101
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Price JF, Akcan-Arikan A. Author Response to Letter. J Card Fail 2019; 25:850. [PMID: 31442493 DOI: 10.1016/j.cardfail.2019.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Jack F Price
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Houston, Texas
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Sections of Pediatric Nephrology and Critical Care Medicine, Baylor College of Medicine, Houston, Texas
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102
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Psotka MA, Fiuzat M, Carson PE, Kao DP, Cerkvenik J, Schaber DE, Verta P, Kazmierski RT, Shinnar M, Stockbridge N, Unger EF, Zuckerman B, Butler J, Felker GM, Konstam MA, Lindenfeld J, Solomon SD, Teerlink JR, O'Connor CM, Abraham WT. Design of a "Lean" Case Report Form for Heart Failure Therapeutic Development. JACC-HEART FAILURE 2019; 7:913-921. [PMID: 31401097 DOI: 10.1016/j.jchf.2019.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 01/11/2023]
Abstract
The development of treatments for heart failure (HF) is challenged by burdensome clinical trials. Reducing the need for extensive data collection and increasing opportunities for data compatibility between trials may improve efficiency and reduce resource burden. The Heart Failure Collaboratory (HFC) multi-stakeholder consortium sought to create a lean case report form (CRF) for use in HF clinical trials evaluating cardiac devices. The HFC convened patients, clinicians, clinical researchers, the U.S. Food and Drug Administration (FDA), payers, industry partners, and statisticians to create a consensus core CRF. Eight recent clinical trial CRFs for the treatment of HF from 6 industry partners were analyzed. All CRF elements were systematically reviewed. Those elements deemed critical for data collection in HF clinical trials were used to construct the final, harmonized CRF. The original CRFs included 176 distinct data items covering demographics, vital signs, physical examination, medical history, laboratory and imaging testing, device therapy, medications, functional and quality of life assessment, and outcome events. The resulting, minimally inclusive CRF device contains 75 baseline data items and 6 events, with separate modular additions that can be used depending on the additional detail required for a particular intervention. The consensus electronic form is now freely available for use in clinical trials. Creation of a core CRF is important to improve clinical trial efficiency in HF device development in the United States. This living document intends to reduce clinical trial administrative burden, increase evidence integrity, and improve comparability of clinical data between trials.
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Affiliation(s)
| | - Mona Fiuzat
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Peter E Carson
- Department of Cardiology, Washington Veterans Affairs Medical Center, Washington, DC
| | - David P Kao
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | | | | | - Meir Shinnar
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | - Ellis F Unger
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Bram Zuckerman
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi
| | - G Michael Felker
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Marvin A Konstam
- CardioVascular Center of Tufts Medical Center, Boston, Massachusetts
| | - JoAnn Lindenfeld
- Heart Failure and Transplantation Section, Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, California
| | | | - William T Abraham
- Departments of Medicine, Physiology, and Cell Biology, Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, Ohio State University, Columbus, Ohio
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103
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Imamura T, Kinugawa K. Response by Imamura et al. regarding the article “Update of acute and long-term tolvaptan therapy”. J Cardiol 2019; 74:196. [DOI: 10.1016/j.jjcc.2019.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 11/24/2022]
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104
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Tanaka T, Kawana M, Kohsaka S. Interpreting the evidence from tolvaptan clinical trials. J Cardiol 2019; 74:195. [DOI: 10.1016/j.jjcc.2019.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 02/28/2019] [Indexed: 11/16/2022]
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105
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Efficacy of Tolvaptan in Elderly Patients with Heart Failure and Preserved Ejection Fraction. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2019. [DOI: 10.2478/jce-2019-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background: There is no known therapy with proven efficacy for improving clinical outcomes in elderly patients with heart failure (HF) and preserved ejection fraction (HFpEF). In this study, we aimed to evaluate the efficacy of tolvaptan (TLV) in elderly HFpEF patients. Methods: This retrospective observational study involved 100 consecutive elderly HFpEF patients hospitalized at the Nagoya Heart Center, Japan. Inclusion criteria were: (1) patients aged ≥75 years; (2) first hospitalization secondary to HF; (3) received medical therapy for HF, without invasive treatment; and (4) clinical follow-up for >6 months after discharge. The primary endpoint was rehospitalization due to worsening HF, and the secondary endpoint was worsening renal function (WRF) during hospitalization and at 6 months after discharge. Sixty background-matched HFpEF patients were divided into 2 groups: with TLV therapy (TLV (+), n = 29) and without TLV therapy (TLV (–), n = 31). In the TLV (+) group, TLV therapy was continued after discharge. Clinical outcomes of these patients were evaluated. Results: Bed rest period and length of hospital stay were significantly shorter in the TLV (+) group than in the TLV (−) group. The dose of loop diuretics, mean serum creatinine levels, and incidence of WRF development were significantly lower in the TLV (+) group. Incidence of rehospitalization was also significantly lower in the TLV (+) group (log-rank test; p = 0.018). The multivariate logistic regression analysis demonstrated that TLV therapy reduces the incidence of rehospitalization in elderly patients with HFpEF. Conclusions: TLV therapy reduced the bed rest period, length of hospital stay, and rate of rehospitalization without WRF in elderly HFpEF patients, suggesting that TLV could represent an effective therapy for this group of patients.
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106
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Kinugawa K, Sato N, Inomata T, Yasuda M, Shimakawa T, Fukuta Y. Real-World Effectiveness and Tolerability of Tolvaptan in Patients With Heart Failure ― Final Results of the Samsca Post-Marketing Surveillance in Heart Failure (SMILE) Study ―. Circ J 2019; 83:1520-1527. [DOI: 10.1253/circj.cj-19-0158] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Naoki Sato
- Department of Cardiology and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital
| | - Takayuki Inomata
- Department of Cardiology, Kitasato University Kitasato Institute Hospital
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107
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Rao VS, Ahmad T, Brisco-Bacik MA, Bonventre JV, Wilson FP, Siew ED, Felker GM, Anstrom KK, Mahoney DD, Bart BA, Tang WHW, Velazquez EJ, Testani JM. Renal Effects of Intensive Volume Removal in Heart Failure Patients With Preexisting Worsening Renal Function. Circ Heart Fail 2019; 12:e005552. [PMID: 31163974 DOI: 10.1161/circheartfailure.118.005552] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background The relationship between intensive volume removal in acute decompensated heart failure patients with preexisting worsening renal function (WRF) and renal tubular injury, postdischarge renal function, and clinical outcomes is unknown. Methods and Results We used data from the multicenter CARRESS-HF trial (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) that randomized patients with acute decompensated heart failure and preexisting WRF to intensive volume removal with stepped pharmacological therapy or fixed rate ultrafiltration. Patients in the urinary renal tubular injury biomarker substudy (NAG [N-acetyl-b-D-glucosaminidase], KIM-1 [kidney injury molecule-1], and NGAL [neutrophil gelatinase-associated lipocalin]) were evaluated (N=105). The severity of prerandomization WRF was unrelated to baseline renal tubular injury biomarkers ( r=0.14; P=0.17). During randomized intensive volume removal, creatinine further worsened in 53% of patients. Despite a small to moderate magnitude increase in creatinine in most of these patients, postrandomization WRF was strongly associated with worsening in renal tubular injury biomarkers (odds ratio, 12.6; P=0.004). This observation did not differ by mode of volume removal (stepped pharmacological therapy versus ultrafiltration, Pinteraction=0.46). Increase in renal tubular injury biomarkers was associated with a higher incidence of hemoconcentration (odds ratio, 3.1; P=0.015), and paradoxically, better recovery of creatinine at 60 days ( P=0.01). Conclusions In acute decompensated heart failure patients with preexisting WRF, intensive volume removal resulted in a further worsening of creatinine approximately half of the time, a finding associated with a rise in tubular injury biomarkers. However, decongestion and renal function recovery at 60 days were superior in patients with increased tubular injury markers. These data suggest that the benefits of decongestion may outweigh any modest or transient increases in serum creatinine or tubular injury markers that occur during intensive volume removal. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00608491.
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Affiliation(s)
- Veena S Rao
- Sections of Cardiovascular Medicine (V.S.R., T.A., D.D.M., E.J.V., J.M.T.), Yale University School of Medicine, New Haven, CT
| | - Tariq Ahmad
- Sections of Cardiovascular Medicine (V.S.R., T.A., D.D.M., E.J.V., J.M.T.), Yale University School of Medicine, New Haven, CT
| | - Meredith A Brisco-Bacik
- Cardiology Division, Lewis Katz School of Medicine at Temple University, Philadelphia, PA (M.A.B.-B.)
| | - Joseph V Bonventre
- Division of Renal Medicine, Brigham and Women's Hospital, Boston. MA (J.V.B.)
| | - F Perry Wilson
- Nephrology (F.P.W.), Yale University School of Medicine, New Haven, CT
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for AKI (VIP-AKI), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (E.D.S.)
| | - G Michael Felker
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (G.M.F., K.K.A.)
| | - Kevin K Anstrom
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (G.M.F., K.K.A.)
| | - Devin D Mahoney
- Sections of Cardiovascular Medicine (V.S.R., T.A., D.D.M., E.J.V., J.M.T.), Yale University School of Medicine, New Haven, CT
| | - Bradley A Bart
- Division of Cardiology, Hennepin County Medical Center, Minneapolis, MN (B.A.B.)
| | - W H Wilson Tang
- Section of Heart Failure and Cardiac Transplantation, Cleveland Clinic, OH (W.H.W.T.)
| | - Eric J Velazquez
- Sections of Cardiovascular Medicine (V.S.R., T.A., D.D.M., E.J.V., J.M.T.), Yale University School of Medicine, New Haven, CT
| | - Jeffrey M Testani
- Sections of Cardiovascular Medicine (V.S.R., T.A., D.D.M., E.J.V., J.M.T.), Yale University School of Medicine, New Haven, CT
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108
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Yancy CW. Acute Heart Failure: Searching for a New Evident Truth. J Am Coll Cardiol 2019; 69:1420-1423. [PMID: 28302293 DOI: 10.1016/j.jacc.2017.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 01/02/2017] [Indexed: 01/14/2023]
Affiliation(s)
- Clyde W Yancy
- Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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109
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Ma G, Ma X, Wang G, Teng W, Hui X. Effects of tolvaptan add-on therapy in patients with acute heart failure: meta-analysis on randomised controlled trials. BMJ Open 2019; 9:e025537. [PMID: 31048435 PMCID: PMC6501975 DOI: 10.1136/bmjopen-2018-025537] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Treating acute decompensated heartfailure (ADHF) for improving congestion with diuretics may cause worsening renal function (WRF), but the clinical efficacy of tolvaptan add-on therapy on reducing WRF in ADHF patients is inconsistent. This analysis is to evaluate the effects of tolvaptan add-on therapy on reducing WRF in ADHF patients. METHODS Meta-analysis of randomised trials of tolvaptan add-on therapy on reducing WRF in ADHF patients. The MEDLINE, Embase and Cochrane Central Register of Controlled Trials databases were searched for relevant articles from their inception to 31 October, 2017. Two reviewers filtrated the documents on WRF, short-term all-cause mortality, body weight decreased, elevated sodium level for calculating pooled relatives risks, weighted mean difference and associated 95% CIs. We used fixed-effects or random-effects models according to I2 statistics. ACHIEVEMENTS Seven random controlled trials with 937 patients were included for analysis. Compared with the control, tolvaptan add-on therapy did not improve incidence of worsening renal function (RR 0.78, 95% CI 0.48 to 1.26, p=0.31, I2=66%) and short-term all-cause mortality (RR 0.85, 95% CI 0.47 to 1.56, p=0.61, I2=0%). On subgroup analyses, there was a suggestion of possible effect modification by dose of tolvaptan, in which benefit was observed in low-dose (≤15 mg/day) group (RR 0.48, 95% CI 0.23 to 1.02, p=0.05, I2=54%), but not with high-dose (30 mg) group (RR 1.33, 95% CI 0.99 to 1.78, p=0.05, I2=0%). However, tolvaptan add-on therapy reduced body weight in 2 days (standardised mean difference -0.49, 95% CI -0.64 to -0.34, p<0.00001, I2=0%), increased sodium level (mean difference 1.56, 95% CI 0.04 to 3.07, p=0.04, I2=0%). CONCLUSION The result suggests that comparing with the standard diuretic therapy, tolvaptan add-on therapy did not reduce the incidence of WRF and short-term mortality, however, it can decrease body weight and increase the sodium level in patients who are with ADHF. Further researches are still required for confirmation.
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Affiliation(s)
- Guang Ma
- The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Xixi Ma
- The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Guoliang Wang
- The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Wei Teng
- The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Xuezhi Hui
- The First Affiliated Hospital of Henan University, Kaifeng, China
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110
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Sinnenberg L, Givertz MM. Acute heart failure. Trends Cardiovasc Med 2019; 30:104-112. [PMID: 31006522 DOI: 10.1016/j.tcm.2019.03.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/23/2019] [Accepted: 03/25/2019] [Indexed: 12/21/2022]
Abstract
Acute heart failure (AHF) is one of the most common causes for hospital admission and is associated with a high risk of mortality. Compared to chronic heart failure, there is less robust evidence to guide diagnosis, risk stratification and management of AHF. This state-of-the art review aims to summarize new developments in this field. We also highlight areas of ongoing work including novel vasoactive agents, alternative models to traditional hospital admission and strategies to improve patient engagement.
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Affiliation(s)
- Lauren Sinnenberg
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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111
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Gunderson EG, Lillyblad MP, Fine M, Vardeny O, Berei TJ. Tolvaptan for Volume Management in Heart Failure. Pharmacotherapy 2019; 39:473-485. [PMID: 30802995 DOI: 10.1002/phar.2239] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Volume management in acute decompensated and chronic heart failure (HF) remains a significant challenge. Although progress has been made in the development of mortality-reducing neurohormonal regimens in the reduced ejection fraction population, no clinical trial has yet demonstrated anything more than symptomatic relief or biomarker reduction with pharmacotherapeutic volume-based interventions made in the acutely decompensated individual or those with evolving outpatient congestion. As the number of patients with HF continues to grow, in addition to HF-related hospitalizations, identifying therapies that have the potential to aid in diuresis more safely and efficaciously is paramount to decreasing inpatient length of stay and preventing unnecessary admissions. More recently, a significant amount of research has been dedicated to the use of vasopressin antagonists, specifically tolvaptan, as adjunctive therapy to loop and thiazide diuretics. Although these agents do not seem to have a pervasive role in fluid management in the acute decompensated and chronic HF populations, they are effective tools to have available for specific clinical situations. This review summarizes the literature surrounding the use of tolvaptan for volume management in congestive HF, as well as offering practical guidance for use of this agent.
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Affiliation(s)
| | - Matthew P Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Michelle Fine
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
| | - Orly Vardeny
- University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota
| | - Theodore J Berei
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
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112
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Arginine vasopressin antagonism in heart failure: Current status and possible new directions. J Cardiol 2019; 74:49-52. [PMID: 30904236 DOI: 10.1016/j.jjcc.2019.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 01/31/2019] [Indexed: 11/22/2022]
Abstract
Modulating neurohormonal imbalance is the cornerstone of successful therapy in patients with chronic heart failure with reduced ejection fraction (HFrEF). Plasma arginine vasopressin (AVP) levels are elevated in HFrEF and may contribute to disease progression by excess signaling at either the V1a or V2 receptors. The effects of V1a receptor antagonism are almost completely unexplored, but V1a signaling is closely related to that for angiotensin II and blocking that receptor deserves further study. Interfering with V2 signaling causes free water diuresis and improves congestion without worsening renal function when added to loop diuretics but alone did not improve outcomes when carried into the post-acute phase in one large study. Outcomes in chronic HFrEF are quite good while outcomes in acute HF remain poor. Therefore, further study of V2 or combined V1/V2 blockade of the effects of AVP would most likely yield positive results in patients with acute HF, perhaps especially as alternative, not adjunctive therapy to loop diuretics.
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113
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Chioncel O, Collins SP, Ambrosy AP, Pang PS, Antohi EL, Iliescu VA, Maggioni AP, Butler J, Mebazaa A. Improving Postdischarge Outcomes in Acute Heart Failure. Am J Ther 2019; 25:e475-e486. [PMID: 29985826 PMCID: PMC6114135 DOI: 10.1097/mjt.0000000000000791] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville,
TN, USA
| | - Andrew P Ambrosy
- Division of Cardiology, Duke University Medical Center, Durham, NC,
USA Duke Clinical Research Institute, Durham, NC, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of
Medicine, Indiana USA
| | - Elena-Laura Antohi
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Vlad Anton Iliescu
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Aldo P Maggioni
- ANMCO Research Center, Florence, Italy; EORP-European Society of
Cardiology, Sophia Antipolis, France
| | - Javed Butler
- Department of Medicine, University of Mississippi School of
Medicine, Jackson, MI, USA
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care, APHP – Saint
Louis Lariboisière University Hospitals, University Paris Diderot and INSERM
UMR-S 942, Paris, France
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114
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Lu TL, Chang WT, Chan CH, Wu SN. Evidence for Effective Multiple K +-Current Inhibitions by Tolvaptan, a Non-peptide Antagonist of Vasopressin V 2 Receptor. Front Pharmacol 2019; 10:76. [PMID: 30873020 PMCID: PMC6401633 DOI: 10.3389/fphar.2019.00076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 01/21/2019] [Indexed: 12/28/2022] Open
Abstract
Tolvaptan (TLV), an oral non-peptide antagonist of vasopressin V2 receptor, has been increasingly used for managements in patients with hyponatremia and/or syndrome of inappropriate antidiuretic hormone secretion. However, none of the studies have thus far been investigated with regard to its possible perturbations on membrane ion currents in endocrine or neuroendocrine cells. In our electrophysiological study, the whole-cell current recordings showed that the presence of TLV effectively and differentially suppressed the amplitude of delayed rectifier K+ (IK(DR)) and M-type K+ current (IK(M)) in pituitary GH3 cells with an IC50 value of 6.42 and 1.91 μM, respectively. This compound was also capable of shifting the steady-state activation curve of IK(M) to less depolarized potential without any appreciable change in the gating charge of this current. TLV at a concentration greater than 10 μM also suppressed the amplitude of erg-mediated K+ current or the activity of large-conductance Ca2+-activated K+ channels; however, this compound failed to alter the amplitude of hyperpolarization-activated cation current in GH3 cells. In vasopressin-preincubated GH3 cells, TLV-mediated suppression of IK(M) remained little altered. Under current-clamp condition, we also observed that addition of TLV increased the firing of spontaneous action potentials in GH3 cells and further addition of flupirtine could reverse TLV-mediated elevation of the firing. In Madin-Darby canine kidney (MDCK) cells, the K+ current elicited by long ramp pulse was also effectively subject to inhibition by this compound. Findings from the present study were thus stated as saying that the suppression by TLV of multiple type K+ currents could be direct and independent of its antagonism of vasopressin V2 receptors. Our study also reveals an important aspect that should be considered when assessing aquaretic effect of TLV or its structurally similar compounds.
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Affiliation(s)
- Te-Ling Lu
- School of Pharmacy, China Medical University, Taichung, Taiwan
| | - Wei-Ting Chang
- Division of Cardiovascular Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chee-Hong Chan
- Department of Nephrology, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Sheng-Nan Wu
- Department of Physiology, National Cheng Kung University Medical College, Tainan, Taiwan.,Institute of Basic Medical Sciences, National Cheng Kung University Medical College, Tainan, Taiwan
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115
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Imamura T, Kinugawa K. Update of acute and long-term tolvaptan therapy. J Cardiol 2019; 73:102-107. [DOI: 10.1016/j.jjcc.2018.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/09/2018] [Indexed: 01/19/2023]
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116
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Gao WQ, Meng XD, Sun Z. Efficacy of tolvaptan for chronic heart failure: Study protocol for a systematic review of randomized controlled trial. Medicine (Baltimore) 2019; 98:e14540. [PMID: 30762795 PMCID: PMC6408044 DOI: 10.1097/md.0000000000014540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The protocol of this study will be proposed for systematic evaluation of the efficacy and safety of tolvaptan in the treatment of chronic heart failure (CHF). METHODS We will retrieve the following electronic databases for randomized controlled trials assessing the efficacy of tolvaptan in patients with CHF: PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Information, and Wanfang Data. Each database will be retrieved from inception to February 1, 2019 without any limitations. The entire process of study selection, data extraction, and methodological quality evaluation will be conducted by 2 independent authors. RESULTS The protocol of this proposed study will compare the efficacy and safety of tolvaptan in the treatment of patients with CHF. The outcomes will include all-cause mortality, change in body weight, urine output, change in serum sodium; and incidence of all adverse events. CONCLUSION The findings of this proposed study will summarize the current evidence of tolvaptan for CHF. ETHICS AND DISSEMINATION All data used in this systematic review will be collected from the previous published trials. Thus, no research ethics approval is needed for this study. The findings of this study will be published at a peer-reviewed journal. PROSPERO REGISTRATION NUMBER PROSPERO CRD42019120818.
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117
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Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, Testani JM, Tang WHW, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic PM, Ruschitzka F, Coats AJ. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019; 21:137-155. [PMID: 30600580 DOI: 10.1002/ejhf.1369] [Citation(s) in RCA: 565] [Impact Index Per Article: 113.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/14/2018] [Accepted: 10/27/2018] [Indexed: 12/11/2022] Open
Abstract
The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of diuretic therapy. The appropriate use of diuretics however remains challenging, especially when worsening renal function, diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic diuretic strategies, based upon diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Alexandre Mebazaa
- University of Paris Diderot, Hôpitaux Universitaires Saint Louis Lariboisière, APHP, U 942 Inserm, F-CRIN INI-CRCT, Paris, France
| | | | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | | | | | | | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d'Investigations Clinique 1433 and Inserm U1116; CHRU Nancy; F-CRIN INI-CRCT, Nancy, France
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, Athens, Greece.,University of Cyprus, Nicosia, Cyprus
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Tamargo J, Caballero R, Delpón E. New drugs in preclinical and early stage clinical development in the treatment of heart failure. Expert Opin Investig Drugs 2018; 28:51-71. [DOI: 10.1080/13543784.2019.1551357] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Madrid,
Spain
| | - Ricardo Caballero
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Madrid,
Spain
| | - Eva Delpón
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Madrid,
Spain
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Nonin S, Iwata S, Ito A, Tamura S, Kitada R, Kawai Y, Ishikawa S, Doi A, Hanatani A, Yoshiyama M. Right ventricular enlargement predicts responsiveness to tolvaptan in congestive heart failure patients with reduced ejection fraction. IJC HEART & VASCULATURE 2018; 21:69-73. [PMID: 30345343 PMCID: PMC6191974 DOI: 10.1016/j.ijcha.2018.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/18/2018] [Accepted: 09/26/2018] [Indexed: 12/28/2022]
Abstract
Background Tolvaptan is a vasopressin type 2 receptor antagonist used in heart failure (HF) with refractory diuretic resistance. However, since tolvaptan is also ineffective in some HF patients with reduced ejection fraction (HFrEF), the identification of responders is important. Methods The study population consisted of 51 HFrEF patients who were administered tolvaptan (EF, 28 ± 7%). We defined responders as patients with a ≥50% increase in urine volume during the 24-hours after administration of tolvaptan. All patients underwent comprehensive transthoracic echocardiography before administration of tolvaptan. Patients were followed for 120 days to ascertain secondary events (cardiac death and rehospitalization for HF). Results Multiple regression analysis indicated that right ventricular (RV) enlargement (defined as basal RV diameter > 41 mm and midlevel RV diameter > 35 mm, according to guidelines) remained a predictor of response after adjustment for age, sex, starting dosage of tolvaptan, and estimated glomerular filtration rate (odds ratio, 4.88; 95%-confidence interval, 1.26–18.9; P < 0.05), whereas left ventricular parameters and RV dysfunction were not. Kaplan-Meier curves indicated responsiveness to tolvaptan was associated with better prognosis among the overall population (P < 0.05); similar trends were observed among patients with RV dilatation (P = 0.056). Conclusions These findings suggest that RV enlargement, which represents right-sided volume overload, elevated filling pressure, and diastolic dysfunction similar to that seen in constrictive pericarditis, predicts responsiveness to tolvaptan in patients with HFrEF. Moreover, administration of tolvaptan may have the potential to improve the reportedly poor prognosis for HFrEF patients with RV dilatation.
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Affiliation(s)
- Shinichi Nonin
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka 545-8585, Japan
| | - Shinichi Iwata
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka 545-8585, Japan
| | - Asahiro Ito
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka 545-8585, Japan
| | - Soichiro Tamura
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka 545-8585, Japan
| | - Ryoko Kitada
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka 545-8585, Japan
| | - Yu Kawai
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka 545-8585, Japan
| | - Sera Ishikawa
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka 545-8585, Japan
| | - Atsushi Doi
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka 545-8585, Japan
| | - Akihisa Hanatani
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka 545-8585, Japan
| | - Minoru Yoshiyama
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka 545-8585, Japan
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Kinugawa K, Sato N, Inomata T. Effects of Tolvaptan on Volume Overload in Patients with Heart Failure. Int Heart J 2018; 59:1368-1377. [DOI: 10.1536/ihj.18-119] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Naoki Sato
- Internal Medicine, Cardiology and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital
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Hamo CE, O'Connor C, Metra M, Udelson JE, Gheorghiade M, Butler J. A Critical Appraisal of Short-Term End Points in Acute Heart Failure Clinical Trials. J Card Fail 2018; 24:783-792. [PMID: 30217774 DOI: 10.1016/j.cardfail.2018.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 08/02/2018] [Accepted: 08/29/2018] [Indexed: 01/08/2023]
Abstract
The prevalence of heart failure continues to grow, and this is accompanied by an increase in hospitalization for acute heart failure. Hospitalization for heart failure results in a trajectory shift of the syndrome and is associated with worsening outcomes, increased mortality risk, and high costs. Numerous clinical trials over the past 2 decades have had limited success, with no single agent shown to improve mortality risk. The lack of success is multifactorial and in part related to inadequate targets and end points selected for intervention, underscoring the need to better understand and define the pathophysiology of acute heart failure. To better inform future drug development, this review critically explores the short-term end points and outcomes that previous phase III acute heart failure trials have examined.
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Affiliation(s)
- Carine E Hamo
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Christopher O'Connor
- Cardiology Division, Inova Heart and Vascular Institute, Falls Church, Virginia, United States
| | - Marco Metra
- Division of Cardiology, University of Brescia and Civil Hospital, Brescia, Italy
| | - James E Udelson
- Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, United States
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, New York, United States.
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Oguri M, Ishii H, Ohguchi S, Takahara K, Kawamura Y, Yokoi Y, Izumi K, Takahashi H, Kamiya H, Murohara T. Comparison of two dosing methods for immediate administration of tolvaptan in acute decompensated heart failure. J Cardiol 2018; 72:234-239. [DOI: 10.1016/j.jjcc.2018.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 02/06/2018] [Accepted: 02/08/2018] [Indexed: 12/01/2022]
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123
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Grodin JL, Tang WHW. Driving with the headlights on: Measuring adequate urinary sodium excretion on the road to precision diuresis. Am Heart J 2018; 203:93-94. [PMID: 29980250 DOI: 10.1016/j.ahj.2018.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/14/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Wai Hong Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
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124
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Luk A, Groarke JD, Desai AS, Mahmood SS, Gopal DM, Joyce E, Shah SP, Lindenfeld J, Stevenson L, Lakdawala NK. First spot urine sodium after initial diuretic identifies patients at high risk for adverse outcome after heart failure hospitalization. Am Heart J 2018; 203:95-100. [PMID: 29907406 DOI: 10.1016/j.ahj.2018.01.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 01/28/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Relief of congestion is the primary goal of initial therapy for acute decompensated heart failure (ADHF). Early measurement of urine sodium concentration (UNa) may be useful to identify patients with diminished response to diuretics. The aim of this study was to determine if the first spot UNa after diuretic initiation could select patients likely to require more intensive therapy during hospitalization. METHODS At the time of admission, 103 patients with ADHF were identified prospectively, and UNa was measured after the first dose of intravenous diuretic. Clinical outcomes were compared for patients with UNa >60 mmol/L and UNa of ≤60 mmol/L, with the primary outcome of a composite of death at 90 days, mechanical circulatory support during admission, and requirement of inotropic support at discharge. RESULTS Patients with UNa ≤60 had lower admission blood pressure, had less chronic neurohormonal antagonist prior to admission, and were more than twice as likely to experience the primary end point (hazard ratio 2.40, 95% CI 1.02-5.66, P = .045), which was marginally significant after adjusting for renal function and baseline home loop diuretic. Worsening renal function was significantly more common in patients with UNa <60 (23.6% vs 6.5%, P = .05). Although the initial assessment of congestion was similar at admission, patients with low early UNa had a longer length of stay (11 vs 6 days, P < .006) than patients with UNa >60. CONCLUSIONS Assessment of spot UNa after initial intravenous loop diuretic administration may facilitate identification and triage of a population of HF patients at increased risk for adverse events and prolonged hospitalization.
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Affiliation(s)
- Adriana Luk
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - John D Groarke
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Akshay S Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Syed Saad Mahmood
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | | | | | - Sachin P Shah
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Lahey Hospital and Medical Center, Burlington, MA
| | | | - Lynne Stevenson
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Vanderbilt University Medical Center, Nashville, TN
| | - Neal K Lakdawala
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
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125
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Vidic A, Shuster JE, Goff ZD, Godishala A, Joseph SM, Chibnall JT, Hauptman PJ. Vasopressin antagonism for decompensated right-sided heart failure. Int J Cardiol 2018; 274:245-247. [PMID: 30193794 DOI: 10.1016/j.ijcard.2018.08.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/16/2018] [Accepted: 08/09/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Targeted treatment for decompensated right heart failure (RHF) with or without left heart failure is lacking. Vasopressin antagonists (vaptans) may offer an option by increasing urine output and fluid mobilization when used in acute decompensated RHF without impacting blood pressure or renal function, both common complications of loop diuretics. METHODS AND RESULTS We searched electronic medical records from 2 institutions over 4 years for patients with RHF treated with vaptans. Urine output, creatinine, BUN and sodium, 1 day pre- versus 1 day post-vaptan initiation were compared. Baseline (admission) pre-vaptan values for patients with RHF who met inclusion criteria (n = 112) were RAP, median (interquartile range) = 19 (13-24) mmHg; cardiac index, mean ± standard deviation = 1.8 ± 0.4 L/min/m2; BNP, 1078 (523-1690) pg/ml; creatinine clearance of 51 (39-69) ml/min, BUN, 37 (26-54) mg/dl, and serum [Na+] 132 (126-135) mEq/L. Most patients (n = 103/112) received intravenous inotrope (prior to vaptan, n = 91). Overall length of stay was 27 (16-43) days. Vaptan treatment (90% tolvaptan, 10% conivaptan) was associated with increased 24 h urine output, 1517 (906-2394) vs 2337 (1425-3744) mL, p = 0.005, and [Na+], 127 (124-130) vs 130 (126-135) mEq/L, p = 0.001, without significant change in Cr or BUN. Furosemide IV dose equivalent decreased or remained unchanged in 75% of patients at 24 h and 64% at 72 h compared to the 24 h prior to vaptan use. CONCLUSION Vaptans were associated with a significant increase in urine output and serum sodium with an apparent reduction or stabilization of furosemide equivalent dosing in the early treatment period in patients with decompensated RHF. Vaptans may offer a management option for patients failing conventional diuretic-based treatment.
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Affiliation(s)
- Andrija Vidic
- The Department of Medicine, Florida Hospital, Orlando, FL, United States of America
| | - Jerrica E Shuster
- The Department of Pharmacy, Barnes Jewish Hospital, St. Louis, MO, United States of America
| | - Zackary D Goff
- The Department of Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Anuradha Godishala
- The Department of Medicine, Barnes Jewish Hospital, St. Louis, MO, United States of America
| | - Susan M Joseph
- The Department of Medicine, Baylor University, Dallas, TX, United States America
| | - John T Chibnall
- The Department of Medicine, Saint Louis University, St. Louis, MO, United States of America
| | - Paul J Hauptman
- The Department of Medicine, Saint Louis University, St. Louis, MO, United States of America.
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127
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Goldsmith SR, Bart BA, Pin~a IL. Neurohormonal Imbalance: A Neglected Problem—And Potential Therapeutic Target—In Acute Heart Failure. Curr Probl Cardiol 2018; 43:294-304. [DOI: 10.1016/j.cpcardiol.2017.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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128
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Nagler EV, Haller MC, Van Biesen W, Vanholder R, Craig JC, Webster AC. Interventions for chronic non-hypovolaemic hypotonic hyponatraemia. Cochrane Database Syst Rev 2018; 6:CD010965. [PMID: 29953167 PMCID: PMC6513194 DOI: 10.1002/14651858.cd010965.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chronic (present > 48 hours) non-hypovolaemic hyponatraemia occurs frequently, can be caused by various conditions, and is associated with shorter survival and longer hospital stays. Many treatments, such as fluid restriction or vasopressin receptor antagonists can be used to improve the hyponatraemia, but whether that translates into improved patient-important outcomes is less certain. OBJECTIVES This review aimed to 1) look at the benefits and harms of interventions for chronic non-hypovolaemic hypotonic hyponatraemia when compared with placebo, no treatment or head-to-head; and 2) determine if benefits and harms vary in absolute or relative terms dependent on the specific compound within a drug class, on the dosage used, or the underlying disorder causing the hyponatraemia. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 1 December 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also screened the reference lists of potentially relevant studies, contacted authors, and screened the websites of regulatory agencies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of any intervention with placebo, no treatment, standard care, or any other intervention in patients with chronic non-hypovolaemic hypotonic hyponatraemia. We also included subgroups with hyponatraemia from studies with broader inclusion criteria (e.g. people with chronic heart failure or people with cirrhosis with or without hyponatraemia), provided we could obtain outcomes for participants with hyponatraemia from the report or the study authors. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. We expressed treatment effects as mean difference (MD) for continuous outcomes (health-related quality of life, length of hospital stay, change from baseline in serum sodium concentration, cognitive function), and risk ratio (RR) for dichotomous outcomes (death, response and rapid increase in serum sodium concentration, hypernatraemia, polyuria, hypotension, acute kidney injury, liver function abnormalities) together with 95% confidence intervals (CI). MAIN RESULTS We identified 35 studies, enrolling 3429 participants. Twenty-eight studies (3189 participants) compared a vasopressin receptor antagonist versus placebo, usual care, no treatment, or fluid restriction. In adults with chronic, non-hypovolaemic hypotonic hyponatraemia, vasopressin receptor antagonists have uncertain effects on death at six months (15 studies, 2330 participants: RR 1.11, 95% CI 0.92 to 1.33) due to risk of selective reporting and serious imprecision; and on health-related quality of life because results are at serious risk of performance, selective reporting and attrition bias, and suffer from indirectness related to the validity of the Short Form Health Survey (SF-12) in the setting of hyponatraemia. Vasopressin receptor antagonists may reduce hospital stay (low certainty evidence due to risk of performance bias and imprecision) (3 studies, 610 participants: MD -1.63 days, 95% CI -2.96 to -0.30), and may make little or no difference to cognitive function (low certainty evidence due to indirectness and imprecision). Vasopressin receptor antagonists probably increase the intermediate outcome of serum sodium concentration (21 studies, 2641 participants: MD 4.17 mmol/L, 95% CI 3.18 to 5.16), corresponding to two and a half as many people having a 5 to 6 mmol/L increase in sodium concentration compared with placebo at 4 to 180 days (moderate certainty evidence due to risk of attrition bias) (18 studies, 2014 participants: RR 2.49, 95% CI 1.95 to 3.18). But they probably also increase the risk of rapid serum sodium correction - most commonly defined as > 12 mmol/L/d (moderate certainty evidence due to indirectness) (14 studies, 2058 participants: RR 1.67, 95% CI 1.16 to 2.40) and commonly cause side-effects such as thirst (13 studies, 1666 participants: OR 2.77, 95% CI 1.80 to 4.27) and polyuria (6 studies, 1272 participants): RR 4.69, 95% CI 1.59 to 13.85) (high certainty evidence). The potential for liver toxicity remains uncertain due to large imprecision. Effects were generally consistent across the different agents, suggesting class effect.Data for other interventions such as fluid restriction, urea, mannitol, loop diuretics, corticosteroids, demeclocycline, lithium and phenytoin were largely absent. AUTHORS' CONCLUSIONS In people with chronic hyponatraemia, vasopressin receptor antagonists modestly raise serum sodium concentration at the cost of a 3% increased risk of it being rapid. To date there is very low certainty evidence for patient-important outcomes; the effects on mortality and health-related quality of life are unclear and do not rule out appreciable benefit or harm; there does not appear to be an important effect on cognitive function, but hospital stay may be slightly shorter, although available data are limited. Treatment decisions must weigh the value of an increase in serum sodium concentration against its short-term risks and unknown effects on patient-important outcomes. Evidence for other treatments is largely absent.Further studies assessing standard treatments such as fluid restriction or urea against placebo and one-another would inform practice and are warranted. Given the limited available evidence for patient-important outcomes, any study should include these outcomes in a standardised manner.
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Affiliation(s)
- Evi V Nagler
- Ghent University HospitalRenal Division, Sector Metabolic and Cardiovascular ConditionsDe Pintelaan 185GhentBelgium9000
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
| | - Maria C Haller
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
- Medical University ViennaSection for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent SystemsSpitalgasse 23ViennaAustriaA‐1090
- Ordensklinikum Linz ElisabethinenDepartment of NephrologyFadingerstraße 1LinzAustria4020
| | - Wim Van Biesen
- Ghent University HospitalRenal Division, Sector Metabolic and Cardiovascular ConditionsDe Pintelaan 185GhentBelgium9000
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
| | - Raymond Vanholder
- Ghent University HospitalRenal Division, Sector Metabolic and Cardiovascular ConditionsDe Pintelaan 185GhentBelgium9000
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Angela C Webster
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
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Tanaka TD, Sawano M, Ramani R, Friedman M, Kohsaka S. Acute heart failure management in the USA and Japan: overview of practice patterns and review of evidence. ESC Heart Fail 2018; 5:931-947. [PMID: 29932314 PMCID: PMC6165950 DOI: 10.1002/ehf2.12305] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 04/17/2018] [Indexed: 01/23/2023] Open
Abstract
Globally, acute heart failure (AHF) remains an ongoing public health issue with its prevalence and mortality increasing in the east and the west. Effective treatment strategies to stabilize AHF are important to alleviate clinical symptoms and to improve clinical outcomes. However, despite the progress in the management of stable and chronic heart failure, no single agent has been proven to play a definitive role in the management of AHF. As a consequence, contemporary treatment strategies for patients with AHF vary greatly by region. This manuscript reviews the medical treatment options for AHF, with an emphasis on the differences between the treatment strategies in the USA and Japan. This information would provide a framework for clinicians to evaluate and manage patients with AHF and highlight the remaining questions to improve clinical outcomes.
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Affiliation(s)
- Toshikazu D Tanaka
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ravi Ramani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Friedman
- Section of Cardiology, Sarver Heart Center, Banner University Medical Center, Tucson, AZ, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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130
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Teneggi V, Sivakumar N, Chen D, Matter A. Drugs’ development in acute heart failure: what went wrong? Heart Fail Rev 2018; 23:667-691. [DOI: 10.1007/s10741-018-9707-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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131
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Determinants of Diuretic Responsiveness and Associated Outcomes During Acute Heart Failure Hospitalization: An Analysis From the NHLBI Heart Failure Network Clinical Trials. J Card Fail 2018; 24:428-438. [PMID: 29482026 DOI: 10.1016/j.cardfail.2018.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/17/2018] [Accepted: 02/13/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Poor response to loop diuretic therapy is a marker of risk during heart failure hospitalization. We sought to describe baseline determinants of diuretic response and to further explore the relationship between this response and clinical outcomes. METHODS AND RESULTS Patient data from the National Heart, Lung, and Blood Institute Heart Failure Network ROSE-AHF and CARRESS-HF clinical trials were analyzed to determine baseline determinants of diuretic response. Diuretic efficiency (DE) was defined as total 72-hour fluid output per total equivalent loop diuretic dose. Data from DOSE-AHF was then used to determine if these predictors of DE correlated with response to a high- versus low-dose diuretic strategy. At 72 hours, the high-DE group had median fluid output of 9071 ml (interquartile range: 7240-11775) with median furosemide dose of 320 mg (220-480) compared with 8030 ml (6300-9915) and 840 mg (600-1215) respectively for the low DE group. Cystatin C was independently associated with DE (odds ratio 0.36 per 1mg/L increase; 95% confidence interval: 0.24-0.56; P < 0.001). Independently from baseline characteristics, reduced fluid output, weight loss and DE were each associated with increased 60 day mortality. Among patients with estimated glomerular filtration rate below the median, those randomized to a high-dose strategy had improved symptoms compared with those randomized to a low-dose strategy. CONCLUSIONS Elevated baseline cystatin C, as a biomarker of renal dysfunction, is associated with reduced diuretic response during heart failure hospitalization. Higher loop diuretic doses are required for therapeutic decongestion in patients with renal insufficiency. Poor response identifies a high-risk population.
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Sen J, Chung E, McGill D. Tolvaptan for Heart Failure in Chronic Kidney Disease Patients: A Systematic Review and Meta-Analysis. Heart Lung Circ 2018; 27:928-939. [PMID: 29602756 DOI: 10.1016/j.hlc.2017.12.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 11/21/2017] [Accepted: 12/30/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Heart failure (HF) is frequently associated with renal impairment. Tolvaptan is reported to be effective in treating congestion in HF without significant electrolyte loss compared to conventional diuretics. However, the safety and efficacy of its use in patients with chronic kidney disease (CKD) is uncertain. This systematic review and meta-analysis evaluated the efficacy and safety outcomes of tolvaptan for HF management in patients with CKD, with a focus at a physiologic basis related to safety. METHODS We searched for observational studies and randomised clinical trials (RCTs) that assessed the effects of tolvaptan against placebo or standard care in adult patients with HF and CKD. Our protocol was registered with PROSPERO (number CRD42017052775). RESULTS Seventeen studies were included in the qualitative review and six in the meta-analysis involving 1597 patients. Tolvaptan was associated with an increase in sodium concentration. No significant differences in change of eGFR and serum creatinine were found between tolvaptan and control groups. Urine flow rate appears to increase significantly with tolvaptan compared to baseline (p<0.0001). The meta-analysis demonstrated no heterogeneity between studies but the possibility of publication bias due to incomplete reporting in excluded studies and lack of RCTs. CONCLUSIONS The safety profile of tolvaptan appears acceptable for patients with HF and CKD. There is evidence for an improvement in serum sodium and reduction in body water without deterioration in renal function. Further research is needed to elucidate the long-term benefits of tolvaptan as an adjunct or alternative to diuretics in such patients.
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Affiliation(s)
| | - Erin Chung
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; The Hospital for Sick Children, Toronto, Ontario, Canada
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Hiramine Y, Uojima H, Nakanishi H, Hiramatsu A, Iwamoto T, Kimura M, Kawaratani H, Terai S, Yoshiji H, Uto H, Sakaida I, Izumi N, Okita K, Koike K. Response criteria of tolvaptan for the treatment of hepatic edema. J Gastroenterol 2018; 53:258-268. [PMID: 28664229 DOI: 10.1007/s00535-017-1366-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/19/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although tolvaptan is an effective treatment for hepatic edema, there are no established criteria for assessment of the therapeutic effect. The present study evaluates the association between body weight change and clinical symptoms to identify an effective indicator of tolvaptan response. METHODS The study comprised 460 patients. The first data set contained 147 patients with hepatic edema who received tolvaptan in Kagoshima Kouseiren Hospital, a representative institution of this study. From these data, an optimal cutoff value of body weight change, which accurately indicated symptom reduction, was identified. The response rates obtained based on the cutoff value were evaluated by receiver-operating characteristic (ROC) analysis and kappa coefficients. The kappa coefficient was then validated internally using the bootstrap method and externally using the validation data set of 313 patients from four other hospitals. RESULTS A cutoff value for body weight loss of 1.5 kg/week produced the largest area under the ROC curve (0.961; sensitivity, 89.8%; specificity, 92.0%) and a high kappa coefficient (0.831). The correlation between symptom reduction and body weight loss of 1.5 kg/week was evaluated internally and externally, and the cutoff value was validated. CONCLUSIONS The cutoff value of body weight change that most accurately reflected symptom reduction was 1.5 kg/week; this value is expected to be an effective indicator of response to tolvaptan in clinical practice.
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Affiliation(s)
- Yasunari Hiramine
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, 22-25 Tenpozancho, Kagoshima, 890-0061, Japan.
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Hiroyuki Nakanishi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1 Kyonancho, Musashino-shi, Tokyo, 180-8610, Japan
| | - Akira Hiramatsu
- Department of Gastroenterology and Metabolism, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takuya Iwamoto
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube-shi, Yamaguchi, 755-8505, Japan
| | - Mutsuumi Kimura
- Department of Hepatology, Sapporo Kosei General Hospital, 8-5 Kitasanzyo-higashi, Chuo-ku, Sapporo, Hokkaido, 060-0033, Japan
| | - Hideto Kawaratani
- Third Department of Internal Medicine, Nara Medical University, 840 Shijocho, Kashihara-shi, Nara, 634-8521, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
| | - Hitoshi Yoshiji
- Third Department of Internal Medicine, Nara Medical University, 840 Shijocho, Kashihara-shi, Nara, 634-8521, Japan
| | - Hirofumi Uto
- Center for Digestive and Liver Diseases, Miyazaki Medical Center Hospital, 2-16 Takamatsu-cho, Miyazaki, 880-0003, Japan
| | - Isao Sakaida
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube-shi, Yamaguchi, 755-8505, Japan
| | - Namiki Izumi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1 Kyonancho, Musashino-shi, Tokyo, 180-8610, Japan
| | - Kiwamu Okita
- Shunan Memorial Hospital, 1-10-1 Ikunoyaminami, Kudamatsu-shi, Yamaguchi, 744-0033, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Carubelli V, Metra M, Lund LH. Negotiating renal dysfunction when treating patients with heart failure. Expert Rev Cardiovasc Ther 2018; 16:113-122. [PMID: 29292652 DOI: 10.1080/14779072.2018.1422178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Chronic kidney disease (CKD) is one of the most prevalent comorbidities in HF, and no specific treatment is still available for the so-called cardiorenal syndrome. Areas covered: The aim of this review is to describe the interaction of heart and kidney function and the consequences of cardiorenal syndrome, focusing on the use of available therapeutics. Expert commentary: The presence of CKD has been associated with adverse outcomes in HF regardless of ejection fraction. On the other hand, cardiovascular events are the most common causes of morbidity and mortality among CKD patients, reflecting the close pathophysiological crosstalk between these organs. Multiple mechanisms are involved in the development of cardiorenal syndrome, including hemodynamic, neurohormonal and inflammatory mediators. The management of several HF drugs is a challenge in the presence of CKD mainly due to blunted diuretic response and increased risk of worsening of kidney function. Therefore, finding a balance between the optimization of cardiac and renal outcomes is a real negotiation in the everyday clinical practice.
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Affiliation(s)
- Valentina Carubelli
- a Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health , University and Civil Hospital of Brescia , Brescia , Italy
| | - Marco Metra
- a Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health , University and Civil Hospital of Brescia , Brescia , Italy
| | - Lars H Lund
- b Unit of Cardiology, Department of Medicine , Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital , Solna , Sweden
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Yandrapalli S, Jolly G, Biswas M, Rochlani Y, Harikrishnan P, Aronow WS, Lanier GM. Newer hormonal pharmacotherapies for heart failure. Expert Rev Endocrinol Metab 2018; 13:35-49. [PMID: 30063443 DOI: 10.1080/17446651.2018.1406799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Heart failure (HF) is characterized by maladaptive neurohormonal activation of the cardiovascular and renal systems resulting in circulatory inadequacy and frequent acute exacerbations. The increasing burden of HF prompted investigation of underlying pathophysiological mechanisms and the design of pharmacotherapeutics that would target these pathways. AREAS COVERED A MEDLINE search for relevant original investigations and review articles of newer hormonal drugs for HF since the year 2005 till October 2017 provided us with necessary literature. Major trials and relevant clinical investigations were discussed. EXPERT COMMENTARY A multitude of hormonal pathways central to HF were identified, including the natriuretic peptide system and neurohormones such as relaxin, arginine vasopressin, and endothelin. However, drugs targeting these novel pathways (aliskiren, tolvaptan, ularitide, serelaxin, bosentan, macitentan) failed to show mortality benefit. This emphasizes a tremendous unmet need in the pharmacotherapy for HF, especially for the subtypes of acute HF and HF with preserved ejection fraction. Sacubitril/valsartan demonstrated substantial mortality benefit in chronic systolic HF population and is endorsed by international HF guidelines. If proven to be efficacious in larger outcome trials, finerenone can be a valuable addition baseline HF therapy. More basic, translational, and phenotype specific clinical research is warranted to improve HF pharmacotherapy.
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Affiliation(s)
- Srikanth Yandrapalli
- a Department of Internal Medicine , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - George Jolly
- a Department of Internal Medicine , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Medha Biswas
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Yogita Rochlani
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Prakash Harikrishnan
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Wilbert S Aronow
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Gregg M Lanier
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
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Shah P, Pellicori P, Cuthbert J, Clark AL. Pharmacological and Non-pharmacological Treatment for Decompensated Heart Failure: What Is New? Curr Heart Fail Rep 2017; 14:147-157. [PMID: 28421408 PMCID: PMC5423987 DOI: 10.1007/s11897-017-0328-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF THE REVIEW Acute heart failure (AHF) is a life-threatening clinical condition that requires prompt medical attention. The aim of the current review is to summarise the results of recent clinical trials conducted in patients with AHF. RECENT FINDINGS Several novel compounds have apparently beneficial acute effects on cardiovascular haemodynamics and patients' symptoms, but their administration has not yet translated into improved survival and has been deleterious in some cases. The management of patients with AHF is challenging and reflects the heterogeneity of patient's presentation, the complexity and severity of a multi-organ syndrome, and the limited therapeutic options, usually restricted to a combination of diuretics and vasodilators. Ongoing trials of novel treatments may provide evidence of an effect on outcomes.
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Affiliation(s)
- Parin Shah
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK.
| | - Pierpaolo Pellicori
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - Joseph Cuthbert
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - Andrew L Clark
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
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Abstract
PURPOSE OF REVIEW The burden of heart failure in the United States is growing rapidly to epic proportions with serious clinical implications for patients and economic strain for healthcare systems. One of the most common reasons for hospitalization in acute decompensated heart failure (ADHF) is excess volume accumulation which leads to untoward symptoms including dyspnea,orthopnea, and edema. RECENT FINDINGS Over the past several decades, there has been great interest in exploring various decongestive strategies in order to achieve symptomatic improvement and favorable clinical outcomes. These include different modalities of loop diuretic administration, the adjunctive use of non-loop diuretics, and other diuretic sparing strategies. Herein, we provide an appraisal of these decongestive strategies and discuss novel concepts predicting clinical outcomes based on diuretic response and decongestive adequacy while discussing commonly encountered problems such as worsening renal function in ADHF.
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Dhondup T, Qian Q. Acid-Base and Electrolyte Disorders in Patients with and without Chronic Kidney Disease: An Update. KIDNEY DISEASES (BASEL, SWITZERLAND) 2017; 3:136-148. [PMID: 29344508 PMCID: PMC5757582 DOI: 10.1159/000479968] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/03/2017] [Indexed: 12/14/2022]
Abstract
Kidneys play a pivotal role in the maintenance and regulation of acid-base and electrolyte homeostasis, which is the prerequisite for numerous metabolic processes and organ functions in the human body. Chronic kidney diseases compromise the regulatory functions, resulting in alterations in electrolyte and acid-base balance that can be life-threatening. In this review, we discuss the renal regulations of electrolyte and acid-base balance and several common disorders including metabolic acidosis, alkalosis, dysnatremia, dyskalemia, and dysmagnesemia. Common disorders in chronic kidney disease are also discussed. The most recent and relevant advances on pathophysiology, clinical characteristics, diagnosis, and management of these conditions have been incorporated.
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Affiliation(s)
| | - Qi Qian
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Affiliation(s)
- David H. Ellison
- Oregon Clinical & Translational Research Institute, Oregon Health & Science University and VA Portland Health Care System, Portland, OR
| | - G. Michael Felker
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC
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Cheema B, Ambrosy AP, Kaplan RM, Senni M, Fonarow GC, Chioncel O, Butler J, Gheorghiade M. Lessons learned in acute heart failure. Eur J Heart Fail 2017; 20:630-641. [PMID: 29082676 DOI: 10.1002/ejhf.1042] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 09/18/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022] Open
Abstract
Acute heart failure (HF) is a global pandemic with more than one million admissions to hospital annually in the US and millions more worldwide. Post-discharge mortality and readmission rates remain unchanged and unacceptably high. Although recent drug development programmes have failed to deliver novel therapies capable of reducing cardiovascular morbidity and mortality in patients hospitalized for worsening chronic HF, hospitalized HF registries and clinical trial databases have generated a wealth of information improving our collective understanding of the HF syndrome. This review will summarize key insights from clinical trials in acute HF and hospitalized HF registries over the last several decades, focusing on improving the management of patients with HF and reduced ejection fraction.
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Affiliation(s)
- Baljash Cheema
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Andrew P Ambrosy
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Rachel M Kaplan
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Michele Senni
- Cardiovascular Department, Papa Giovannni XXIII Hospital, Bergamo, Italy
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USA
| | - Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases 'Prof. C.C. Iliescu', Cardiology 1, UMF Carol Davila, Bucharest, Romania
| | | | - Mihai Gheorghiade
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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Okabe T, Yakushiji T, Kido T, Oyama Y, Igawa W, Ono M, Ebara S, Yamashita K, Yamamoto MH, Saito S, Amemiya K, Isomura N, Ochiai M. The association between high-dose loop diuretic use at discharge and cardiovascular mortality in patients with heart failure. ESC Heart Fail 2017; 5:87-94. [PMID: 28967699 PMCID: PMC5793979 DOI: 10.1002/ehf2.12221] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 07/14/2017] [Accepted: 08/17/2017] [Indexed: 12/12/2022] Open
Abstract
AIMS Few studies have reported the impact of high-dose loop diuretics at discharge on prognosis in Japanese patients with heart failure (HF). Our purpose was to assess the relationship between the dose of loop diuretics at discharge and cardiovascular mortality in patients with HF. METHODS AND RESULTS We enrolled decompensated HF patients who were admitted to our hospital between March 2010 and March 2015, and compared HF patients who received high-dose loop diuretics at discharge (HD group) with low-dose loop diuretics at discharge (LD group) with regard to risk of cardiovascular mortality, and all-cause mortality. High-dose loop diuretic was defined as ≥40 mg/day of oral furosemide at discharge. A total of 215 patients were enrolled to the study. The median follow-up duration was 641 days. All-cause and cardiovascular mortality were significantly lower in the LD group than in the HD group (10.4% vs. 31.6%, P < 0.001; 2.2% vs. 24.6%, P < 0.001, respectively). High-dose loop diuretics were associated with cardiovascular mortality in multivariate Cox proportional hazards model (hazard ratio, 16.06, 95% confidence interval 3.457 to 116.8; P < 0.001). The largest area under the receiver operating characteristic curve (0.85) for cardiovascular death was obtained with a threshold of 40 mg furosemide. CONCLUSIONS High-dose loop diuretic use at discharge was one of the predictors of cardiovascular mortality in patients with HF. An oral furosemide dose of 40 mg daily may be defined as 'high-dose' loop diuretics in Japanese patients with chronic HF.
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Affiliation(s)
- Toshitaka Okabe
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Tadayuki Yakushiji
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Takehiko Kido
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Yuji Oyama
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Wataru Igawa
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Morio Ono
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Seitaro Ebara
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Kennosuke Yamashita
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Myong Hwa Yamamoto
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Shigeo Saito
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Kisaki Amemiya
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Naoei Isomura
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Masahiko Ochiai
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo, Tsuzuki, Yokohama, 224-8503, Japan
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Hyponatraemia and congestive heart failure refractory to diuretic treatment. Utility of tolvaptan. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2017.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kinoshita M, Okayama H, Kosaki T, Hosokawa S, Kawamura G, Shigematsu T, Takahashi T, Kawada Y, Hiasa G, Yamada T, Matsuoka H, Kazatani Y. Favorable effects of early tolvaptan administration in very elderly patients after repeat hospitalizations for acute decompensated heart failure. Heart Vessels 2017; 33:163-169. [PMID: 28889231 DOI: 10.1007/s00380-017-1048-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 09/01/2017] [Indexed: 01/11/2023]
Abstract
Tolvaptan (TLV) is an oral selective vasopressin 2 receptor antagonist that acts on the distal nephrons, causing a loss of electrolyte-free water. To date, its early administration in very elderly patients after repeat hospitalizations for acute decompensated heart failure (ADHF) despite receiving optimal medical therapy has not been evaluated. Fifty-six ADHF patients who were >80 years old and had been repeatedly hospitalized were retrospectively enrolled in this study. Twenty-five patients (14 men; mean age 86.7 ± 5.3 years; control group) received standard therapy and 31 patients (15 men; mean age 85.5 ± 4.5 years; TLV group) received oral TLV within 24 h of admission. The rate of worsening renal function was significantly lower in the TLV group than in the control group (13 vs. 40%, P < 0.05). The duration of the return to body weight at a steady state was significantly shorter in the TLV group (5.3 ± 2.8 days) than in the control group (13.9 ± 9.2 days, P < 0.01). Consequently, the hospitalization period in the TLV group (13.5 ± 5.9 days) was significantly shorter than that in the control group (24.7 ± 12.3 days, P < 0.01). In conclusion, the early administration of TLV to very elderly patients who underwent repeat hospitalizations for ADHF resulted in immediate decongestion and thus reduced the hospitalization period with a lower incidence of worsening renal function.
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Affiliation(s)
- Masaki Kinoshita
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
| | - Hideki Okayama
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan.
| | - Tetsuya Kosaki
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
| | - Saki Hosokawa
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
| | - Go Kawamura
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
| | - Tatsuya Shigematsu
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
| | - Tatsunori Takahashi
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
| | - Yoshitaka Kawada
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
| | - Go Hiasa
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
| | - Tadakatsu Yamada
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
| | - Hiroshi Matsuoka
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
| | - Yukio Kazatani
- Department of Cardiology, Ehime Prefectural Central Hospital, 83 Kasuga-machi, Matsuyama, Ehime, 790-0024, Japan
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Wang C, Xiong B, Cai L. Effects of Tolvaptan in patients with acute heart failure: a systematic review and meta-analysis. BMC Cardiovasc Disord 2017. [PMID: 28633650 PMCID: PMC5479045 DOI: 10.1186/s12872-017-0598-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Acute heart failure, which requires urgent evaluation and treatment, is a leading cause for admission to the emergency department. The aim of this meta-analysis was to evaluate the effects of tolvaptan on acute heart failure and compare them with the effects of conventional therapy or placebo. Methods The electronic databases PubMed, EMBASE, and the Cochrane Controlled Trial registry were searched from their starting dates to October 24, 2016. Two authors independently read the trials and extracted related information from the included studies. We used fixed-effects or random-effects models to assess the overall combined risk estimates according to I2 statistics. Analysis to determine sensitivity and publication bias was conducted. Results Six randomised controlled trials from eight articles, with a total of 746 patients, were included for analysis. Compared with the control, tolvaptan reduced body weight in two days (WMD 1.35; 95% CI 0.75 to 1.96), elevated sodium level in two days (WMD 2.33; 95% CI 1.08 to 3.57) and five days (WMD 1.57; 95% CI 0.04 to 3.09), and ameliorated symptoms of dyspnoea (RR 0.82; 95% CI 0.71–0.95). However, tolvaptan did not improve long-term (RR 1.04; 95% CI 0.66–1.62) or short-term all-cause mortality (RR 0.89; 95% CI 0.45–1.76), incidence of clinical events (worsening heart failure, RR 0.75; 95% CI 0.50–1.12 and worsening renal function, RR 0.97; 95% CI 0.75–1.27), and length of hospital stay in patients (WMD 0.14; 95% CI -0.29 to 2.38) with acute heart failure. Conclusion Tolvaptan can decrease body weight, increase serum sodium level, and ameliorate some of the congestion symptoms in patients with acute heart failure, which may help avoid the overdose of loop diuretics, especially in patients with renal dysfunction. Electronic supplementary material The online version of this article (doi:10.1186/s12872-017-0598-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chunbin Wang
- Department of Cardiology, The Third People's Hospital of Chengdu,The Second Affiliated Chengdu Clinical College of Chongqing Medical University, Chengdu, 610031, Sichuan, China
| | - Bo Xiong
- Department of Cardiology, The Third People's Hospital of Chengdu,The Second Affiliated Chengdu Clinical College of Chongqing Medical University, Chengdu, 610031, Sichuan, China
| | - Lin Cai
- Department of Cardiology, The Third People's Hospital of Chengdu,The Second Affiliated Chengdu Clinical College of Chongqing Medical University, Chengdu, 610031, Sichuan, China.
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147
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Fernández-Ruiz I. No early benefits of adjunct therapy with tolvaptan for acute heart failure. Nat Rev Cardiol 2017; 14:256. [DOI: 10.1038/nrcardio.2017.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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148
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Pose A, Almenar L, Manzano L, Gavira JJ, López Granados A, Delgado J, Aramburu O, Arévalo JC, Méndez M, Comín J, Manito N. Hyponatraemia and congestive heart failure refractory to diuretic treatment. Utility of tolvaptan. Rev Clin Esp 2017; 217:398-404. [PMID: 28372784 DOI: 10.1016/j.rce.2017.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/07/2017] [Accepted: 02/18/2017] [Indexed: 11/28/2022]
Abstract
Heart failure (HF) is currently one of the most significant healthcare problems in Spain and has a continuously increasing prevalence. Advances in our understanding of the various biological responses that promote cardiac remodelling and pulmonary venous congestion constitute the basis of current treatment. This article, prepared by members of the HF groups of the Spanish Society of Cardiology and the Spanish Society of Internal Medicine, discusses the current therapeutic strategies for patients with congestion refractory to diuretic treatment. The article includes our clinical experience with the use of tolvaptan as an additional treatment for congestion associated with hyponatraemia. To this end, we propose an algorithm for the use of tolvaptan in patients with congestive HF, natraemia <130mEq/l and poor response to conventional diuretic treatment.
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Affiliation(s)
- A Pose
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, España.
| | - L Almenar
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - L Manzano
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, España
| | - J J Gavira
- Servicio de Cardiología, Clínica Universitaria de Navarra, Pamplona, España
| | - A López Granados
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, España
| | - J Delgado
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, España
| | - O Aramburu
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Macarena, Sevilla, España
| | - J C Arévalo
- Servicio de Medicina Interna, Hospital Comarcal de Zafra, Zafra, Badajoz, España
| | - M Méndez
- Servicio de Medicina Interna, Hospital Universitario San Carlos, Madrid, España
| | - J Comín
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
| | - N Manito
- Servicio de Cardiología, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
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149
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Yandrapalli S, Tariq S, Aronow WS. Advances in chemical pharmacotherapy for managing acute decompensated heart failure. Expert Opin Pharmacother 2017; 18:471-485. [PMID: 28276970 DOI: 10.1080/14656566.2017.1299708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Acute decompensated heart failure (ADHF) contributes largely to the burden of heart failure and is associated with a poorer prognosis. Although numerous clinical trials evaluated the benefit of newer medications for ADHF, most of them were not successful. Areas covered: This review focusses on the updates on recent developments in chemical pharmacotherapy for the management of ADHF. A MEDLINE search for relevant review articles and original investigations on newer drugs for ADHF provided us with necessary literature. Expert opinion: Currently, popular therapies like diuretics, vasodilators, and inotropes offer symptomatic relief but do not provide survival benefit. Although multiple medications targeting novel pathways in ADHF were studied extensively, they failed to show either symptomatic or mortality benefit in available randomized trials. Improving our understanding of the complex pathophysiology of ADHF along with designing studies which include patients who are more representative of the real-world heart failure population, standardizing methods for endpoint assessment, and evaluating the role on novel biomarkers of organ dysfunction is important to improve ADHF research. Enhancing preventive strategies like improving baseline therapy in chronic heart failure patients and developing strategies for early identification of ADHF are important as our quest for innovative ADHF pharmacotherapy continues.
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Affiliation(s)
- Srikanth Yandrapalli
- a Cardiology Division, Department of Medicine , Westchester Medical Center and New York Medical College , Valhalla , NY , USA
| | - Sohaib Tariq
- a Cardiology Division, Department of Medicine , Westchester Medical Center and New York Medical College , Valhalla , NY , USA
| | - Wilbert S Aronow
- a Cardiology Division, Department of Medicine , Westchester Medical Center and New York Medical College , Valhalla , NY , USA
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150
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Pham D, Grodin JL. Dilemmas in the Dosing of Heart Failure Drugs: Titrating Diuretics in Chronic Heart Failure. Card Fail Rev 2017; 3:108-112. [PMID: 29387462 DOI: 10.15420/cfr.2017:10:1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Despite advances in medical therapy over the past few decades, the incidence of heart failure hospitalisation continues to rise. Diuretics are the most common therapy used to treat heart failure as they relieve congestion. However, there is a lack of guidance on how to best use these medications. Guidelines support the use of diuretics at the lowest clinically effective dose but do not specify a diuretic strategy beyond that. Here we review the diuretics available for treatment, potential mechanisms of diuretic resistance and ways to address this in the ambulatory setting, and review tools that have been developed to help guide diuretic use in the treatment of chronic heart failure.
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Affiliation(s)
- David Pham
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center,Dallas, Texas, USA
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center,Dallas, Texas, USA
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