201
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Demissei BG, Valente MA, Cleland JG, O'Connor CM, Metra M, Ponikowski P, Teerlink JR, Cotter G, Davison B, Givertz MM, Bloomfield DM, Dittrich H, van der Meer P, van Veldhuisen DJ, Hillege HL, Voors AA. Optimizing clinical use of biomarkers in high-risk acute heart failure patients. Eur J Heart Fail 2015; 18:269-80. [DOI: 10.1002/ejhf.443] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/07/2015] [Accepted: 09/23/2015] [Indexed: 12/28/2022] Open
Affiliation(s)
- Biniyam G. Demissei
- Department of Cardiology; University of Groningen, University Medical Centre Groningen; Hanzeplein 1 9713 GZ Groningen the Netherlands
- Department of Epidemiology; University of Groningen, University Medical Centre Groningen; Groningen the Netherlands
| | - Mattia A.E. Valente
- Department of Cardiology; University of Groningen, University Medical Centre Groningen; Hanzeplein 1 9713 GZ Groningen the Netherlands
| | | | | | | | | | - John R. Teerlink
- University of California at San Francisco and San Francisco Veterans Affairs Medical Center; San Francisco CA USA
| | | | | | | | | | - Howard Dittrich
- Abboud Cardiovascular Research Center; University of Iowa Carver College of Medicine; Iowa USA
| | - Peter van der Meer
- Department of Cardiology; University of Groningen, University Medical Centre Groningen; Hanzeplein 1 9713 GZ Groningen the Netherlands
| | - Dirk J. van Veldhuisen
- Department of Cardiology; University of Groningen, University Medical Centre Groningen; Hanzeplein 1 9713 GZ Groningen the Netherlands
| | - Hans L. Hillege
- Department of Cardiology; University of Groningen, University Medical Centre Groningen; Hanzeplein 1 9713 GZ Groningen the Netherlands
- Department of Epidemiology; University of Groningen, University Medical Centre Groningen; Groningen the Netherlands
| | - Adriaan A. Voors
- Department of Cardiology; University of Groningen, University Medical Centre Groningen; Hanzeplein 1 9713 GZ Groningen the Netherlands
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202
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Cooper LB, Hammill BG, Sharma PP, DeVore AD, Mentz RJ, Fonarow GC, Pang PS, Curtis LH, Hernandez AF. Differences in health care use and outcomes by the timing of in-hospital worsening heart failure. Am Heart J 2015; 170:1124-32. [PMID: 26678634 DOI: 10.1016/j.ahj.2015.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/07/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients hospitalized with acute heart failure may experience worsening symptoms requiring escalation of therapy. In-hospital worsening heart failure is associated with worse in-hospital and postdischarge outcomes, but associations between the timing of worsening heart failure and outcomes are unknown. METHODS Using data from a large clinical registry linked to Medicare claims, we examined characteristics, outcomes, and costs of patients hospitalized for acute heart failure. We defined in-hospital worsening heart failure by the use of inotropes or intravenous vasodilators or initiation of mechanical circulatory support, hemodialysis, or ventilation. The study groups were early worsening heart failure (n = 1,990), late worsening heart failure (n = 4,223), complicated presentation (n = 15,361), and uncomplicated hospital course (n = 41,334). RESULTS Among 62,908 patients, those with late in-hospital worsening heart failure had higher in-hospital and postdischarge mortality than patients with early worsening heart failure or complicated presentation. Those with early or late worsening heart failure had more frequent all-cause and heart failure readmissions at 30 days and 1 year, with resultant higher costs, compared with patients with an uncomplicated hospital course. CONCLUSION Although late worsening heart failure was associated with the highest mortality, both early and late worsening heart failures were associated with more frequent readmissions and higher health care costs compared to uncomplicated hospital course. Prevention of worsening heart failure may be an important focus in the care of hospitalized patients with acute heart failure.
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Affiliation(s)
- Lauren B Cooper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC.
| | - Bradley G Hammill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Puza P Sharma
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, CA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
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203
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Afsar B, Ortiz A, Covic A, Solak Y, Goldsmith D, Kanbay M. Focus on renal congestion in heart failure. Clin Kidney J 2015; 9:39-47. [PMID: 26798459 PMCID: PMC4720202 DOI: 10.1093/ckj/sfv124] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/27/2015] [Indexed: 12/11/2022] Open
Abstract
Hospitalizations due to heart failure are increasing steadily despite advances in medicine. Patients hospitalized for worsening heart failure have high mortality in hospital and within the months following discharge. Kidney dysfunction is associated with adverse outcomes in heart failure patients. Recent evidence suggests that both deterioration in kidney function and renal congestion are important prognostic factors in heart failure. Kidney congestion in heart failure results from low cardiac output (forward failure), tubuloglomerular feedback, increased intra-abdominal pressure or increased venous pressure. Regardless of the cause, renal congestion is associated with increased morbidity and mortality in heart failure. The impact on outcomes of renal decongestion strategies that do not compromise renal function should be explored in heart failure. These studies require novel diagnostic markers that identify early renal damage and renal congestion and allow monitoring of treatment responses in order to avoid severe worsening of renal function. In addition, there is an unmet need regarding evidence-based therapeutic management of renal congestion and worsening renal function. In the present review, we summarize the mechanisms, diagnosis, outcomes, prognostic markers and treatment options of renal congestion in heart failure.
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Affiliation(s)
- Baris Afsar
- Department of Medicine, Division of Nephrology , Konya Numune State Hospital , Konya , Turkey
| | - Alberto Ortiz
- Nephrology and Hypertension Department , IIS-Fundacion Jimenez Diaz and School of Medicine , Madrid , Spain
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center , 'C.I. PARHON' University Hospital, and 'Grigore T. Popa' University of Medicine , Iasi , Romania
| | - Yalcin Solak
- Department of Nephrology , Sakarya Training and Research Hospital , Sakarya , Turkey
| | - David Goldsmith
- Renal and Transplantation Department , Guy's and St Thomas' Hospitals , London , UK
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology , Koc University School of Medicine , Istanbul , Turkey
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204
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Demissei BG, Cleland JG, O'Connor CM, Metra M, Ponikowski P, Teerlink JR, Davison B, Givertz MM, Bloomfield DM, Dittrich H, van Veldhuisen DJ, Hillege HL, Voors AA, Cotter G. Procalcitonin-based indication of bacterial infection identifies high risk acute heart failure patients. Int J Cardiol 2015; 204:164-71. [PMID: 26666342 DOI: 10.1016/j.ijcard.2015.11.141] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/16/2015] [Accepted: 11/22/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bacterial infections in patients hospitalized with acute heart failure are related to worse prognosis, but they can be difficult to diagnose. In this study we evaluated the prevalence, clinical correlates and association with outcomes of significantly elevated procalcitonin levels in patients hospitalized for acute heart failure without clear signs of bacterial infection. METHODS 1781 patients from the PROTECT trial were included. Patients with a body temperature >38°C, sepsis or active infection requiring IV antibiotics were excluded. Significant elevation of procalcitonin was considered present when levels exceeded 0.20 ng/mL. In-hospital and post-discharge outcomes were compared between groups of patients with and without elevated procalcitonin levels. RESULTS Procalcitonin ≥ 0.20 ng/mL was seen in 6.0% of patients (N=104). This group of patients had lower serum albumin, lower hemoglobin, higher leukocyte count, higher C-reactive protein, higher blood urea nitrogen, higher heart rate and more pulmonary rales. Interestingly, no significant differences were observed between the two groups in terms of severity of heart failure evidenced by left ventricular ejection fraction (LVEF) or B-type natriuretic peptide (BNP) levels. Patients with significantly elevated procalcitonin levels were more often classified as treatment failure or unchanged status, and had an increased risk of 30-day all-cause mortality even after adjustment for established prognosticators; HR=2.3 (95% CI, 1.3-4.2), (P=0.005). CONCLUSION Patients with acute heart failure and significantly elevated procalcitonin levels, indicating probable undiagnosed/untreated bacterial infection, had poorer in-hospital and post-discharge outcomes, despite similar severity of heart failure.
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Affiliation(s)
- Biniyam G Demissei
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | | | - John R Teerlink
- University of California at San Francisco, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | | | | | | | - Howard Dittrich
- Abboud Cardiovascular Research Center, University of Iowa Carver College of Medicine, IA, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans L Hillege
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Epidemiology, 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.
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205
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Abstract
Renal and cardiac diseases are both prevalent and carry significant morbidity and mortality. They share common vascular risk factors and are physiologically interlinked. Dysfunction in one organ affects the other. Concurrent renal and cardiac disease is associated with a poor prognosis. This close relationship is reflected through cardiorenal syndrome. A classification system has been proposed; however, the underlying process is complex and multifactorial. Management of this syndrome focuses on improving heart function, reducing volume overload, and managing heart failure and chronic kidney disease. This, however, is challenging, limited by paucity of evidence and may lead to suboptimal therapy. Increased recognition of this syndrome should raise awareness in providing early therapy and avoiding adverse outcomes due to under-treatment. In this article, we provide an overview of our current understanding of cardiorenal syndrome, as well as its pathophysiology and treatment options.
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Affiliation(s)
| | - Sui Phin Kon
- King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
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206
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Ural D, Çavuşoğlu Y, Eren M, Karaüzüm K, Temizhan A, Yılmaz MB, Zoghi M, Ramassubu K, Bozkurt B. Diagnosis and management of acute heart failure. Anatol J Cardiol 2015; 15:860-89. [PMID: 26574757 PMCID: PMC5336936 DOI: 10.5152/anatoljcardiol.2015.6567] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an 'aged' population.As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department,intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.
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Affiliation(s)
- Dilek Ural
- Department of Cardiology, Medical Faculty of Kocaeli University; Kocaeli-Turkey.
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207
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Emmens JE, Ter Maaten JM, Matsue Y, Metra M, O'Connor CM, Ponikowski P, Teerlink JR, Cotter G, Davison B, Cleland JG, Givertz MM, Bloomfield DM, Dittrich HC, Todd J, van Veldhuisen DJ, Hillege HL, Damman K, van der Meer P, Voors AA. Plasma kidney injury molecule-1 in heart failure: renal mechanisms and clinical outcome. Eur J Heart Fail 2015; 18:641-9. [PMID: 26511274 DOI: 10.1002/ejhf.426] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/14/2015] [Accepted: 08/09/2015] [Indexed: 11/11/2022] Open
Abstract
AIMS Urinary kidney injury molecule-1 (KIM-1) is a marker of tubular damage and associated with worse outcome in heart failure (HF). Plasma KIM-1 has not been described in HF. METHODS AND RESULTS In a renal mechanistic cohort of 120 chronic HF patients, we established the association between plasma KIM-1, renal invasive haemodynamic parameters {renal blood flow ([(131) I]hippuran clearance) and measured glomerular filtration rate (GFR; [(125) I]iothalamate)} and urinary tubular damage markers. The association between plasma KIM-1, plasma creatinine, and clinical outcome was further explored in a cohort of 2033 acute HF patients. Median plasma KIM-1 was 171.5 pg/mL (122.8-325.7) in chronic (n = 99) and 295.1 pg/mL (182.2-484.2) in acute HF (n = 1588). In chronic HF, plasma KIM-1 was associated with GFR (P < 0.001), creatinine, and cystatin C. Plasma KIM-1 was associated with urinary N-acetyl-β-d-glucosaminidase (NAG), but not with other urinary tubular damage markers. Log plasma KIM-1 predicted adverse clinical outcome after adjustment for age, gender, and GFR [hazard ratio (HR) 1.94, 95% confidence interval (CI) 1.07-3.53, P = 0.030]. Statistical significance was lost after correction for NT-proBNP (HR 1.61, 95% CI 0.81-3.20, P = 0.175). In acute HF, higher plasma KIM-1 levels were associated with higher creatinine, lower albumin, and presence of diabetes. Log plasma KIM-1 predicted 60-day HF rehospitalization (HR 1.27, 95% CI 1.03-1.55, P = 0.024), but not 180-day mortality or 60-day death or renal or cardiovascular rehospitalization. CONCLUSIONS Plasma KIM-1 is associated with glomerular filtration and urinary NAG, but not with other urinary tubular damage markers. Plasma KIM-1 does not predict outcome in chronic HF after correction for NT-proBNP. In acute HF, plasma KIM-1 predicts HF rehospitalization in multivariable analysis.
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Affiliation(s)
- Johanna E Emmens
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | - Jozine M Ter Maaten
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | - Yuya Matsue
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | | | | | | | - John R Teerlink
- University of California at San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | | | | | | | | | | | - Howard C Dittrich
- University of Iowa Carver College of Medicine Cardiovascular Research Center, Iowa City, IA, USA
| | | | - Dirk J van Veldhuisen
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | - Hans L Hillege
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, The Netherlands
| | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | - Peter van der Meer
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | - Adriaan A Voors
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
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208
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209
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Abstract
Acute heart failure is a prognostic factor due to its high mortality during the acute phase and the increased frequency of medium to long-term adverse events. The pathophysiological mechanisms triggered during these exacerbations can persist after reaching clinical stability, remaining even after the acute episode has ended. A certain degree of neurohormonal activation, oxidative stress, apoptosis and inflammation (among other conditions) can therefore persist, resulting in organ damage, not just of the myocardium but likely the entire cardiovascular apparatus. This new insight into the persistence of harmful mechanisms that last beyond the exacerbations could be the start of a change in perspective for developing new therapeutic strategies that seek an overall control of hemodynamic and congestive changes that occur during acute decompensated heart failure and changes that remain after achieving clinical stability.
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210
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Richards AM. Biomarkers in Acute Heart Failure - Cardiac And Kidney. Card Fail Rev 2015; 1:107-111. [PMID: 28785442 PMCID: PMC5490877 DOI: 10.15420/cfr.2015.1.2.107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 08/11/2015] [Indexed: 01/30/2023] Open
Abstract
Natriuretic peptides (NP) are well-validated aids in the diagnosis of acute decompensated heart failure (ADHF). In acute presentations, both brain natriuretic peptide (BNP) and N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) offer high sensitivity (>90 %) and negative predictive values (>95 %) for ruling out ADHF at thresholds of 100 and 300 pg/ml, respectively. Plasma NP rise with age. For added rule-in performance age-adjusted thresholds (450 pg/ml for under 50 years, 900 pg/ml for 50-75 years and 1,800 pg/ml for those >75 years) can be applied to NT-proBNP results. Test performance (specificity and accuracy but not sensitivity) is clearly reduced by renal dysfunction and atrial fibrillation. Obesity offsets the threshold downwards (to ~50 pg/ml for BNP), but overall discrimination is preserved. Reliable markers for impending acute kidney injury in ADHF constitute an unmet need, with candidates, such as kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin, failing to perform sufficiently well, and new possibilities, including the cell cycle markers insulin growth factor binding protein 7 and tissue inhibitor of metalloproteinases type 2, remain the subject of research.
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Affiliation(s)
- A Mark Richards
- Christchurch Heart Institute, University of Otago,Christchurch, New Zealand
- Cardiovascular Research Institute,National University of Singapore, Singapore
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211
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Pai P. Cardiorenal syndrome. Int J Organ Transplant Med 2015. [DOI: 10.1016/j.hkjn.2015.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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212
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Greene SJ, AlKhawam L, Ambrosy AP, Vaduganathan M, Mentz RJ. Hospitalized Heart Failure in the United States. Heart Fail Clin 2015; 11:591-601. [DOI: 10.1016/j.hfc.2015.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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213
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Rademaker MT, Ellmers LJ, Charles CJ, Mark Richards A. Urocortin 2 protects heart and kidney structure and function in an ovine model of acute decompensated heart failure: Comparison with dobutamine. Int J Cardiol 2015; 197:56-65. [DOI: 10.1016/j.ijcard.2015.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 05/18/2015] [Accepted: 06/12/2015] [Indexed: 11/29/2022]
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214
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Mentz RJ, Velazquez EJ, Metra M, McKendry C, Chiswell K, Fiuzat M, Givertz MM, Voors AA, Teerlink JR, O'Connor CM. Comparative effectiveness of torsemide versus furosemide in heart failure patients: insights from the PROTECT trial. Future Cardiol 2015; 11:585-95. [PMID: 26403536 DOI: 10.2217/fca.15.56] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM The authors assessed the comparative effectiveness of torsemide versus furosemide in the PROTECT trial. METHODS The authors assessed the relationship between loop diuretic at discharge and death or cardiovascular/renal hospitalization within 30 days, and death through 150 days postdischarge using inverse probability weighting. RESULTS Out of 1004 patients, 83.5% received furosemide and 16.5% torsemide. Torsemide patients had higher blood urea nitrogen, and more in-hospital worsening heart failure. Following adjustment, torsemide was associated with similar 30-day outcomes compared with furosemide (p = 0.93), but remained associated with increased 150-day death (hazard ratio: 2.26; 95% CI: 1.40-3.66; p < 0.001). CONCLUSION Patients treated with torsemide had features of greater disease severity, similar 30-day outcomes but increased 150-day mortality. Prospective randomized trials are needed to investigate the effect of torsemide versus furosemide.
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Affiliation(s)
- Robert J Mentz
- Duke University, Durham, NC 27708, USA.,Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
| | - Eric J Velazquez
- Duke University, Durham, NC 27708, USA.,Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
| | - Marco Metra
- University of Brescia, Piazza del Mercato, 15, Brescia BS, Italy
| | - Colleen McKendry
- Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
| | - Mona Fiuzat
- Duke University, Durham, NC 27708, USA.,Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
| | | | | | - John R Teerlink
- University of California at San Francisco (SF) & SF Veterans Affairs Medical Center, 500 Parnassus Ave, San Francisco, CA 94143, USA
| | - Christopher M O'Connor
- Duke University, Durham, NC 27708, USA.,Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
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215
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Reid R, Ezekowitz JA, Brown PM, McAlister FA, Rowe BH, Braam B. The Prognostic Importance of Changes in Renal Function during Treatment for Acute Heart Failure Depends on Admission Renal Function. PLoS One 2015; 10:e0138579. [PMID: 26380982 PMCID: PMC4575105 DOI: 10.1371/journal.pone.0138579] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 09/01/2015] [Indexed: 11/28/2022] Open
Abstract
Background Worsening and improving renal function during acute heart failure have been associated with adverse outcomes but few studies have considered the admission level of renal function upon which these changes are superimposed. Objectives The objective of this study was to evaluate definitions that incorporate both admission renal function and change in renal function. Methods 696 patients with acute heart failure with calculable eGFR were classified by admission renal function (Reduced [R, eGFR<45 ml/min] or Preserved [P, eGFR≥45 ml/min]) and change over hospital admission (worsening [WRF]: eGFR ≥20% decline; stable [SRF]; and improving [IRF]: eGFR ≥20% increase). The primary outcome was all-cause mortality. The prevalence of Pres and Red renal function was 47.8% and 52.2%. The frequency of R-WRF, R-SRF, and R-IRF was 11.4%, 28.7%, and 12.1%, respectively; the incidence of P-WRF, P-SRF, and P-IRF was 5.7%, 35.3%, and 6.8%, respectively. Survival was shorter for patients with R-WRF compared to R-IRF (median survival times 13.9 months (95%CI 7.7–24.9) and 32.5 months (95%CI 18.8–56.1), respectively), resulting in an acceleration factor of 2.3 (p = 0.016). Thus, an increase compared with a decrease in renal function was associated with greater than two times longer survival among patients with Reduced renal function.
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Affiliation(s)
- Ryan Reid
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Justin A. Ezekowitz
- Division of Cardiology, University of Alberta, Edmonton, Canada
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
- * E-mail:
| | - Paul M. Brown
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Finlay A. McAlister
- Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Canada
- Division of General Internal Medicine, University of Alberta, Edmonton, Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Canada
- School of Public Health, University of Alberta, Edmonton, Canada
| | - Branko Braam
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
- Department of Physiology, University of Alberta, Edmonton, Canada
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216
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Costanzo MR, Negoianu D, Fonarow GC, Jaski BE, Bart BA, Heywood JT, Nabut JL, Schollmeyer MP. Rationale and design of the Aquapheresis Versus Intravenous Diuretics and Hospitalization for Heart Failure (AVOID-HF) trial. Am Heart J 2015; 170:471-82. [PMID: 26385030 DOI: 10.1016/j.ahj.2015.05.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/29/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In patients hospitalized with acutely decompensated heart failure, unresolved signs and symptoms of fluid overload have been consistently associated with poor outcomes. Regardless of dosing and type of administration, intravenous loop diuretics have not reduced heart failure events or mortality in patients with acutely decompensated heart failure. The results of trials comparing intravenous loop diuretics to mechanical fluid removal by isolated venovenous ultrafiltration have yielded conflicting results. Studies evaluating early decongestive strategies have shown that ultrafiltration removed more fluid and was associated with fewer heart failure-related rehospitalization than intravenous loop diuretics. In contrast, when used in the setting of worsening renal function, ultrafiltration was associated with poorer renal outcomes and no reduction in heart failure events. METHODS The AVOID-HF trial seeks to determine if an early strategy of ultrafiltration in patients with acutely decompensated heart failure is associated with fewer heart failure events at 90 days compared with a strategy based on intravenous loop diuretics. Study subjects from 40 highly experienced institutions are randomized to either early ultrafiltration or intravenous loop diuretics. In both treatment arms, fluid removal therapies are adjusted according to the patients' hemodynamic condition and renal function. The study was unilaterally terminated by the sponsor in the absence of futility and safety concerns after the enrollment of 221 subjects, or 27% of the originally planned sample size of 810 patients. CONCLUSIONS The AVOID-HF trial's principal aim is to compare the safety and efficacy of ultrafiltration vs that of intravenous loop diuretics in patients hospitalized with acutely decompensated heart failure. Because stepped treatment approaches are applied in both ultrafiltration and intravenous loop diuretics groups and the primary end point is time to first heart failure event within 90 days, it is hoped that the AVOID-HF trial, despite its untimely termination by the sponsor, will provide further insight on how to optimally decongest patients with fluid-overloaded heart failure.
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217
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ter Maaten JM, Valente MAE, Metra M, Bruno N, O'Connor CM, Ponikowski P, Teerlink JR, Cotter G, Davison B, Cleland JG, Givertz MM, Bloomfield DM, Dittrich HC, van Veldhuisen DJ, Hillege HL, Damman K, Voors AA. A combined clinical and biomarker approach to predict diuretic response in acute heart failure. Clin Res Cardiol 2015; 105:145-53. [PMID: 26280875 PMCID: PMC4735256 DOI: 10.1007/s00392-015-0896-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/20/2015] [Indexed: 11/29/2022]
Abstract
Background Poor diuretic response in acute heart failure is related to poor clinical outcome. The underlying mechanisms and pathophysiology behind diuretic resistance are incompletely understood. We evaluated a combined approach using clinical characteristics and biomarkers to predict diuretic response in acute heart failure (AHF). Methods and results We investigated explanatory and predictive models for diuretic response—weight loss at day 4 per 40 mg of furosemide—in 974 patients with AHF included in the PROTECT trial. Biomarkers, addressing multiple pathophysiological pathways, were determined at baseline and after 24 h. An explanatory baseline biomarker model of a poor diuretic response included low potassium, chloride, hemoglobin, myeloperoxidase, and high blood urea nitrogen, albumin, triglycerides, ST2 and neutrophil gelatinase-associated lipocalin (r2 = 0.086). Diuretic response after 24 h (early diuretic response) was a strong predictor of diuretic response (β = 0.467, P < 0.001; r2 = 0.523). Addition of diuretic response after 24 h to biomarkers and clinical characteristics significantly improved the predictive model (r2 = 0.586, P < 0.001). Conclusions Biomarkers indicate that diuretic unresponsiveness is associated with an atherosclerotic profile with abnormal renal function and electrolytes. However, predicting diuretic response is difficult and biomarkers have limited additive value. Patients at risk of poor diuretic response can be identified by measuring early diuretic response after 24 h. Electronic supplementary material The online version of this article (doi:10.1007/s00392-015-0896-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jozine M ter Maaten
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Mattia A E Valente
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | | | - Noemi Bruno
- Department of Cardiovascular Sciences, "Sapienza" University of Rome, Rome, Italy
| | | | | | - John R Teerlink
- University of California at San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | | | | | | | | | | | - Howard C Dittrich
- University of Iowa Carver College of Medicine Cardiovascular Research Center, Iowa City, IA, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Hans L Hillege
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,University Medical Center Groningen, Department of Epidemiology, University of Groningen, Groningen, The Netherlands
| | - Kevin Damman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
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218
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Cooper LB, DeVore AD, Michael Felker G. The Impact of Worsening Heart Failure in the United States. Heart Fail Clin 2015; 11:603-14. [PMID: 26462100 DOI: 10.1016/j.hfc.2015.07.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In-hospital worsening heart failure represents a clinical scenario wherein a patient hospitalized for acute heart failure experiences a worsening of their condition, requiring escalation of therapy. Worsening heart failure is associated with worse in-hospital and postdischarge outcomes. Worsening heart failure is increasingly being used as an endpoint or combined endpoint in clinical trials, as it is unique to episodes of acute heart failure and captures an important event during the inpatient course. While prediction models have been developed to identify worsening heart failure, there are no known FDA-approved medications associated with decreased worsening heart failure. Continued study is warranted.
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Affiliation(s)
- Lauren B Cooper
- Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA.
| | - Adam D DeVore
- Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
| | - G Michael Felker
- Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
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219
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Butler J, Gheorghiade M, Kelkar A, Fonarow GC, Anker S, Greene SJ, Papadimitriou L, Collins S, Ruschitzka F, Yancy CW, Teerlink JR, Adams K, Cotter G, Ponikowski P, Felker GM, Metra M, Filippatos G. In-hospital worsening heart failure. Eur J Heart Fail 2015; 17:1104-13. [DOI: 10.1002/ejhf.333] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 06/28/2015] [Accepted: 07/02/2015] [Indexed: 01/08/2023] Open
Affiliation(s)
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - Anita Kelkar
- Cardiology Division; Emory University; Atlanta GA USA
| | - Gregg C. Fonarow
- Cardiology Division; University of California Los Angeles; Los Angeles CA USA
| | - Stefan Anker
- Department of Cardiology; Charite Campus Virchow-Klinikum; Berlin Germany
| | - Stephen J. Greene
- Center for Cardiovascular Innovation; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | | | - Sean Collins
- Department of Emergency Medicine; Vanderbilt University; Nashville TN USA
| | | | - Clyde W. Yancy
- Center for Cardiovascular Innovation; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - John R. Teerlink
- Cardiology Division; University of California San Francisco; San Francisco CA USA
| | - Kirkwood Adams
- Cardiology Division; University of North Carolina; Chapel Hill NC USA
| | | | | | - G. Michael Felker
- Duke Clinical Research Institute; Duke University Medical Center; Durham NC USA
| | - Marco Metra
- Cardiology Division; University of Brescia; Brescia Italy
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220
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Kelly JP, Mentz RJ, Hasselblad V, Ezekowitz JA, Armstrong PW, Zannad F, Felker GM, Califf RM, O'Connor CM, Hernandez AF. Worsening heart failure during hospitalization for acute heart failure: Insights from the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF). Am Heart J 2015; 170:298-305. [PMID: 26299227 DOI: 10.1016/j.ahj.2015.04.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 04/09/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Despite initial in-hospital treatment of acute heart failure (HF), some patients experience worsening HF (WHF). There are limited data about the outcomes and characteristics of patients who experience in-hospital WHF. METHODS AND RESULTS We assessed the characteristics and outcomes of patients with and without WHF in the ASCEND-HF trial. Worsening HF was defined as at least 1 symptom or sign of new, persistent, or WHF requiring additional intravenous inotropic/vasodilator or mechanical therapy during index hospitalization. We assessed the relationship between WHF and 30-day mortality, 30-day mortality or HF hospitalization, and 180-day mortality. We also assessed whether there was a differential association between early (days 1-3) vs late (day ≥4) WHF and outcomes. Of 7,141 patients with acute HF, 354 (5%) experienced WHF. Patients with WHF were more often male and had a history of atrial fibrillation or diabetes, lower blood pressure, and higher creatinine. After risk adjustment, WHF was associated with increased 30-day mortality (odds ratio 13.37, 95% CI 9.85-18.14), 30-day mortality or HF rehospitalization (odds ratio 6.78, 95% CI 5.25-8.76), and 180-day mortality (hazard ratio 3.90, 95% CI 3.14-4.86) (all P values < .0001). There was no evidence of a difference in outcomes between early and late WHF (all P values for comparison ≥ .2). CONCLUSIONS Worsening HF during index hospitalization was associated with worse 30- and 180-day outcomes. Worsening HF may represent an important patient-centered outcome in acute HF and a focus of future treatments.
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Affiliation(s)
- Jacob P Kelly
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Vic Hasselblad
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | | | - Faiez Zannad
- Centre Hospitalier Universitaire, Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
| | - G Michael Felker
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Robert M Califf
- Duke Translational Medicine Institute, Duke Medicine, Durham, NC
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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221
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Thinking Outside the Box: Treating Acute Heart Failure Outside the Hospital to Improve Care and Reduce Admissions. J Card Fail 2015; 21:667-73. [DOI: 10.1016/j.cardfail.2015.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 05/12/2015] [Accepted: 05/15/2015] [Indexed: 01/16/2023]
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222
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Campbell RT, McKean AR, McMurray JJV. Acute heart failure: have we got it all wrong? Eur J Heart Fail 2015; 16:1263-7. [PMID: 25452162 DOI: 10.1002/ejhf.197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 10/11/2014] [Indexed: 01/08/2023] Open
Affiliation(s)
- Ross T Campbell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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223
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Platz E, Jhund PS, Campbell RT, McMurray JJ. Assessment and prevalence of pulmonary oedema in contemporary acute heart failure trials: a systematic review. Eur J Heart Fail 2015; 17:906-16. [PMID: 26230356 DOI: 10.1002/ejhf.321] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/06/2015] [Accepted: 06/12/2015] [Indexed: 01/01/2023] Open
Abstract
AIMS Pulmonary oedema is a common and important finding in acute heart failure (AHF). We conducted a systematic review to describe the methods used to assess pulmonary oedema in recent randomized AHF trials and report its prevalence in these trials. METHODS AND RESULTS Of 23 AHF trials published between 2002 and 2013, six were excluded because they were very small or not randomized, or missing full-length publications. Of the remaining 17 (n = 200-7141) trials, six enrolled patients with HF and reduced ejection fraction (HF-REF) and 11, patients with both HF-REF and HF with preserved ejection fraction (HF-PEF). Pulmonary oedema was an essential inclusion criterion, in most trials, based upon findings on physical examination ('rales'), radiographic criteria ('signs of congestion'), or both. The prevalence of pulmonary oedema in HF-REF trials ranged from 75% to 83% and in combined HF-REF and HF-PEF trials from 51% to 100%. Five trials did not report the prevalence or extent of pulmonary oedema assessed by either clinical examination or chest x-ray. Improvement of pulmonary congestion with treatment was inconsistently reported and commonly grouped with other signs of congestion into a score. One trial suggested that patients with rales over >2/3 of the lung fields on admission were at higher risk of adverse outcomes than those without. CONCLUSION Although pulmonary oedema is a common finding in AHF, represents a therapeutic target, and may be of prognostic importance, recent trials used inconsistent criteria to define it, and did not consistently report its severity at baseline or its response to treatment. Consistent and ideally quantitative, methods for the assessment of pulmonary oedema in AHF trials are needed.
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Affiliation(s)
- Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ross T Campbell
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - John J McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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224
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Verbrugge FH, Dupont M, Finucan M, Gabi A, Hawwa N, Mullens W, Taylor DO, Young JB, Starling RC, Tang WHW. Response and tolerance to oral vasodilator up-titration after intravenous vasodilator therapy in advanced decompensated heart failure. Eur J Heart Fail 2015. [PMID: 26213182 DOI: 10.1002/ejhf.324] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
AIMS The aim of this study was to assess the haemodynamic response and tolerance to aggressive oral hydralazine/isosorbide dinitrate (HYD/ISDN) up-titration after intravenous vasodilator therapy in advanced decompensated heart failure (ADHF). METHODS AND RESULTS Medical records of 147 consecutive ADHF patients who underwent placement of a pulmonary artery catheter and received intravenous vasodilator therapy were reviewed. Intravenous sodium nitroprusside and sodium nitroglycerin as first-line agent for those with preserved blood pressures were utilized in 143 and 32 patients, respectively. Sixty-one percent of patients were converted to oral HYD/ISDN combination therapy through a standardized conversion protocol. These patients had a significantly higher admission mean pulmonary arterial wedge pressure compared with patients not converted (28 ± 7 vs. 25 ± 8 mmHg, respectively; P-value 0.024). Beneficial haemodynamic response to decongestive therapy, defined as low cardiac filling pressures and cardiac index ≥2.20 L/min/m(2) without emergent hypotension, was achieved in 32% and 29% of patients who did or did not receive oral HYD/ISDN, respectively (P-value 0.762). HYD/ISDN dosing was progressively and consistently decreased up to the moment of hospital discharge and during outpatient follow-up, primarily due to incident hypotension. CONCLUSION The use of a standardized haemodynamically guided up-titration protocol for conversion from intravenous to oral vasodilators may warrant subsequent dose reductions upon stabilization.
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Affiliation(s)
- Frederik H Verbrugge
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Michael Finucan
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - Alaa Gabi
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - Nael Hawwa
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - David O Taylor
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - James B Young
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
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225
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Brisco MA, Cheng SJ, Laur O, Kula AJ, Testani JM. Evidence of Mild Liver Dysfunction Identifies Stable Heart Failure Outpatients with Reversible Renal Dysfunction. Cardiorenal Med 2015. [PMID: 26195975 DOI: 10.1159/000430505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In decompensated heart failure (HF), reversible renal dysfunction (RD) is more frequently observed in patients with mild liver dysfunction likely due to the shared pathophysiologic factors involved. The objective of this study was to determine if these findings also apply to stable HF outpatients. METHODS Patients in the Beta-Blocker Evaluation of Survival Trial (BEST) were studied. Improvement in renal function (IRF) was defined as a 20% improvement in the estimated glomerular filtration rate from baseline to 3 months. RESULTS Elevated bilirubin (BIL), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were significantly associated with signs of congestion or poor perfusion. IRF occurred in 12.0% of all patients and was more common in those with elevated BIL (OR = 1.5, p = 0.003), ALT (OR = 1.4, p = 0.01), and AST (OR = 1.4, p = 0.01). In a model containing all 3 liver parameters and baseline characteristics, including markers of congestion/poor perfusion, BIL (OR = 1.6, p = 0.001) and ALT (OR = 1.7, p < 0.001) were independently associated with IRF. CONCLUSIONS Biochemical evidence of mild liver dysfunction is significantly associated with IRF in stable HF outpatients. Given the widespread availability and low cost of these markers, additional research is necessary to determine the utility of these parameters in identifying patients with reversible RD who may benefit from cardiorenal interventions.
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Affiliation(s)
- Meredith A Brisco
- Cardiology Division, Department of Medicine, Medical University of South Carolina, Charleston, S.C., USA
| | - Susan J Cheng
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn., USA
| | - Olga Laur
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn., USA
| | - Alexander J Kula
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn., USA
| | - Jeffrey M Testani
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Conn., USA ; Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn., USA
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226
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Brown K, Chee J, Kyung S, Vettichira B, Papadimitriou L, Butler J. Mineralocorticoid Receptor Antagonism in Acute Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015. [PMID: 26199117 DOI: 10.1007/s11936-015-0402-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OPINION STATEMENT Heart failure (HF) remains a tremendous burden to health care systems and patients worldwide. The cornerstone neurohormonal disruption that leads to the debilitating sequelae in HF patients revolves primarily around aldosterone and the renin-angiotensin-aldosterone system (RAAS). Aldosterone plays a detrimental role in tissue remodeling by inducing inflammation and fibrosis within the cardiovascular and renal systems, leaving mineralocorticoid receptor antagonists (MRAs) as key pharmacological tools to slow pathogenesis and improve patient outcomes. The role of MRA in improving morbidity and mortality in outpatients with chronic HF and low ejection fraction is well established and supported by large randomized controlled trials. However, evidence-based data relating to the use of MRA in acute HF (AHF) remain somewhat limited, and therefore, the use of MRA is not ubiquitously considered in the acute setting. Current studies for the use of MRA in AHF are limited by small sample size as well as safety concerns relating to the dose-dependent effects on electrolyte homeostasis and renal function. Here, we discuss the imperative need for additional trials elucidating the potential benefits of MRA in AHF as an adjunct diuretic therapy. We not only discuss the role of MRA in neurohormonal regulation of aldosterone but also highlight a potential dose-dependent role for MRA in natriuresis. Furthermore, we showcase existing and recent evidence-based data demonstrating the effectiveness of MRA in AHF and on long-term outcomes. Finally, we look at several treatment strategies and safety concerns as they relate to MRA use so as to aid in avoidance of MRA-related complications while facilitating achievement of treatment goals.
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Affiliation(s)
- Kemar Brown
- Division of Cardiology, Health Sciences Center, Stony Brook University, T-16, Room 080, Stony Brook, NY, 11794, USA
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227
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Kelly JP, Mentz RJ, Mebazaa A, Voors AA, Butler J, Roessig L, Fiuzat M, Zannad F, Pitt B, O'Connor CM, Lam CSP. Patient selection in heart failure with preserved ejection fraction clinical trials. J Am Coll Cardiol 2015; 65:1668-1682. [PMID: 25908073 DOI: 10.1016/j.jacc.2015.03.043] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 03/08/2015] [Indexed: 12/11/2022]
Abstract
Recent clinical trials in patients with heart failure with preserved ejection fraction (HFpEF) have provided important insights into participant selection strategies. Historically, HFpEF trials have included patients with relatively preserved left ventricular ejection fraction ranging from 40% to 55% and a clinical history of heart failure. Contemporary HFpEF trials have also incorporated inclusion criteria such as hospitalization for HFpEF, altered functional capacity, cardiac structural and functional abnormalities, and abnormalities in neurohormonal status (e.g., elevated natriuretic peptide levels). Careful analyses of the effect of these patient selection criteria on outcomes in prior trials provide valuable lessons for future trial design. We review recent and ongoing HFpEF clinical trials from a patient selection perspective and appraise trial patient selection methodologies in relation to outcomes. This review reflects discussions between clinicians, scientists, trialists, regulators, and regulatory representatives at the 10th Global CardioVascular Clinical Trialists Forum in Paris, France, on December 6, 2013.
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Affiliation(s)
- Jacob P Kelly
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care, University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Adriaan A Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, New York
| | - Lothar Roessig
- Global Clinical Development, Bayer Pharma AG, Berlin, Germany
| | - Mona Fiuzat
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques, Université de Lorraine and CHU de Nancy, Nancy, France
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Christopher M O'Connor
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Carolyn S P Lam
- Department of Cardiology, National Heart Centre Singapore, Singapore
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228
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Affiliation(s)
- Muthiah Vaduganathan
- From the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (M.V.); Division of Cardiology, Stony Brook University, NY (J.B.); University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL (M.G.)
| | - Javed Butler
- From the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (M.V.); Division of Cardiology, Stony Brook University, NY (J.B.); University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL (M.G.)
| | - Bertram Pitt
- From the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (M.V.); Division of Cardiology, Stony Brook University, NY (J.B.); University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL (M.G.)
| | - Mihai Gheorghiade
- From the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (M.V.); Division of Cardiology, Stony Brook University, NY (J.B.); University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL (M.G.)
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229
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Martín-Sánchez FJ, Rodríguez-Adrada E, Llorens P, Formiga F. [Key messages for the initial management of the elderly patient with acute heart failure]. Rev Esp Geriatr Gerontol 2015; 50:185-194. [PMID: 25959134 DOI: 10.1016/j.regg.2015.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/08/2015] [Accepted: 02/09/2015] [Indexed: 06/04/2023]
Abstract
Acute heart failure is a high prevalence geriatric syndrome that has become one of the most frequent causes of visits to emergency departments, as well as hospital admission, and is associated with high morbidity, mortality and functional impairment. There has been an increasing amount of information published in recent years on the initial management of acute heart failure and the results of the short-term outcomes, as well as the natural history of the disease. The objective of this study is to provide several recommendations that should be taken into account in the initial management of the elderly patient with acute heart failure in the emergency departments, and to review the most interesting currently on-going clinical trials.
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Affiliation(s)
- F Javier Martín-Sánchez
- Servicio de Urgencias, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España.
| | - Esther Rodríguez-Adrada
- Servicio de Urgencias, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Pere Llorens
- Servicio de Urgencias, Hospital General Universitario de Alicante, Alicante, España
| | - Francesc Formiga
- Programa Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
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230
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Mentz RJ, Metra M, Cotter G, Milo O, McKendry C, Chiswell K, Davison BA, Cleland JGF, Bloomfield DM, Dittrich HC, Fiuzat M, Ponikowski P, Givertz MM, Voors AA, Teerlink JR, O'Connor CM. Early vs. late worsening heart failure during acute heart failure hospitalization: insights from the PROTECT trial. Eur J Heart Fail 2015; 17:697-706. [PMID: 26083764 DOI: 10.1002/ejhf.308] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 03/31/2015] [Accepted: 04/22/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Worsening heart failure (WHF) symptoms despite initial therapy during admission for acute heart failure (AHF) is associated with worse outcomes. The association between the time of the WHF event and the intensity of WHF therapy with outcomes is unknown. METHODS AND RESULTS In the PROTECT trial of 2033 AHF patients, we investigated the association between time of occurrence of WHF and intensity of therapy, with subsequent outcomes. WHF was defined by standardized, physician-determined assessment. Early WHF was defined as occurring on days 2-3 and late on days 4-7. Low intensity included restarting/increasing diuretics or vasodilators and high intensity included initiation of inotropes, vasopressors, inodilators, or mechanical support. Outcomes were death or cardiovascular/renal hospitalization over 60 days and death over 180 days. Of the 1879 patients with complete follow-up after day 7, 12.7% (n = 238) experienced WHF: 47.9% early and 52.1% late. Treatment intensity was low in 72.3% and high in 24.8% (2.9% missing). After adjusting for baseline predictors of outcome, WHF was associated with a trend toward increased 60-day death or cardiovascular/renal hospitalization [hazard ratio (HR) 1.26; 95% confidence interval (CI) 0.99-1.60; P = 0.063] and increased 180-day death (HR 1.77; 95% CI 1.33-2.34; P < 0.001). There was no evidence of a differential association between the time of occurrence of WHF and outcomes. High-intensity therapy was not significantly associated with increased event rates (180-day mortality: HR 1.44; 95% CI 0.80-2.59 vs. low). CONCLUSIONS Inhospital WHF was associated with increased 180-day death. The time of occurrence and intensity of WHF therapy may provide less prognostic information than whether or not WHF occurred.
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Affiliation(s)
- Robert J Mentz
- Duke University Hospital, Medicine, Division of Cardiology, 2301 Erwin Road, Durham, NC 27713, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | | | | | - John G F Cleland
- National Heart and Lung Institute, Imperial College London (Royal Brompton & Harefield Hospitals) and Department of Cardiology, Castle Hill Hospital, University of Hull, Kingston-upon-Hull, UK
| | | | - Howard C Dittrich
- University of Iowa Carver College of Medicine Cardiovascular Research Center, Iowa City, IA, USA
| | - Mona Fiuzat
- Duke University Hospital, Medicine, Division of Cardiology, 2301 Erwin Road, Durham, NC 27713, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - John R Teerlink
- University of California at San Francisco (SF) and SF Veterans Affairs Medical Center, SF, CA, USA
| | - Christopher M O'Connor
- Duke University Hospital, Medicine, Division of Cardiology, 2301 Erwin Road, Durham, NC 27713, USA
- Duke Clinical Research Institute, Durham, NC, USA
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231
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Jackson N, Atar D, Borentain M, Breithardt G, van Eickels M, Endres M, Fraass U, Friede T, Hannachi H, Janmohamed S, Kreuzer J, Landray M, Lautsch D, Le Floch C, Mol P, Naci H, Samani NJ, Svensson A, Thorstensen C, Tijssen J, Vandzhura V, Zalewski A, Kirchhof P. Improving clinical trials for cardiovascular diseases: a position paper from the Cardiovascular Round Table of the European Society of Cardiology. Eur Heart J 2015; 37:747-54. [PMID: 26077039 DOI: 10.1093/eurheartj/ehv213] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 05/04/2015] [Indexed: 12/12/2022] Open
Abstract
AIMS Cardiovascular disease is the most common cause of mortality and morbidity in the world, but the pharmaceutical industry's willingness to invest in this field has declined because of the many challenges involved with bringing new cardiovascular drugs to market, including late-stage failures, escalating regulatory requirements, bureaucracy of the clinical trial business enterprise, and limited patient access after approval. This contrasts with the remaining burden of cardiovascular disease in Europe and in the world. Thus, clinical cardiovascular research needs to adapt to address the impact of these challenges in order to ensure development of new cardiovascular medicines. METHODS AND RESULTS The present paper is the outcome of a two-day workshop held by the Cardiovascular Round Table of the European Society of Cardiology. We propose strategies to improve development of effective new cardiovascular therapies. These can include (i) the use of biomarkers to describe patients who will benefit from new therapies more precisely, achieving better human target validation; (ii) targeted, mechanism-based approaches to drug development for defined populations; (iii) the use of information technology to simplify data collection and follow-up in clinical trials; (iv) streamlining adverse event collection and reducing monitoring; (v) extended patent protection or limited rapid approval of new agents to motivate investment in early phase development; and (vi) collecting data needed for health technology assessment continuously throughout the drug development process (before and after approval) to minimize delays in patient access. Collaboration across industry, academia, regulators, and payers will be necessary to enact change and to unlock the existing potential for cardiovascular clinical drug development. CONCLUSIONS A coordinated effort involving academia, regulators, industry, and payors will help to foster better and more effective conduct of clinical cardiovascular trials, supporting earlier availability of innovative therapies and better management of cardiovascular diseases.
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Affiliation(s)
| | - Dan Atar
- Oslo University Hospital Ulleval and University of Oslo, Oslo, Norway
| | | | - Günter Breithardt
- Department of Cardiovascular Medicine, Universitätsklinikum Münster, Münster, Germany Centre for Cardiovascular Sciences, School of Clinical and Experimental Medicine, University of Birmingham and Sandwell and West Birmingham Hospitals National Health Service Trust, Wolfson Drive, Birmingham B15 2TT, UK
| | | | | | | | - Tim Friede
- Department of Medical Statistics, University Medical Center, Göttingen, Germany DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | | | | | - Jörg Kreuzer
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | | | | | | | - Peter Mol
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | - Huseyin Naci
- London School of Economics and Political Science, London, UK
| | | | | | | | - Jan Tijssen
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Paulus Kirchhof
- Centre for Cardiovascular Sciences, School of Clinical and Experimental Medicine, University of Birmingham and Sandwell and West Birmingham Hospitals National Health Service Trust, Wolfson Drive, Birmingham B15 2TT, UK Atrial Fibrillation Competence NETwork (AFNET) e.V., Münster, Germany
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232
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Abstract
Heart and kidney are closely related in the clinical syndrome of heart failure (HF). It is now sufficiently clear that renal dysfunction occurs frequently in all phenotypes of HF, and when present, it is associated with higher mortality and morbidity. While the pathophysiology is multifactorial, the most important factors are a reduced renal perfusion and venous congestion. Recent interest has focused on worsening renal function (WRF), a situation strongly related to mortality, but seemingly only when HF status deteriorates. Unfortunately, to date clinicians are unable to identify specifically those patients with a grim prognosis following WRF. Although much has been learned on cardiorenal interaction in HF, still more questions have been left unanswered. The coming decade should provide us with more dedicated epidemiologic, mechanistic, and controlled trials in HF patients with reduced renal function. An updated classification of the cardiorenal syndrome that incorporates recent evidence and points towards areas of interest and uncertainties, and areas where progress is needed could facilitate this process. Ultimately, this should lead to preventive and treatment strategies that can preserve renal function and associated outcome in patients with HF.
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Affiliation(s)
- Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Hanzeplein 1, 9700RB Groningen, The Netherlands
| | - Jeffrey M Testani
- Department of Internal Medicine and Program of Applied Translational Research, Yale University, New Haven, CT, USA
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233
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Mebazaa A, Longrois D, Metra M, Mueller C, Richards AM, Roessig L, Seronde MF, Sato N, Stockbridge NL, Gattis Stough W, Alonso A, Cody RJ, Cook Bruns N, Gheorghiade M, Holzmeister J, Laribi S, Zannad F. Agents with vasodilator properties in acute heart failure: how to design successful trials. Eur J Heart Fail 2015; 17:652-64. [PMID: 26040488 DOI: 10.1002/ejhf.294] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/17/2015] [Accepted: 04/22/2015] [Indexed: 01/08/2023] Open
Abstract
Agents with vasodilator properties (AVDs) are frequently used in the treatment of acute heart failure (AHF). AVDs rapidly reduce preload and afterload, improve left ventricle to aorta and right ventricle to pulmonary artery coupling, and may improve symptoms. Early biomarker changes after AVD administration have suggested potentially beneficial effects on cardiac stretch, vascular tone, and renal function. AVDs that reduce haemodynamic congestion without causing hypoperfusion might be effective in preventing worsening organ dysfunction. Existing AVDs have been associated with different results on outcomes in randomized clinical trials, and observational studies have suggested that AVDs may be associated with a clinical outcome benefit. Lessons have been learned from past AVD trials in AHF regarding preventing hypotension, selecting the optimal endpoint, refining dyspnoea measurements, and achieving early randomization and treatment initiation. These lessons have been applied to the design of ongoing pivotal clinical trials, which aim to ascertain if AVDs improve clinical outcomes. The developing body of evidence suggests that AVDs may be a clinically effective therapy to reduce symptoms, but more importantly to prevent end-organ damage and improve clinical outcomes for specific patients with AHF. The results of ongoing trials will provide more clarity on the role of AVDs in the treatment of AHF.
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Affiliation(s)
- Alexandre Mebazaa
- University Paris Diderot, Sorbonne Paris Cité, Paris, France.,U942 INSERM, AP-HP, Paris, France.,APHP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, University Paris Diderot, Sorbonne Paris Cité, Paris, U1148 INSERM, Paris, France
| | - Marco Metra
- Cardiology, University of Brescia, Brescia, Italy
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Arthur Mark Richards
- Cardiovascular Research Institute, National University of Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lothar Roessig
- Global Clinical Development, Bayer Pharma AG, Berlin, Germany
| | - Marie France Seronde
- Department of Cardiology, University Hospital of Besançon, U942 INSERM, Besançon, France
| | - Naoki Sato
- Internal Medicine, Cardiology, and Intensive Care Medicine, Nippon Medical School Musashi-Kosugi Hospital, Kanagawa, Japan
| | - Norman L Stockbridge
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | | | - Angeles Alonso
- Scientific Advice Working Party European Medicines Agency, Madrid, Spain
| | | | | | - Mihai Gheorghiade
- Department of Medicine, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Said Laribi
- APHP, Department of Emergency Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, INSERM U942, Paris, France
| | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
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234
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Abstract
PURPOSE OF REVIEW Fluid removal and relief of congestion are central to treatment of acute heart failure. Diuretics have been the decongestive mainstay but their known limitations have led to the exploration of alternative strategies. This review compares diuretics with ultrafiltration and examines the recent evidence evaluating their use. RECENT FINDINGS Relevant recent studies are the Diuretic Optimization Strategies Evaluation trial (of diuretics) and the Cardiorenal Rescue Study in Acute Decompensated Heart Failure (of ultrafiltration). The Diuretic Optimization Strategies Evaluation study evaluated strategies of loop diuretic use during acute heart failure (continuous infusion versus intermittent bolus and high dose versus low dose). After 72 h, there was no significant difference with either comparison for the coprimary end points. Patients treated with a high-dose strategy tended to have greater diuresis and more decongestion compared with low-dose therapy, at the cost of transient changes in renal function. The Cardiorenal Rescue Study in Acute Decompensated Heart Failure study showed that in acute heart failure patients with persistent congestion and worsening renal function, ultrafiltration, as compared with a medical therapy, was associated with similar weight loss but greater increase in serum creatinine and more adverse events. SUMMARY Decongestion remains a major challenge in acute heart failure. Although recent studies provide useful data to guide practice, the relatively poor outcomes point to the continued need to identify better strategies for safe and effective decongestion.
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235
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Varr BC, Maurer MS. Emerging role of serelaxin in the therapeutic armamentarium for heart failure. Curr Atheroscler Rep 2015; 16:447. [PMID: 25108571 DOI: 10.1007/s11883-014-0447-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute heart failure (AHF) remains a major cause of morbidity and mortality, with an increasing prevalence anticipated over the next few decades as the population ages, heightening already significant health and economic burdens to society. New therapies for AHF have stalled over the past decade for a multitude of reasons, principal among them the heterogeneous population of patients affected with potentially multiple operative pathophysiologic mechanisms making a single targeted therapy a challenge. Serelaxin, a recombinant form of human relaxin-2, mediates adaptive cardiovascular effects during pregnancy that could be beneficial in the AHF population, primarily through nitric oxide-mediated vasodilation. Serelaxin is a novel therapeutic agent that has shown promise in the treatment of AHF in predefined subpopulations, though studies powered for "hard" outcomes are still pending. In this review, we examine the clinical investigations to date involving serelaxin in patients with heart failure and its possible emerging role in the future therapy of AHF.
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Affiliation(s)
- Brandon C Varr
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA,
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236
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Núñez J, Miñana G, Santas E, Bertomeu-González V. Síndrome cardiorrenal en la insuficiencia cardiaca aguda: revisando paradigmas. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.10.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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237
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Worsening Heart Failure. JACC-HEART FAILURE 2015; 3:404-407. [DOI: 10.1016/j.jchf.2015.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 02/11/2015] [Indexed: 01/08/2023]
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238
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Greene SJ, Fonarow GC, Solomon SD, Subacius H, Maggioni AP, Böhm M, Lewis EF, Zannad F, Gheorghiade M. Global variation in clinical profile, management, and post-discharge outcomes among patients hospitalized for worsening chronic heart failure: findings from the ASTRONAUT trial. Eur J Heart Fail 2015; 17:591-600. [PMID: 25930208 DOI: 10.1002/ejhf.280] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 03/27/2015] [Accepted: 04/01/2015] [Indexed: 11/05/2022] Open
Abstract
AIMS This study sought to investigate regional variation in clinical characteristics, therapy utilization, and post-discharge outcomes among patients hospitalized for heart failure (HHF) enrolled in the multinational ASTRONAUT (Aliskiren Trial on Acute Heart Failure Outcomes) trial. METHODS AND RESULTS The ASTRONAUT trial randomized 1615 HHF patients with ejection fraction ≤40% to aliskiren or placebo. Enrolled patients were from Eastern Europe (n = 495, 30.7%), Asia/Pacific (n = 439, 27.2%), Western Europe (n = 395, 24.5%), Latin America (n = 163, 10.1%), and North America (n = 123, 7.6%). Marked differences were seen across geographic regions in terms of baseline demographics, vital signs, laboratory tests, co-morbidity burden, and use of guideline-recommended therapies. All-cause death at 12 months ranged from 7.3% in North America to 26.7% in Asia/Pacific, with differences largely driven by sudden cardiac death. Rates of repeat HHF at 12 months ranged from 22.7% in Latin America to 43.9% in North America. After adjustment for patient characteristics, region was an independent predictor of death at 12 months, with highest risk in Asia/Pacific (hazard ratio 3.04, 95% confidence interval 1.47-6.29, compared with North America) and lowest risk in North America and Western Europe. There was no association between region and the composite of cardiovascular mortality or HHF. CONCLUSION For patients enrolled in this HHF trial, baseline characteristics and risk of death differed markedly by geographic region. Rates of death and repeat HHF demonstrated a general inverse relationship. Global differences in patient characteristics and outcomes should be accounted for when designing future HHF clinical trials.
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Affiliation(s)
- Stephen J Greene
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Haris Subacius
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Eldrin F Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Faiez Zannad
- Clinical Investigation Center, INSERM-CHU de Nancy Hôpital Jeanne d'Arc, Dommartin-les Toul Cedex, France
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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239
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Hummel A, Empen K, Dörr M, Felix SB. De novo acute heart failure and acutely decompensated chronic heart failure. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:298-310. [PMID: 26008893 PMCID: PMC4452901 DOI: 10.3238/arztebl.2015.0298] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 12/17/2014] [Accepted: 12/17/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Heart failure is one of the most common diseases of adults in Europe, with an overall prevalence of 1-2%. Among persons aged 60 and above, its prevalence is above 10% in men and 8% in women. Acute heart failure has a poor prognosis; it is associated with a high rate of rehospitalization and a 1-year mortality of 20-30%. METHODS This review is based on pertinent literature, including guidelines, retrieved by a selective search in PubMed. RESULTS There are different types of acute heart failure; the basic diagnostic assessment is performed at once and consists of ECG, echocardiography, and the measurement of N-terminal pro-brain natriuretic peptide (NTproBNP) and troponin levels. The most common causes of decompensation are arrhythmia, valvular dysfunction, and acute cardiac ischemia, each of which accounts for 30% of cases. The potential indication for immediate revascularization should be carefully considered in cases where acute heart failure is due to coronary heart disease. The basic treatment of acute heart failure is symptomatic, with the administration of oxygen, diuretics, and vasodilators. Ino-tropic agents, vasopressors, and temporary mechanical support for the circulatory system are only used to treat cardiogenic shock. CONCLUSION The treatment of acute heart failure is markedly less evidence-based than that of chronic heart failure. Newer treatment approaches that are intended to improve outcomes still need to be tested in multicenter trials.
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Affiliation(s)
- Astrid Hummel
- University Medicine Greifswald, Department of Internal Medicine B
| | - Klaus Empen
- University Medicine Greifswald, Department of Internal Medicine B
| | - Marcus Dörr
- University Medicine Greifswald, Department of Internal Medicine B
| | - Stephan B Felix
- University Medicine Greifswald, Department of Internal Medicine B
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240
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Takaya Y, Yoshihara F, Yokoyama H, Kanzaki H, Kitakaze M, Goto Y, Anzai T, Yasuda S, Ogawa H, Kawano Y. Risk Stratification of Acute Kidney Injury Using the Blood Urea Nitrogen/Creatinine Ratio in Patients With Acute Decompensated Heart Failure. Circ J 2015; 79:1520-5. [PMID: 25854814 DOI: 10.1253/circj.cj-14-1360] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Risk stratification of acute kidney injury (AKI) is important for acute decompensated heart failure (ADHF). The aim of this study was to determine whether clinical markers, such as the blood urea nitrogen/creatinine ratio (BUN/Cr) or BUN or creatinine values alone, stratify the risk of AKI for mortality. METHODS AND RESULTS In all, 371 consecutive ADHF patients were enrolled in the study. AKI was defined as serum creatinine ≥0.3 mg/dl or a 1.5-fold increase in serum creatinine levels within 48 h. During ADHF therapy, AKI occurred in 99 patients; 55 patients died during the 12-month follow-up period. Grouping patients according to AKI and a median BUN/Cr at admission of 22.1 (non-AKI+low BUN/Cr, non-AKI+high BUN/Cr, AKI+low BUN/Cr, and AKI+high BUN/Cr groups) revealed higher mortality in the AKI+high BUN/Cr group (log-rank test, P<0.001). Cox's proportional hazard analysis revealed an association between AKI+high BUN/Cr and mortality, whereas the association with AKI+low BUN/Cr did not reach statistical significance. When patients were grouped according to AKI and median BUN or creatinine values at admission, AKI was associated with mortality, regardless of BUN or creatinine. CONCLUSIONS The combination of AKI and elevated BUN/Cr, but not BUN or creatinine individually, is linked with an increased risk of mortality in ADHF patients, suggesting that the BUN/Cr is useful for risk stratification of AKI.
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Affiliation(s)
- Yoichi Takaya
- Department of Cardiology, National Cerebral and Cardiovascular Center
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241
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Ponikowski P, Jankowska EA. Patogenia y presentación clínica de la insuficiencia cardiaca aguda. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.01.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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242
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Núñez J, Miñana G, Santas E, Bertomeu-González V. Cardiorenal Syndrome in Acute Heart Failure: Revisiting Paradigms. ACTA ACUST UNITED AC 2015; 68:426-35. [PMID: 25758162 DOI: 10.1016/j.rec.2014.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/27/2014] [Indexed: 12/21/2022]
Abstract
Cardiorenal syndrome has been defined as the simultaneous dysfunction of both the heart and the kidney. Worsening renal function that occurs in patients with acute heart failure has been classified as cardiorenal syndrome type 1. In this setting, worsening renal function is a common finding and is due to complex, multifactorial, and not fully understood processes involving hemodynamic (renal arterial hypoperfusion and renal venous congestion) and nonhemodynamic factors. Traditionally, worsening renal function has been associated with worse outcomes, but recent findings have revealed mixed and heterogeneous results, perhaps suggesting that the same phenotype represents a diversity of pathophysiological and clinical situations. Interpreting the magnitude and chronology of renal changes together with baseline renal function, fluid overload status, and clinical response to therapy might help clinicians to unravel the clinical meaning of renal function changes that occur during an episode of heart failure decompensation. In this article, we critically review the contemporary evidence on the pathophysiology and clinical aspects of worsening renal function in acute heart failure.
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Affiliation(s)
- Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain.
| | - Gema Miñana
- Servicio de Cardiología, Hospital de Manises, Manises, Valencia, Spain
| | - Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Vicente Bertomeu-González
- Departamento de Cardiología, Hospital Universitario de San Juan, Universidad Miguel Hernández, San Juan de Alicante, Alicante, Spain
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243
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Verbrugge FH, Grieten L, Mullens W. Management of the cardiorenal syndrome in decompensated heart failure. Cardiorenal Med 2015; 4:176-88. [PMID: 25737682 DOI: 10.1159/000366168] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The management of the cardiorenal syndrome (CRS) in decompensated heart failure (HF) is challenging, with high-quality evidence lacking. SUMMARY The pathophysiology of CRS in decompensated HF is complex, with glomerular filtration rate (GFR) and urine output representing different aspects of kidney function. GFR depends on structural factors (number of functional nephrons and integrity of the glomerular membrane) versus hemodynamic alterations (volume status, renal perfusion, arterial blood pressure, central venous pressure or intra-abdominal pressure) and neurohumoral activation. In contrast, urine output and volume homeostasis are mainly a function of the renal tubules. Treatment of CRS in decompensated HF patients should be individualized based on the underlying pathophysiological processes. KEY MESSAGES Congestion, defined as elevated cardiac filling pressures, is not a surrogate for volume overload. Transient decreases in GFR might be accepted during decongestion, but hypotension must be avoided. Paracentesis and compression therapy are essential to remove fluid overload from third spaces. Increasing the effective circulatory volume improves renal function when cardiac output is depressed. As mechanical support is invasive and inotropes are related to increased mortality, afterload reduction through vasodilator therapy remains the preferred strategy in patients who are normo- or hypertensive. Specific therapies to augment renal perfusion (rolofylline, dopamine or nesiritide) have rendered disappointing results, but recently, serelaxin has been shown to improve renal function, even with a trend towards reduced all-cause mortality in selected patients. Diuretic resistance is associated with worse outcomes, independent of the underlying GFR. Combinational diuretic therapy, with ultrafiltration as a bail-out strategy, is indicated in case of diuretic resistance.
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Affiliation(s)
- Frederik Hendrik Verbrugge
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium ; Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Lars Grieten
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium ; Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - 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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244
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Ponikowski P, Jankowska EA. Pathogenesis and clinical presentation of acute heart failure. ACTA ACUST UNITED AC 2015; 68:331-7. [PMID: 25743769 DOI: 10.1016/j.rec.2015.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 01/13/2015] [Indexed: 12/11/2022]
Abstract
Acute heart failure constitutes a heterogeneous clinical syndrome, whose pathophysiology is complex and not completely understood. Given the diversity of clinical presentations, several different pathophysiological mechanisms along with factors triggering circulatory decompensation are involved. This article discusses the available evidence on the pathophysiological phenomena attributed or/and associated with episodes of acute heart failure and describes different clinical profiles, which, from a clinical perspective, constitute a key element for therapeutic decision-making.
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Affiliation(s)
- Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Centre for Heart Diseases, Military Hospital, Wroclaw, Poland.
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Centre for Heart Diseases, Military Hospital, Wroclaw, Poland
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Burnstock G, Pelleg A. Cardiac purinergic signalling in health and disease. Purinergic Signal 2015; 11:1-46. [PMID: 25527177 PMCID: PMC4336308 DOI: 10.1007/s11302-014-9436-1] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 11/25/2014] [Indexed: 01/09/2023] Open
Abstract
This review is a historical account about purinergic signalling in the heart, for readers to see how ideas and understanding have changed as new experimental results were published. Initially, the focus is on the nervous control of the heart by ATP as a cotransmitter in sympathetic, parasympathetic, and sensory nerves, as well as in intracardiac neurons. Control of the heart by centers in the brain and vagal cardiovascular reflexes involving purines are also discussed. The actions of adenine nucleotides and nucleosides on cardiomyocytes, atrioventricular and sinoatrial nodes, cardiac fibroblasts, and coronary blood vessels are described. Cardiac release and degradation of ATP are also described. Finally, the involvement of purinergic signalling and its therapeutic potential in cardiac pathophysiology is reviewed, including acute and chronic heart failure, ischemia, infarction, arrhythmias, cardiomyopathy, syncope, hypertrophy, coronary artery disease, angina, diabetic cardiomyopathy, as well as heart transplantation and coronary bypass grafts.
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Affiliation(s)
- Geoffrey Burnstock
- Autonomic Neuroscience Centre, University College Medical School, Rowland Hill Street, London, NW3 2PF, UK,
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Maisel A, Xue Y, Greene SJ, Pang PS, Januzzi JL, Piña IL, DeFilippi C, Butler J. The Potential Role of Natriuretic Peptide–Guided Management for Patients Hospitalized for Heart Failure. J Card Fail 2015; 21:233-9. [DOI: 10.1016/j.cardfail.2014.11.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 10/11/2014] [Accepted: 11/17/2014] [Indexed: 12/22/2022]
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Greene SJ, Fonarow GC, Vaduganathan M, Khan SS, Butler J, Gheorghiade M. The vulnerable phase after hospitalization for heart failure. Nat Rev Cardiol 2015; 12:220-9. [DOI: 10.1038/nrcardio.2015.14] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Felker GM, Butler J, Collins SP, Cotter G, Davison BA, Ezekowitz JA, Filippatos G, Levy PD, Metra M, Ponikowski P, Soergel DG, Teerlink JR, Violin JD, Voors AA, Pang PS. Heart failure therapeutics on the basis of a biased ligand of the angiotensin-2 type 1 receptor. Rationale and design of the BLAST-AHF study (Biased Ligand of the Angiotensin Receptor Study in Acute Heart Failure). JACC-HEART FAILURE 2015; 3:193-201. [PMID: 25650371 DOI: 10.1016/j.jchf.2014.09.008] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/15/2014] [Accepted: 09/18/2014] [Indexed: 01/14/2023]
Abstract
The BLAST-AHF (Biased Ligand of the Angiotensin Receptor Study in Acute Heart Failure) study is designed to test the efficacy and safety of TRV027, a novel biased ligand of the angiotensin-2 type 1 receptor, in patients with acute heart failure (AHF). AHF remains a major public health problem, and no currently-available therapies have been shown to favorably affect outcomes. TRV027 is a novel biased ligand of the angiotensin-2 type 1 receptor that antagonizes angiotensin-stimulated G-protein activation while stimulating β-arrestin. In animal models, these effects reduce afterload while increasing cardiac performance and maintaining stroke volume. In initial human studies, TRV027 appears to be hemodynamically active primarily in patients with activation of the renin-angiotensin-aldosterone system, a potentially attractive profile for an AHF therapeutic. BLAST-AHF is an international prospective, randomized, phase IIb, dose-ranging study that will randomize up to 500 AHF patients with systolic blood pressure ≥120 mm Hg and ≤200 mm Hg within 24 h of initial presentation to 1 of 3 doses of intravenous TRV027 (1, 5, or 25 mg/h) or matching placebo (1:1:1:1) for at least 48 h and up to 96 h. The primary endpoint is a composite of 5 clinical endpoints (dyspnea, worsening heart failure, length of hospital stay, 30-day rehospitalization, and 30-day mortality) combined using an average z-score. Secondary endpoints will include the assessment of dyspnea and change in amino-terminal pro-B-type natriuretic peptide. The BLAST-AHF study will assess the efficacy and safety of a novel biased ligand of the angiotensin-2 type 1 receptor in AHF.
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Affiliation(s)
- G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
| | - Javed Butler
- Division of Cardiology, Stony Brook University, Stony Brook, New York
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee
| | - Gad Cotter
- Momentum Research, Inc, Durham, North Carolina
| | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre at the University of Alberta, Edmonton, Alberta, Canada
| | | | - Phillip D Levy
- Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State School of Medicine, Detroit, Michigan
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health; University of Brescia, Brescia, Italy
| | - Piotr Ponikowski
- Department of Cardiology, Medical University, Clinical Military Hospital, Wroclaw, Poland
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California-San Francisco, San Francisco, California
| | | | - Adriaan A Voors
- Department of Cardiology, University of Groningen, Groningen, the Netherlands
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Collins S, Storrow AB, Albert NM, Butler J, Ezekowitz J, Felker GM, Fermann GJ, Fonarow GC, Givertz MM, Hiestand B, Hollander JE, Lanfear DE, Levy PD, Pang PS, Peacock WF, Sawyer DB, Teerlink JR, Lenihan DJ. Early management of patients with acute heart failure: state of the art and future directions. A consensus document from the society for academic emergency medicine/heart failure society of America acute heart failure working group. J Card Fail 2015; 21:27-43. [PMID: 25042620 PMCID: PMC4276508 DOI: 10.1016/j.cardfail.2014.07.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 06/28/2014] [Accepted: 07/10/2014] [Indexed: 12/18/2022]
Abstract
Heart failure (HF) afflicts nearly 6 million Americans, resulting in one million emergency department (ED) visits and over one million annual hospital discharges. An aging population and improved survival from cardiovascular diseases is expected to further increase HF prevalence. Emergency providers play a significant role in the management of patients with acute heart failure (AHF). It is crucial that emergency physicians and other providers involved in early management understand the latest developments in diagnostic testing, therapeutics and alternatives to hospitalization. Further, clinical trials must be conducted in the ED in order to improve the evidence base and drive optimal initial therapy for AHF. Should ongoing and future studies suggest early phenotype-driven therapy improves in-hospital and post-discharge outcomes, ED treatment decisions will need to evolve accordingly. The potential impact of future studies which incorporate risk-stratification into ED disposition decisions cannot be underestimated. Predictive instruments that identify a cohort of patients safe for ED discharge, while simultaneously addressing barriers to successful outpatient management, have the potential to significantly impact quality of life and resource expenditures.
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Affiliation(s)
- Sean Collins
- Nashville Veterans Affairs Medical Center and Vanderbilt University, Nashville, Tennessee.
| | | | | | | | | | | | | | | | | | | | | | | | | | - Peter S Pang
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - John R Teerlink
- San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California
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