151
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Kuroda S, Damman K, ter Maaten JM, Voors AA, Okumura T, Kida K, Oishi S, Akiyama E, Suzuki S, Yamamoto M, Kitai T, Yoshida K, Matsumura A, Matsue Y. Very Early Diuretic Response After Admission for Acute Heart Failure. J Card Fail 2019; 25:12-19. [DOI: 10.1016/j.cardfail.2018.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 08/24/2018] [Accepted: 09/05/2018] [Indexed: 12/28/2022]
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152
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Pavo N, Yarragudi R, Puttinger H, Arfsten H, Strunk G, Bojic A, Hülsmann M, Vychytil A. Parameters associated with therapeutic response using peritoneal dialysis for therapy refractory heart failure and congestive right ventricular dysfunction. PLoS One 2018; 13:e0206830. [PMID: 30452453 PMCID: PMC6242305 DOI: 10.1371/journal.pone.0206830] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 10/19/2018] [Indexed: 02/01/2023] Open
Abstract
Background In patients with refractory heart failure (HF) peritoneal dialysis (PD) is associated with improved functional status and decrease in hospitalization. However, previous studies did not focus on right ventricular dysfunction as an important pathophysiologic component of cardiorenal syndrome. Methods In a prospective cohort study PD was started in 40 patients with refractory right HF (with/without left HF). Refractoriness to conservative therapy was defined as persistent right heart congestion/ascites with intensified diuretic treatment and/or ≥2 hospitalizations within 6 months because of cardiac decompensation despite optimal medical treatment, and/or acute renal failure during intensified conservative treatment of cardiac decompensations. Results Patient survival was 55.0% at 1 year, 35.0% at 2 years and 27.5% at 3 years. The number of hospitalization days declined after initiation of PD for both cardiac [13 (IQR 1–53) days before vs. 1 (IQR 0–12) days after start of PD, p<0.001] and unplanned reasons [12 (IQR 3–44) days before vs. 1 (IQR 0–33) days after start of PD, p = 0.007]. Using a combined endpoint including survival time of ≥1 year and either improvement in quality of life or decline in hospitalizations we found that patients with extended ascites, higher systolic pulmonary artery pressure, more marked impairment of right ventricular function and tricuspid valve insufficiency, higher residual renal function as well as those who could perform PD without assistance have benefited most from this therapy. Conclusions Patients with more pronounced backward failure, less marked residual renal functional impairment and those not depending on assistance for therapy are likely to profit most from PD.
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Affiliation(s)
- Noemi Pavo
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Rajashri Yarragudi
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Heidi Puttinger
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Henrike Arfsten
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Guido Strunk
- Complexity Research, Vienna, Austria
- FH Campus Vienna, Vienna, Austria
- Technical University Dortmund, Dortmund, Germany
| | - Andja Bojic
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Andreas Vychytil
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
- * E-mail:
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153
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Matsumura K, Morishita S, Taniguchi N, Takehana K, Takahashi H, Otagaki M, Yoshioka K, Yamamoto Y, Takagi M, Shiojima I. Prognostic factors for long-term outcomes in acute decompensated heart failure patients under tolvaptan treatment. Heart Vessels 2018; 34:607-615. [PMID: 30386917 DOI: 10.1007/s00380-018-1290-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022]
Abstract
Inconsistent results have been reported concerning the effect of tolvaptan treatment on long-term prognostic outcomes in patients with acute decompensated heart failure (ADHF) and data are limited on prognostic factors affecting this patient population. We investigated prognostic factors influencing long-term clinical outcomes in patients with ADHF treated with tolvaptan in a real-world setting. A total of 263 consecutive patients hospitalized for ADHF and treated with tolvaptan were retrospectively enrolled. The patients were stratified into those who developed the combined event of cardiac death or rehospitalization for worsening heart failure within 1 year (n = 108) and those who were free of this combined event within 1 year (n = 155). Adjusted multivariate Cox proportional hazards model revealed that change in serum sodium level between pre-treatment and 24 h after tolvaptan administration [hazard ratio (HR) 0.913, 95% confidence interval (CI) 0.841-0.989, p = 0.025] and the time taken for tolvaptan initiation from admission (HR 1.043, 95% CI 1.009-1.074, p = 0.015) were independent predictors of combined event occurrence within 1 year. Moreover, change in serum sodium level > 1 mEq/L between pre-treatment and 24 h after administration and initiation of tolvaptan < 5 days after admission correlated significantly with the incidence of the combined event (log-rank test p = 0.003 and p = 0.002, respectively). In conclusion, increased serum sodium level early after administration and early initiation of tolvaptan are possibly useful for assessing the long-term prognosis after tolvaptan treatment in patients with ADHF.
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Affiliation(s)
- Koichiro Matsumura
- Department of Cardiology, Kansai Medical University Medical Center, 10-15, Fumizono-cho, Moriguchi-shi, Osaka, 570-8507, Japan.
| | - Shun Morishita
- Division of Cardiology, Department of Medicine II, Kansai Medical University, Osaka, Japan
| | - Naoki Taniguchi
- Division of Cardiology, Department of Medicine II, Kansai Medical University, Osaka, Japan
| | - Kazuya Takehana
- Division of Cardiology, Department of Medicine II, Kansai Medical University, Osaka, Japan
| | - Hiroki Takahashi
- Department of Cardiology, Kansai Medical University Medical Center, 10-15, Fumizono-cho, Moriguchi-shi, Osaka, 570-8507, Japan
| | - Munemitsu Otagaki
- Department of Cardiology, Kansai Medical University Medical Center, 10-15, Fumizono-cho, Moriguchi-shi, Osaka, 570-8507, Japan
| | - Kei Yoshioka
- Department of Cardiology, Kansai Medical University Medical Center, 10-15, Fumizono-cho, Moriguchi-shi, Osaka, 570-8507, Japan
| | - Yoshihiro Yamamoto
- Department of Cardiology, Kansai Medical University Medical Center, 10-15, Fumizono-cho, Moriguchi-shi, Osaka, 570-8507, Japan
| | - Masahiko Takagi
- Department of Cardiology, Kansai Medical University Medical Center, 10-15, Fumizono-cho, Moriguchi-shi, Osaka, 570-8507, Japan
| | - Ichiro Shiojima
- Division of Cardiology, Department of Medicine II, Kansai Medical University, Osaka, Japan
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154
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Jardim SI, Ramos dos Santos L, Araújo I, Marques F, Branco P, Gaspar A, Fonseca C. A 2018 overview of diuretic resistance in heart failure. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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155
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Jardim SI, Ramos dos Santos L, Araújo I, Marques F, Branco P, Gaspar A, Fonseca C. A 2018 overview of diuretic resistance in heart failure. Rev Port Cardiol 2018; 37:935-945. [DOI: 10.1016/j.repc.2018.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/18/2018] [Accepted: 03/11/2018] [Indexed: 01/01/2023] Open
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156
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Collins SP, Jenkins CA, Baughman A, Miller KF, Storrow AB, Han JH, Brown NJ, Liu D, Luther JM, McNaughton CD, Self WH, Peng D, Testani JM, Lindenfeld J. Early urine electrolyte patterns in patients with acute heart failure. ESC Heart Fail 2018; 6:80-88. [PMID: 30295437 PMCID: PMC6351901 DOI: 10.1002/ehf2.12368] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/23/2018] [Accepted: 08/30/2018] [Indexed: 12/24/2022] Open
Abstract
Aims We conducted a prospective study of emergency department (ED) patients with acute heart failure (AHF) to determine if worsening HF (WHF) could be predicted based on urinary electrolytes during the first 1–2 h of ED care. Loop diuretics are standard therapy for AHF patients. A subset of patients hospitalized for AHF will develop a blunted natriuretic response to loop diuretics, termed diuretic resistance, which often leads to WHF. Early detection of diuretic resistance could facilitate escalation of therapy and prevention of WHF. Methods and results Patients were eligible if they had an ED AHF diagnosis, had not yet received intravenous diuretics, had a systolic blood pressure > 90 mmHg, and were not on dialysis. Urine electrolytes and urine output were collected at 1, 2, 4, and 6 h after diuretic administration. Worsening HF was defined as clinically persistent or WHF requiring escalation of diuretics or administration of intravenous vasoactives after the ED stay. Of the 61 patients who qualified in this pilot study, there were 10 (16.3%) patients who fulfilled our definition of WHF. At 1 h after diuretic administration, patients who developed WHF were more likely to have low urinary sodium (9.5 vs. 43.0 mmol; P < 0.001) and decreased urine sodium concentration (48 vs. 80 mmol/L; P = 0.004) than patients without WHF. All patients with WHF had a total urine sodium of <35.4 mmol at 1 h (100% sensitivity and 60% specificity). Conclusions One hour after diuretic administration, a urine sodium excretion of <35.4 mmol was highly suggestive of the development of WHF. These relationships require further testing to determine if early intervention with alternative agents can prevent WHF.
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Affiliation(s)
- Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adrienne Baughman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nancy J Brown
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James M Luther
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Internal Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Internal Medicine, Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dungeng Peng
- Department of Internal Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Division of Cardiology, Yale University, New Haven, CT, USA
| | - JoAnn Lindenfeld
- Department of Internal Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Different diuretic properties between tolvaptan and furosemide in congestive heart failure patients with diuretic resistance and renal impairment: a subanalysis of the K-STAR. Heart Vessels 2018; 34:442-451. [DOI: 10.1007/s00380-018-1270-x] [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: 05/09/2018] [Accepted: 09/21/2018] [Indexed: 11/26/2022]
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158
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Effects of levocarnitine on cardiac function, urinary albumin, hs-CRP, BNP, and troponin in patients with coronary heart disease and heart failure. Hellenic J Cardiol 2018; 61:99-102. [PMID: 30195728 DOI: 10.1016/j.hjc.2018.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To investigate the effects of levocarnitine on cardiac function, urinary albumin (ALB), high-sensitivity C-reactive protein (hs-CRP), brain natriuretic peptide (BNP), and troponin in patients with coronary heart disease (CHD) and heart failure (HF). METHODS In total, 246 patients with CHD-caused HF were selected and randomly divided into Group A and Group B. A fully automatic biochemical analyzer was used to measure the levels of ALB, hs-CRP, BNP, and troponin in both groups of patients, and the expression levels of LVDD and LVEF were detected by cardiac color ultrasonography. Patients in Group B were intravenously injected with 3.0 g of levocarnitine, once per day. After 14 days, changes in levels of ALB, hs-CRP, BNP, troponin, LVDD, and LVEF in Group A patients were detected. RESULTS The effective cure rates of patients in both groups were 65.8% and 81.3%, respectively, and there was a statistically significant difference between the two groups (p < 0.05). After administration of levocarnitine, all indicators showed decreasing trends, but the LVEF level increased. Among them, patients treated with levocarnitine showed the most evident decrease in LVEF. Decrease in BNP was the largest (p < 0.05). Additionally, there was no statistical difference in incidence rate between the two groups (5.8% vs. 2.5%, p = 0.222). CONCLUSION Levocarnitine can effectively improve ALB, hs-CRP, BNP, troponin, and LVDD levels to improve cardiac function rating and thus improve cardiac function.
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159
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Elashery AR, Aykent K, Kurdi H, Ibrahim M, He S, Petrini JR, Kramer HM. Association between loop diuretic dose administered in first 24 hours of heart failure admissions and length of hospital stay. J Community Hosp Intern Med Perspect 2018; 8:195-199. [PMID: 30181825 PMCID: PMC6116148 DOI: 10.1080/20009666.2018.1503916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022] Open
Abstract
Background: Heart failure remains one of the highest disease burdens in the USA and worldwide. Heart failure guidelines recommend starting with a higher or equal to home dose of loop diuretics in acute decompensated heart failure admissions. To date, no study has been published assessing the effect of first 24 h loop diuretic dose on length of hospital stay. Objective: We hypothesize that the higher the first 24 h loop diuretic dose to home dose ratio, the shorter the length of hospital stay will be. Design/Methods: Retrospective chart review was conducted in a community teaching hospital and included patients discharged between February, 2015 and April, 2016, with a primary diagnosis of acute decompensated heart failure. The primary outcome was the length of hospital stay. The study population was divided into three groups based on the hospital to home dose ratio. Results: Among the 609 patients included in the data analysis, there was no statistically significant difference in length of hospital stay among the study groups. Inpatient mortality and incidence of acute kidney injury were highest in the group that received a first-24-hours hospital dose that was less than their home dose. Percentage of weight loss and 30-day readmission were not statistically significantly different among the groups. Conclusion: There was no association between the dose ratio and length of hospital stay in each group. Additional randomized controlled trials need to be conducted to provide more evidence and guidance for dosing loop diuretics in acute decompensated heart failure admissions.
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Affiliation(s)
| | - Kazim Aykent
- Cardiovascular Department, Danbury Hospital, Danbury, USA
| | - Hussam Kurdi
- Cardiovascular Department, Danbury Hospital, Danbury, USA
| | | | - Shiquan He
- Cardiovascular Department, Danbury Hospital, Danbury, USA
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160
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Verbrugge FH. Editor's Choice-Diuretic resistance in acute heart failure. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 7:379-389. [PMID: 29897275 DOI: 10.1177/2048872618768488] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diuretic resistance is a powerful predictor of adverse outcome in acute heart failure (AHF), irrespectively of underlying glomerular filtration rate. Metrics of diuretic efficacy such as natriuresis, urine output, weight loss, net fluid balance, or fractional sodium excretion, differ in their risk for measurement error, convenience, and biological plausibility, which should be taken into account when interpreting their results. Loop diuretic resistance in AHF has multiple causes including altered drug pharmacokinetics, impaired renal perfusion and effective circulatory volume, neurohumoral activation, post-diuretic sodium retention, the braking phenomenon and functional as well as structural adaptations in the nephron. Ideally, these mechanisms should guide specific treatment decisions with the goal of achieving complete decongestion. Therefore, volume overload needs to be identified correctly to avoid poor diuretic response due to electrolyte depletion or dehydration. Next, renal perfusion should be optimised if possible and loop diuretics should be prescribed above their threshold dose. Addition of thiazide-type diuretics should be considered when a progressive decrease in loop diuretic efficacy is observed with prolonged use (i.e., the braking phenomenon). Furthermore, thiazide-type diuretics are a useful addition in patients with low glomerular filtration rate. However, they limit free water excretion and are relatively contraindicated in cases of hypotonic hyponatremia, where acetazolamide is the better option. Finally, ultrafiltration should be considered in patients with refractory diuretic resistance as persistent volume overload after decongestive treatment is associated with worse outcomes. Whether more upfront use of any of these individually tailored decongestion strategies is superior to monotherapy with loop diuretics remains to be shown by adequately powered randomised clinical trials.
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161
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Assessment of Congestion in Acute Heart Failure: When Simplicity Does Not Go Along With Accuracy. J Card Fail 2018; 24:550-552. [DOI: 10.1016/j.cardfail.2018.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 12/28/2022]
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162
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Pulmonary hypertension associated with left heart disease: Updated Recommendations of the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:53-62. [PMID: 30527996 DOI: 10.1016/j.ijcard.2018.08.080] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 12/25/2022]
Abstract
In the summer of 2016, delegates from the German Society of Cardiology (DGK), the German Respiratory Society (DGP), and the German Society of Pediatric Cardiology (DGPK) met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary hypertension (PH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines, aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH associated with left heart disease. In this context, the European Guidelines point out that the drugs currently approved to treat patients with PAH (prostanoids, endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, sGC stimulators) have not sufficiently been investigated in other forms of PH. However, despite the lack of respective efficacy data, an uncritical use of targeted PAH drugs in patients with PH associated with left heart disease is currently observed at an increasing rate. This development is a matter of concern. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease. In that sense, the distinction between isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH) and their proper definition may be of particular relevance. The detailed results and recommendations of the working group on PH associated with left heart disease, which were last updated in the spring of 2018, are summarized in this article.
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163
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Verbrugge FH, Martens P, Boonen L, Nijst P, Verhaert D, Noyens P, De Vusser P, Dupont M, Tang WHW, Mullens W. Loop diuretic down-titration in stable chronic heart failure is often achievable, especially when urinary chloride concentration is low. Acta Cardiol 2018; 73:335-341. [PMID: 28971753 DOI: 10.1080/00015385.2017.1385152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND This study investigates spot urinary chloride concentration in euvolemic chronic heart failure (CHF) patients. METHODS This prospective cohort study included 50 ambulatory CHF patients on maintenance loop diuretics without recent hospital admission, clinical signs of volume overload, or adjustment in neurohumoral blocker or diuretic therapy. Spot urinary samples were collected immediately after loop diuretic intake. Subsequently, loop diuretic dose was reduced with 50% or stopped if ≤40 mg furosemide equivalents. Successful down-titration was defined as persistent dose reduction after 7 d without body weight increase >1.5 kg. RESULTS Urinary chloride concentration was 3045 ± 1271 mg/L overall. Patients with higher versus lower urinary chloride concentrations took the same dose of loop diuretics [40 mg (20-40 mg) furosemide equivalents; p value = .509] and had similar plasma NT-proBNP levels [1179 ng/L (311-2195 ng/L) versus 900 ng/L (255-1622 ng/L), respectively; p value = .461]. Down-titration was successful in 72% versus 76%, respectively (p value = 1.000). At 30 d, loop diuretic dose remained reduced in 59% versus 76% of patients, respectively (p value = .238). The proportion of patients free from diuretic therapy was 45% versus 62% in the high versus low chloride concentration group (p value = .265). CONCLUSIONS Loop diuretic down-titration was successful in 3 out of 4 euvolemic CHF patients, irrespectively of urinary chloride concentration on spot samples collected after diuretic intake.
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Affiliation(s)
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Levinia Boonen
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Petra Nijst
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - David Verhaert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Patrick Noyens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Philip De Vusser
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - W. H. Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
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164
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Kitai T, Tang WHW, Xanthopoulos A, Murai R, Yamane T, Kim K, Oishi S, Akiyama E, Suzuki S, Yamamoto M, Kida K, Okumura T, Kaji S, Furukawa Y, Matsue Y. Impact of early treatment with intravenous vasodilators and blood pressure reduction in acute heart failure. Open Heart 2018; 5:e000845. [PMID: 30018782 PMCID: PMC6045748 DOI: 10.1136/openhrt-2018-000845] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 05/25/2018] [Accepted: 06/13/2018] [Indexed: 01/19/2023] Open
Abstract
Objective Although vasodilators are used in acute heart failure (AHF) management, there have been no clear supportive evidence regarding their routine use. Recent European guidelines recommend systolic blood pressure (SBP) reduction in the range of 25% during the first few hours after diagnosis. This study aimed to examine clinical and prognostic significance of early treatment with intravenous vasodilators in relation to their subsequent SBP reduction in hospitalised AHF. Methods We performed post hoc analysis of 1670 consecutive patients enrolled in the Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure. Intravenous vasodilator use within 6 hours of hospital arrival and subsequent SBP changes were analysed. Outcomes were gauged by 1-year mortality and diuretic response (DR), defined as total urine output 6 hours posthospital arrival per 40 mg furosemide-equivalent diuretic use. Results Over half of the patients (56.0%) were treated with intravenous vasodilators within the first 6 hours. In this vasodilator-treated cohort, 554 (59.3%) experienced SBP reduction ≤25%, while 381 (40.7%) experienced SBP reduction >25%. In patients experiencing ≤25% drop in SBP, use of vasodilator was associated with greater DR compared with no vasodilators (p<0.001). Moreover, vasodilator treatment with ≤25% drop in SBP was independently associated with lower all-cause mortality compared with those treated without vasodilators (adjusted HR 0.74, 95% CI 0.57 to 0.96, p=0.028). Conclusions Intravenous vasodilator therapy was associated with greater DR and lower mortality, provided SBP reduction was less than 25%. Our results highlight the importance in early administration of intravenous vasodilators without causing excess SBP reduction in AHF management. Clinical trial registration URL: http://www.umin.ac.jp/ctr/ Unique identifier: UMIN000014105.
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Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Cellular and Molecular Medicine, Center for Microbiome and Human Health, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Center for Clinical Genomics, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrew Xanthopoulos
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ryosuke Murai
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takafumi Yamane
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shogo Oishi
- Department of Cardiology, Himeji Cardiovascular Center, Himeji, Japan
| | - Eiichi Akiyama
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Satoshi Suzuki
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Masayoshi Yamamoto
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Keisuke Kida
- Department of Cardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yuya Matsue
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Cardiovascular Medicine, Juntendo University, Tokyo, Japan
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Efficient, Efficacious, Effective: Still a Long Way to Go for Diuretic Treatment of Acute Decompensated Heart Failure. J Card Fail 2018; 24:439-441. [DOI: 10.1016/j.cardfail.2018.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 06/14/2018] [Accepted: 06/14/2018] [Indexed: 11/22/2022]
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167
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Brinkley DM, Burpee LJ, Chaudhry SP, Smallwood JA, Lindenfeld J, Lakdawala NK, Desai AS, Stevenson LW. Spot Urine Sodium as Triage for Effective Diuretic Infusion in an Ambulatory Heart Failure Unit. J Card Fail 2018; 24:349-354. [DOI: 10.1016/j.cardfail.2018.01.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/26/2017] [Accepted: 01/23/2018] [Indexed: 11/28/2022]
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168
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Prevalence, predictors and clinical outcome of residual congestion in acute decompensated heart failure. Int J Cardiol 2018; 258:185-191. [DOI: 10.1016/j.ijcard.2018.01.067] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/30/2017] [Accepted: 01/15/2018] [Indexed: 12/28/2022]
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169
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Harjola VP, Parissis J, Brunner-La Rocca HP, Čelutkienė J, Chioncel O, Collins SP, De Backer D, Filippatos GS, Gayat E, Hill L, Lainscak M, Lassus J, Masip J, Mebazaa A, Miró Ò, Mortara A, Mueller C, Mullens W, Nieminen MS, Rudiger A, Ruschitzka F, Seferovic PM, Sionis A, Vieillard-Baron A, Weinstein JM, de Boer RA, Crespo-Leiro MG, Piepoli M, Riley JP. Comprehensive in-hospital monitoring in acute heart failure: applications for clinical practice and future directions for research. A statement from the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2018; 20:1081-1099. [PMID: 29710416 DOI: 10.1002/ejhf.1204] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/20/2018] [Accepted: 03/26/2018] [Indexed: 12/17/2022] Open
Abstract
This paper provides a practical clinical application of guideline recommendations relating to the inpatient monitoring of patients with acute heart failure, through the evaluation of various clinical, biomarker, imaging, invasive and non-invasive approaches. Comprehensive inpatient monitoring is crucial to the optimal management of acute heart failure patients. The European Society of Cardiology heart failure guidelines provide recommendations for the inpatient monitoring of acute heart failure, but the level of evidence underpinning most recommendations is limited. Many tools are available for the in-hospital monitoring of patients with acute heart failure, and each plays a role at various points throughout the patient's treatment course, including the emergency department, intensive care or coronary care unit, and the general ward. Clinical judgment is the preeminent factor guiding application of inpatient monitoring tools, as the various techniques have different patient population targets. When applied appropriately, these techniques enable decision making. However, there is limited evidence demonstrating that implementation of these tools improves patient outcome. Research priorities are identified to address these gaps in evidence. Future research initiatives should aim to identify the optimal in-hospital monitoring strategies that decrease morbidity and prolong survival in patients with acute heart failure.
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Affiliation(s)
- Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | | | | | - Jelena Čelutkienė
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine, Clinic of Cardiac and Vascular Diseases, Vilnius, Lithuania
| | - Ovidiu Chioncel
- University of Medicine Carol Davila/Institute of Emergency for Cardiovascular Disease, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel De Backer
- Department of Intensive Care Medicine, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Etienne Gayat
- Département d'Anesthésie- Réanimation-SMUR, Hôpitaux Universitaires Saint Louis-Lariboisière, INSERM-UMR 942, AP-, HP, Université Paris Diderot, Paris, France
| | | | - Mitja Lainscak
- Department of Internal Medicine and Department of Research and Education, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Johan Lassus
- Cardiology, Heart and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Josep Masip
- Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain.,Hospital Sanitas CIMA, Barcelona, Spain
| | - Alexandre Mebazaa
- U942 INSERM, AP-HP, Paris, France.,Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT), Nancy, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France.,AP-HP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Òscar Miró
- Emergency Department, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Andrea Mortara
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk - Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | | | - Alain Rudiger
- Cardio-surgical Intensive Care Unit, University and University Hospital Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Petar M Seferovic
- Department of Internal Medicine, Belgrade University School of Medicine and Heart Failure Center, Belgrade University Medical Center, Belgrade, Serbia
| | - Alessandro Sionis
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antoine Vieillard-Baron
- INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ, 94807 Villejuif, France, University Hospital Ambroise Paré, AP-, HP, Boulogne-Billancourt, France
| | | | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology, G. da Saliceto Hospital, Piacenza, Italy
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170
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Feola M, Testa M, Ferreri C, Cardone M, Sola M, Ariotti S, Rosso GL. Role of Response-to-Diuretic in Predicting Prognosis in Discharged Heart Failure Patients After an Acute Decompensation. Arch Med Res 2018; 49:198-204. [DOI: 10.1016/j.arcmed.2018.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
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171
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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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172
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Wang Y, Shi W, Blanchette A, Peng J, Qi S, Luo H, Ledoux J, Wu J. EPHB6 and testosterone in concert regulate epinephrine release by adrenal gland chromaffin cells. Sci Rep 2018; 8:842. [PMID: 29339804 PMCID: PMC5770418 DOI: 10.1038/s41598-018-19215-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 12/27/2017] [Indexed: 12/22/2022] Open
Abstract
Erythropoietin-producing human hepatocellular receptor (EPH) B6 (EPHB6) is a member of the receptor tyrosine kinase family. We previously demonstrated that EPHB6 knockout reduces catecholamine secretion in male but not female mice, and castration reverses this phenotype. We showed here that male EPHB6 knockout adrenal gland chromaffin cells presented reduced acetylcholine-triggered Ca2+ influx. Such reduction depended on the non-genomic effect of testosterone. Increased large conductance calcium-activated potassium channel current densities were recorded in adrenal gland chromaffin cells from male EPHB6 knockout mice but not from castrated knockout or female knockout mice. Blocking of the large conductance calcium-activated potassium channel in adrenal gland chromaffin cells from male knockout mice corrected their reduced Ca2+ influx. We conclude that the absence of EPHB6 and the presence of testosterone would lead to augmented large conductance calcium-activated potassium channel currents, which limit voltage-gated calcium channel opening in adrenal gland chromaffin cells. Consequently, acetylcholine-triggered Ca2+ influx is reduced, leading to lower catecholamine release in adrenal gland chromaffin cells from male knockout mice. This explains the reduced resting-state blood catecholamine levels, and hence the blood pressure, in male but not female EPHB6 knock mice. These findings have certain clinical implications.
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Affiliation(s)
- Yujia Wang
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 0A9, Canada
- The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310003, China
| | - Wei Shi
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 0A9, Canada
| | | | - Junzheng Peng
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 0A9, Canada
| | - Shijie Qi
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 0A9, Canada
| | - Hongyu Luo
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 0A9, Canada.
| | - Jonathan Ledoux
- Montreal Heart Institute, Montreal, Quebec, H1T 1C8, Canada.
| | - Jiangping Wu
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, H2X 0A9, Canada.
- Nephrology Department, CHUM, Montreal, Quebec, H2L 4M1, Canada.
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173
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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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174
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Kondo T, Yamada T, Tamaki S, Morita T, Furukawa Y, Iwasaki Y, Kawasaki M, Kikuchi A, Ozaki T, Sato Y, Seo M, Ikeda I, Fukuhara E, Abe M, Nakamura J, Sakata Y, Fukunami M. Serial Change in Serum Chloride During Hospitalization Could Predict Heart Failure Death in Acute Decompensated Heart Failure Patients. Circ J 2018; 82:1041-1050. [DOI: 10.1253/circj.cj-17-0938] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takumi Kondo
- Division of Cardiology, Osaka General Medical Center
- Division of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | | | | | | | | | | | | | | | | | - Masahiro Seo
- Division of Cardiology, Osaka General Medical Center
| | - Iyo Ikeda
- Division of Cardiology, Osaka General Medical Center
| | - Eiji Fukuhara
- Division of Cardiology, Osaka General Medical Center
| | - Makoto Abe
- Division of Cardiology, Osaka General Medical Center
| | - Jun Nakamura
- Division of Cardiology, Osaka General Medical Center
| | - Yasushi Sakata
- Division of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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175
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Kogure T, Jujo K, Hamada K, Saito K, Hagiwara N. Good response to tolvaptan shortens hospitalization in patients with congestive heart failure. Heart Vessels 2017; 33:374-383. [PMID: 29128962 DOI: 10.1007/s00380-017-1072-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022]
Abstract
Tolvaptan has been gradually spread to use as a potent diuretic for congestive heart failure in the limited country. However, the response to this aquaretic drug still is unpredictable. A total of 92 patients urgently hospitalized due to congestive heart failure and treated with tolvaptan in addition to standard treatment was retrospectively analyzed. Responder of tolvaptan treatment was defined as a patient with peak negative fluid balance greater than 500 mL/day, and clinical profiles were compared between 76 responders and 16 non-responders. Responders started to increase daily urine volume (UV) from Day 1 through Day 3. In contrast, non-responders showed no significant increase in daily UV from the baseline up to Day 5. Time between admission and tolvaptan administration was shorter in responders, even without statistical significance (3.3 vs. 4.6 days, p = 0.053). Multivariate analysis revealed that blood urea nitrogen (BUN) [cutoff: 34 mg/dL, odds ratio (OR) 9.0, 95% confidence interval (CI) 1.42-57.3, p < 0.01] and plasma renin activity (PRA) (cutoff: 4.7 ng/mL/h, OR 6.1, 95% CI 1.01-36.4, p < 0.01) at baseline were independent predictors for tolvaptan responsiveness. It suggests that renal perfusion may affect tolvaptan-induced UV. Finally, durations of stay in intensive care unit and total hospitalization were significantly shorter in responders (median: 6.0 vs. 13.0 days, p = 0.022; 15.0 vs. 25.0 days, p = 0.016, respectively). Responders of tolvaptan have lower BUN and renin activity at baseline, and shorten hospitalization period. Trial Registration The study was registered at University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) with the identifier UMIN000023594. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000024988.
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Affiliation(s)
- Tomohito Kogure
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Kentaro Jujo
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo, 162-0054, Japan.
| | - Kazuyuki Hamada
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Katsumi Saito
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo, 162-0054, Japan
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176
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Abstract
Heart failure is common in adults, accounting for substantial morbidity and mortality worldwide. Its prevalence is increasing because of ageing of the population and improved treatment of acute cardiovascular events, despite the efficacy of many therapies for patients with heart failure with reduced ejection fraction, such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β blockers, and mineralocorticoid receptor antagonists, and advanced device therapies. Combined angiotensin receptor blocker neprilysin inhibitors (ARNIs) have been associated with improvements in hospital admissions and mortality from heart failure compared with enalapril, and guidelines now recommend substitution of ACE inhibitors or ARBs with ARNIs in appropriate patients. Improved safety of left ventricular assist devices means that these are becoming more commonly used in patients with severe symptoms. Antidiabetic therapies might further improve outcomes in patients with heart failure. New drugs with novel mechanisms of action, such as cardiac myosin activators, are under investigation for patients with heart failure with reduced left ventricular ejection fraction. Heart failure with preserved ejection fraction is a heterogeneous disorder that remains incompletely understood and will continue to increase in prevalence with the ageing population. Although some data suggest that spironolactone might improve outcomes in these patients, no therapy has conclusively shown a significant effect. Hopefully, future studies will address these unmet needs for patients with heart failure. Admissions for acute heart failure continue to increase but, to date, no new therapies have improved clinical outcomes.
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Affiliation(s)
- Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - John R Teerlink
- School of Medicine, University of California, San Francisco, CA, USA; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
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177
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Palazzuoli A, Ruocco G, Vescovo G, Valle R, Di Somma S, Nuti R. Rationale and study design of intravenous loop diuretic administration in acute heart failure: DIUR-AHF. ESC Heart Fail 2017; 4:479-486. [PMID: 28980452 PMCID: PMC5695186 DOI: 10.1002/ehf2.12226] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 08/05/2017] [Accepted: 09/01/2017] [Indexed: 11/07/2022] Open
Abstract
AIMS Although loop diuretics are the most commonly used drugs in acute heart failure (AHF) treatment, their short-term and long-term effects are relatively unknown. The significance of worsening renal function occurrence during intravenous treatment is not clear enough. This trial aims to clarify all these features and contemplate whether continuous infusion is better than an intermittent strategy in terms of decongestion efficacy, diuretic efficiency, renal function, and long-term prognosis. METHODS AND RESULTS This is a prospective, multicentre, randomized study that compares continuous infusion to intermittent infusion and a low vs. high diuretic dose of furosemide in patients with a diagnosis of acute heart failure, BNP ≥ 100 pg/mL, and specific chest X-ray signs. Randomization criteria have been established at a 1:1 ratio using a computer-generated scheme of either twice-daily bolus injection or continuous infusion for a time period ranging from 72 to 120 h. The initial dose will be 80 mg/day of intravenous furosemide and, in the case of poor response, will be doubled using an escalation algorithm. A high diuretic dose is defined as a furosemide daily amount >120 mg/day respectively. CONCLUSIONS Continuous and high dose groups could reveal a more intensive diuresis and a greater decongestion with respect to intermittent and low dose groups; high dose and poor loop diuretic efficiency should be related to increased diuretic resistance, renal dysfunction occurrence, and greater congestion status. Poor diuretic response will be associated with less decongestion and an adverse prognosis.
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Affiliation(s)
- Alberto Palazzuoli
- Department of Internal Medicine, Cardiovascular Diseases UnitS. Maria alle Scotte Hospital, University of SienaSienaItaly
| | - Gaetano Ruocco
- Department of Internal Medicine, Cardiovascular Diseases UnitS. Maria alle Scotte Hospital, University of SienaSienaItaly
| | | | | | - Salvatore Di Somma
- Department of Emergency MedicineUniversity of Roma, Sant'Andrea HospitalRomeItaly
| | - Ranuccio Nuti
- Department of Internal Medicine, Cardiovascular Diseases UnitS. Maria alle Scotte Hospital, University of SienaSienaItaly
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178
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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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179
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180
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Ferreira J. Vascular phenotypes of acute decompensated vs. new-onset heart failure: treatment implications. ESC Heart Fail 2017; 4:679-685. [PMID: 28960929 PMCID: PMC5695185 DOI: 10.1002/ehf2.12210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/20/2017] [Accepted: 08/09/2017] [Indexed: 12/28/2022] Open
Abstract
Aims Acute heart failure (HF) is a frequent and life‐threatening syndrome with heterogeneous clinical, haemodynamic, and neurohormonal features. This article describes the vascular phenotypes associated with acute decompensated chronic HF (ADCHF), and new‐onset acute HF (NOAHF). Data Synthesis Worsening of chronic HF occurs with full activation of adaptive mechanisms that maintain blood pressure (BP) and systemic perfusion. Rapid onset of HF in the setting of previous normal functioning heart not only does not allow full activation of adaptive mechanisms but also generates inappropriate responses from systemic endothelium leading to low BP/hypotension. Consequently, the treatment of ADCHF is based on diuretics and vasodilators, while in NOAHF, vasoconstrictors may be required to maintain BP to allow the correction of the acute cardiac disease. Conclusions Patients with ADCHF and NOAHF present different vascular phenotypes with treatment implications.
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Affiliation(s)
- Jorge Ferreira
- Department of Cardiology, Hospital Santa Cruz, CHLO, Av Prof Reynaldo Santos, 2790-134, Carnaxide, Portugal
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181
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Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, Giannetti N, Grzeslo A, Hamilton PG, Heckman GA, Howlett JG, Koshman SL, Lepage S, McKelvie RS, Moe GW, Rajda M, Swiggum E, Virani SA, Zieroth S, Al-Hesayen A, Cohen-Solal A, D'Astous M, De S, Estrella-Holder E, Fremes S, Green L, Haddad H, Harkness K, Hernandez AF, Kouz S, LeBlanc MH, Masoudi FA, Ross HJ, Roussin A, Sussex B. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017; 33:1342-1433. [PMID: 29111106 DOI: 10.1016/j.cjca.2017.08.022] [Citation(s) in RCA: 435] [Impact Index Per Article: 62.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 02/06/2023] Open
Abstract
Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.
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Affiliation(s)
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | - Michael Chan
- Edmonton Cardiology Consultants, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Adam Grzeslo
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Serge Lepage
- Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | | | - Miroslaw Rajda
- QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Sean A Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Sabe De
- London Health Sciences, Western University, London, Ontario, Canada
| | | | - Stephen Fremes
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Green
- University of Alberta, Edmonton, Alberta, Canada
| | - Haissam Haddad
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, Québec, Canada
| | | | | | | | - Andre Roussin
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bruce Sussex
- Memorial University, St John's, Newfoundland, Canada
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182
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Efficacy of sequential nephron blockade with intravenous chlorothiazide to promote diuresis in cardiac intensive care infants. Cardiol Young 2017; 27:1104-1109. [PMID: 27834164 DOI: 10.1017/s1047951116002122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Sequential nephron blockade using intravenous chlorothiazide is often used to enhance urine output in patients with inadequate response to loop diuretics. A few data exist to support this practice in critically ill infants. METHODS We included 100 consecutive patients <1 year of age who were administered intravenous chlorothiazide while receiving furosemide therapy in the cardiac ICU in our study. The primary end point was change in urine output 24 hours after chlorothiazide administration, and patients were considered to be responders if an increase in urine output of 0.5 ml/kg/hour was documented. Data on demographic, clinical, fluid intake/output, and furosemide and chlorothiazide dosing were collected. Multivariable regression analyses were performed to determine variables significant for increase in urine output after chlorothiazide administration. RESULTS The study population was 48% male, with a mean weight of 4.9±1.8 kg, and 69% had undergone previous cardiovascular surgery. Intravenous chlorothiazide was initiated at 89 days (interquartile range 20-127 days) of life at a dose of 4.6±2.7 mg/kg/day (maximum 12 mg/kg/day). Baseline estimated creatinine clearance was 83±42 ml/minute/1.73 m2. Furosemide dose before chlorothiazide administration was 2.8±1.4 mg/kg/day and 3.3±1.5 mg/kg/day after administration. A total of 43% of patients were categorised as responders, and increase in furosemide dose was the only variable significant for increase in urine output on multivariable analysis (p<0.05). No graphical trends were noted for change in urine output and dose of chlorothiazide. CONCLUSIONS Sequential nephron blockade with intravenous chlorothiazide was not consistently associated with improved urine output in critically ill infants.
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183
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Metra M. August 2017 at a glance: tailored treatment, acute heart failure and cardiac resynchronization. Eur J Heart Fail 2017; 19:969-970. [DOI: 10.1002/ejhf.936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/05/2017] [Accepted: 06/08/2017] [Indexed: 12/15/2022] Open
Affiliation(s)
- Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health; University of Brescia; Italy
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184
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Rao VS, Planavsky N, Hanberg JS, Ahmad T, Brisco-Bacik MA, Wilson FP, Jacoby D, Chen M, Tang WHW, Cherney DZI, Ellison DH, Testani JM. Compensatory Distal Reabsorption Drives Diuretic Resistance in Human Heart Failure. J Am Soc Nephrol 2017; 28:3414-3424. [PMID: 28739647 DOI: 10.1681/asn.2016111178] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 06/19/2017] [Indexed: 12/31/2022] Open
Abstract
Understanding the tubular location of diuretic resistance (DR) in heart failure (HF) is critical to developing targeted treatment strategies. Rodents chronically administered loop diuretics develop DR due to compensatory distal tubular sodium reabsorption, but whether this translates to human DR is unknown. We studied consecutive patients with HF (n=128) receiving treatment with loop diuretics at the Yale Transitional Care Center. We measured the fractional excretion of lithium (FELi), the gold standard for in vivo assessment of proximal tubular and loop of Henle sodium handling, to assess sodium exit after loop diuretic administration and FENa to assess the net sodium excreted into the urine. The mean±SD prediuretic FELi was 16.2%±9.5%, similar to that in a control cohort without HF not receiving diuretics (n=52; 16.6%±9.2%; P=0.82). Administration of a median of 160 (interquartile range, 40-270) mg intravenous furosemide equivalents increased FELi by 12.6%±10.8% (P<0.001) but increased FENa by only 4.8%±3.3%. Thus, only 34% (interquartile range, 15.6%-75.7%) of the estimated diuretic-induced sodium release did not undergo distal reabsorption. After controlling for urine diuretic levels, the increase in FELi explained only 6.4% of the increase in FENa (P=0.002). These data suggest that administration of high-dose loop diuretics to patients with HF yields meaningful increases in sodium exit from the proximal tubule/loop of Henle. However, little of this sodium seems to reach the urine, consistent with findings from animal models that indicate that distal tubular compensatory sodium reabsorption is a primary driver of DR.
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Affiliation(s)
| | - Noah Planavsky
- Department of Geology and Geophysics, Yale University, New Haven, Connecticut
| | | | | | - Meredith A Brisco-Bacik
- Department of Medicine, Cardiovascular Division, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Francis P Wilson
- Department of Internal Medicine and.,Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut
| | | | | | - W H Wilson Tang
- Section of Heart Failure and Cardiac Transplantation, Cleveland Clinic, Cleveland, Ohio
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, Toronto General Hospital and Toronto General Hospital Research Institute, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada; and
| | - David H Ellison
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, Oregon
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185
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Plasma Neutrophil Gelatinase-Associated Lipocalin and Predicting Clinically Relevant Worsening Renal Function in Acute Heart Failure. Int J Mol Sci 2017; 18:ijms18071470. [PMID: 28698481 PMCID: PMC5535961 DOI: 10.3390/ijms18071470] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 06/29/2017] [Accepted: 07/04/2017] [Indexed: 11/21/2022] Open
Abstract
The aim of this study was to evaluate the ability of Neutrophil Gelatinase-Associated Lipocalin (NGAL) to predict clinically relevant worsening renal function (WRF) in acute heart failure (AHF). Plasma NGAL and serum creatinine changes during the first 4 days of admission were investigated in 1447 patients hospitalized for AHF and enrolled in the Placebo-Controlled Randomized Study of the Selective A1Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function (PROTECT) study. WRF was defined as serum creatinine rise ≥ 0.3 mg/dL through day 4. Biomarker patterns were described using linear mixed models. WRF developed in 325 patients (22%). Plasma NGAL did not rise earlier than creatinine in patients with WRF. After multivariable adjustment, baseline plasma NGAL, but not creatinine, predicted WRF. AUCs for WRF prediction were modest (<0.60) for all models. NGAL did not independently predict death or rehospitalization (p = n.s.). Patients with WRF and high baseline plasma NGAL had a greater risk of death, and renal or cardiovascular rehospitalization by 60 days than patients with WRF and a low baseline plasma NGAL (p for interaction = 0.024). A rise in plasma NGAL after baseline was associated with a worse outcome in patients with WRF, but not in patients without WRF (p = 0.007). On the basis of these results, plasma NGAL does not provide additional, clinically relevant information about the occurrence of WRF in patients with AHF.
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186
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Grodin JL, Gallup D, Anstrom KJ, Felker GM, Chen HH, Tang WHW. Implications of Alternative Hepatorenal Prognostic Scoring Systems in Acute Heart Failure (from DOSE-AHF and ROSE-AHF). Am J Cardiol 2017; 119:2003-2009. [PMID: 28433216 DOI: 10.1016/j.amjcard.2017.03.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/14/2017] [Accepted: 03/14/2017] [Indexed: 12/28/2022]
Abstract
Because hepatic dysfunction is common in patients with heart failure (HF), the Model for End-Stage Liver Disease (MELD) may be attractive for risk stratification. Although alternative scores such as the MELD-XI or MELD-Na may be more appropriate in HF populations, the short-term clinical implications of these in patients with acute heart failure (AHF) are unknown. The MELD-XI and MELD-Na were calculated at baseline in 453 patients with AHF in the DOSE-AHF and ROSE-AHF trials. The correlations and associations for each score with cardiorenal biomarkers, short-term end points at 72 hours including worsening renal function and clinical events to 60 days were determined. The median MELD-XI and MELD-Na was 16 and 17, respectively. Both were correlated with baseline cystatin C, amino terminus pro-B-type natriuretic peptide, and plasma renin activity (p <0.003 for all). MELD-XI ≤16 and MELD-Na ≤17 were associated with a slight increase in cystatin C (p <0.02 for both), higher diuretic efficiency (p <0.001 for both), but not with change in global visual assessment scores (p >0.05 for both) at 72 hours. Neither score was associated with worsening renal function or worsening HF (p >0.05 for all). Similarly, both the MELD-XI and MELD-Na were not associated with 60-day death/any rehospitalization and 60-day death/HF rehospitalization in adjusted analyses when analyzes as a dichotomous or continuous variable (p >0.05 for all). In conclusion, the alternative MELD scores correlated with baseline cardiorenal biomarkers, and lower baseline MELD scoring was associated with higher diuretic efficiency and a slight increase in cystatin C through 72 hours. However, MELD-Na and MELD-XI were not predictive of 60-day clinical events.
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Affiliation(s)
- Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Dianne Gallup
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - G Michael Felker
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Horng H Chen
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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187
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Wu B, Yan W, Li X, Kong X, Yu X, Zhu Y, Xing C, Mao H. Initiation and Cessation Timing of Renal Replacement Therapy in Patients with Type 1 Cardiorenal Syndrome: An Observational Study. Cardiorenal Med 2017; 7:118-127. [PMID: 28611785 DOI: 10.1159/000454932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 10/24/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Renal replacement therapy (RRT) is a rescue therapy for patients with type 1 cardiorenal syndrome (CRS) with poor prognoses. However, the optimal timing for initiation and cessation of RRT remains controversial. The purpose of this study was to determine the optimal timing of initiation and cessation of RRT for patients with type 1 CRS. METHODS In this retrospective analysis, patients with refractory type 1 CRS receiving RRT were divided into 3 groups according to weaning from RRT and death within 90 days. Baseline characteristics, underlying heart disease, comorbidities, drug use before RRT, indicators of RRT initiation, and prognosis were compared between the 3 groups. RESULTS Fifty-two patients were enrolled, which included 27 males and 25 females with a mean age of 70.7 ± 16.1 years and a 90-day mortality rate of 65.4%. The mean urine output before RRT initiation was 800 mL/ 24 h in the RRT-independent group, 650 mL/24 h in the RRT-dependent group, and 345 mL/ 24 h in the death group (p = 0.021). Additionally, there were obvious differences in fluid balance between the 3 groups (167, 250, and 1,270 mL, respectively, p = 0.016). Patients could be successfully weaned from RRT when urine output was >880 mL and fluid balance volume was <150 mL. CONCLUSION The mean fluid balance of survivors was remarkably less than that of the death group at RRT initiation. RRT termination can be considered when urine output is >880 mL/24 h and volume balance is <150 mL/24 h.
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Affiliation(s)
- Buyun Wu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wenyan Yan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xing Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangqing Kong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangbao Yu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yamei Zhu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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188
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Aoki S, Okumura T, Sawamura A, Kitagawa K, Morimoto R, Sakakibara M, Murohara T. Usefulness of the Combination of In-Hospital Poor Diuretic Response and Systemic Congestion to Predict Future Cardiac Events in Patients With Acute Decompensated Heart Failure. Am J Cardiol 2017; 119:2010-2016. [PMID: 28438307 DOI: 10.1016/j.amjcard.2017.03.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/14/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
We aimed to (1) investigate the relation between diuretic response (DR) with or without systemic congestion and prognosis and (2) explore the potential predictors of poor DR for risk stratification in patients with acute decompensated heart failure (ADHF). We enrolled 186 consecutive patients hospitalized for ADHF. The DR was defined as (body weight at discharge - body weight at admission)/40 mg furosemide or equivalent loop diuretic dose. Systemic congestion on admission was simply evaluated by the presence of leg edema or jugular venous distention. All patients were divided into 4 groups based on the median of DR (-0.50 kg/40 mg) and the status of systemic congestion; GR/C (good DR with systemic congestion, n = 66), GR/N (good DR without systemic congestion, n = 27), PR/C (poor DR with systemic congestion, n = 48); and PR/N (poor DR without systemic congestion, n = 45). The composite outcome was defined as cardiac death and rehospitalization for worsening heart failure. In survival analysis, the cardiac event-free rate in PR/C was significantly lower than that in any other groups (log-rank, p <0.001), and PR/C was an independent predictor of cardiac events (hazard ratio 2.17, p = 0.016). In conclusion, the combination of in-hospital poor DR, characterized by previous ischemic heart disease, and prehospital dose of daily loop diuretics, and systemic congestion provides a risk stratification for future cardiac events in patients with ADHF.
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189
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Kataoka H. The "chloride theory", a unifying hypothesis for renal handling and body fluid distribution in heart failure pathophysiology. Med Hypotheses 2017; 104:170-173. [PMID: 28673579 DOI: 10.1016/j.mehy.2017.06.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 06/03/2017] [Accepted: 06/07/2017] [Indexed: 11/27/2022]
Abstract
Body fluid volume regulation is a complex process involving the interaction of various afferent (sensory) and neurohumoral efferent (effector) mechanisms. Historically, most studies focused on the body fluid dynamics in heart failure (HF) status through control of the balance of sodium, potassium, and water in the body, and maintaining arterial circulatory integrity is central to a unifying hypothesis of body fluid regulation in HF pathophysiology. The pathophysiologic background of the biochemical determinants of vascular volume in HF status, however, has not been known. I recently demonstrated that changes in vascular and red blood cell volumes are independently associated with the serum chloride concentration, but not the serum sodium concentration, during worsening HF and its recovery. Based on these observations and the established central role of chloride in the renin-angiotensin-aldosterone system, I propose a unifying hypothesis of the "chloride theory" for HF pathophysiology, which states that changes in the serum chloride concentration are the primary determinant of changes in plasma volume and the renin-angiotensin-aldosterone system under worsening HF and therapeutic resolution of worsening HF.
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190
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Harjola VP, Mullens W, Banaszewski M, Bauersachs J, Brunner-La Rocca HP, Chioncel O, Collins SP, Doehner W, Filippatos GS, Flammer AJ, Fuhrmann V, Lainscak M, Lassus J, Legrand M, Masip J, Mueller C, Papp Z, Parissis J, Platz E, Rudiger A, Ruschitzka F, Schäfer A, Seferovic PM, Skouri H, Yilmaz MB, Mebazaa A. Organ dysfunction, injury and failure in acute heart failure: from pathophysiology to diagnosis and management. A review on behalf of the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2017; 19:821-836. [PMID: 28560717 DOI: 10.1002/ejhf.872] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 03/20/2017] [Accepted: 04/04/2017] [Indexed: 12/18/2022] Open
Abstract
Organ injury and impairment are commonly observed in patients with acute heart failure (AHF), and congestion is an essential pathophysiological mechanism of impaired organ function. Congestion is the predominant clinical profile in most patients with AHF; a smaller proportion presents with peripheral hypoperfusion or cardiogenic shock. Hypoperfusion further deteriorates organ function. The injury and dysfunction of target organs (i.e. heart, lungs, kidneys, liver, intestine, brain) in the setting of AHF are associated with increased risk for mortality. Improvement in organ function after decongestive therapies has been associated with a lower risk for post-discharge mortality. Thus, the prevention and correction of organ dysfunction represent a therapeutic target of interest in AHF and should be evaluated in clinical trials. Treatment strategies that specifically prevent, reduce or reverse organ dysfunction remain to be identified and evaluated to determine if such interventions impact mortality, morbidity and patient-centred outcomes. This paper reflects current understanding among experts of the presentation and management of organ impairment in AHF and suggests priorities for future research to advance the field.
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Affiliation(s)
- Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk, Belgium.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Marek Banaszewski
- Intensive Cardiac Therapy Clinic, Institute of Cardiology, Warsaw, Poland
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Medical School Hannover, Hannover, Germany
| | | | - Ovidiu Chioncel
- Institute of Emergency in Cardiovascular Disease, University of Medicine Carol Davila, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Centre, Nashville, TN, USA
| | - Wolfram Doehner
- Centre for Stroke Research, Berlin, Germany.,Department of Cardiology, Charité Medical University, Berlin, Germany
| | - Gerasimos S Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Andreas J Flammer
- University Heart Centre, University Hospital Zurich, Zurich, Switzerland
| | - Valentin Fuhrmann
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Mitja Lainscak
- Department of Internal Medicine, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Department of Research and Education, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Johan Lassus
- Cardiology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Matthieu Legrand
- U942 Inserm, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT), Nancy, France.,Department of Anaesthesiology, Critical Care and Burn Unit, St Louis Hospital, University Paris Denis Diderot, Paris, France
| | - Josep Masip
- Consorci Sanitari Integral (Public Health Consortium), University of Barcelona, Barcelona, Spain.,Department of Cardiology, Hospital Sanitas CIMA, Barcelona, Spain
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Research Centre for Molecular Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - John Parissis
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alain Rudiger
- Cardio-Surgical Intensive Care Unit, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- University Heart Centre, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Medical School Hannover, Hannover, Germany
| | - Petar M Seferovic
- Department of Internal Medicine, Belgrade University School of Medicine, Belgrade, Serbia.,Heart Failure Centre, Belgrade University Medical Centre, Belgrade, Serbia
| | - Hadi Skouri
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Mehmet Birhan Yilmaz
- Department of Cardiology, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
| | - Alexandre Mebazaa
- U942 Inserm, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT), Nancy, France.,University Paris Diderot, Paris, France.,Department of Anaesthesia and Critical Care, University Hospitals Saint Louis-Lariboisière, Paris, France
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191
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Matsue Y, Ter Maaten JM, Suzuki M, Torii S, Yamaguchi S, Fukamizu S, Ono Y, Fujii H, Kitai T, Nishioka T, Sugi K, Onishi Y, Noda M, Kagiyama N, Satoh Y, Yoshida K, van der Meer P, Damman K, Voors AA, Goldsmith SR. Early treatment with tolvaptan improves diuretic response in acute heart failure with renal dysfunction. Clin Res Cardiol 2017; 106:802-812. [PMID: 28540483 PMCID: PMC5613036 DOI: 10.1007/s00392-017-1122-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Poor response to diuretics is associated with worse prognosis in patients with acute heart failure (AHF). We hypothesized that treatment with tolvaptan improves diuretic response in patients with AHF. METHODS We performed a secondary analysis of the AQUAMARINE open-label randomized study in which a total of 217 AHF patients with renal impairment (eGFR < 60 mL/min/1.73 m2) were randomized to either tolvaptan or conventional treatment. We evaluated diuretic response to 40 mg furosemide or its equivalent based on two different parameters: change in body weight and net fluid loss within 48 h. RESULTS The mean time from patient presentation to randomization was 2.9 h. Patients with a better diuretic response showed greater relief of dyspnea and less worsening of renal function. Tolvaptan patients showed a significantly better diuretic response measured by diuretic response based both body weight [-1.16 (IQR -3.00 to -0.57) kg/40 mg vs. -0.51 (IQR -1.13 to -0.20) kg/40 mg; P < 0.001] and net fluid loss [2125.0 (IQR 1370.0-3856.3) mL/40 mg vs. 1296.3 (IQR 725.2-1726.5) mL/40 mg; P < 0.001]. Higher diastolic blood pressure and use of tolvaptan were independent predictors of a better diuretic response. CONCLUSIONS Better diuretic response was associated with greater dyspnea relief and less WRF. Early treatment with tolvaptan significantly improved diuretic response in AHF patients with renal dysfunction.
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Affiliation(s)
- Yuya Matsue
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Department of Cardiology, Kameda Medical Center, 929, Higashi-Cho, Kamogawa, Chiba, Japan.
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Makoto Suzuki
- Department of Cardiology, Kameda Medical Center, 929, Higashi-Cho, Kamogawa, Chiba, Japan
| | - Sho Torii
- Department of Cardiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Satoshi Yamaguchi
- Department of Cardiology, Tomishiro Central Hospital, Okinawa, Japan
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Yuichi Ono
- Department of Cardiology, Ome Municipal General Hospital, Tokyo, Japan
| | - Hiroyuki Fujii
- Department of Cardiology, Yokohama Minami Kyosai Hospital, Kanagawa, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Toshihiko Nishioka
- Department of Cardiology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Kaoru Sugi
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yuko Onishi
- Department of Cardiology, Hiratsuka Kyosai Hospital, Kanagawa, Japan
| | - Makoto Noda
- Department of Cardiology, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Nobuyuki Kagiyama
- Department of Cardiology, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Yasuhiro Satoh
- Department of Cardiology, National Disaster Medical Center, Tokyo, Japan
| | - Kazuki Yoshida
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Peter van der Meer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kevin Damman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Steven R Goldsmith
- Division of Cardiology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
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192
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Verbrugge FH, Damman K, Tang WHW. Diuretics in cardiorenal syndrome: what's new? Intensive Care Med 2017; 44:359-362. [PMID: 28523406 DOI: 10.1007/s00134-017-4834-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/05/2017] [Indexed: 01/15/2023]
Affiliation(s)
- Frederik H Verbrugge
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Kevin Damman
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA
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193
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Doering A, Jenkins CA, Storrow AB, Lindenfeld J, Fermann GJ, Miller KF, Sperling M, Collins SP. Markers of diuretic resistance in emergency department patients with acute heart failure. Int J Emerg Med 2017; 10:17. [PMID: 28484958 PMCID: PMC5422212 DOI: 10.1186/s12245-017-0143-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/25/2017] [Indexed: 11/21/2022] Open
Abstract
Background Loop diuretics are common therapy for emergency department (ED) patients with acute heart failure (AHF). Diuretic resistance (DR) is a term used to describe blunted natriuretic response to loop diuretics. It would be important to detect DR prior to it becoming clinically apparent, so early interventions can be initiated. However, several definitions have been proposed, and it is not clear if they identify similar patients. We compared these definitions and described the clinical characteristics of patients who fulfilled them. Methods To qualify for this secondary analysis of 1033 ED patients with AHF, all patients needed to receive intravenous diuretics in the ED and have urine available within 24 h of their ED evaluation. A poor diuretic response, suggesting DR, was characterized by (1) a fractional sodium excretion (FeNa) of less than 0.2%; (2) spot urinary sodium of less than 50 meq/L; and (3) a urinary Na/K ratio <1.0. McNemar’s test was used to compare the different cohorts identified by the three definitions. Secondary analyses evaluated associations between each DR definition and hospital length of stay (LOS), ED revisits and rehospitalizations for AHF, and mortality using the Wilcoxon rank-sum tests and linear regression or Pearson chi-square test and logistic regression, as appropriate. Results The median age of the 187 patients was 64, and 50% were African-American. There were 5.9% of patients with a FeNa less than 0.2%, 17.1% had urinary sodium less than 50 meq/L, and 10.7% had a urinary Na/K ratio <1.0. The three definitions identified significantly different patients with very little overlap (p < 0.02 for all comparisons). There were 37 (19.8%) patients who were readmitted to the ED or hospital or died within 30 days of ED evaluation. Patients with spot urinary sodium less than 50 meq/L were more likely to be readmitted (p = 0.03). Conclusions The patient proportion with poor natriuresis and DR varies depending on the definition used. Early ED therapy would be impacted at different rates if clinical decisions are made based on these definitions. These findings need to be further explored in a prospective ED-based study. Trial registration ClinicalTrials.gov, NCT00508638 Electronic supplementary material The online version of this article (doi:10.1186/s12245-017-0143-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrew Doering
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - JoAnn Lindenfeld
- Department of Internal Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory J Fermann
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Sperling
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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194
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Scrutinio D, Passantino A, Guida P, Ammirati E, Oliva F, Sarzi Braga S, La Rovere MT, Lagioia R, Frigerio M, Di Somma S. Relationship among body mass index, NT-proBNP, and mortality in decompensated chronic heart failure. Heart Lung 2017; 46:172-177. [DOI: 10.1016/j.hrtlng.2017.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 01/09/2017] [Accepted: 01/09/2017] [Indexed: 12/20/2022]
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195
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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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196
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Involvement of systemic venous congestion in heart failure. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2016.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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197
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Abstract
Loop diuretics are central to the management of fluid overload in acute decompensated heart failure. However, a variance in the response to loop diuretics can alter a patient's clinical course and has an adverse effect on clinical outcomes. Thus, a diminished response to loop diuretics is an important clinical issue. Factors thought to contribute to diuretic resistance include erratic oral absorption in congested states and postdiuretic sodium retention. Further contributing to diuretic resistance in patients with advanced heart failure are decreases in renal perfusion and alterations in sodium handling that occur in an attempt to maintain circulatory homeostasis. Several pharmacologic interventions have been used to improve diuretic response. Intravenous diuretic administration, increasing diuretic doses, or changing diuretic agents can potentially overcome pharmacokinetic obstacles which contribute to drug resistance. Combination diuretic therapy may be useful to overcome increased sodium retention, dopamine may improve renal perfusion, and hypertonic saline may transiently increase intravascular volume and improve sodium delivery to the tubules of the nephron. Despite the prevalence of diuretic resistance, there remains a paucity of clinical trial evidence to help guide therapy in these patients.
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198
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Mullens W, Verbrugge FH, Nijst P, Tang WHW. Renal sodium avidity in heart failure: from pathophysiology to treatment strategies. Eur Heart J 2017; 38:1872-1882. [DOI: 10.1093/eurheartj/ehx035] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/16/2017] [Indexed: 01/10/2023] Open
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Takaya Y, Yoshihara F, Yokoyama H, Kanzaki H, Kitakaze M, Goto Y, Anzai T, Yasuda S, Ogawa H, Kawano Y, Kangawa K. Impact of decreased serum albumin levels on acute kidney injury in patients with acute decompensated heart failure: a potential association of atrial natriuretic peptide. Heart Vessels 2017; 32:932-943. [PMID: 28176004 DOI: 10.1007/s00380-017-0954-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 01/20/2017] [Indexed: 01/22/2023]
Abstract
Although hypoalbuminemia at admission is a risk for acute kidney injury (AKI) and mortality in patients with acute decompensated heart failure (ADHF), the clinical significance of decreased serum albumin levels (DAL) during ADHF therapy has not been elucidated. This study aimed to evaluate whether DAL was associated with AKI, and whether intravenous atrial natriuretic peptide (ANP) administration, which provides an effective treatment for ADHF but promotes albumin extravasation, was associated with DAL and AKI. A total of 231 consecutive patients with ADHF were enrolled. AKI was defined as ≥0.3 mg/dl absolute or 1.5-fold increase in serum creatinine levels within 48 h. AKI occurred in 73 (32%) of the 231 patients during ADHF therapy. The median value of decreases in serum albumin levels was 0.3 g/dl at 7 days after admission. When DAL was defined as ≥0.3 g/dl decrease in serum albumin levels, DAL occurred in 113 patients, and was independently associated with AKI. Of the 231 patients, 73 (32%) were treated with intravenous ANP. DAL occurred more frequently in patients receiving ANP than in those not receiving ANP (77 vs. 36%, p < 0.001), and ANP was independently associated with DAL. The incidence of AKI was higher in patients receiving ANP than in those not receiving ANP (48 vs. 24%, p < 0.001). ANP was independently associated with AKI. In conclusion, DAL is associated with AKI. Intravenous ANP administration may be one of the promoting factors of DAL, which leads to AKI, indicating a possible novel mechanism of AKI.
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Affiliation(s)
- Yoichi Takaya
- Department of Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Fumiki Yoshihara
- Department of Hypertension and Nephrology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan.
| | - Hiroyuki Yokoyama
- Department of Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideaki Kanzaki
- Department of Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Kitakaze
- Department of Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoichi Goto
- Department of Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Toshihisa Anzai
- Department of Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Yasuda
- Department of Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hisao Ogawa
- Department of Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuhei Kawano
- Department of Hypertension and Nephrology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Kenji Kangawa
- Research Institute, National Cerebral and Cardiovascular Center, Suita, Japan
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Ferreira JP, Girerd N, Bettencourt Medeiros P, Bento Ricardo M, Almeida T, Rola A, Zannad F, Rossignol P, Aragão I. Lack of Diuretic Efficiency (but Not Low Diuresis) Early in An Acutely Decompensated Heart Failure Episode Is Associated with Increased 180-Day Mortality. Cardiorenal Med 2017; 7:137-149. [PMID: 28611787 DOI: 10.1159/000455903] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 12/07/2016] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The assessment of the amount of urine produced by the dose of administered diuretic has been proposed as the main signal of interest in diuretic responsiveness - diuretic efficiency (DE). The main aim of our study is to determine if a low DE is associated with 180-day all-cause mortality (ACM). METHODS During a 3-year period, we retrospectively studied patients with acutely decompensated heart failure (ADHF) and respiratory insufficiency admitted to the emergency room of a tertiary university hospital in Porto, Portugal. A total of 170 patients (age 76.2 ± 10.3 years) were included. The outcome of ACM occurred in 43 (25.3%) patients during the 180-day follow-up period. DE was evaluated for a maximum of 3 h after emergency room admission. The lowest DE was defined as ≤140 mL of diuresis per 40 mg of furosemide equivalents. RESULTS No significant differences in age, comorbidities, baseline HF symptoms, or disease-modifying medication were found between the lowest and highest DE groups. The lowest DE group had higher blood urea and lower estimated glomerular filtration rate (eGFR) levels (41.3 ± 24.5 vs. 56.7 ± 23.2 mL/min/1.73 m2, p < 0.001). The patients with the lowest DE had significantly higher rates of ACM during the 180-day follow-up, even after adjustment for other clinically relevant variables: hazard ratio (HR) [95% CI] = 2.31 [1.16-4.58], p = 0.016. The lowest diuresis (≤300 mL) and the highest intravenous furosemide dose (>80 mg) alone were not significantly associated with the outcome. After adjustment for N-terminal prohormone of brain natriuretic peptide, the association between the lowest DE and the outcome lost strength (HR [95% CI] = 1.53 [0.75-3.13], p = 0.240). CONCLUSION A low DE (≤140 mL/40 mg of furosemide) in the first 3 h after an ADHF episode was associated with increased mid-term mortality rates.
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Affiliation(s)
- João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERMU1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France.,Cardiovascular Research and Development Unit, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERMU1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France
| | | | | | - Tiago Almeida
- Internal Medicine Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Alexandre Rola
- Internal Medicine Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERMU1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERMU1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France
| | - Irene Aragão
- Intensive Care Unit, Centro Hospitalar do Porto, Porto, Portugal
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