Eur Heart J 2023; 44:4508-4532. [PMID: 37793121 PMCID: PMC10645050 DOI: 10.1093/eurheartj/ehad653] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/12/2023] [Accepted: 08/08/2023] [Indexed: 10/06/2023] Open
Abstract
Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options.
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Affiliation(s)
- Rebecca T Hahn
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York,USA
| | - Matthew K Lawlor
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Charles J Davidson
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Anna Sannino
- Baylor Research Institute, The Heart Hospital Baylor Plano, Plano, Texas, USA
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, Naples, Italy
| | - Ernest Spitzer
- Cardialysis, Rotterdam, the Netherlands
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Philipp Lurz
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Brian R Lindman
- Structural Heart and Valve Center, Cardiovascular Division, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Suzanne J Baron
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Baim Institute of Clinical Research, Boston, Massachusetts, USA
| | - Scott Chadderdon
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Omar K Khalique
- Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York, USA
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA
| | - Maurizio Taramasso
- Herzzentrum Hirslanden Zürich, Zürich, Switzerland
- University of Zürich, Zürich, Switzerland
| | - Paul A Grayburn
- Baylor Scott and White Heart and Vascular Hospital at Plano, Plano, Texas, USA
| | - Luigi Badano
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Jonathon Leipsic
- Department of Radiology and Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephan Windecker
- Department of Cardiology, University Cardiovascular Center, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York,USA
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York,USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York,USA
- Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York, USA
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Mack
- Baylor Scott and White Health, Dallas, Texas, USA
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, New York, New York,USA
- University of California-San Diego, San Diego, California, USA
| | - Martin B Leon
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York,USA
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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124
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Villacorta H. In-Hospital Worsening Heart Failure: Can We Predict It At Admission? Arq Bras Cardiol 2023; 120:e20230525. [PMID: 37971048 PMCID: PMC10519240 DOI: 10.36660/abc.20230525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 11/19/2023] Open
Affiliation(s)
- Humberto Villacorta
- Universidade Federal FluminenseNiteróiRJBrasilUniversidade Federal Fluminense, Niterói, RJ – Brasil
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125
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Nagao K, Maruichi‐Kawakami S, Aida K, Matsuto K, Imamoto K, Yukawa H, Kanazawa T, Kobayashi Y, Takahashi N, Ito H, Hayashi F, Inada T. Association Between the Liver Fibrosis Markers and Scores, and Hemodynamic Congestion Assessed by Peripheral Venous Pressure in Patients With Acute Heart Failure. J Am Heart Assoc 2023; 12:e030788. [PMID: 37929710 PMCID: PMC10727400 DOI: 10.1161/jaha.123.030788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/20/2023] [Indexed: 11/07/2023]
Abstract
Background Peripheral venous pressure (PVP) has been shown to be a reliable surrogate for right atrial pressure in assessing congestion in patients with heart failure (HF). Liver fibrosis markers and scores can be useful in assessing organ injury in patients with acute HF. This study aimed to investigate the association of liver fibrosis markers and scores with PVP in patients with acute HF. Methods and Results The 7S domain of the collagen type IV N-terminal propeptide (P4NP 7S), aspartate aminotransferase-to-platelet ratio index, fibrosis-4, and nonalcoholic fatty liver disease fibrosis score were determined along with PVP measurements before discharge in 229 patients with acute HF. The strongest correlation with PVP was found for P4NP 7S (Pearson r=0.40). Patients with high P4NP 7S levels (≥median [6.2 ng/mL]) had an increased risk of cardiovascular death or HF hospitalization (adjusted hazard ratio [HR], 1.80 [95% CI, 1.09-3.04], P=0.02). The concomitant high PVP (≥mean [8 mm Hg])/high P4NP 7S group, in contrast to the high PVP/low P4NP 7S or low PVP/high P4NP 7S group, had a significant risk relative to the low PVP/low P4NP 7S group for cardiovascular death or HF hospitalization (adjusted HR, 2.63 [95% CI, 1.43-5.05], P=0.002). A sustained elevation in PVP for 1 month postdischarge was associated with a persistent increase in P4NP 7S. Conclusions The study demonstrated the relationship between the liver fibrosis marker P4NP 7S and congestion. PVP and P4NP 7S could be useful for assessing congestion-related organ injury and predicting prognosis in patients with acute HF.
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Affiliation(s)
- Kazuya Nagao
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
- Department of Cardiovascular MedicineKyoto University Graduate School of MedicineKyotoJapan
| | | | - Kenji Aida
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
| | - Kenichi Matsuto
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
| | - Kazumasa Imamoto
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
| | - Hiroshi Yukawa
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
| | - Takenori Kanazawa
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
| | - Yohei Kobayashi
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
| | - Naoki Takahashi
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
| | - Haruyasu Ito
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
| | - Fujio Hayashi
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
| | - Tsukasa Inada
- Department of Cardiology, Cardiovascular CenterOsaka Red Cross HospitalOsakaJapan
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126
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Hahn RT, Lawlor MK, Davidson CJ, Badhwar V, Sannino A, Spitzer E, Lurz P, Lindman BR, Topilsky Y, Baron SJ, Chadderdon S, Khalique OK, Tang GHL, Taramasso M, Grayburn PA, Badano L, Leipsic J, Lindenfeld J, Windecker S, Vemulapalli S, Redfors B, Alu MC, Cohen DJ, Rodés-Cabau J, Ailawadi G, Mack M, Ben-Yehuda O, Leon MB, Hausleiter J. Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints. Ann Thorac Surg 2023; 116:908-932. [PMID: 37804270 DOI: 10.1016/j.athoracsur.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 10/09/2023]
Abstract
Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options.
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Affiliation(s)
- Rebecca T Hahn
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York.
| | - Matthew K Lawlor
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York
| | | | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Anna Sannino
- Baylor Research Institute, The Heart Hospital Baylor Plano, Plano, Texas; Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Ernest Spitzer
- Cardialysis, Rotterdam, the Netherlands; Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Philipp Lurz
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Brian R Lindman
- Structural Heart and Valve Center, Cardiovascular Division, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Suzanne J Baron
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts; Baim Institute of Clinical Research, Boston, Massachusetts
| | - Scott Chadderdon
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Omar K Khalique
- Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York
| | - Maurizio Taramasso
- Herzzentrum Hirslanden Zürich, Zürich, Switzerland; University of Zürich, Zürich, Switzerland
| | - Paul A Grayburn
- Baylor Scott and White Heart and Vascular Hospital at Plano, Plano, Texas
| | - Luigi Badano
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Jonathon Leipsic
- Department of Radiology and Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephan Windecker
- Department of Cardiology, University Cardiovascular Center, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina; Duke University School of Medicine, Durham, North Carolina
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York; Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, New York, New York; University of California-San Diego, San Diego, California
| | - Martin B Leon
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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127
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Jhand A, Baran DA. How Deep Is My Ocean? Defining Decongestion for Patients and Trialists. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101171. [PMID: 39132862 PMCID: PMC11308069 DOI: 10.1016/j.jscai.2023.101171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 08/13/2024]
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128
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Georges G, Fudim M, Burkhoff D, Leon MB, Généreux P. Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 2. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101059. [PMID: 39131062 PMCID: PMC11307977 DOI: 10.1016/j.jscai.2023.101059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 08/13/2024]
Abstract
Congestion is the most common manifestation of acute decompensated heart failure (ADHF). Residual congestion despite initial medical therapy is common and is recognized to be associated with worse outcomes; however, there are currently no standardized definition regarding decongestion end point. In the second part of this 2-part review, we provide a critical appraisal of decongestion definitions previously used in ADHF studies, review alternative metrics to define severity of volume overload, and propose a more granular 4-class congestion grading scheme and decongestion end point definitions that could potentially be included in future ADHF trials and consensus definitions.
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Affiliation(s)
- Gabriel Georges
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Martin B. Leon
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
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129
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Salah HM, Biegus J, Ponikowski PP, Fudim M. Role of Lymphatics in Heart Failure. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101204. [PMID: 39131069 PMCID: PMC11308066 DOI: 10.1016/j.jscai.2023.101204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 08/13/2024]
Abstract
The lymphatic system plays a crucial, yet often overlooked, role in maintaining fluid homeostasis, and its dysregulation is a key feature of heart failure (HF). Lymphatic dysregulation in patients with HF typically results from a combination of self-perpetuating congestive mechanisms, such as increased fluid filtration, decreased lymph drainage into the central venous system, impaired lymph vessel integrity, dysfunctional lymphatic valves, and dysfunctional renal lymphatic system. These pathomechanisms collectively overwhelm the lymphatic system and hinder its ability to decongest the interstitial space with subsequent manifestation and progression of clinical congestion. Targeting the lymphatic system to counteract these congestive pathomechanisms and facilitate interstitial fluid removal represents a novel pathway to treat congestion in HF. In this study, we discuss the physiological roles of the lymphatic system in fluid homeostasis and the pathophysiological alteration of these roles in HF. We also discuss innovative technologies that aim to use the lymphatic system pathway to treat congestion in HF and provide future directions related to these approaches.
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Affiliation(s)
- Husam M. Salah
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | | | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Duke Clinical Research Institute, Durham, North Carolina
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130
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Okoye C, Mazzarone T, Cargiolli C, Guarino D. Discontinuation of Loop Diuretics in Older Patients with Chronic Stable Heart Failure: A Narrative Review. Drugs Aging 2023; 40:981-990. [PMID: 37620655 PMCID: PMC10600299 DOI: 10.1007/s40266-023-01061-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 08/26/2023]
Abstract
Loop diuretics (LDs) represent the cornerstone treatment for relieving pulmonary congestion in patients with heart failure (HF). Their benefit is well-recognized in the short term because of their ability to eliminate fluid retention. However, long term, they could adversely influence prognosis due to activation of the neurohumoral mechanism, particularly in older, frail patients. Moreover, the advent of new drugs capable of improving outcomes and reducing pulmonary and systemic congestion signs in HF emphasizes the possibility of a progressive reduction and discontinuation of LD treatment. Nevertheless, few studies were aimed at investigating the safety of LDs withdrawal in older patients with chronic stable HF. This current review aims to approach current evidence regarding the safety and effectiveness of LDs discontinuation in patients with chronic stable HF, and is based on the material obtained via the PubMed and Scopus databases from January 2000 to November 2022. Our search yielded five relevant studies, including two randomized controlled trials. All participants presented stable HF at the time of study enrolment. Apart from one study, all the investigations were conducted in patients with HF with reduced ejection fraction. The most common outcomes examined were the need for diuretic resumption or the event of death and rehospitalization after diuretic withdrawal. As a whole, although based on a few investigations with a low grade of evidence, diuretic therapy discontinuation might be a safe strategy that deserves consideration for patients with stable HF. However, extensive investigations in older adults, accounting for frailty status, are warranted to confirm these data in this peculiar class of patients.
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Affiliation(s)
- Chukwuma Okoye
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa, 2, 56124, Pisa, Italy.
- Department of Neurobiology, Aging Research Center, Karolinska Institutet, Stockholm, Sweden.
| | - Tessa Mazzarone
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa, 2, 56124, Pisa, Italy
| | - Cristina Cargiolli
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa, 2, 56124, Pisa, Italy
| | - Daniela Guarino
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa, 2, 56124, Pisa, Italy
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131
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Georges G, Fudim M, Burkhoff D, Leon MB, Généreux P. Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 1. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101060. [PMID: 39131061 PMCID: PMC11307876 DOI: 10.1016/j.jscai.2023.101060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 08/13/2024]
Abstract
Despite recent advances in the treatment of patients with chronic heart failure, acute decompensated heart failure remains associated with significant mortality and morbidity because many novel therapies have failed to demonstrate meaningful benefit. Persistent congestion in the setting of escalating diuretic therapy has been repeatedly shown to be a marker of poor prognosis and is currently being targeted by various emerging device-based therapies. Because these therapies inherently carry procedural risk, patient selection is key in the future trial design. However, it remains unclear which patients are at a higher risk of residual congestion or adverse outcomes despite maximally tolerated decongestive therapy. In the first part of this 2-part review, we aimed to outline patient risk factors and summarize current evidence for early recognition of high-risk profile for residual congestion and adverse outcomes. These factors are classified as relating to the following: (1) previous clinical course, (2) severity of congestion, (3) diuretic response, and (4) degree of renal impairment. We also aimed to provide an overview of key inclusion criteria in recent acute decompensated heart failure trials and investigational device studies and propose potential criteria for selection of high-risk patients in future trials.
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Affiliation(s)
- Gabriel Georges
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Martin B. Leon
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
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132
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Khan WJ, Arriola-Montenegro J, Mutschler MS, Bensimhon D, Halmosi R, Toth K, Alexy T. A novel opportunity to improve heart failure care: focusing on subcutaneous furosemide. Heart Fail Rev 2023; 28:1315-1323. [PMID: 37439967 DOI: 10.1007/s10741-023-10331-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
The prevalence of heart failure (HF) continues to rise in developed nations. Symptomatic congestion is the most common reason for patients to seek medical attention, and management often requires intravenous (IV) diuretic administration in the hospital setting. Typically, the number of admissions increases as the disease progresses, not only impacting patient survival and quality of life but also driving up healthcare expenditures. pH-neutral furosemide delivered subcutaneously using a proprietary, single-use infusor system (Furoscix) has a tremendous potential to transition in-hospital decongestive therapy to the outpatient setting or to the patient's home. This review is aimed at providing an overview of the pharmacodynamic and pharmacokinetic profile of the novel pH-neutral furosemide in addition to the most recent clinical trials demonstrating its benefit when used in the home setting. Given the newest data and approval by the Food and Drug Administration in the US, it has the potential to revolutionize the care of patients with decompensated HF. Undoubtedly, it will lead to improved quality of life as well as significantly reduced healthcare costs related to hospital admissions.
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Affiliation(s)
- Wahab J Khan
- Department of Medicine, Avera Health, Sioux Falls, SD, 57105, USA
| | - Jose Arriola-Montenegro
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Melinda S Mutschler
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Daniel Bensimhon
- Division of Cardiovascular Medicine, Cone Health, Greensboro, NC, 27401, USA
| | - Robert Halmosi
- Division of Cardiology, 1st Department of Medicine, Medical School, University of Pecs, 7624, Pecs, Hungary
| | - Kalman Toth
- Division of Cardiology, 1st Department of Medicine, Medical School, University of Pecs, 7624, Pecs, Hungary
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, 55455, USA.
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133
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Cox ZL, Siddiqi HK, Stevenson LW, Bales B, Han JH, Hart K, Imhoff B, Ivey-Miranda JB, Jenkins CA, Lindenfeld J, Shotwell MS, Miller KF, Ooi H, Rao VS, Schlendorf K, Self WH, Siew ED, Storrow A, Walsh R, Wrenn JO, Testani JM, Collins SP. Randomized controlled trial of urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE): Rationale and design. Am Heart J 2023; 265:121-131. [PMID: 37544492 PMCID: PMC10592235 DOI: 10.1016/j.ahj.2023.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
Diuresis to achieve decongestion is a central aim of therapy in patients hospitalized for acute decompensated heart failure (ADHF). While multiple clinical trials have investigated initial diuretic strategies for a designated period of time, there is a paucity of evidence to guide diuretic titration strategies continued until decongestion is achieved. The use of urine chemistries (urine sodium and creatinine) in a natriuretic response prediction equation accurately estimates natriuresis in response to diuretic dosing, but a randomized clinical trial is needed to compare a urine chemistry-guided diuresis strategy with a strategy of usual care. The urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE) trial is designed to test the hypothesis that protocolized diuretic therapy guided by spot urine chemistry through completion of intravenous diuresis will be superior to usual care and improve outcomes over the 14 days following randomization. ESCALATE will randomize and obtain complete data on 450 patients with acute heart failure to a diuretic strategy guided by urine chemistry or a usual care strategy. Key inclusion criteria include an objective measure of hypervolemia with at least 10 pounds of estimated excess volume, and key exclusion criteria include significant valvular stenosis, hypotension, and a chronic need for dialysis. Our primary outcome is days of benefit over the 14 days after randomization. Days of benefit combines patient symptoms captured by global clinical status with clinical state quantifying the need for hospitalization and intravenous diuresis. CLINICAL TRIAL REGISTRATION: NCT04481919.
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, Nashville, TN; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN.
| | - Hasan K Siddiqi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lynne W Stevenson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Brian Bales
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, TN
| | - Kimberly Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Brant Imhoff
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Henry Ooi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, TN
| | - Veena S Rao
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Kelly Schlendorf
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Edward D Siew
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alan Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan Walsh
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jesse O Wrenn
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey M Testani
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, TN
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134
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de la Espriella R, Núñez-Marín G, Codina P, Núñez J, Bayés-Genís A. Biomarkers to Improve Decision-making in Acute Heart Failure. Card Fail Rev 2023; 9:e13. [PMID: 37942188 PMCID: PMC10628997 DOI: 10.15420/cfr.2023.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/19/2023] [Indexed: 11/10/2023] Open
Abstract
Acute heart failure (AHF) is a complex clinical syndrome that requires prompt diagnosis, risk stratification and effective treatment strategies to reduce morbidity and mortality. Biomarkers are playing an increasingly important role in this process, offering valuable insights into the underlying pathophysiology and facilitating personalised patient management. This review summarises the significance of various biomarkers in the context of AHF, with a focus on their clinical applications to stratify risk and potential for guiding therapy choices.
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Affiliation(s)
| | - Gonzalo Núñez-Marín
- Department of Cardiology, Hospital Clínico Universitario de ValenciaValencia, Spain
| | - Pau Codina
- Heart Institute, Hospital Universitari Germans Trias i PujolBarcelona, Spain
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario de ValenciaValencia, Spain
- Department of Medicine, Universitat de ValènciaValencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades CardiovascularesMadrid, Spain
| | - Antoni Bayés-Genís
- Heart Institute, Hospital Universitari Germans Trias i PujolBarcelona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades CardiovascularesMadrid, Spain
- Department of Medicine, Universitat Autònomoa de BarcelonaBarcelona, Spain
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135
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Hahn RT, Lawlor MK, Davidson CJ, Badhwar V, Sannino A, Spitzer E, Lurz P, Lindman BR, Topilsky Y, Baron SJ, Chadderdon S, Khalique OK, Tang GHL, Taramasso M, Grayburn PA, Badano L, Leipsic J, Lindenfeld J, Windecker S, Vemulapalli S, Redfors B, Alu MC, Cohen DJ, Rodés-Cabau J, Ailawadi G, Mack M, Ben-Yehuda O, Leon MB, Hausleiter J. Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints. J Am Coll Cardiol 2023; 82:1711-1735. [PMID: 37804294 DOI: 10.1016/j.jacc.2023.08.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/12/2023] [Accepted: 08/08/2023] [Indexed: 10/09/2023]
Abstract
Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options.
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Affiliation(s)
- Rebecca T Hahn
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA.
| | - Matthew K Lawlor
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Charles J Davidson
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Anna Sannino
- Baylor Research Institute, The Heart Hospital Baylor Plano, Plano, Texas, USA; Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, Naples, Italy. https://twitter.com/AnnaSannino198
| | - Ernest Spitzer
- Cardialysis, Rotterdam, the Netherlands; Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Philipp Lurz
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Brian R Lindman
- Structural Heart and Valve Center, Cardiovascular Division, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Suzanne J Baron
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA; Baim Institute of Clinical Research, Boston, Massachusetts, USA
| | - Scott Chadderdon
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA. https://twitter.com/PDXHeartValveMD
| | - Omar K Khalique
- Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York, USA
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA
| | - Maurizio Taramasso
- Herzzentrum Hirslanden Zürich, Zürich, Switzerland; University of Zürich, Zürich, Switzerland
| | - Paul A Grayburn
- Baylor Scott and White Heart and Vascular Hospital at Plano, Plano, Texas, USA
| | - Luigi Badano
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Jonathon Leipsic
- Department of Radiology and Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephan Windecker
- Department of Cardiology, University Cardiovascular Center, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina, USA; Duke University School of Medicine, Durham, North Carolina, USA
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York, USA
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Mack
- Baylor Scott and White Health, Dallas, Texas, USA
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, New York, New York, USA; University of California-San Diego, San Diego, California, USA. https://twitter.com/oribenyehuda
| | - Martin B Leon
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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136
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Marx N, Federici M, Schütt K, Müller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J 2023; 44:4043-4140. [PMID: 37622663 DOI: 10.1093/eurheartj/ehad192] [Citation(s) in RCA: 250] [Impact Index Per Article: 250.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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137
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Hammer A, Niessner A, Sulzgruber P. Early Initiation of SGLT2 Inhibitors in Acute Heart Failure: a Focus on Diuresis and Renal Protection. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07512-6. [PMID: 37828148 DOI: 10.1007/s10557-023-07512-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE Acute heart failure (AHF) represents a critical and life-threatening condition characterized by the sudden onset or exacerbation of symptoms, such as dyspnea and fluid retention, due to impaired cardiac function. Despite advances in the treatment of chronic heart failure (HF), the management of AHF remains challenging, with limited therapeutic options available. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have emerged as a promising drug class in AHF management. METHODS/RESULTS The objective of this article was to conduct a comprehensive review of the existing literature in the domain of SGLT2 inhibitors and their relevance in the context of AHF. CONCLUSION The existing evidence underscores the importance of SGLT2 inhibitors in enhancing decongestive therapy for AHF patients. Early initiation appears both practical and beneficial, leading to improved and sustained decongestion, a reduction in heart failure-related events, enhanced quality of life, and decreased mortality rates, all while maintaining a favorable safety profile. Consequently, it should be considered to initiate SGLT2 inhibitor treatment as early and as safely as possible to facilitate effective decongestion. However, careful patient selection and monitoring are essential when considering the use of these drugs in the management of AHF.
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Affiliation(s)
- Andreas Hammer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Patrick Sulzgruber
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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138
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 707] [Impact Index Per Article: 707.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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139
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Cosentino N, Marenzi G, Muratori M, Magrì D, Cattadori G, Agostoni P. Fluid balance in heart failure. Eur J Prev Cardiol 2023; 30:ii9-ii15. [PMID: 37819223 DOI: 10.1093/eurjpc/zwad166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 10/13/2023]
Abstract
Fluid retention is a major determinant of symptoms in patients with heart failure (HF), and it is closely associated with prognosis. Hence, congestion represents a critical therapeutic target in this clinical setting. The first therapeutic strategy in HF patients with fluid overload is optimization of diuretic intervention to maximize water and sodium excretion. When diuretic therapy fails to relieve congestion, renal replacement therapy represents the only alternative option for fluid removal, as well as a way to restore diuretic responsiveness. On this background, the pathophysiology of fluid balance in HF is complex, with heart, kidney, and lung being deeply involved in volume regulation and management. Therefore, the interplay between these organs should be appreciated and considered when fluid overload in HF patients is targeted.
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Affiliation(s)
- Nicola Cosentino
- Centro Cardiologico Monzino, I.R.C.C.S., Via Parea 4, Milan 20138, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Giancarlo Marenzi
- Centro Cardiologico Monzino, I.R.C.C.S., Via Parea 4, Milan 20138, Italy
| | - Manuela Muratori
- Centro Cardiologico Monzino, I.R.C.C.S., Via Parea 4, Milan 20138, Italy
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, 'Sapienza' Università degli Studi di Roma, Roma 00198, Italy
| | - Gaia Cattadori
- Unità Operativa Cardiologia Riabilitativa, IRCCS Multimedica, Milan 20123, Italy
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140
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Trullàs JC, Morales-Rull JL, Casado J, Carrera-Izquierdo M, Sánchez-Marteles M, Conde-Martel A, Dávila-Ramos MF, Llácer P, Salamanca-Bautista P, Chivite D, Jordana-Comajuncosa R, Villalonga M, Páez-Rubio MI, Manzano L, Formiga F. Combining loop and thiazide diuretics for acute heart failure across the estimated glomerular filtration rate spectrum: A post-hoc analysis of the CLOROTIC trial. Eur J Heart Fail 2023; 25:1784-1793. [PMID: 37540036 DOI: 10.1002/ejhf.2988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023] Open
Abstract
AIMS In patients with acute heart failure (AHF), the addition of hydrochlorothiazide (HCTZ) to furosemide improved diuretic response in the CLOROTIC trial. This work aimed to evaluate if these effects differ across the estimated glomerular filtration rate (eGFR) spectrum. METHODS AND RESULTS This post-hoc analysis of the CLOROTIC trial analysed 230 patients with AHF and explored the influence of eGFR on primary and secondary endpoints. The median eGFR was 43 ml/min/1.73 m2 (range 14-109) and 23% had eGFR ≥60 ml/min/1.73 m2 (group 1), 24% from 45 to 59 ml/min/1.73 m2 (group 2), and 53% <45 ml/min/1.73 m2 (group 3). Patients treated with HCTZ had greatest weight loss at 72 h in all three groups, but patients in group 1 had a significantly greater response (-2.1 kg [-3.0 to 0.5]), compared to patients in groups 2 (-1.3 kg [-2.3 to 0.2]) and 3 (-0.1 kg [-1.3 to 0.4]) (p-value for interaction = 0.246). At 96 h, the differences in weight were -1.8 kg (-3.0 to -0.3), -1.4 kg (-2.6 to 0.3), and -0.5 kg (-1.3 to -0.1) in groups 1, 2, and 3, respectively (p-value for interaction = 0.256). There were no significant differences observed with the addition of HCTZ in terms of diuretic response, mortality or rehospitalizations, or safety endpoints (impaired renal function, hyponatraemia, and hypokalaemia) among the three eGFR groups (all p-values for interaction were no significant). CONCLUSION The addition of eGFR-adjusted doses of oral HCTZ to loop diuretics in patients with AHF improved diuretic response across the eGFR spectrum. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: NCT01647932; EudraCT number: 2013-001852-36.
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Affiliation(s)
- Joan Carles Trullàs
- Internal Medicine Department, Hospital d'Olot i Comarcal de la Garrotxa, Girona, Spain
- Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Barcelona, Spain
| | - José Luís Morales-Rull
- Heart Failure Unit, Internal Medicine Department, Hospital Universitari Arnau de Villanova, Institut de Recerca Biomédica (IRBLleida), Lleida, Spain
| | - Jesús Casado
- Internal Medicine Department, Hospital Universitario de Getafe, Madrid, Spain
| | | | - Marta Sánchez-Marteles
- Internal Medicine Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Alicia Conde-Martel
- Internal Medicine Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | - Pau Llácer
- Internal Medicine Department, Hospital de Manises, Manises, Spain
| | - Prado Salamanca-Bautista
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
| | - David Chivite
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
| | | | - Maria Villalonga
- Internal Medicine Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - Luís Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Francesc Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
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Martens P, Burkhoff D, Cowger JA, Jorde UP, Kapur NK, Tang WHW. Emerging Individualized Approaches in the Management of Acute Cardiorenal Syndrome With Renal Assist Devices. JACC. HEART FAILURE 2023; 11:1289-1303. [PMID: 37676211 DOI: 10.1016/j.jchf.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 09/08/2023]
Abstract
Growing insights into the pathophysiology of acute cardiorenal syndrome (CRS) in acute decompensated heart failure have indicated that not every rise in creatinine is associated with adverse outcomes. Detection of persistent volume overload and diuretic resistance associated with creatinine rise may identify patients with true acute CRS. More in-depth phenotyping is needed to identify pathologic processes in renal arterial perfusion, venous outflow, and microcirculatory-interstitial-lymphatic axis alterations that can contribute to acute CRS. Recently, various novel device-based interventions designed to target different pathophysiologic components of acute CRS are in early feasibility and proof-of-concept studies. However, appropriate trial endpoints that reflect improvement in cardiorenal trajectories remain elusive and highly debated. In this review the authors describe the variety of physiological derangements leading to acute CRS and the opportunity to individualize the management of acute CRS with novel renal assist devices that can target specific components of these alterations.
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Affiliation(s)
- Pieter Martens
- Kaufman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jennifer A Cowger
- Division of Cardiovascular Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ulrich P Jorde
- Department of Medicine, Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Navin K Kapur
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
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142
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Sabe SA, Sabe MA, Kennedy KF, Sellke FW, Ehsan A. Risk Factors for Heart Failure Readmission After Cardiac Surgery. JACC. ADVANCES 2023; 2:100599. [PMID: 38938350 PMCID: PMC11198058 DOI: 10.1016/j.jacadv.2023.100599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/05/2023] [Accepted: 06/23/2023] [Indexed: 06/29/2024]
Abstract
Background Heart failure (HF) is a leading cause of readmission after cardiac surgery, yet risk factors for HF readmission after cardiac surgery remain poorly characterized. Objectives This study aimed to identify risk factors associated with 30-day HF-specific readmissions after cardiac surgery using a national database. Methods We queried the 2016 to 2018 National Readmissions Database to identify U.S. patients who underwent coronary artery bypass grafting (CABG), mitral valve repair/replacement, and/or aortic valve repair/replacement. Exclusion criteria included history of ventricular assist device or heart transplant, dialysis-dependent renal insufficiency, and death during index admission. Clinical variables were defined using International Classification of Diseases-10th Revision codes. The primary outcome was a 30-day readmission for HF following discharge. Multivariable logistic regression was used to account for relevant clinical and demographic covariates and identify independent risk factors for HF readmissions following cardiac surgery. Results Our study included 394,050 patients who underwent cardiac surgery (mean age 66 ± 12 years, 63% isolated CABG, 27% isolated valve, 11% CABG + valve). Of these patients, 7,318 were readmitted within 30 days of discharge for a principal diagnosis of HF. Independent risk factors of HF-specific readmission included older age, female sex, prolonged length of stay, comorbid congestive HF, nondialysis dependent chronic kidney disease, chronic obstructive pulmonary disease, chronic liver disease, obesity, atrial fibrillation, and acute kidney injury. Prior CABG was marginally protective for HF-specific readmission. Conclusions Using a national registry, we identified risk factors associated with HF readmission after cardiac surgery. Further analysis of these risk factors and their association with HF readmission is warranted.
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Affiliation(s)
- Sharif A. Sabe
- Division of Cardiothoracic Surgery, Department of Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Marwa A. Sabe
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin F. Kennedy
- Independent consultant for Lifespan, Providence, Rhode Island, USA
| | - Frank W. Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Afshin Ehsan
- Division of Cardiothoracic Surgery, Department of Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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143
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Meekers E, Dauw J, Martens P, Dhont S, Verbrugge FH, Nijst P, Ter Maaten JM, Damman K, Mebazaa A, Filippatos G, Ruschitzka F, Tang WHW, Dupont M, Mullens W. Renal function and decongestion with acetazolamide in acute decompensated heart failure: the ADVOR trial. Eur Heart J 2023; 44:3672-3682. [PMID: 37623428 DOI: 10.1093/eurheartj/ehad557] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/09/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND AND AIMS In the ADVOR trial, acetazolamide improved decongestion in acute decompensated heart failure (ADHF). Whether the beneficial effects of acetazolamide are consistent across the entire range of renal function remains unclear. METHODS This is a pre-specified analysis of the ADVOR trial that randomized 519 patients with ADHF to intravenous acetazolamide or matching placebo on top of intravenous loop diuretics. The main endpoints of decongestion, diuresis, natriuresis, and clinical outcomes are assessed according to baseline renal function. Changes in renal function are evaluated between treatment arms. RESULTS On admission, median estimated glomerular filtration rate (eGFR) was 40 (30-52) mL/min/1.73 m². Acetazolamide consistently increased the likelihood of decongestion across the entire spectrum of eGFR (P-interaction = .977). Overall, natriuresis and diuresis were higher with acetazolamide, with a higher treatment effect for patients with low eGFR (both P-interaction < .007). Acetazolamide was associated with a higher incidence of worsening renal function (WRF; rise in creatinine ≥ 0.3 mg/dL) during the treatment period (40.5% vs. 18.9%; P < .001), but there was no difference in creatinine after 3 months (P = .565). This was not associated with a higher incidence of heart failure hospitalizations and mortality (P-interaction = .467). However, decongestion at discharge was associated with a lower incidence of adverse clinical outcomes irrespective of the onset of WRF (P-interaction = .805). CONCLUSIONS Acetazolamide is associated with a higher rate of successful decongestion across the entire range of renal function with more pronounced effects regarding natriuresis and diuresis in patients with a lower eGFR. While WRF occurred more frequently with acetazolamide, this was not associated with adverse clinical outcomes. CLINICALTRIALS.GOV IDENTIFIER NCT03505788.
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Affiliation(s)
- Evelyne Meekers
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Universiteitslaan, Diepenbeek, Belgium
| | - Jeroen Dauw
- Faculty of Medicine and Life Sciences, Hasselt University, Universiteitslaan, Diepenbeek, Belgium
- Department of Cardiology, AZ Sint-Lucas, Ghent, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sebastiaan Dhont
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Universiteitslaan, Diepenbeek, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Petra Nijst
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Kevin Damman
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Alexandre Mebazaa
- Department of Anesthesia & Critical Care, Université Paris Cité, Inserm MASCOT, APHP, Paris, France
| | | | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Wai Hong Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Universiteitslaan, Diepenbeek, Belgium
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144
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Fernández-Rodríguez JM, Casado J, Formiga F, González-Franco A, Arévalo JC, Beltrán M, Cerqueiro González JM, Llàcer P, Manzano L, Morales-Rull JL, Pérez Silvestre J, Conde-Martel A. Executive summary of the 2023 update on the consensus regarding basic conduct during hospital admission for patients with acute heart failure. Rev Clin Esp 2023; 223:499-509. [PMID: 37507048 DOI: 10.1016/j.rceng.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/22/2023] [Indexed: 07/30/2023]
Abstract
Acute heart failure (AHF) is associated with significant morbidity and mortality and it stands as the primary cause of hospitalization for individuals over the age of 65 in Spain. This document outlines the main recommendations as follows: (1) Upon admission, it is crucial to conduct a comprehensive assessment, taking into account the patient's standard treatment and comorbidities, as these factors determine the prognosis of the disease. (2) During the initial hours of hospital care, prioritizing decongestive treatment is essential. It is recommended to adopt an early staged diuretic therapeutic approach based on the patient's response. (3) In order to manage patients in the stable phase, it is advisable to consider initiating and/or adjusting evidence-based drug treatments such as sacubitril/valsartan or angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta blockers, aldosterone antagonists, and SGLT2 inhibitors. (4) Upon hospital discharge, utilizing a checklist is recommended to optimize the patient's management and identify the most efficient options for ensuring continuity of care post-discharge.
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Affiliation(s)
- J M Fernández-Rodríguez
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.
| | - J Casado
- Servicio de Medicina Interna, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - F Formiga
- Servicio de Medicina Interna, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - A González-Franco
- Unidad de Gestión Clínica de Medicina Interna, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - J C Arévalo
- Servicio de Medicina Interna, Hospital Universitario de Badajoz, Badajoz, Spain
| | - M Beltrán
- Servicio de Medicina Interna, Hospital Virgen del Camino, Sanlúcar de Barrameda, Cádiz, Spain
| | | | - P Llàcer
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - L Manzano
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Departamento de Medicina y Especialidades Médicas, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - J L Morales-Rull
- Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain
| | - J Pérez Silvestre
- Servicio de Medicina Interna, Unidad Insuficiencia Cardiaca Paciente Crónico y Edad Avanzada, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - A Conde-Martel
- Servicio de Medicina Interna, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas, Las Palmas de Gran Canaria, Spain
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Beargie SM, Tolbert L, Tunney RK, Cox ZL, Gong W, Zalawadiya S. Serial evaluation of loop diuretic efficiency following left ventricular assist device implantation. Int J Artif Organs 2023; 46:555-561. [PMID: 37646461 DOI: 10.1177/03913988231193446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
More than 50% of heart failure (HF) patients require diuretic therapy after left ventricular assist device (LVAD). Although few data related to diuretic response (DR) exist in stage D patients, tubular sodium reabsorption may be clinically prognostic independent of estimated glomerular filtration rate (eGFR) and proteinuria within this cohort. We aimed to characterize DR serially before and after LVAD implantation in a stage D population. We conducted a prospective, observational cohort study of HF patients receiving diuretics with plans to undergo LVAD implantation. We measured urine sodium (UNa) and creatinine (UCr) at three points after diuretic therapy: pre-LVAD, post-LVAD prior to discharge, and as an outpatient. Prior to LVAD, patients (N = 19) had an average eGFR of 54.0 ± 18.0 mL/min/1.73 m2, spot UNa of 74.8 ± 28.0 mmol/L, and fractional excretion of sodium (FENa) of 3.1 ± 2.7%. Pre-LVAD, eGFR did not correlate with spot UNa nor FENa (p > 0.05 for both). LVAD implantation did not improve DR post-LVAD (mean change FENa per 40 mg IV furosemide 0.5 ± 1.0%; p = 0.84), and 90% of patients required loop diuretics at 90 days post-surgery. Improved hemodynamics following LVAD may not improve DR or tubular function; larger studies are needed to confirm our results and assess the utility of DR to predict post-LVAD outcomes.
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Affiliation(s)
- Sarah M Beargie
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Lindsey Tolbert
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert K Tunney
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zachary L Cox
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
- Lipscomb University College of Pharmacy, Nashville, TN, USA
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandip Zalawadiya
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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146
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Koprululu Kucuk G, Guney AI, Sunbul M, Guctekin T, Koç G, Kirac D. Il-6 and UGT1A1 variations may related to furosemide resistance in heart failure patients. IUBMB Life 2023; 75:830-843. [PMID: 37260062 DOI: 10.1002/iub.2732] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/07/2023] [Indexed: 06/02/2023]
Abstract
Furosemide is a diuretic and is used for the treatment of patients with heart failure (HF). It has been found that in some HF patients, the drug does not treat patients efficiently. This condition is named as furosemide resistance. In this study, it is aimed to investigate the relationship between UDP-glucuronosyltransferase 1 (UGT1A1) and interleukine-6 (IL-6) variations with furosemide resistance in HF patients. Sixty HF patients using furosemide (patient group) and 30 healthy individuals (control group) were enrolled in this study. Patients were divided into two subgroups as non-responders (furosemide resistant) group (n = 30) and the responders (non-resistant) group (n = 30) according to the presence of furosemide resistance (n = 30). Variations in the first exon of UGT1A1 and rs1800795 and rs1800796 variations in IL-6 were analyzed by direct sequencing and real-time polymerase chain reaction (RT-PCR), respectively. The effects of newly detected mutations on 3-D protein structure were analyzed by in silico analysis. At the end of the study, 11 variations were detected in UGT1A1, of which nine of them are novel and eight of them cause amino acid change. Also, rs1800795 and rs1800796 variations were detected in all the groups. When patient and control groups were compared with each other, rs1800796 mutation in IL-6 was found statistically high in the patient group (p = 0.027). When the three groups were compared with each other, similarly, rs1800796 mutation in IL-6 was found statistically high in the non-responders group (p = 0.043). When allele distributions were compared between the patient and control groups, the C allele of rs1800795 mutation in IL-6 was found statistically high in the patient group (p = 0.032). When allele distributions were compared between the three groups, 55T-insertion in UGT1A1 was found statistically high in the non-responders group (p = 0.017). According to in silico analysis results, two variations were found deleterious and six variations were detected as probably damaging to protein functions. Our study may contribute to the elucidation of pharmacogenetic features (drug response-gene relationship) and the development of individual-specific treatment strategies in HF patients using furosemide.
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Affiliation(s)
- G Koprululu Kucuk
- Faculty of Medicine, Department of Medical Biology, Yeditepe University, Istanbul, Turkey
- Department of Radiotherapy, Istanbul Sisli Vocational School, Istanbul, Turkey
| | - A I Guney
- Faculty of Medicine, Department of Medical Genetics, Marmara University, Istanbul, Turkey
| | - M Sunbul
- Faculty of Medicine, Department of Cardiology, Marmara University, Istanbul, Turkey
| | - T Guctekin
- Faculty of Medicine, Department of Cardiology, Marmara University, Istanbul, Turkey
| | - G Koç
- Faculty of Medicine, Department of Medical Biology, Istanbul Aydın University, Istanbul, Turkey
| | - D Kirac
- Faculty of Medicine, Department of Medical Biology, Yeditepe University, Istanbul, Turkey
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147
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Lindner ML, Lohmeyer JL, Adam EH, Zacharowski K, Weber CF. [Mechanisms of action and clinical application of diuretics in intensive care medicine]. DIE ANAESTHESIOLOGIE 2023; 72:757-770. [PMID: 37768358 DOI: 10.1007/s00101-023-01338-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 09/29/2023]
Abstract
The paired kidneys play a significant role in the human body due to the multitude of physiological tasks. Complex biochemical processes keep the sensitive electrolyte and water balance stable and thus ensure the organism's ability to adapt to exogenous and endogenous factors, which is essential for survival. The drug class of diuretics includes substances with very differing pharmacological characteristics. The functioning of the nephron is therefore indispensable for a deeper understanding of the pharmacodynamics, pharmacokinetics and side effect profile of diuretics. In the treatment of acute heart failure with pulmonary congestion, certain diuretics represent an important therapeutic option to counteract hypervolemia and thus an increase in preload. According to current data, diuretics have no proven benefits in the treatment or prevention of acute kidney injury but they can counteract hypervolemia and under certain conditions even reduce the use of renal replacement procedures.
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Affiliation(s)
- M-L Lindner
- Abteilung für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Kliniken Hamburg GmbH, Asklepios Klinik Wandsbek, Alphonsstraße 14, 22043, Hamburg, Deutschland.
| | - J L Lohmeyer
- Abteilung für Anästhesiologie, Intensiv‑, Notfall-, und Schmerzmedizin, Asklepios Kliniken Hamburg GmbH, Asklepios Klinik Altona, Paul-Ehrlich-Straße 1, 22763, Hamburg, Deutschland
| | - E H Adam
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor Stern Kai 7, 60590, Frankfurt, Deutschland
| | - K Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor Stern Kai 7, 60590, Frankfurt, Deutschland
| | - C F Weber
- Abteilung für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Kliniken Hamburg GmbH, Asklepios Klinik Wandsbek, Alphonsstraße 14, 22043, Hamburg, Deutschland
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor Stern Kai 7, 60590, Frankfurt, Deutschland
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148
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Ter Maaten JM, Beldhuis IE, van der Meer P, Krikken JA, Postmus D, Coster JE, Nieuwland W, van Veldhuisen DJ, Voors AA, Damman K. Natriuresis-guided diuretic therapy in acute heart failure: a pragmatic randomized trial. Nat Med 2023; 29:2625-2632. [PMID: 37640861 PMCID: PMC10579092 DOI: 10.1038/s41591-023-02532-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/03/2023] [Indexed: 08/31/2023]
Abstract
Measurement of natriuresis has been suggested as a reliable, easily obtainable biomarker for assessment of the response to diuretic treatment in patients with acute heart failure (AHF). Here, to assess whether natriuresis-guided diuretic therapy in patients with AHF improves natriuresis and clinical outcomes, we conducted the pragmatic, open-label Pragmatic Urinary Sodium-based algoritHm in Acute Heart Failure trial, in which 310 patients (45% female) with AHF requiring treatment with intravenous loop diuretics were randomly assigned to natriuresis-guided therapy or standard of care (SOC). In the natriuresis-guided arm, natriuresis was determined at set timepoints, prompting treatment intensification if spot urinary sodium levels were <70 mmol l-1. The dual primary endpoints were 24 h urinary sodium excretion and a combined endpoint of time to all-cause mortality or adjudicated heart failure rehospitalization at 180 days. The first primary endpoint was met, as natriuresis in the natriuresis-guided and SOC arms was 409 ± 178 mmol arm versus 345 ± 202 mmol, respectively (P = 0.0061). However, there were no significant differences between the two arms for the combined endpoint of time to all-cause mortality or first heart failure rehospitalization, which occurred in 46 (31%) and 50 (31%) of patients in the natriuresis-guided and SOC arms, respectively (hazard ratio 0.92 [95% confidence interval 0.62-1.38], P = 0.6980). These findings suggest that natriuresis-guided therapy could be a first step towards personalized treatment of AHF. ClinicalTrials.gov registration: NCT04606927 .
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Affiliation(s)
- Jozine M Ter Maaten
- Department of Cardiology, University Medical Center Groningen, University of Gronigen, Groningen, the Netherlands.
| | - Iris E Beldhuis
- Department of Cardiology, University Medical Center Groningen, University of Gronigen, Groningen, the Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Gronigen, Groningen, the Netherlands
| | - Jan A Krikken
- Department of Cardiology, University Medical Center Groningen, University of Gronigen, Groningen, the Netherlands
| | - Douwe Postmus
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jenifer E Coster
- Department of Cardiology, University Medical Center Groningen, University of Gronigen, Groningen, the Netherlands
| | - Wybe Nieuwland
- Department of Cardiology, University Medical Center Groningen, University of Gronigen, Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Gronigen, Groningen, the Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Gronigen, Groningen, the Netherlands
| | - Kevin Damman
- Department of Cardiology, University Medical Center Groningen, University of Gronigen, Groningen, the Netherlands
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Aklilu AM, Kumar S, Yamamoto Y, Moledina DG, Sinha F, Testani JM, Wilson FP. Outcomes Associated with Sodium-Glucose Cotransporter-2 Inhibitor Use in Acute Heart Failure Hospitalizations Complicated by AKI. KIDNEY360 2023; 4:1371-1381. [PMID: 37644648 PMCID: PMC10615381 DOI: 10.34067/kid.0000000000000250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
Key Points In a multicenter retrospective cohort study of adults hospitalized with acute heart failure, exposure to sodium-glucose cotransporter-2 inhibitor during AKI was associated with lower risk of 30-day mortality. Exposure to sodium-glucose cotransporter-2 inhibitor during acute heart failure–associated AKI was associated with no difference in time to renal recovery. The findings were reproducible in inverse probability-weighted analysis. Background Although sodium-glucose cotransporter-2 inhibitor (SGLT2i) use during acute heart failure (AHF) hospitalizations is associated with symptomatic improvement, reduction in rehospitalizations, and mortality, these medications are often withheld during AKI because of concerns about worsening GFR. We aimed to investigate the safety of SGLT2i exposure during AKI among patients hospitalized with AHF. We hypothesized that SGLT2i exposure would not worsen mortality but may prolong return of creatinine to baseline. Methods This was a retrospective study of adults hospitalized across five Yale New Haven Health System hospitals between January 2020 and May 2022 with AHF complicated by Kidney Disease Improving Global Outcomes–defined AKI. Patients with stage 5 CKD and those with potential contraindications to SGLT2i were excluded. We tested the association of SGLT2i use with kidney function recovery at 14 days and death at 30 days using time-varying, multivariable Cox-regression analyses. Results Of 3305 individuals hospitalized with AHF and AKI, 356 received SGLT2i after AKI diagnosis either as initiation or continuation. The rate of renal recovery was not significantly different among those exposed and unexposed to SGLT2i after AKI (adjusted hazard ratio, 0.94; 95% confidence interval, 0.79 to 1.11; P = 0.46). SGLT2i exposure was associated with lower risk of 30-day mortality (adjusted hazard ratio, 0.45; 95% confidence interval, 0.23 to 0.87; P = 0.02). Sensitivity analyses using an inverse probability-weighted time-varying Cox regression analysis and using alternate definitions of AHF with different NT-proBNP cutoffs yielded similar results. Rates of renal recovery were similar between the exposed and unexposed cohorts regardless of the proximity of SGLT2i exposure to AKI diagnosis. Conclusion In adults experiencing AHF-associated AKI, exposure to SGLT2i was associated with decreased mortality and no delay in renal recovery. Prospective studies are needed to elucidate the effect of SGLT2i exposure during AKI, particularly during heart failure hospitalizations.
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Affiliation(s)
- Abinet M. Aklilu
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
| | - Sanchit Kumar
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
| | - Dennis G. Moledina
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
| | - Frederick Sinha
- Department of Internal Medicine II, University Medical Center Regensburg, Germany
| | - Jeffrey M. Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - F. Perry Wilson
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
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150
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Baudry G, Coutance G, Dorent R, Bauer F, Blanchart K, Boignard A, Chabanne C, Delmas C, D'Ostrevy N, Epailly E, Gariboldi V, Gaudard P, Goéminne C, Grosjean S, Guihaire J, Guillemain R, Mattei M, Nubret K, Pattier S, Vermes E, Sebbag L, Duarte K, Girerd N. Diuretic dose is a strong prognostic factor in ambulatory patients awaiting heart transplantation. ESC Heart Fail 2023; 10:2843-2852. [PMID: 37408178 PMCID: PMC10567662 DOI: 10.1002/ehf2.14467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023] Open
Abstract
AIMS The prognostic value of 'high dose' loop diuretics in advanced heart failure outpatients is unclear. We aimed to assess the prognosis associated with loop diuretic dose in ambulatory patients awaiting heart transplantation (HT). METHODS AND RESULTS All ambulatory patients (n = 700, median age 55 years and 70% men) registered on the French national HT waiting list between 1 January 2013 and 31 December 2019 were included. Patients were divided into 'low dose', 'intermediate dose', and 'high dose' loop diuretics corresponding to furosemide equivalent doses of ≤40, 40-250, and >250 mg, respectively. The primary outcome was a combined criterion of waitlist death and urgent HT. N-terminal pro-B-type natriuretic peptide, creatinine levels, pulmonary capillary wedge pressure, and pulmonary pressures gradually increased with higher diuretic dose. At 12 months, the risk of waitlist death/urgent HT was 7.4%, 19.2%, and 25.6% (P = 0.001) for 'low dose', 'intermediate dose', and 'high dose' patients, respectively. When adjusting for confounders, including natriuretic peptides, hepatic, and renal function, the 'high dose' group was associated with increased waitlist mortality or urgent HT [adjusted hazard ratio (HR) 2.23, 1.33 to 3.73; P = 0.002] and a six-fold higher risk of waitlist death (adjusted HR 6.18, 2.16 to 17.72; P < 0.001) when compared with the 'low dose' group. 'Intermediate doses' were not significantly associated with these two outcomes in adjusted models (P > 0.05). CONCLUSIONS A 'high dose' of loop diuretics is strongly associated with residual congestion and is a predictor of outcome in patients awaiting HT despite adjustment for classical cardiorenal risk factors. This routine variable may be helpful for risk stratification of pre-HT patients.
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Affiliation(s)
- Guillaume Baudry
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F‐CRIN INI‐CRCT, ReicatraVandoeuvre‐lès‐Nancy54500France
| | - Guillaume Coutance
- Department of Cardiac and Thoracic SurgeryCardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique‐Hôpitaux de Paris (AP‐HP). Sorbonne University Medical SchoolParisFrance
| | - Richard Dorent
- Department of Cardiac SurgeryCHU Bichat‐Claude Bernard, AP‐HP, Université Paris VIIParisFrance
| | - Fabrice Bauer
- Department of Cardiology and Cardiovascular SurgeryHospital Charles NicolleRouenFrance
| | - Katrien Blanchart
- Department of Cardiology and Cardiac SurgeryUniversity Hospital of Caen, University of CaenCaenFrance
| | - Aude Boignard
- Department of Cardiology and Cardiovascular SurgeryCHU MichallonGrenobleFrance
| | - Céline Chabanne
- Department of Thoracic and Cardiovascular SurgeryCHU Pontchaillou, Inserm U1099RennesFrance
| | - Clément Delmas
- Department of CardiologyCentre Hospitalier Universitaire de ToulouseToulouseFrance
| | - Nicolas D'Ostrevy
- Department of Cardiology and Cardiac SurgeryCHU Clermont‐FerrandClermont‐FerrandFrance
| | - Eric Epailly
- Department of Cardiology and Cardiovascular SurgeryHôpitaux Universitaires de StrasbourgStrasbourgFrance
| | - Vlad Gariboldi
- Department of Cardiac SurgeryLa Timone HospitalMarseilleFrance
| | - Philippe Gaudard
- Department of Cardiac Surgery, Anesthesiology and Critical Care MedicineArnaud de Villeneuve Hospital, CHRU MontpellierMontpellierFrance
| | - Céline Goéminne
- Department of Cardiac SurgeryCHU Lille, Institut Coeur‐PoumonsLilleFrance
| | - Sandrine Grosjean
- Department of Cardiology and Cardiac SurgeryDijon University HospitalDijonFrance
| | - Julien Guihaire
- Department of Cardiothoracic SurgeryMarie Lannelongue Hospital, University of Paris Sud, Inserm U999 (Pulmonary Hypertension: Pathophysiology and Novel Therapies [PAH])Le Plessis RobinsonFrance
| | - Romain Guillemain
- Department of Cardiology and Cardiac SurgeryEuropean Georges Pompidou HospitalParisFrance
| | - Mathieu Mattei
- Department of Cardiology and Cardiac SurgeryCHU de Nancy, Hopital de BraboisNancyFrance
| | - Karine Nubret
- Department of Thoracic and Cardiovascular SurgeryHôpital Cardiologique du Haut‐Lévêque, Université Bordeaux IIBordeauxFrance
| | - Sabine Pattier
- Department of Cardiology and Heart Transplantation UnitCHU NantesNantesFrance
| | - Emmanuelle Vermes
- Department of Cardiothoracic SurgeryTours University HospitalToursFrance
| | - Laurent Sebbag
- Department of Heart Failure and TransplantationHôpital Cardiovasculaire Louis Pradel, Hospices Civils de LyonBronFrance
| | - Kevin Duarte
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F‐CRIN INI‐CRCT, ReicatraVandoeuvre‐lès‐Nancy54500France
| | - Nicolas Girerd
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F‐CRIN INI‐CRCT, ReicatraVandoeuvre‐lès‐Nancy54500France
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