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Buttar C, Alai H, Matanes FN, Cassidy MM, Stencel J, Le Jemtel TH. Full decongestion in acute heart failure therapy. Am J Med Sci 2024; 368:182-189. [PMID: 38880301 DOI: 10.1016/j.amjms.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/07/2024] [Accepted: 06/07/2024] [Indexed: 06/18/2024]
Abstract
Incomplete decongestion is the main cause of readmission in the early post-discharge period of a hospitalization for acute heart failure. Recent heart failure guidelines have highlighted initiation and rapid up-titration of quadruple therapy with angiotensin receptor neprilysin inhibitor, beta adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor to prevent hospitalizations for heart failure with reduced ejection fraction. However, full decongestion remains the foremost therapeutic goal of hospitalization for heart failure. While early addition of sodium glucose cotransporter 2 inhibitors and mineralocorticoid receptor antagonists may be helpful, the value of the other therapeutics comes after decongestion is complete.
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Affiliation(s)
- Chandan Buttar
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Hamid Alai
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Faris N Matanes
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Mark M Cassidy
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Jason Stencel
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Thierry H Le Jemtel
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA.
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Oskouie S, Pandey A, Sauer AJ, Greene SJ, Mullens W, Khan MS, Quinn KL, Ho JE, Albert NM, Van Spall HGC. From Hospital to Home: Evidence-Based Care for Worsening Heart Failure. JACC. ADVANCES 2024; 3:101131. [PMID: 39184855 PMCID: PMC11342447 DOI: 10.1016/j.jacadv.2024.101131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/02/2024] [Accepted: 06/10/2024] [Indexed: 08/27/2024]
Abstract
Heart failure (HF) is a leading cause of hospitalization in older adults. Patients are at high risk of readmission and death following hospitalization for HF. There is no standard approach of health care delivery during the hospital-to-home transition period, leaving missed opportunities in care optimization. In this review, we discuss contemporary randomized clinical trials that tested decongestion strategies, disease-modifying therapies, and health care services that inform the care of patients with worsening HF. We provide evidence-informed recommendations for optimizing therapies and improving outcomes during and following hospitalization for HF. These include adequate decongestion with loop diuretics and select sequential nephron blockade strategies based on early evaluation of diuretic response; initiation of disease-modifying pharmacotherapies prior to hospital discharge with close follow-up and optimization after discharge; cardiac rehabilitation; and transitional or palliative care referral post-hospitalization. Evidence-based implementation strategies to facilitate broad uptake include digital health tools and algorithm-driven optimization of pharmacotherapies.
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Affiliation(s)
- Suzanne Oskouie
- Division of Cardiology, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Ambarish Pandey
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew J. Sauer
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Stephen J. Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kieran L. Quinn
- Department of Medicine, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Tammy Latner Centre for Palliative Care, Toronto, Ontario, Canada
| | - Jennifer E. Ho
- Division of Cardiology, Department of Medicine, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nancy M. Albert
- Research and Innovation- Nursing Institute and Kaufman Center for Heart Failure- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Harriette GC. Van Spall
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
- Research Institute of St. Joseph’s Hospital Hamilton, Ontario, Canada
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Nardone M, Sridhar VS, Yau K, Odutayo A, Cherney DZI. Proximal versus distal diuretics in congestive heart failure. Nephrol Dial Transplant 2024; 39:1392-1403. [PMID: 38425090 DOI: 10.1093/ndt/gfae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Indexed: 03/02/2024] Open
Abstract
Volume overload represents a hallmark clinical feature linked to the development and progression of heart failure (HF). Alleviating signs and symptoms of volume overload represents a foundational HF treatment target that is achieved using loop diuretics in the acute and chronic setting. Recent work has provided evidence to support guideline-directed medical therapies, such as sodium glucose cotransporter 2 (SGLT2) inhibitors and mineralocorticoid receptor (MR) antagonists, as important adjunct diuretics that may act synergistically when used with background loop diuretics in people with chronic HF. Furthermore, there is growing interest in understanding the role of SGLT2 inhibitors, carbonic anhydrase inhibitors, thiazide diuretics, and MR antagonists in treating volume overload in patients hospitalized for acute HF, particularly in the setting of loop diuretic resistance. Thus, the current review demonstrates that: (i) SGLT2 inhibitors and MR antagonists confer long-term cardioprotection in chronic HF patients but it is unclear whether natriuresis or diuresis represents the primary mechanisms for this benefit, (ii) SGLT2 inhibitors, carbonic anhydrase inhibitors, and thiazide diuretics increase natriuresis in the acute HF setting, but implications on long-term outcomes remain unclear and warrants further investigation, and (iii) a multi-nephron segment approach, using agents that act on distinct segments of the nephron, potentiate diuresis to alleviate signs and symptoms of volume overload in acute HF.
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Affiliation(s)
- Massimo Nardone
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Vikas S Sridhar
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Kevin Yau
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Ayodele Odutayo
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - David Z I Cherney
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
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Kobayashi M, Yamashina A, Satomi K, Tezuka A, Ito S, Asakura M, Kitakaze M, Ferreira JP. Adverse events associated with early initiation of Eplerenone in patients hospitalized for acute heart failure. Int J Cardiol 2024; 415:132477. [PMID: 39181408 DOI: 10.1016/j.ijcard.2024.132477] [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] [Received: 03/08/2024] [Revised: 07/17/2024] [Accepted: 08/20/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND The guidelines recommend the initiation or up-titration of heart failure (HF) treatments following an HF hospitalization; however, concerns about adverse events may limit the use of mineralocorticoid receptor antagonists (MRAs). Patient profiles or disease severity might impact adverse events associated with MRA therapy in acute HF. METHODS The EARLIER trial included patients with acute HF who were randomized to eplerenone or placebo over 6 months. Adverse events (i.e., worsening renal function [WRF], hyperkalemia, hypotension, and volume depletion/dehydration) were assessed. HF-related outcome included a composite of all-cause mortality, HF re-hospitalization, investigator-reported worsening HF and out-of-hospital diuretic intensification. RESULTS In 297 patients (mean age: 67 ± 13 years; 73% males), adverse events were observed: 44.4% experienced WRF (>20% drop in estimated glomerular filtration rate[eGFR] and/or investigator-reported WRF), 8.4% had hyperkalemia (potassium >5.5 mmol/L and/or investigator-reported hyperkalemia), 27.9% experienced hypotension (systolic blood pressure[SBP] <90 mmHg and/or investigator-reported hypotension), and 16.8% had investigator-reported volume depletion/dehydration. Eplerenone vs. placebo did not elevate the incidence of these events (all-p-values>0.0 5). Multivariable analyses revealed that, irrespective of treatment allocation, older age (>7 5 years), prevalent diabetes, symptomatic congestion, and microalbuminuria were associated with increased risk of WRF. Baseline eGFR<60 ml/min/1.73m2 and SBP < 90 mmHg predicted hyperkalemia and hypotension, respectively, while older patients were more likely to experience volume depletion/dehydration. However, these patient profiles did not alter the benefit of eplerenone on outcomes (HR [9 5%CI] = 0.53 [0.29 to 0.97], P = 0.04; all-p-for-interaction>0.10). CONCLUSION Eplerenone did not increase adverse events compared with placebo in acute HF. Importantly, disease severity and comorbidity burden greatly influence adverse events, but not benefit from eplerenone.
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Affiliation(s)
| | | | - Kazuhiro Satomi
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Ayako Tezuka
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Shin Ito
- Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, Hyogo, Japan
| | - Masafumi Kitakaze
- Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Osaka, Japan; Hanwa Memorial Hospital, Osaka, Japan
| | - João Pedro Ferreira
- Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal; Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
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Siddiqi HK, Cox ZL, Stevenson LW, Damman K, Ter Maaten JM, Bales B, Han JH, Ivey-Miranda JB, Lindenfeld J, Miller KF, Ooi H, Rao VS, Schlendorf K, Storrow AB, Walsh R, Wrenn J, Testani JM, Collins SP. The utility of urine sodium-guided diuresis during acute decompensated heart failure. Heart Fail Rev 2024:10.1007/s10741-024-10424-8. [PMID: 39128947 DOI: 10.1007/s10741-024-10424-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 08/13/2024]
Abstract
Diuresis to achieve decongestion is a central aim of therapy in patients hospitalized for acute decompensated heart failure (ADHF). While multiple approaches have been tried to achieve adequate decongestion rapidly while minimizing adverse effects, no single diuretic strategy has shown superiority, and there is a paucity of data and guidelines to utilize in making these decisions. Observational cohort studies have shown associations between urine sodium excretion and outcomes after hospitalization for ADHF. Urine chemistries (urine sodium ± urine creatinine) may guide diuretic titration during ADHF, and multiple randomized clinical trials have been designed to compare a strategy of urine chemistry-guided diuresis to usual care. This review will summarize current literature for diuretic monitoring and titration strategies, outline evidence gaps, and describe the recently completed and ongoing clinical trials to address these gaps in patients with ADHF with a particular focus on the utility of urine sodium-guided strategies.
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Affiliation(s)
- Hasan K Siddiqi
- Department of Medicine, Vanderbilt University Medical Center, North Tower, 1215 21st Avenue South, 5th Floor, Office 5033C, Nashville, TN, 37232-8802, USA.
| | - Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, Nashville, TN, USA
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lynne W Stevenson
- Department of Medicine, Vanderbilt University Medical Center, North Tower, 1215 21st Avenue South, 5th Floor, Office 5033C, Nashville, TN, 37232-8802, USA
| | - Kevin Damman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jozine M Ter Maaten
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Brian Bales
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric, Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, North Tower, 1215 21st Avenue South, 5th Floor, Office 5033C, Nashville, TN, 37232-8802, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Henry Ooi
- Department of Medicine, Vanderbilt University Medical Center, North Tower, 1215 21st Avenue South, 5th Floor, Office 5033C, Nashville, TN, 37232-8802, USA
- Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Veena S Rao
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kelly Schlendorf
- Department of Medicine, Vanderbilt University Medical Center, North Tower, 1215 21st Avenue South, 5th Floor, Office 5033C, Nashville, TN, 37232-8802, USA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan Walsh
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jesse Wrenn
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric, Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Hollenberg SM, Stevenson LW, Ahmad T, Bozkurt B, Butler J, Davis LL, Drazner MH, Kirkpatrick JN, Morris AA, Page RL, Siddiqi HK, Storrow AB, Teerlink JR. 2024 ACC Expert Consensus Decision Pathway on Clinical Assessment, Management, and Trajectory of Patients Hospitalized With Heart Failure Focused Update: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2024:S0735-1097(24)07449-7. [PMID: 39127954 DOI: 10.1016/j.jacc.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
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Wu L, Rodriguez M, El Hachem K, Krittanawong C. Diuretic Treatment in Heart Failure: A Practical Guide for Clinicians. J Clin Med 2024; 13:4470. [PMID: 39124738 PMCID: PMC11313642 DOI: 10.3390/jcm13154470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Congestion and fluid retention are the hallmarks of decompensated heart failure and the major reason for the hospitalization of patients with heart failure. Diuretics have been used in heart failure for decades, and they remain the backbone of the contemporary management of heart failure. Loop diuretics is the preferred diuretic, and it has been given a class I recommendation by clinical guidelines for the relief of congestion symptoms. Although loop diuretics have been used virtually among all patients with acute decompensated heart failure, there is still very limited clinical evidence to guide the optimized diuretics use. This is a sharp contrast to the rapidly growing evidence of the rest of the guideline-directed medical therapy of heart failure and calls for further studies. The loop diuretics possess a unique pharmacology and pharmacokinetics that lay the ground for different strategies to increase diuretic efficiency. However, many of these approaches have not been evaluated in randomized clinical trials. In recent years, a stepped and protocolized diuretics dosing has been suggested to have superior benefits over an individual clinician-based strategy. Diuretic resistance has been a major challenge to decongestion therapy for patients with heart failure and is associated with a poor clinical prognosis. Recently, therapy options have emerged to help overcome diuretic resistance to loop diuretics and have been evaluated in randomized clinical trials. In this review, we aim to provide a comprehensive review of the pharmacology and clinical use of loop diuretics in the context of heart failure, with attention to its side effects, and adjuncts, as well as the challenges and future direction.
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Affiliation(s)
- Lingling Wu
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Mario Rodriguez
- John T. Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY 10029, USA
| | - Chayakrit Krittanawong
- Section of Cardiology, Cardiology Division, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY 10016, USA
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Natov PS, Ivey-Miranda JB, Cox ZL, Rao VS, Butler J, Konstam MA, Kiernan MS, Kapur NK, Testani JM. Increased Spironolactone Dosing in Acute Heart Failure Alters Potassium Homeostasis but Does not Enhance Decongestion. J Card Fail 2024:S1071-9164(24)00230-6. [PMID: 38986838 DOI: 10.1016/j.cardfail.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/28/2024] [Accepted: 06/07/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND The ATHENA-HF (Aldosterone Targeted Neurohormonal Combined with Natriuresis Therapy in Heart Failure) clinical trial found no improvements in natriuretic peptide levels or clinical congestion when spironolactone 100 mg/day for 96 hours was used in addition to usual treatment for acute heart failure. METHODS We performed a post hoc analysis of ATHENA-HF to determine whether spironolactone treatment induced any detectable pharmacodynamic effects and whether patients with potentially greater aldosterone activity experienced additional decongestion. Trial subjects previously treated with spironolactone were excluded. We first examined for changes in renal potassium handling. Using the baseline serum potassium level as a surrogate marker of spironolactone activity, we then divided each treatment arm into tertiles of baseline serum potassium and explored for differences in laboratory and clinical congestion outcomes. RESULTS Among spironolactone-naïve patients, the change in serum potassium did not differ after 24 hours or 48 hours but was significantly greater with spironolactone treatment compared to placebo at 72 hours (0.23 ± 0.55 vs 0.03 ± 0.60 mEq/L; P = 0.042) and 96 hours (0.32 ± 0.51 vs 0.13 ± 0.72 mEq/L; P = 0.046). Potassium supplementation was similar at treatment start and at 24 hours, but spironolactone-treated patients required substantially less potassium replacement at 48 hours (24% vs 36%; P = 0.048), 72 hours (21% vs 37%; P = 0.013), and 96 hours (11% vs 38%; P < 0.001). When the treatment arms were divided into tertiles of baseline serum potassium, there were no differences in the 96-hour log N-terminal pro-B-type natriuretic peptide levels, net fluid loss, urine output, or dyspnea relief in any of the potassium groups, with no effect modification by treatment exposure. CONCLUSIONS Spironolactone 100 mg/day for 96 hours in patients receiving intravenous loop diuresis for acute heart failure has no clear added decongestive ability but does meaningfully limit potassium wasting.
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Affiliation(s)
- Peter S Natov
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA; Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, Nashville, TN, USA
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA; Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Marvin A Konstam
- Department of Medicine, Division of Cardiology, The CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Michael S Kiernan
- Department of Medicine, Division of Cardiology, The CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Navin K Kapur
- Department of Medicine, Division of Cardiology, The CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.
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Llàcer P, Romero G, Trullàs JC, de la Espriella R, Cobo M, Quiroga B, Casado J, Slon-Roblero MF, Morales-Rull JL, Morgado JI, Ortiz A, Formiga F, Melendo-Viu M, de Sequera P, Recio A, Díez J, Manzano L, Núñez J. Consensus on the approach to hydrosaline overload in acute heart failure. SEMI/SEC/S.E.N. recommendations. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:556-565. [PMID: 38432324 DOI: 10.1016/j.rec.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/09/2024] [Indexed: 03/05/2024]
Abstract
Most of the signs and symptoms of heart failure can be explained by fluid overload, which is also related to disease progression. Fluid overload is a complex phenomenon that extends beyond increased intravascular pressures and poses challenges for accurate diagnosis and effective treatment. Current recommendations advise a multiparametric approach, including clinical data (symptoms/signs), imaging tests, and biomarkers. This article proposes a practical therapeutic approach to managing hydrosaline overload in heart failure in both inpatient and outpatient settings. This document is an initiative of the Spanish Society of Internal Medicine (SEMI) in collaboration with the Spanish Society of Cardiology (SEC) and the Spanish Society of Nephrology (S.E.N.).
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Affiliation(s)
- Pau Llàcer
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (Irycis), Madrid, Spain; Departamento de Medicina y Especialidades Médicas, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Gregorio Romero
- Servicio de Nefrología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain; Grupo de Trabajo de Medicina CardioRenal (CaReSEN), Sociedad Española de Nefrología (S.E.N.)
| | - Joan Carles Trullàs
- Servicio de Medicina Interna, Hospital d'Olot i Comarcal de la Garrotxa, Olot, Girona, Spain; Laboratori de Reparació i Regeneració Tissular (TRbLab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Barcelona, Spain
| | - Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria del Hospital Clínico de Valencia (Incliva), Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Marta Cobo
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA), Majadahonda, Madrid, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Borja Quiroga
- Servicio de Nefrología, Hospital Universitario de La Princesa, Instituto de Investigación del Hospital de La Princesa (IIS-La Princesa), Madrid, Spain
| | - Jesús Casado
- Servicio de Medicina Interna, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - María F Slon-Roblero
- Servicio de Nefrología, Hospital Universitario de Navarra, Pamplona, Navarra, Spain; Área de las Enfermedades Cardiovasculares y Renales, Instituto Navarro para la Investigación de la Salud (IdiSNA), Pamplona, Navarra, Spain
| | - José Luis Morales-Rull
- Servicio de Medicina Interna, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica (IRBLleida), Lleida, Spain
| | | | - Alberto Ortiz
- Servicio de Nefrología e Hipertensión, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (iiS-FJD), Universidad Autónoma de Madrid (UAM), Red de Investigación Cooperativa Orientada a Resultados en Salud b0d0 (RICORSb0d0), Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Francesc Formiga
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - María Melendo-Viu
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Patricia de Sequera
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, Spain
| | - Alejandro Recio
- Servicio de Cardiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Javier Díez
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Centro de Investigación Médica Aplicada (CIMA), Universidad de Navarra, Pamplona, Navarra, Spain
| | - Luis Manzano
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (Irycis), Madrid, Spain; Departamento de Medicina y Especialidades Médicas, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria del Hospital Clínico de Valencia (Incliva), Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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Horiuchi Y, Wettersten N. Treatment strategies for diuretic resistance in patients with heart failure. J Cardiol 2024:S0914-5087(24)00122-9. [PMID: 38914279 DOI: 10.1016/j.jjcc.2024.06.005] [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] [Received: 04/01/2024] [Revised: 06/13/2024] [Accepted: 06/18/2024] [Indexed: 06/26/2024]
Abstract
Improving congestion with diuretic therapy is crucial in the treatment of heart failure (HF). However, despite the use of loop diuretics, diuresis may be inadequate and congestion persists, which is known as diuretic resistance. Diuretic resistance and residual congestion are associated with a higher risk of rehospitalization and mortality. Causes of diuretic resistance in HF include diuretic pharmacokinetic changes, renal hemodynamic perturbations, neurohumoral activations, renal tubular remodeling, and use of nephrotoxic drugs as well as patient comorbidities. Combination diuretic therapy (CDT) has been advocated for the treatment of diuretic resistance. Thiazides, acetazolamides, tolvaptan, mineralocorticoid receptor antagonist, and sodium-glucose co-transporter-2 inhibitors are among the candidates, but none of these treatments has yet demonstrated significant diuretic efficacy or improved prognosis. At present, it is essential to identify and treat the causes of diuretic resistance in individual patients and to use CDT based on a better understanding of the characteristics of each drug to achieve adequate diuresis. Further research is needed to effectively assess and manage diuretic resistance and ultimately improve patient outcomes.
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Affiliation(s)
- Yu Horiuchi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan.
| | - Nicholas Wettersten
- Division of Cardiovascular Medicine, San Diego Veterans Affairs Medical Center, San Diego, CA, USA; Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, CA, USA
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11
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Schwann AN, Jaffe LM, Givertz MM, Wood KL, Engelman DT. Early Initiation of Guideline-Directed Medical Therapy for Heart Failure After Cardiac Surgery. Ann Thorac Surg 2024:S0003-4975(24)00463-6. [PMID: 38878947 DOI: 10.1016/j.athoracsur.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
There is an evolving role for guideline-directed medical therapy (GDMT) in managing heart failure with reduced ejection fraction after cardiac surgery. GDMT is based on the use of pharmacologic agents from each of 4 distinct drug classes, also known as the 4 pillars of heart failure therapy: β-blockers, renin-angiotensin system inhibitors, often paired with neprilysin inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. Despite the demonstrated benefits of GDMT in reducing mortality and hospitalization rates in the nonsurgical literature, there is conspicuous underuse of GDMT after cardiac surgery. The lack of published literature and practical challenges surrounding the timing for initiation of GDMT in the immediate postoperative period has limited standardized implementation strategies. A multidisciplinary approach will be necessary to assist in initiating, titrating, and monitoring the response to these therapies in patients with heart failure with reduced ejection fraction after cardiac surgery.
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Affiliation(s)
- Alexandra N Schwann
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Leeor M Jaffe
- Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katherine L Wood
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Daniel T Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts.
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12
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Vaduganathan M, Claggett BL, Lam CSP, Pitt B, Senni M, Shah SJ, Voors AA, Zannad F, Desai AS, Jhund PS, Viswanathan P, Bomfim Wirtz A, Schloemer P, Lay-Flurrie J, McMurray JJV, Solomon SD. Finerenone in patients with heart failure with mildly reduced or preserved ejection fraction: Rationale and design of the FINEARTS-HF trial. Eur J Heart Fail 2024; 26:1324-1333. [PMID: 38742248 DOI: 10.1002/ejhf.3253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/04/2024] [Accepted: 04/09/2024] [Indexed: 05/16/2024] Open
Abstract
AIM Steroidal mineralocorticoid receptor antagonists (MRAs), spironolactone and eplerenone, are strongly recommended in the treatment of patients with chronic heart failure (HF) with reduced left ventricular ejection fraction (LVEF), but the balance of efficacy and safety in those with higher LVEF has not been well established. Broad use of steroidal MRAs has further been limited in part due to safety concerns around risks of hyperkalaemia, gynecomastia, and kidney dysfunction. These risks may be mitigated by the unique pharmacological properties of the non-steroidal MRA finerenone. The FINEARTS-HF trial is designed to evaluate the long-term efficacy and safety of the selective non-steroidal MRA finerenone among patients with HF with mildly reduced or preserved ejection fraction. METHODS FINEARTS-HF is a global, multicentre, event-driven randomized trial evaluating oral finerenone versus matching placebo in symptomatic patients with HF with LVEF ≥40%. Adults (≥40 years) with HF with New York Heart Association class II-IV symptoms, LVEF ≥40%, evidence of structural heart disease, and diuretic use for at least the previous 30 days were eligible. All patients required elevated natriuretic peptide levels: for patients in sinus rhythm, N-terminal pro-B-type natriuretic peptide (NT-proBNP) ≥300 pg/ml (or B-type natriuretic peptide [BNP] ≥100 pg/ml) were required, measured within 30 days (in those without a recent worsening HF event) or within 90 days (in those with a recent worsening HF event). Qualifying levels of NT-proBNP or BNP were tripled if a patient was in atrial fibrillation at screening. Estimated glomerular filtration rate <25 ml/min/1.73 m2 or serum potassium >5.0 mmol/L were key exclusion criteria. Patients were enrolled irrespective of clinical care setting (whether hospitalized, recently hospitalized, or ambulatory). The primary endpoint is the composite of cardiovascular death and total (first and recurrent) HF events. The trial started on 14 September 2020 and has validly randomized 6001 participants across 37 countries. Approximately 2375 total primary composite events are targeted. CONCLUSIONS The FINEARTS-HF trial will determine the efficacy and safety of the non-steroidal MRA finerenone in a broad population of hospitalized and ambulatory patients with HF with mildly reduced or preserved ejection fraction. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT04435626 and EudraCT 2020-000306-29.
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Affiliation(s)
- Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Bertram Pitt
- University of Michigan, School of Medicine, Ann Arbor, MI, USA
| | - Michele Senni
- University Bicocca Milan, Milan, Italy
- Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Adriaan A Voors
- University Medical Center Groningen, Groningen, The Netherlands
| | - Faiez Zannad
- Université de Lorraine, Inserm Clinical Investigation Centre, CHU, Nancy, France
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | | | | | | | | | - John J V McMurray
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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13
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Khan MS, Chan PS, Sherrod CF, Ikemura N, Sauer AJ, Jones PG, Fonarow GC, Butler J, DeVore AD, Lund LH, Spertus JA. Generalizable Approach to Quantifying Guideline-Directed Medical Therapy. Circ Heart Fail 2024; 17:e011164. [PMID: 38742418 PMCID: PMC11108743 DOI: 10.1161/circheartfailure.123.011164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/30/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting. METHODS The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0-100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0-7), and modified HF Collaboratory (0-100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, β-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores. RESULTS Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was -1.94 (17.8); HF collaborator, -0.11 (1.32); and modified HF Collaboratory, -1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients. CONCLUSIONS KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed.
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Affiliation(s)
- Mirza S. Khan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Paul S. Chan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Charles F. Sherrod
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Nobuhiro Ikemura
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Andrew J. Sauer
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Philip G. Jones
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Gregg C. Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Adam D. DeVore
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Lars H. Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - John A. Spertus
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
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14
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Schuermans A, Verbrugge FH. Decongestion (instead of ultrafiltration?). Curr Opin Cardiol 2024; 39:188-195. [PMID: 38362936 DOI: 10.1097/hco.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE OF REVIEW To summarize the contemporary evidence on decongestion strategies in patients with acute heart failure (AHF). RECENT FINDINGS While loop diuretic therapy has remained the backbone of decongestive treatment in AHF, multiple randomized clinical trials suggest that early combination with other diuretic classes or molecules with diuretic properties should be considered. Mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors are disease-modifying drugs in heart failure that favourably influence prognosis early on, advocating their start as soon as possible in the absence of any compelling contraindications. Short-term upfront use of acetazolamide in adjunction to intravenous loop diuretic therapy relieves congestion faster, avoids diuretic resistance, and may shorten hospitalization length. Thiazide-like diuretics remain a good option to break diuretic resistance. Currently, ultrafiltration in AHF remains mainly reserved for patient with an inadequate response to pharmacological treatment. SUMMARY In most patients with AHF, decongestion can be achieved effectively and safely through combination diuretic therapies. Appropriate diuretic therapy may shorten hospitalization length and improve quality of life, but has not yet proven to reduce death or heart failure readmissions. Ultrafiltration currently has a limited role in AHF, mainly as bail-out strategy, but evidence for a more upfront use remains inconclusive.
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Affiliation(s)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
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15
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Sheehan M, Sokoloff L, Reza N. Acute Heart Failure: From The Emergency Department to the Intensive Care Unit. Cardiol Clin 2024; 42:165-186. [PMID: 38631788 PMCID: PMC11064814 DOI: 10.1016/j.ccl.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Acute heart failure (AHF) is a frequent cause of hospitalization around the world and is associated with high in-hospital and post-discharge morbidity and mortality. This review summarizes data on diagnosis and management of AHF from the emergency department to the intensive care unit. While more evidence is needed to guide risk stratification and care of patients with AHF, hospitalization is a key opportunity to optimize evidence-based medical therapy for heart failure. Close linkage to outpatient care is essential to improve post-hospitalization outcomes.
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Affiliation(s)
- Megan Sheehan
- Division of Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Maloney Building 5th Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Lara Sokoloff
- Division of Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Maloney Building 5th Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 11th Floor South Pavilion, Room 11-145, Philadelphia, PA 19104, USA.
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16
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Mocan D, Lala RI, Puschita M, Pilat L, Darabantiu DA, Pop-Moldovan A. The Congestion "Pandemic" in Acute Heart Failure Patients. Biomedicines 2024; 12:951. [PMID: 38790913 PMCID: PMC11117769 DOI: 10.3390/biomedicines12050951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/07/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
Congestion not only represents a cardinal sign of heart failure (HF) but is also now recognized as the primary cause of hospital admissions, rehospitalization, and mortality among patients with acute heart failure (AHF). Congestion can manifest through various HF phenotypes in acute settings: volume overload, volume redistribution, or both. Recognizing the congestion phenotype is paramount, as it implies different therapeutic strategies for decongestion. Among patients with AHF, achieving complete decongestion is challenging, as more than half still experience residual congestion at discharge. Residual congestion is one of the strongest predictors of future cardiovascular events and poor outcomes. Through this review, we try to provide a better understanding of the congestion phenomenon among patients with AHF by highlighting insights into the pathophysiological mechanisms behind congestion and new diagnostic and management tools to achieve and maintain efficient decongestion.
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Affiliation(s)
- Daniela Mocan
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | - Radu Ioan Lala
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
- Cardiology Department, Arad County Clinical Emergency Hospital, 310037 Arad, Romania
| | - Maria Puschita
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | - Luminita Pilat
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | | | - Adina Pop-Moldovan
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
- Cardiology Department, Arad County Clinical Emergency Hospital, 310037 Arad, Romania
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17
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Van den Eynde J, Verbrugge FH. Renal Sodium Avidity in Heart Failure. Cardiorenal Med 2024; 14:270-280. [PMID: 38565080 DOI: 10.1159/000538601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Increased renal sodium avidity is a hallmark feature of the heart failure syndrome. SUMMARY Increased renal sodium avidity refers to the inability of the kidneys to elicit potent natriuresis in response to sodium loading. This eventually causes congestion, which is a major contributor to hospital admissions and mortality in heart failure. KEY MESSAGES Important novel concepts such as the renal tamponade hypothesis, accelerated nephron loss, and the role of hypochloremia, the sympathetic nervous system, inflammation, the lymphatic system, and interstitial sodium buffers are involved in the pathophysiology of renal sodium avidity. A good understanding of these concepts is crucially important with respect to treatment recommendations regarding dietary sodium restriction, fluid restriction, rapid up-titration of guideline-directed medical therapies, combination diuretic therapy, natriuresis-guided diuretic therapy, use of hypertonic saline, and ultrafiltration.
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Affiliation(s)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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18
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Tumelty E, Chung I, Hussain S, Ali MA, Addada H, Banerjee D. An Updated Review of the Management of Chronic Heart Failure in Patients with Chronic Kidney Disease. Rev Cardiovasc Med 2024; 25:144. [PMID: 39076544 PMCID: PMC11264008 DOI: 10.31083/j.rcm2504144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 07/31/2024] Open
Abstract
Chronic kidney disease (CKD) is common in patients with heart failure (HF) and is associated with high morbidity and mortality. There has been remarkable progress in the treatment of HF over recent years with the establishment of guideline-directed medical therapies including: (1) Beta-blockers, (2) renal angiotensin aldosterone system (RAAS) inhibition (i.e., angiotensin-converting enzyme inhibitor [ACEi], aldosterone receptor blocker [ARB] or angiotensin receptor-neprilysin inhibitor [ARNI]); (3) mineralocorticoid receptor antagonists (MRA), and (4) sodium-glucose cotransporter-2 inhibitors (SGLT2i). However, there are challenges to the implementation of these medications in patients with concomitant CKD due to increased vulnerability to common side-effects (including worsening renal function, hyperkalaemia, hypotension), and most of the pivotal trials which provide evidence of the efficacy of these medications excluded patients with severe CKD. Patients with CKD and HF often have regular healthcare encounters with multiple professionals and can receive conflicting guidance regarding their medication. Thus, despite being at higher risk of adverse cardiovascular events, patients who have both HF and CKD are more likely to be under-optimised on evidence-based therapies. This review is an updated summary of the evidence available for the management of HF (including reduced, mildly reduced and preserved left ventricular ejection fraction) in patients with various stages of CKD. The review covers the evidence for recommended medications, devices such as implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), intravenous (IV) iron, and discusses how frailty affects the management of these patients. It also considers emerging evidence for the prevention of HF in the cohort of patients with CKD. It synthesises the available evidence regarding when to temporarily stop, continue or rechallenge medications in this cohort. Chronic HF in context of CKD remains a challenging scenario for clinicians to manage, which is usually complicated by frailty, multimorbidity and polypharmacy. Treatment should be tailored to a patients individual needs and management in specialised cardio-renal clinics with a multi-disciplinary team approach has been recommended. This review offers a concise summary on this expansive topic.
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Affiliation(s)
- Ella Tumelty
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Isaac Chung
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Sabba Hussain
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Mahrukh Ayesha Ali
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Harshavardhani Addada
- Cardiovascular and Genetics Research Institute St George’s University of London, SW17 0QT London, UK
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
- Cardiovascular and Genetics Research Institute St George’s University of London, SW17 0QT London, UK
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19
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Cuthbert JJ, Clark AL. Diuretic Treatment in Patients with Heart Failure: Current Evidence and Future Directions - Part I: Loop Diuretics. Curr Heart Fail Rep 2024; 21:101-114. [PMID: 38240883 PMCID: PMC10924023 DOI: 10.1007/s11897-024-00643-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE OF REVIEW Fluid retention or congestion is a major cause of symptoms, poor quality of life, and adverse outcome in patients with heart failure (HF). Despite advances in disease-modifying therapy, the mainstay of treatment for congestion-loop diuretics-has remained largely unchanged for 50 years. In these two articles (part I: loop diuretics and part II: combination therapy), we will review the history of diuretic treatment and the current trial evidence for different diuretic strategies and explore potential future directions of research. RECENT FINDINGS We will assess recent trials including DOSE, TRANSFORM, ADVOR, CLOROTIC, OSPREY-AHF, and PUSH-AHF amongst others, and assess how these may influence current practice and future research. There are few data on which to base diuretic therapy in clinical practice. The most robust evidence is for high dose loop diuretic treatment over low-dose treatment for patients admitted to hospital with HF, yet this is not reflected in guidelines. There is an urgent need for more and better research on different diuretic strategies in patients with HF.
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Affiliation(s)
- Joseph James Cuthbert
- Clinical Sciences Centre, Hull York Medical School, University of Hull, Cottingham Road, Kingston-Upon-Hull, East Yorkshire, UK.
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals Trust, Castle Road, Cottingham, East Yorkshire, UK.
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals Trust, Castle Road, Cottingham, East Yorkshire, UK
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20
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Umeh CA, Mohta T, Kaur G, Truong R, Darji P, Vue C, Cherukuri VB, Eghreriniovo B, Gupta R. Acetazolamide and Hydrochlorothiazide in Patients With Acute Decompensated Heart Failure: Insights From Recent Trials. Cardiol Res 2024; 15:69-74. [PMID: 38645830 PMCID: PMC11027779 DOI: 10.14740/cr1627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/05/2024] [Indexed: 04/23/2024] Open
Abstract
Acetazolamide and thiazide diuretics have been combined with loop diuretics to overcome diuretic resistance in heart failure patients. However, recent studies have assessed the upfront combination of acetazolamide and hydrochlorothiazide with loop diuretics in hospitalized patients with acute decompensated heart failure without loop diuretic resistance. We reviewed two recent randomized controlled trials on the upfront use of acetazolamide and thiazide diuretics in acute decompensated heart failure, respectively. When the two trials on acetazolamide are considered together, adding oral or intravenous acetazolamide to loop diuretics in decompensated heart failure patients resulted in increased diuresis and natriuresis. However, the effects were significantly higher in patients with serum bicarbonate ≥ 27 mmol/L and those with higher baseline glomerular filtration rate (GFR). Similarly, when the two trials on thiazide diuretics are considered together, adding hydrochlorothiazide to loop diuretics in decompensated heart failure patients resulted in increased diuresis and weight loss. However, it increases the risk of impaired renal function. When all the trials are considered together, the upfront use of acetazolamide may be helpful in carefully selected patients, including patients with underlying elevated bicarbonate levels (≥ 27 mmol/L) and those with good renal function (GFR > 50). Conversely, though the upfront use of thiazide diuretic added to intravenous furosemide improved diuretic response in acute decompensated heart failure, it causes an increased risk of worsening renal function and lack of clear evidence of reducing hospital length of stay.
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Affiliation(s)
- Chukwuemeka A. Umeh
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
- School of Medicine, St. George’s University, Grenada, West Indies, Grenada
- American University of Antigua, Osbourn, Antigua and Barbuda
| | - Tamanna Mohta
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Gagan Kaur
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Roland Truong
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Puja Darji
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Chong Vue
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
- American University of Antigua, Osbourn, Antigua and Barbuda
| | - Vijaya Bhargavi Cherukuri
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
- American University of Antigua, Osbourn, Antigua and Barbuda
| | - Benson Eghreriniovo
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Rahul Gupta
- Department of Internal Medicine, University of California, San Diego, CA 92122, USA
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21
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Si J, Ding Z, Hu Y, Zhang X, Zhang Y, Cao H, Liu Y. Predictors and prognostic implications of left ventricular ejection fraction trajectory improvement in the spectrum of heart failure with reduced and mildly reduced ejection fraction. J Cardiol 2024; 83:250-257. [PMID: 37802201 DOI: 10.1016/j.jjcc.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/11/2023] [Accepted: 09/28/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND The latest guidelines emphasize the significance of evaluating the left ventricular ejection fraction (LVEF) trajectory in patients with heart failure (HF). Because patients with HF with reduced ejection fraction (HFrEF) and HF with mildly reduced ejection fraction (HFmrEF) have reduction in systolic function, they might be in a trajectory of LVEF improvement after medical and device-based therapies. While previous studies have primarily focused on LVEF improvement in HFrEF, there is limited research on LVEF trajectory improvement across the spectrum of HFrEF and HFmrEF. This study aimed to assess the determinants and prognostic implications of LVEF trajectory improvement in HFrEF and HFmrEF patients. METHODS The cohort was classified into the improved group (HFrEF-to-HF with improved ejection fraction (HFimpEF) and HFmrEF-to-HF with preserved ejection fraction (HFpEF)) and the unimproved group (lack of improved group criteria). The primary endpoints were the composite of all-cause mortality or HF hospitalization, all-cause mortality, and HF hospitalization. Predictors of LVEF trajectory improvement were also evaluated. RESULTS A total 1303 patients were included in the study (improved/unimproved group: n = 497/806). Cox regression analysis showed that the improved group experienced lower risks of prespecified end points than the unimproved group. Multivariate logistic regression analysis showed that atrial flutter, use of spironolactone, and treatment with catheter ablation were associated with LVEF trajectory improvement, while myocardial infarction, prior percutaneous catheter intervention or coronary artery bypass graft, E/e', and left ventricular end-diastolic diameter were identified as negative predictors of LVEF trajectory improvement. In the improved subgroup, the prognosis for the HFrEF-to-HFimpEF and HFmrEF-to-HFpEF was comparable. CONCLUSIONS LVEF trajectory improvement patients had improved clinical outcomes and it was associated with important clinical, baseline cardiac structure and function, and treatment factors. Outcomes were similar in both HFrEF-to-HFimpEF and HFmrEF-to-HFpEF subgroups. These results suggest that emphasis should be placed on LVEF trajectory improvement to improve the outcomes of this population.
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Affiliation(s)
- Jinping Si
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Zijie Ding
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Yuze Hu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Xinxin Zhang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Yanli Zhang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Huajun Cao
- Clinical Laboratory, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China.
| | - Ying Liu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China.
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22
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Kazory A. Contemporary Decongestive Strategies in Acute Heart Failure. Semin Nephrol 2024; 44:151512. [PMID: 38702211 DOI: 10.1016/j.semnephrol.2024.151512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024]
Abstract
Congestion is the primary driver of hospital admissions in patients with heart failure and the key determinant of their outcome. Although intravenous loop diuretics remain the predominant agents used in the setting of acute heart failure, the therapeutic response is known to be variable, with a significant subset of patients discharged from the hospital with residual hypervolemia. In this context, urinary sodium excretion has gained attention both as a marker of response to loop diuretics and as a marker of prognosis that may be a useful clinical tool to guide therapy. Several decongestive strategies have been explored to improve diuretic responsiveness and removal of excess fluid. Sequential nephron blockade through combination diuretic therapy is one of the most used methods to enhance natriuresis and counter diuretic resistance. In this article, I provide an overview of the contemporary decongestive approaches and discuss the clinical data on the use of add-on diuretic therapy. I also discuss mechanical removal of excess fluid through extracorporeal ultrafiltration with a brief review of the results of landmark studies. Finally, I provide a short overview of the strategies that are currently under investigation and may prove helpful in this setting.
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Affiliation(s)
- Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, College of Medicine, University of Florida, Gainesville, FL.
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23
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Abstract
Acute heart failure (AHF) is a clinical complex disease and a worldwide issue due to its inconsistent diagnosis and poor prognosis. The cornerstone of pathophysiology of AHF is systemic venous congestion, which is led by the underlying structural and functional cardiac condition. Systemic venous congestion is a major target for AHF management because it causes symptoms and organs dysfunction, and is associated with poor prognosis. The mainstay of decongestive therapy is diuresis with intravenous loop diuretics combined with other diuretics including thiazides when necessary, and non-invasive ventilation. The presence of unresolved congestion at discharge can lead heart failure related rehospitalization, and careful follow-up is required especially during "vulnerable phase", several months after discharge. The updated recommendation for management of AHF has been provided by latest guidelines from European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Failure Society of America. Several large studies have currently demonstrated the benefits of guideline-directed oral medical therapies, and trials are ongoing on medication such as selective sodium-glucose transport proteins 2 inhibitors and protocols for congestive therapy. This review aimed to summarize the latest insights in AHF, based primarily on the most recent guidelines and large randomized controlled trials.
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Affiliation(s)
- Ayu Asakage
- Université de Paris Cité, Paris, France; INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France.
| | - Alexandre Mebazaa
- Université de Paris Cité, Paris, France; INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France; Department of Anesthesiology, Critical Care and Burn Unit, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; FHU PROMICE
| | - Benjamin Deniau
- Université de Paris Cité, Paris, France; INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France; Department of Anesthesiology, Critical Care and Burn Unit, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; FHU PROMICE; INI-CRCT
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24
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Segar MW, Khan MS, Patel KV, Butler J, Ravichandran AK, Walsh MN, Willett D, Fonarow GC, Drazner MH, Mentz RJ, Hall J, Farr MA, Hedayati SS, Yancy C, Allen LA, Tang WHW, Pandey A. A Phenomapping Tool and Clinical Score to Identify Low Diuretic Efficiency in Acute Decompensated Heart Failure. JACC. HEART FAILURE 2024; 12:508-520. [PMID: 38099890 DOI: 10.1016/j.jchf.2023.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/19/2023] [Accepted: 09/27/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Individuals with acute decompensated heart failure (ADHF) have a varying response to diuretic therapy. Strategies for the early identification of low diuretic efficiency to inform decongestion therapies are lacking. OBJECTIVES The authors sought to develop and externally validate a machine learning-based phenomapping approach and integer-based diuresis score to identify patients with low diuretic efficiency. METHODS Participants with ADHF from ROSE-AHF, CARRESS-HF, and ATHENA-HF were pooled in the derivation cohort (n = 794). Multivariable finite-mixture model-based phenomapping was performed to identify phenogroups based on diuretic efficiency (urine output over the first 72 hours per total intravenous furosemide equivalent loop diuretic dose). Phenogroups were externally validated in other pooled ADHF trials (DOSE/ESCAPE). An integer-based diuresis score (BAN-ADHF score: blood urea nitrogen, creatinine, natriuretic peptide levels, atrial fibrillation, diastolic blood pressure, hypertension and home diuretic, and heart failure hospitalization) was developed and validated based on predictors of the diuretic efficiency phenogroups to estimate the probability of low diuretic efficiency using the pooled ADHF trials described earlier. The associations of the BAN-ADHF score with markers and symptoms of congestion, length of stay, in-hospital mortality, and global well-being were assessed using adjusted regression models. RESULTS Clustering identified 3 phenogroups based on diuretic efficiency: phenogroup 1 (n = 370; 47%) had lower diuretic efficiency (median: 13.1 mL/mg; Q1-Q3: 7.7-19.4 mL/mg) than phenogroups 2 (n = 290; 37%) and 3 (n = 134; 17%) (median: 17.8 mL/mg; Q1-Q3: 10.8-26.1 mL/mg and median: 35.3 mL/mg; Q1-Q3: 17.5-49.0 mL/mg, respectively) (P < 0.001). The median urine output difference in response to 80 mg intravenous twice-daily furosemide between the lowest and highest diuretic efficiency group (phenogroup 1 vs 3) was 3,520 mL/d. The BAN-ADHF score demonstrated good model performance for predicting the lowest diuretic efficiency phenogroup membership (C-index: 0.92 in DOSE/ESCAPE validation cohort) that was superior to measures of kidney function (creatinine or blood urea nitrogen), natriuretic peptide levels, or home diuretic dose (DeLong P < 0.001 for all). Net urine output in response to 80 mg intravenous twice-daily furosemide among patients with a low vs high (5 vs 20) BAN-ADHF score was 2,650 vs 660 mL per 24 hours, respectively. Participants with higher BAN-ADHF scores had significantly lower global well-being, higher natriuretic peptide levels on discharge, a longer in-hospital stay, and a higher risk of in-hospital mortality in both derivation and validation cohorts. CONCLUSIONS The authors developed and validated a phenomapping strategy and diuresis score for individuals with ADHF and differential response to diuretic therapy, which was associated with length of stay and mortality.
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Affiliation(s)
- Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | | | - Kershaw V Patel
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
| | | | - Mary Norine Walsh
- Department of Cardiology, St Vincent Heart Center, Indianapolis, Indiana, USA
| | - DuWayne Willett
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gregg C Fonarow
- Ronald Reagan UCLA Medical Center, Ahmanson-UCLA Cardiomyopathy Center, Division of Cardiology, Los Angeles, California, USA
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Robert J Mentz
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Hall
- Institute for Precision Cardiovascular Medicine at the American Heart Association, Dallas, Texas, USA
| | - Maryjane A Farr
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - S Susan Hedayati
- Division of Nephrology, Department of Medicine, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Clyde Yancy
- Division of Cardiology, Department of Internal Medicine, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Larry A Allen
- Division of Cardiology, University of Colorado, Aurora, Colorado, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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25
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Palazzuoli A, Ruocco G, Del Buono MG, Pavoncelli S, Delcuratolo E, Abbate A, Lavie CJ. The role and application of current pharmacological management in patients with advanced heart failure. Heart Fail Rev 2024; 29:535-548. [PMID: 38285236 DOI: 10.1007/s10741-024-10383-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Abstract
In the last decades, several classifications and definitions have been proposed for advanced heart failure (ADVHF) patients, including clinical, functional, hemodynamic, imaging, and electrocardiographic features. Despite different inclusion criteria, ADVHF is characterized by some common items, such as drug intolerance, low arterial pressure, multiple organ dysfunction, chronic kidney disease, and diuretic use dependency. Additional features include fatigue, hypotension, hyponatremia, and unintentional weight loss associated with a specific laboratory profile reflecting systemic multiorgan dysfunction. Notably, studies evaluating guideline-directed medical therapy recently endorsed by guidelines in stable HF, including the 4 drug classes all together (i.e., betablocker, mineral corticoid antagonist, renin angiotensin inhibitors/neprilysin inhibitors, and sodium glucose transporter inhibitors), remain scarcely analyzed in ADVHF and New York Heart Association (NYHA) Class IV. Additionally, due to the common conditions associated with advanced stages, the balance between drug tolerance and potential benefits of the contemporary use of all agents is questioned. Therefore, less hard endpoints, such as exercise tolerance, quality of life (QoL) and self-competency, are not clearly demonstrated. Specific analyses evaluating outcome and rehospitalization of each drug provided conflicting results and are often limited to subjects with stable conditions and less advanced NYHA class. Current European Society of Cardiology/American Heart Association (ESC/AHA) Guidelines do not indicate the type of treatment, dosage, and administration modalities, and they do not suggest specific indications for ADVHF patients. Due to these concerns, there is an impelling need to understand what drugs may be used as the first line, what management leads to the better outcome, and what is the best treatment algorithm in this setting. In this paper, we summarize the most common pitfalls and limitations for the use of the traditional agents, and we propose a personalized approach aiming at preserve drug tolerance and maintaining adverse event protection and satisfactory QoL.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardiothoracic and Vascular Department, Le Scotte Hospital, University of Siena, Viale Bracci 12, 53100, Siena, Italy.
| | - Gaetano Ruocco
- Cardiology Unit, "Buon Consiglio Hospital" Fatebenefratelli, Naples, Italy
| | - Marco Giuseppe Del Buono
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, Rome, Italy
| | - Simona Pavoncelli
- Cardiovascular Diseases Unit, Cardiothoracic and Vascular Department, Le Scotte Hospital, University of Siena, Viale Bracci 12, 53100, Siena, Italy
| | - Elvira Delcuratolo
- Cardiovascular Diseases Unit, Cardiothoracic and Vascular Department, Le Scotte Hospital, University of Siena, Viale Bracci 12, 53100, Siena, Italy
| | - Antonio Abbate
- Berne Cardiovascular Research Center, Division of Cardiology and Heart and Vascular Center, University of Virginia-School of Medicine, Charlottesville, VA, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
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26
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Abuelazm M, Badr A, Turkmani M, Amin MA, Amin AM, Aboutaleb A, Gowaily I, Soliman Y, Abdelazeem B. The efficacy and safety of new potassium binders on renin-angiotensin-aldosterone system inhibitor optimization in heart failure patients: a systematic review and meta-analysis. ESC Heart Fail 2024; 11:28-43. [PMID: 38012095 PMCID: PMC10804144 DOI: 10.1002/ehf2.14588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/08/2023] [Accepted: 10/29/2023] [Indexed: 11/29/2023] Open
Abstract
Guideline-directed medical therapy (GDMT) has improved outcomes in patients with heart failure, including the use of renin-angiotensin-aldosterone system inhibitors, which can hinder the excretion of potassium, resulting in hyperkalaemia. New potassium binders (NPBs) can prevent this adverse effect; however, the efficacy and safety of NPB for this indication have not been fully established. We conducted a systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), which were retrieved by systematically searching PubMed, Web of Science, Scopus, and Cochrane through 26 April 2023. The risk of bias assessment was conducted, following Cochrane's updated Risk of Bias 2 assessment tool. We used the fixed-effects model to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), with a 95% confidence interval (CI) (PROSPERO ID: CRD42023426113). We included six RCTs with a total of 1432 patients. NPB was significantly associated with successful mineralocorticoid receptor antagonist (MRA) optimization [RR: 1.13 with 95% CI (1.02-1.25), P = 0.02], decreased patients with MRA at less than the target dose [RR: 0.72 with 95% CI (0.57-0.90), P = 0.004], and decreased hyperkalaemic episodes [RR: 0.42 with 95% CI (0.24-0.72), P = 0.002]. However, there was no difference between NPB and placebo regarding angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB)/angiotensin receptor/neprilysin inhibitor (ANRi) optimization [RR: 1.02 with 95% CI (0.89-1.17), P = 0.76] and serum potassium change [MD: -0.31 with 95% CI (-0.61 to 0.00), P = 0.05], with an acceptable safety profile except for the increased incidence of hypokalaemia with NPB [RR: 1.57 with 95% CI (1.12-2.21), P = 0.009]. NPB has been shown to improve GDMT outcomes by enhancing MRA optimization and reducing hyperkalaemic episodes. However, there are limited data on the effects of NPB on ACEi/ARB/ANRi optimization. Future RCTs should investigate ACEi/ARB/ANRi optimization and conduct head-to-head comparisons of NPB (patiromer and sodium zirconium cyclosilicate).
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Affiliation(s)
| | - Amr Badr
- Department of CardiologyBanha Teaching HospitalBanhaEgypt
| | - Mustafa Turkmani
- Department of Internal MedicineMcLaren Health CareOaklandMIUSA
- Department of Internal MedicineMichigan State UniversityEast LansingMIUSA
| | | | | | | | | | | | - Basel Abdelazeem
- Department of Internal MedicineMichigan State UniversityEast LansingMIUSA
- Department of CardiologyWest Virginia UniversityMorgantownWVUSA
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27
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Trullàs JC, Casado J. [Diuretic resistance in heart failure]. Med Clin (Barc) 2024; 162:19-21. [PMID: 37919121 DOI: 10.1016/j.medcli.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Joan Carles Trullàs
- Servicio de Medicina Interna, Hospital d'Olot i Comarcal de la Garrotxa, Girona, Catalunya, España; Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Barcelona, Catalunya, España; Grupo de Trabajo de Insuficiencia Cardiaca y Fibrilación Auricular de la Sociedad Española de Medicina Interna, Madrid, España.
| | - Jesús Casado
- Grupo de Trabajo de Insuficiencia Cardiaca y Fibrilación Auricular de la Sociedad Española de Medicina Interna, Madrid, España; Servicio de Medicina Interna, Hospital Universitario de Getafe, Madrid, España
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28
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Wilson BJ, Bates D. Diuretic Strategies in Acute Decompensated Heart Failure: A Narrative Review. Can J Hosp Pharm 2024; 77:e3323. [PMID: 38204501 PMCID: PMC10754413 DOI: 10.4212/cjhp.3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/15/2023] [Indexed: 01/12/2024]
Abstract
Background Heart failure is a common condition with considerable associated costs, morbidity, and mortality. Patients often present to hospital with dyspnea and edema. Inadequate inpatient decongestion is an important contributor to high readmission rates. There is little evidence concerning diuresis to guide clinicians in caring for patients with acute decompensated heart failure. Contemporary diuretic strategies have been defined by expert opinion and older landmark clinical trials. Objective To present a narrative review of contemporary recommendations, along with their underlying evidence and pharmacologic rationale, for diuretic strategies in inpatients with acute decompensated heart failure. Data Sources PubMed, OVID, and Embase databases were searched from inception to December 22, 2022, with the following search terms: heart failure, acute heart failure, decompensated heart failure, furosemide, bumetanide, ethacrynic acid, hydrochlorothiazide, indapamide, metolazone, chlorthalidone, spironolactone, eplerenone, and acetazolamide. Study Selection Randomized controlled trials and systematic reviews involving at least 100 adult patients (> 18 years) were included. Trials involving torsemide, chlorothiazide, and tolvaptan were excluded. Data Synthesis Early, aggressive administration of a loop diuretic has been associated with expedited symptom resolution, shorter length of stay, and possibly reduced mortality. Guidelines make recommendations about dose and frequency but do not recommend any particular loop diuretic over another; however, furosemide is most commonly used. Guidelines recommend that the initial furosemide dose (on admission) be 2-2.5 times the patient's home dose. A satisfactory diuretic response can be defined as spot urine sodium content greater than 50-70 mmol/L at 2 hours; urine output greater than 100-150 mL/h in the first 6 hours or 3-5 L in 24 hours; or a change in weight of 0.5-1.5 kg in 24 hours. If congestion persists after the maximization of loop diuretic therapy over the first 24-48 hours, an adjunctive diuretic such as thiazide or acetazolamide should be added. If decongestion targets are not met, continuous infusion of furosemide may be considered. Conclusions Heart failure with congestion can be managed with careful administration of high-dose loop diuretics, supported by thiazides and acetazolamide when necessary. Clinical trials are underway to further evaluate this strategy.
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Affiliation(s)
- Ben J Wilson
- , MD, FRCPC, is a Clinical Assistant Professor with the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Duane Bates
- , BScPharm, ACPR, is a Clinical Pharmacist with the Calgary Zone, Alberta Health Services, Calgary, Alberta
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29
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Bilgeri V, Spitaler P, Puelacher C, Messner M, Adukauskaite A, Barbieri F, Bauer A, Senoner T, Dichtl W. Decongestion in Acute Heart Failure-Time to Rethink and Standardize Current Clinical Practice? J Clin Med 2024; 13:311. [PMID: 38256444 PMCID: PMC10816514 DOI: 10.3390/jcm13020311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/31/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Most episodes of acute heart failure (AHF) are characterized by increasing signs and symptoms of congestion, manifested by edema, pleura effusion and/or ascites. Immediately and repeatedly administered intravenous (IV) loop diuretics currently represent the mainstay of initial therapy aiming to achieve adequate diuresis/natriuresis and euvolemia. Despite these efforts, a significant proportion of patients have residual congestion at discharge, which is associated with a poor prognosis. Therefore, a standardized approach is needed. The door to diuretic time should not exceed 60 min. As a general rule, the starting IV dose is 20-40 mg furosemide equivalents in loop diuretic naïve patients or double the preexisting oral home dose to be administered via IV. Monitoring responses within the following first hours are key issues. (1) After 2 h, spot urinary sodium should be ≥50-70 mmol/L. (2) After 6 h, the urine output should be ≥100-150 mL/hour. If these target measures are not reached, the guidelines currently recommend a doubling of the original dose to a maximum of 400-600 mg furosemide per day and in patients with severely impaired kidney function up to 1000 mg per day. Continuous infusion of loop diuretics offers no benefit over intermittent boluses (DOSE trial). Emerging evidence by recent randomized trials (ADVOR, CLOROTIC) supports the concept of an early combination diuretic therapy, by adding either acetazolamide (500 mg IV once daily) or hydrochlorothiazide. Acetazolamide is particularly useful in the presence of a baseline bicarbonate level of ≥27 mmol/L and remains effective in the presence of preexisting/worsening renal dysfunction but should be used only in the first three days to prevent severe metabolic disturbances. Patients should not leave the hospital when they are still congested and/or before optimized long-term guideline-directed medical therapy has been initiated. Special attention should be paid to AHF patients during the vulnerable post-discharge period, with an early follow-up visit focusing on up-titrate treatments of recommended doses within 2 weeks (STRONG-HF).
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Affiliation(s)
- Valentin Bilgeri
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Philipp Spitaler
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Christian Puelacher
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Moritz Messner
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Agne Adukauskaite
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Fabian Barbieri
- Deutsches Herzzentrum der Charité, Hindenburgdamm 30, 12203 Berlin, Germany;
| | - Axel Bauer
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Thomas Senoner
- Department of Anesthesiology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
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30
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Sabina M, Barakat Z, Feliciano A, Lamb A, Alsamman MM. Unlocking the Potential of Acetazolamide: A Literature Review of an Adjunctive Approach in Heart Failure Management. J Clin Med 2024; 13:288. [PMID: 38202295 PMCID: PMC10780103 DOI: 10.3390/jcm13010288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/28/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024] Open
Abstract
Background: Heart failure (HF) patients often experience persistent fluid overload despite standard diuretic therapy. The adjunctive use of acetazolamide, a carbonic anhydrase inhibitor, in combination with loop diuretics has shown promise in improving decongestion and diuretic efficacy. This literature review aims to analyze six studies evaluating the effectiveness of acetazolamide as an additive treatment for acute decompensated heart failure (ADHF) and its impact on various outcomes. Methods: We searched the PubMed database using the terms "acetazolamide heart failure". We refined our search with specific filters (as shown our PRISMA flow diagram) and exclusion criteria, narrowing down our results to five studies. We included an extra study via expert recommendation, ultimately including six studies for comprehensive analysis. Results: The review highlights the positive effects of acetazolamide on decongestion, natriuresis, and diuresis in HF patients. However, it also showcases the limitations of these trials. Discussion: While the reviewed studies demonstrate the potential benefits of acetazolamide in enhancing decongestion and diuretic efficiency, there are limitations to consider, including small sample sizes, lack of blinding, and limited external validity. Further research is needed to confirm these findings, compare acetazolamide with other diuretic combinations, and explore its effects in a broader population of heart failure patients, including those in the United States. The use of acetazolamide in HF management warrants continued investigation to optimize its role in improving decongestion and patient outcomes.
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Affiliation(s)
- Michael Sabina
- Lakeland Regional Health Medical Center, Lakeland 33805-4500, FL, USA; (Z.B.); (A.F.); (A.L.); (M.M.A.)
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Alevroudis I, Kotoulas SC, Tzikas S, Vassilikos V. Congestion in Heart Failure: From the Secret of a Mummy to Today's Novel Diagnostic and Therapeutic Approaches: A Comprehensive Review. J Clin Med 2023; 13:12. [PMID: 38202020 PMCID: PMC10779505 DOI: 10.3390/jcm13010012] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/04/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
This review paper presents a review of the evolution of this disease throughout the centuries, describes and summarizes the pathophysiologic mechanisms, briefly discusses the mechanism of action of diuretics, presents their role in decongesting heart failure in patients, and reveals the data behind ultrafiltration in the management of acutely or chronically decompensated heart failure (ADHF), focusing on all the available data and advancements in this field. Acutely decompensated heart failure (ADHF) presents a critical clinical condition characterized by worsening symptoms and signs of heart failure, necessitating prompt intervention to alleviate congestion and improve cardiac function. Diuretics have traditionally been the mainstay for managing fluid overload in ADHF. Mounting evidence suggests that due to numerous causes, such as coexisting renal failure or chronic use of loop diuretics, an increasing rate of diuretic resistance is noticed and needs to be addressed. There has been a series of trials that combined diuretics of different categories without the expected results. Emerging evidence suggests that ultrafiltration may offer an alternative or adjunctive approach.
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Affiliation(s)
- Ioannis Alevroudis
- Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece (V.V.)
- Intensive Care Medicine Clinic, Ippokratio General Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | | | - Stergios Tzikas
- Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece (V.V.)
| | - Vassilios Vassilikos
- Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece (V.V.)
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32
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Taban-Sadeghi M, Khani E, Khezripour K, Enamzadeh E, Safaei N, Entezari-Maleki T. Effects of Triamterene in Hospitalized Patients with Heart Failure and Diuretic Resistance: A Randomized Clinical Trial. J Clin Pharmacol 2023; 63:1352-1358. [PMID: 37493211 DOI: 10.1002/jcph.2321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/20/2023] [Indexed: 07/27/2023]
Abstract
Due to the potential benefits of triamterene in diuretic resistance, this study was performed to assess whether triamterene add-on to the standard treatment of heart failure (HF)-related diuretic resistance improves outcomes. A randomized clinical trial was performed on 45 hospitalized patients with HF with reduced ejection fraction who had diuretic resistance. Patients were randomized to receive either triamterene 50 mg plus hydrochlorothiazide 25 mg (n = 23) or hydrochlorothiazide 50 mg alone (n = 22) until hospital discharge. The primary outcomes were changes in weight and fluid input-to-output ratio. Secondary outcomes were respiratory rate, hospitalization duration, serum sodium and potassium, estimated glomerular filtration rate, creatinine, and blood urea nitrogen levels during the study period. The mean (standard deviation) of weight changes was not significantly different in the intervention and the control groups (-6.3 [4.8] vs -4.8 [2.4] kg, respectively; P = .1). No significant differences were shown in input-to-output changes between the 2 groups (208.0 [243.4] in the intervention and 600.2 [250.3] in the control group; P = .4). Although the respiratory rate of triamterene-treated patients decreased, the difference did not reach statistical significance (P = .2). Other secondary outcomes were also similar in both groups. This study did not support the use of triamterene as an add-on therapy for patients with HF-related diuretic resistance.
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Affiliation(s)
| | - Elnaz Khani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kimia Khezripour
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elgar Enamzadeh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Naser Safaei
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Taher Entezari-Maleki
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
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33
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Kaddour M, Burri H. Conduction System Pacing: Have We Finally Found the Holy Grail of Physiological Pacing? Heart Int 2023; 17:2-5. [PMID: 38419718 PMCID: PMC10898585 DOI: 10.17925/hi.2023.17.2.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/25/2023] [Indexed: 03/02/2024] Open
Abstract
The late fifties are considered a high point in the history of cardiac pacing, since this era is marked by the first pacemaker implantation, which has since evolved into life-saving therapy. Right ventricular apical and biventricular pacing are the classic techniques that are recommended as first-l ine approaches for most indications in current guidelines. However, conduction system pacing has emerged as being able to deliver a more physiological form of pacing and is becoming mainstream practice in a growing number of centres. In this review, we aim to compare traditional pacing methods with conduction system pacing.
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Affiliation(s)
- Myriam Kaddour
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
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34
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Moreira GR, Villacorta H. A Personalized Approach to the Management of Congestion in Acute Heart Failure. Heart Int 2023; 17:35-42. [PMID: 38455673 PMCID: PMC10919353 DOI: 10.17925/hi.2023.17.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/18/2023] [Indexed: 03/09/2024] Open
Abstract
Heart failure (HF) is the common final pathway of several conditions and is characterized by hyperactivation of numerous neurohumoral pathways. Cardiorenal interaction plays an essential role in the progression of the disease, and the use of diuretics is a cornerstone in the treatment of hypervolemic patients, especially in acute decompensated HF (ADHF). The management of congestion is complex and, to avoid misinterpretations and errors, one must understand the interface between the heart and the kidneys in ADHF. Congestion itself may impair renal function and must be treated aggressively. Transitory elevations in serum creatinine during decongestion is not associated with worse outcomes and diuretics should be maintained in patients with clear hypervolemia. Monitoring urinary sodium after diuretic administration seems to improve the response to diuretics as it allows for adjustments in doses and a personalized approach. Adequate assessment of volemia and the introduction and titration of guideline-directed medical therapy are mandatory before discharge. An early visit after discharge is highly recommended, to assess for residual congestion and thus avoid readmissions.
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Affiliation(s)
- Gustavo R Moreira
- Cardiology Division, Fluminense Federal University, Niterói, Rio de Janeiro State, Brazil
| | - Humberto Villacorta
- Cardiology Division, Fluminense Federal University, Niterói, Rio de Janeiro State, Brazil
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35
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Lavalle C, Di Lullo L, Jabbour JP, Palombi M, Trivigno S, Mariani MV, Summaria F, Severino P, Badagliacca R, Miraldi F, Bellasi A, Vizza CD. New Challenges in Heart Failure with Reduced Ejection Fraction: Managing Worsening Events. J Clin Med 2023; 12:6956. [PMID: 38002571 PMCID: PMC10672118 DOI: 10.3390/jcm12226956] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/25/2023] [Accepted: 11/05/2023] [Indexed: 11/26/2023] Open
Abstract
Patients with an established diagnosis of heart failure (HF) with reduced ejection fraction (HFrEF) are prone to experience episodes of worsening symptoms and signs despite continued therapy, termed "worsening heart failure" (WHF). Despite guideline-directed medical therapy, worsening of chronic heart failure accounts for almost 50% of all hospital admissions for HF, and patients experiencing WHF carry a substantially higher risk of death and hospitalization than patients with "stable" HF. New drugs are emerging as arrows in the quiver for clinicians to address the residual risk of HF hospitalization and cardiovascular deaths in patients with WHF. This question-and-answer-based review will discuss the emerging definition of WHF in light of the recent clinical consensus released by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC), the new therapeutic approaches to treat WHF and then move on to their timing and safety concerns (i.e., renal profile).
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Affiliation(s)
- Carlo Lavalle
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, L. Parodi—Delfino Hospital, 00034 Rome, Italy;
| | - Jean Pierre Jabbour
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Marta Palombi
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Sara Trivigno
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | | | - Paolo Severino
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Fabio Miraldi
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Antonio Bellasi
- Department of Medicine, Division of Nephrology, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
| | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
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36
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Georges G, Fudim M, Burkhoff D, Leon MB, Généreux P. Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 2. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101059. [PMID: 39131062 PMCID: PMC11307977 DOI: 10.1016/j.jscai.2023.101059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 08/13/2024]
Abstract
Congestion is the most common manifestation of acute decompensated heart failure (ADHF). Residual congestion despite initial medical therapy is common and is recognized to be associated with worse outcomes; however, there are currently no standardized definition regarding decongestion end point. In the second part of this 2-part review, we provide a critical appraisal of decongestion definitions previously used in ADHF studies, review alternative metrics to define severity of volume overload, and propose a more granular 4-class congestion grading scheme and decongestion end point definitions that could potentially be included in future ADHF trials and consensus definitions.
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Affiliation(s)
- Gabriel Georges
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Martin B. Leon
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
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Georges G, Fudim M, Burkhoff D, Leon MB, Généreux P. Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 1. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101060. [PMID: 39131061 PMCID: PMC11307876 DOI: 10.1016/j.jscai.2023.101060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 08/13/2024]
Abstract
Despite recent advances in the treatment of patients with chronic heart failure, acute decompensated heart failure remains associated with significant mortality and morbidity because many novel therapies have failed to demonstrate meaningful benefit. Persistent congestion in the setting of escalating diuretic therapy has been repeatedly shown to be a marker of poor prognosis and is currently being targeted by various emerging device-based therapies. Because these therapies inherently carry procedural risk, patient selection is key in the future trial design. However, it remains unclear which patients are at a higher risk of residual congestion or adverse outcomes despite maximally tolerated decongestive therapy. In the first part of this 2-part review, we aimed to outline patient risk factors and summarize current evidence for early recognition of high-risk profile for residual congestion and adverse outcomes. These factors are classified as relating to the following: (1) previous clinical course, (2) severity of congestion, (3) diuretic response, and (4) degree of renal impairment. We also aimed to provide an overview of key inclusion criteria in recent acute decompensated heart failure trials and investigational device studies and propose potential criteria for selection of high-risk patients in future trials.
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Affiliation(s)
- Gabriel Georges
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Martin B. Leon
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
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38
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Hu JR, Schwann AN, Tan JW, Nuqali A, Riello RJ, Beasley MH. Sequencing Quadruple Therapy for Heart Failure with Reduced Ejection Fraction: Does It Really Matter? Cardiol Clin 2023; 41:511-524. [PMID: 37743074 DOI: 10.1016/j.ccl.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
The conventional sequence of guideline-directed medical therapy (GDMT) initiation in heart failure with reduced ejection fraction (HFrEF) assumes that the effectiveness and tolerability of GDMT agents mirror their order of discovery, which is not true. In this review, the authors discuss flexible GDMT sequencing that should be permitted in special populations, such as patients with bradycardia, chronic kidney disease, or atrial fibrillation. Moreover, the initiation of certain GDMT medications may enable tolerance of other GDMT medications. Most importantly, the achievement of partial doses of all four pillars of GDMT is better than achievement of target dosing of only a couple.
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Affiliation(s)
- Jiun-Ruey Hu
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/ruey_hu
| | - Alexandra N Schwann
- Department of Internal Medicine, Yale New Haven Hospital, P.O. Box 208030, New Haven, CT, 06520-8030, USA. https://twitter.com/aschwann212
| | - Jia Wei Tan
- Division of Nephrology, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304, USA. https://twitter.com/jiiiiawei
| | - Abdulelah Nuqali
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/AbdulelahNuqali
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/ralphadelta
| | - Michael H Beasley
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA.
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Kazory A. Combination Diuretic Therapy to Counter Renal Sodium Avidity in Acute Heart Failure: Trials and Tribulations. Clin J Am Soc Nephrol 2023; 18:1372-1381. [PMID: 37102974 PMCID: PMC10578637 DOI: 10.2215/cjn.0000000000000188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/20/2023] [Indexed: 04/28/2023]
Abstract
In contrast to significant advances in the management of patients with chronic heart failure over the past few years, there has been little change in how patients with acute heart failure are treated. Symptoms and signs of fluid overload are the primary reason for hospitalization of patients who experience acute decompensation of heart failure. Intravenous loop diuretics remain the mainstay of therapy in this patient population, with a significant subset of them showing suboptimal response to these agents leading to incomplete decongestion at the time of discharge. Combination diuretic therapy, that is, using loop diuretics along with an add-on agent, is a widely applied strategy to counter renal sodium avidity through sequential blockade of sodium absorption within renal tubules. The choice of the second diuretic is affected by several factors, including the site of action, the anticipated secondary effects, and the available evidence on their efficacy and safety. While the current guidelines recommend combination diuretic therapy as a viable option to overcome suboptimal response to loop diuretics, it is also acknowledged that this strategy is not supported by strong evidence and remains an area of uncertainty. The recent publication of landmark studies has regenerated the interest in sequential nephron blockade. In this article, we provide an overview of the results of the key studies on combination diuretic therapy in the setting of acute heart failure and discuss their findings primarily with regard to the effect on renal sodium avidity and cardiorenal outcomes.
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Affiliation(s)
- Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida
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Vazir A, Kapelios CJ, Agaoglu E, Metra M, Lopatin Y, Seferovic P, Mullens W, Filippatos G, Rosano G, Coats AJS, Chioncel O. Decongestion strategies in patients presenting with acutely decompensated heart failure: A worldwide survey among physicians. Eur J Heart Fail 2023; 25:1555-1570. [PMID: 37565377 DOI: 10.1002/ejhf.2985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/09/2023] [Accepted: 07/25/2023] [Indexed: 08/12/2023] Open
Abstract
AIMS Decongestion strategies for acute decompensated heart failure (ADHF) characterized by volume overload differ widely. The aim of this independent international academic web-based survey was to capture the therapeutic strategies that physicians use to treat ADHF and to assess differences in therapeutic approaches between cardiologists versus non-cardiologists. METHODS AND RESULTS Physicians were invited to complete a web-based questionnaire, capturing anonymized data on physicians' characteristics and treatment preferences based on a hypothetical clinical scenario of a patient hospitalized with ADHF. A total of 641 physicians from 60 countries participated. A wide variation in the management of the patient was observed. There was conservative use of diuretics, i.e. only 7% started intravenous furosemide at a dose ≥2 times the baseline oral dose, and infrequent use of ultrasound in assessing congestion (20.4%). Spot urinary sodium was infrequently or never measured by ≥85% of physicians. A third considered a patient with ongoing oedema as being stabilized. There were significant differences between cardiologists and non-cardiologists in the management of ADHF, the targets for daily body weight loss and urine output, diuretic escalation strategies (66.3% vs. 40.7% would escalate diuresis by adding a thiazide) and assessment of response to treatment (27.0% vs. 52.9% considered patients with minimal congestion as stabilized). CONCLUSIONS There is substantial variability amongst physicians and between cardiologists and non-cardiologists in the management of patients with ADHF, with regard to clinical parameters used to tailor treatment, treatment goals, diuretic dosing and escalation strategies.
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Affiliation(s)
- Ali Vazir
- Royal Brompton Hospital, Royal Brompton and Harefield Hospitals Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Chris J Kapelios
- Royal Brompton Hospital, Royal Brompton and Harefield Hospitals Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- National and Kapodistrian University of Athens, Athens, Greece
| | - Elif Agaoglu
- Royal Brompton Hospital, Royal Brompton and Harefield Hospitals Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Yury Lopatin
- Volgograd State Medical University, Regional Cardiology Centre, Volgograd, Russia
| | - Petar Seferovic
- University of Belgrade Faculty of Medicine, Belgrade, Serbia
| | - Wilfred Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Gerasimos Filippatos
- National & Kapodistrian University of Athens, School of Medicine, Attikon University Hospital Athens, Athens, Greece
| | - Giuseppe Rosano
- St George's Hospitals, NHS Trust, University of London, London, UK
| | | | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania, University of Medicine Carol Davila, Bucharest, Romania
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Gogikar A, Nanda A, Janga LSN, Sambe HG, Yasir M, Man RK, Mohammed L. Combination Diuretic Therapy With Thiazides: A Systematic Review on the Beneficial Approach to Overcome Refractory Fluid Overload in Heart Failure. Cureus 2023; 15:e44624. [PMID: 37720125 PMCID: PMC10500380 DOI: 10.7759/cureus.44624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023] Open
Abstract
Heart failure (HF) is a notable public health issue, and intravenous loop diuretics are frequently employed to address acute decompensated heart failure (ADHF) and alleviate symptoms of congestion. However, prolonged use of loop diuretics can lead to drug resistance, and some patients experience refractory volume overload that does not respond to treatment. Sequential nephron blockade, which involves combining loop and thiazide diuretics, has been proposed as a strategy to overcome diuretic resistance and improve fluid overload management. This systematic review aims to critically evaluate the effectiveness and safety of this combination diuretic therapy. Following the directives detailed in the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search was conducted. Eligibility criteria were established to select relevant studies, including the requirement for studies to be conducted on human subjects and published as free full-text papers in English within the last 10 years. Several databases were searched using a combination of Medical Subject Heading (MeSH) phrases and keywords related to heart failure, loop diuretics, and thiazide diuretics. The search yielded 948 references, and after screening titles, abstracts, and full-text papers, eight final studies (five observational studies and three randomized control trials) were included in the review. Based on the findings of this systematic review, there is substantial evidence to endorse the efficacy of combination diuretic therapy of loop and thiazide diuretics in augmenting diuresis and enhancing outcomes for patients who exhibit insufficient responses to single-agent diuretics. Additionally, the review provides valuable insights about the timing and type of diuretics to use, helping clinicians make informed therapeutic decisions. However, to ensure patient safety and well-being, it is imperative to take into account the potential for electrolyte disturbances and impacts on renal function, necessitating diligent and vigilant monitoring as well as effective management strategies. In light of these findings, further research is warranted to optimize the dosing regimens and to delve deeper into the long-term safety and efficacy of combination therapy. Such research endeavors will undoubtedly contribute to refining treatment approaches and advancing patient care in the field of HF management.
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Affiliation(s)
- Amaresh Gogikar
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ankita Nanda
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Hembashima G Sambe
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mohamed Yasir
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ruzhual K Man
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lubna Mohammed
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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42
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Biegus J, Fudim M, Salah HM, Heerspink HJL, Voors AA, Ponikowski P. Sodium-glucose cotransporter-2 inhibitors in heart failure: Potential decongestive mechanisms and current clinical studies. Eur J Heart Fail 2023; 25:1526-1536. [PMID: 37477086 DOI: 10.1002/ejhf.2967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/19/2023] [Accepted: 07/01/2023] [Indexed: 07/22/2023] Open
Abstract
Congestion is a key pathophysiological feature of heart failure (HF) syndrome that drives most of the clinical manifestations of acute HF and is related with poor quality of life and outcomes. Therefore, safe and effective decongestion is an important therapeutic target in the management of acute HF and despite the use of guideline-recommended loop diuretics, adequate decongestion is not always achieved in patients with acute HF. Recently, sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been shown to provide clinical benefits across a broad spectrum of patients with HF, including consistent reduction in the risk of acute HF episodes. While the exact mechanisms underlying these benefits remain a matter of debate, a growing body of evidence suggests that effective decongestion may be partly responsible, especially in the setting of acute HF. In this review, we discuss the potential decongestive mechanisms of SGLT-2 inhibitors, such as osmotic diuresis, natriuresis, preservation of glomerular filtration and facilitation of interstitial drainage, which can collectively translate into effective and safe decongestion. Furthermore, we provide a comprehensive review of up-to-date clinical data of SGLT-2 inhibitor use in the acute HF population.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Marat Fudim
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Medicine, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Husam M Salah
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, 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
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
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Gomes da Silva F, Calça R, Rita Martins A, Araújo I, Aguiar C, Fonseca C, Branco P. Diuretic-resistant heart failure and the role of ultrafiltration: A proposed protocol. Rev Port Cardiol 2023; 42:797-803. [PMID: 36948455 DOI: 10.1016/j.repc.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 02/13/2022] [Accepted: 05/09/2022] [Indexed: 03/24/2023] Open
Abstract
Acute heart failure (HF) decompensation generally manifests with signs and symptoms of congestion that strongly predict poor poor patient outcome. Loop diuretics are the cornerstone of therapy to counteract fluid overload and are widely used for acute management and chronic stabilization of HF. However, a diminished response to loop diuretics is a common problem, affecting the patient's clinical course and potentially prolonging hospitalization. Diuretic resistance is defined as failure to decongest despite appropriate and escalating loop diuretic therapy. We propose a protocol for the management of diuretic resistance. The initial approach should include an assessment of causes of pseudo-diuretic resistance. Adjustments to loop diuretic therapy, such as increasing doses and frequency of administration and sequential nephron blockade, may be successful. For hospitalized patients with progressive disease there are more invasive methods for fluid removal. Switching from oral to intravenous loop diuretics is essential to avoid variable absorption and for symptomatic relief. Extracorporeal ultrafiltration is also an option since this technique is highly effective at removing plasma fluid from blood. While extracorporeal ultrafiltration is an invasive solution, peritoneal dialysis is a home-based, intermittent therapeutic option that can enable efficient management of fluid overload, preventing HF-related hospital admission, and improving quality of life. As a last resort for fluid removal, a peritoneal dialysis regimen should fully exploit its decongestive properties and should be tailored to the patient's characteristics and clinical needs.
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Affiliation(s)
| | - Rita Calça
- Serviço de Nefrologia, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Ana Rita Martins
- Serviço de Nefrologia, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Inês Araújo
- Serviço de Medicina Interna, Hospital de São Francisco Xavier, Lisboa, Portugal
| | - Carlos Aguiar
- Serviço de Cardiologia, Hospital de Santa Cruz, Lisboa, Portugal
| | - Cândida Fonseca
- Serviço de Medicina Interna, Hospital de São Francisco Xavier, Lisboa, Portugal
| | - Patrícia Branco
- Serviço de Nefrologia, Hospital de Santa Cruz, Carnaxide, Portugal
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Packer M, Butler J. Similarities and distinctions between acetazolamide and sodium-glucose cotransporter 2 inhibitors in patients with acute heart failure: Key insights into ADVOR and EMPULSE. Eur J Heart Fail 2023; 25:1537-1543. [PMID: 37403655 DOI: 10.1002/ejhf.2968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/06/2023] Open
Abstract
Both acetazolamide and sodium-glucose cotransporter 2 (SGLT2) inhibitors block sodium reabsorption in the proximal renal tubule primarily through inhibition of sodium-hydrogen exchanger isoform 3 (NHE3), but neither SGLT2 inhibitors nor acetazolamide produce a sustained natriuresis due to compensatory upregulation of sodium reabsorption at distal nephron sites. Nevertheless, acetazolamide and SGLT2 inhibitors have been used as adjunctive therapy to loop diuretics in states where NHE3 is upregulated, e.g. acute heart failure. Two randomized controlled trials have been carried out with acetazolamide in acute heart failure (DIURESIS-CHF and ADVOR). In ADVOR, acetazolamide improved physical signs of fluid retention, but this finding could not be explained by the modest observed diuretic effect. Acetazolamide did not produce a natriuresis in the DIURESIS-CHF trial, and in ADVOR, immediate effects on symptoms and body weight were not reported, and the drug had no effect on morbidity or mortality after 90 days. Three randomized controlled trials have been carried out with empagliflozin (EMPAG-HF, EMPA-RESPONSE-AHF and EMPULSE) in acute heart failure. The EMPULSE trial did not report effects on diuresis or in changes in physical signs of congestion during the first week of treatment, but in EMPAG-HF and EMPA-RESPONSE-AHF, empagliflozin had no effect of dyspnoea, urinary sodium excretion or body weight during the first 4 days. In the EMPULSE trial, empagliflozin improved health status at 15 days and reduced the risk of worsening heart failure events at 90 days, but these effects are similar in magnitude and time course to the early statistical significance on the risk of heart failure hospitalizations achieved within 14-30 days in the major trials of SGLT2 inhibitors in patients with chronic heart failure. Neurohormonal inhibitors produce this early effect in the absence of a diuresis. Additionally, in numerous randomized controlled trials, in-hospital diuretic intensification has not reduced the risk of major heart failure events, even when treatment is sustained. These findings, taken collectively, suggest that any immediate diuretic effects of acetazolamide and SGLT2 inhibitors in acute heart failure are not likely to influence the short- or long-term clinical course of patients.
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Affiliation(s)
- Milton Packer
- Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
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Beldhuis IE, Damman K, Pang PS, Greenberg B, Davison BA, Cotter G, Gimpelewicz C, Felker GM, Filippatos G, Teerlink JR, Metra M, Voors AA, Ter Maaten JM. Mineralocorticoid receptor antagonist initiation during admission is associated with improved outcomes irrespective of ejection fraction in patients with acute heart failure. Eur J Heart Fail 2023; 25:1584-1592. [PMID: 37462255 DOI: 10.1002/ejhf.2975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/28/2023] [Accepted: 07/12/2023] [Indexed: 08/05/2023] Open
Abstract
AIMS Heart failure (HF) guidelines recommend initiation and optimization of guideline-directed medical therapy, including mineralocorticoid receptor antagonists (MRAs), before hospital discharge. However, scientific evidence for this recommendation is lacking. Our objective was to determine whether initiation of MRA prior to hospital discharge is associated with improved outcomes. METHODS AND RESULTS We performed a secondary analysis of 6197 patients enrolled in the RELAX-AHF-2 study. Patients were divided into four groups according to MRA therapy at baseline and discharge. At baseline 30% of patients received MRA therapy, which increased to 50% of patients at discharge. In-hospital initiation of an MRA was observed in 1690 (27%) patients, 1438 (23%) patients remained on MRA therapy, 418 (7%) patients discontinued MRA treatment, and 2651 (43%) patients did not receive an MRA during hospital stay. Compared with patients who did not receive MRA therapy, in-hospital initiation of an MRA was independently associated with lower risks of mortality (multivariable hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.60-0.96; p = 0.02), cardiovascular death (HR 0.77, 95% CI 0.59-1.01; p = 0.06), hospitalization for HF or renal failure (HR 0.72, 95% CI 0.60-0.86; p = 0.0003) and the composite endpoint of cardiovascular death and/or rehospitalization for HF or renal failure (HR 0.71, 95% CI 0.61-0.83; p < 0.0001) at 180 days. These results were independent of baseline left ventricular ejection fraction. CONCLUSION In patients hospitalized for acute HF, in-hospital initiation of an MRA was associated with improved post-discharge outcomes, independent of left ventricular ejection fraction and other potential confounders.
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Affiliation(s)
- Iris E Beldhuis
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University, Indianapolis, IN, USA
| | - Barry Greenberg
- University of California San Diego Health, Sulpizio Family Cardiovascular Center, La Jolla, CA, USA
| | | | - Gad Cotter
- Momentum Research and Inserm U942 MASCOT, Paris, France
| | | | - G Michael Felker
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC, USA
| | - Gerasimos Filippatos
- Department of Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, CA, USA
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiologic Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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Martens P, Testani J, Damman K. Prevention and treatment of diuretic resistance in acute heart failure: when to use which combination of diuretics? Eur Heart J 2023; 44:2978-2981. [PMID: 37572039 DOI: 10.1093/eurheartj/ehad463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/14/2023] Open
Affiliation(s)
- Pieter Martens
- Kauffman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Jeffrey Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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47
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Olson M, Thompson Z, Xie L, Nair A. Broadening Heart Failure Care Beyond Cardiology: Challenges and Successes Within the Landscape of Multidisciplinary Heart Failure Care. Curr Cardiol Rep 2023; 25:851-861. [PMID: 37436647 DOI: 10.1007/s11886-023-01907-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE OF REVIEW Heart failure (HF) is a growing public health concern that impairs the quality of life and is associated with significant mortality. As the prevalence of heart failure increases, multidisciplinary care is essential to provide comprehensive care to individuals. RECENT FINDINGS The challenges of implementing an effective multidisciplinary care team can be daunting. Effective multidisciplinary care begins at the initial diagnosis of heart failure. The transition of care from the inpatient to the outpatient setting is critically important. The use of home visits, case management, and multidisciplinary clinics has been shown to decrease mortality and heart failure hospitalizations, and major society guidelines endorse multidisciplinary care for heart failure patients. Expanding heart failure care beyond cardiology entails incorporating primary care, advanced practice providers, and other disciplines. Patient education and self-management are fundamental to multidisciplinary care, as is a holistic approach to effectively address comorbid conditions. Ongoing challenges include navigating social disparities within heart failure care and limiting the economic burden of the disease.
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Affiliation(s)
- Michael Olson
- Baylor College of Medicine, 7200 Cambridge St, Ste 6C, Houston, TX, 77030, USA
| | - Zachary Thompson
- Baylor College of Medicine, 7200 Cambridge St, Ste 6C, Houston, TX, 77030, USA
| | - Lola Xie
- Baylor College of Medicine, 7200 Cambridge St, Ste 6C, Houston, TX, 77030, USA
- The Texas Heart Institute, Cardiology, Houston, TX, 77030, USA
| | - Ajith Nair
- Baylor College of Medicine, 7200 Cambridge St, Ste 6C, Houston, TX, 77030, USA.
- The Texas Heart Institute, Cardiology, Houston, TX, 77030, USA.
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Llàcer P, Núñez J, Croset F, García M, Fabregate M, Ruiz R, López G, Fernández C, Del Hoyo B, Campos J, Gomis A, Manzano L. Usefulness of urinary potassium to creatinine ratio to predict diuretic response in patients with acute heart failure and preserved ejection fraction. Clin Cardiol 2023; 46:906-913. [PMID: 37287326 PMCID: PMC10436792 DOI: 10.1002/clc.24040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Patients with acute heart failure (AHF) require intensification in the diuretic strategy. However, the optimal diuretic strategy remains unclear. In this work, we aimed to evaluate the role of urinary potassium to creatinine ratio (K/Cr) to predict diuretic and natriuretic response to thiazide or mineralocorticoid receptor antagonists (MRAs) in a cohort of patients with AHF and preserved ejection fraction (AHF-pEF). HYPOTHESIS Patients with a high urinary K/Cr ratio will have a better diuretic and natriuretic response with spironolactone versus chlorthalidone. METHODS This is a study of 44 patients with AHF-pEF with suboptimal loop diuretic response. The primary endpoint was the baseline K/Cr associated with natriuretic and diuretic effect of chlorthalidone versus spironolactone at 24 and 72 h. Mixed linear regression models were used to analyze the endpoints. Estimates were reported as least squares mean with their respective 95% confidence interval (CIs). RESULTS The median age of the study population was 85 years (82.5-88.5), and 30 (68.2%) were women. The inferential multivariate analysis suggested a greater natriuretic and diuretic effect of chlorthalidone across K/Cr levels. In the upper category, chlorthalidone translated into a statistically increase in natriuresis at 24 and 72 h. Chlorthalidone versus spironolactone showed ∆uNa of 25.7 mmol/L at 24 h (95% CI = -3.7 to 55.4, p = .098) and ∆uNa of 24.8 mmol/L at 72 h (95% CI = -4 to 53.6, p = .0106). The omnibus p value is .027. Multivariate analyses revealed a significant increase in 72 h cumulative diuresis irrespective of K/Cr status in those on chlorthalidone. CONCLUSIONS In patients with AHF-pEF and suboptimal diuretic response, diuresis and natriuresis are higher with the administration of chlorthalidone over spironolactone. These data don't support the hypothesis that the K/Cr ratio can help guide the choice of thiazide diuretic versus MRA in AHF-pEF patients on loop diuretic.
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Affiliation(s)
- Pau Llàcer
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de AlcaláMadridSpain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico UniversitarioUniversitat de València, INCLIVAValenciaSpain
- CIBER CardiovascularMadridSpain
| | - François Croset
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de AlcaláMadridSpain
| | - Marina García
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Martín Fabregate
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Raúl Ruiz
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Genoveva López
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Cristina Fernández
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Beatriz Del Hoyo
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Jorge Campos
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Antonio Gomis
- Nephrology DepartmentHospital Universitario Ramón y CajalMadridSpain
| | - Luis Manzano
- Internal Medicine DepartmentHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de AlcaláMadridSpain
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Butte Z, Ambrosy AP. Acetazolamide as a decongestion strategy in acute decompensated heart failure: Balancing fluid removal and electrolyte disturbances. Eur J Heart Fail 2023; 25:1320-1322. [PMID: 37323079 DOI: 10.1002/ejhf.2935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/12/2023] [Indexed: 06/17/2023] Open
Affiliation(s)
- Zara Butte
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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50
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Packer M, Wilcox CS, Testani JM. Critical Analysis of the Effects of SGLT2 Inhibitors on Renal Tubular Sodium, Water and Chloride Homeostasis and Their Role in Influencing Heart Failure Outcomes. Circulation 2023; 148:354-372. [PMID: 37486998 PMCID: PMC10358443 DOI: 10.1161/circulationaha.123.064346] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/25/2023] [Indexed: 07/26/2023]
Abstract
SGLT2 (sodium-glucose cotransporter 2) inhibitors interfere with the reabsorption of glucose and sodium in the early proximal renal tubule, but the magnitude and duration of any ensuing natriuretic or diuretic effect are the result of an interplay between the degree of upregulation of SGLT2 and sodium-hydrogen exchanger 3, the extent to which downstream compensatory tubular mechanisms are activated, and (potentially) the volume set point in individual patients. A comprehensive review and synthesis of available studies reveals several renal response patterns with substantial variation across studies and clinical settings. However, the common observation is an absence of a large acute or chronic diuresis or natriuresis with these agents, either when given alone or combined with other diuretics. This limited response results from the fact that renal compensation to these drugs is rapid and nearly complete within a few days or weeks, preventing progressive volume losses. Nevertheless, the finding that fractional excretion of glucose and lithium (the latter being a marker of proximal sodium reabsorption) persists during long-term treatment with SGLT2 inhibitors indicates that pharmacological tolerance to the effects of these drugs at the level of the proximal tubule does not meaningfully occur. This persistent proximal tubular effect of SGLT2 inhibitors can be hypothesized to produce a durable improvement in the internal set point for volume homeostasis, which may become clinically important during times of fluid expansion. However, it is difficult to know whether a treatment-related change in the volume set point actually occurs or contributes to the effect of these drugs to reduce the risk of major heart failure events. SGLT2 inhibitors exert cardioprotective effects by a direct effect on cardiomyocytes that is independent of the presence of or binding to SGLT2 or the actions of these drugs on the proximal renal tubule. Nevertheless, changes in the volume set point mediated by SGLT2 inhibitors might potentially act cooperatively with the direct favorable molecular and cellular effects of these drugs on cardiomyocytes to mediate their benefits on the development and clinical course of heart failure.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, TX (M.P.)
- Imperial College London, United Kingdom (M.P.)
| | - Christopher S. Wilcox
- Division of Nephrology and Hypertension, Kidney, and Vascular Research Center, Georgetown University, Washington, DC (C.S.W.)
| | - Jeffrey M. Testani
- Section of Cardiovascular Medicine, Yale University, New Haven, CT (J.M.T.)
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