WITHDRAWN: Diuretics for heart failure

Combination diuretic therapies in heart failure: Insights from GUIDE-IT

Introduction

Diuretics are the mainstay of maintaining and restoring euvolemia in the management of heart failure. Loop diuretics are often preferred, however, combination diuretic therapy (CDT) with a thiazide diuretic is often used to overcome diuretic resistance and increase diuretic effect. We performed an analysis of the GUIDE-IT study to assess all-cause mortality and time to first hospitalizations in patients necessitating CDT.

Methods

Patients from the GUIDE-IT dataset were stratified by their requirement for CDT with a thiazide to achieve euvolemia. A total of 894 patients were analyzed, 733 of which were treated with loop diuretics alone vs 161 used either chlorothiazide or metolazone in addition to loop diuretics. Kaplan-Meir curves were derived with log-rank p-values to evaluate for differences between the groups.

Results

There was no significant difference in all-cause mortality regardless of CDT utilization status (mean survival of 612.704 days vs 603.326 days, p = 0.083). On subgroup analysis, there was no significant difference in all-cause mortality amongst those using loop diuretics compared to CDT in the BNP-guided therapy group, (mean survival time 576.385 days vs 620.585 days, p = 0.0523), nor the control group (614.1 days vs 588.9 days; p = 0.5728). Time to first hospitalization was reduced in all using CDT compared to loop diuretics alone (280.5 days vs 407.2 days, p < 0.0001). On subgroup analysis, both the BNP-guided group as well as the control group had reduced time to first hospitalization in the CDT group compared to those who did not require CDT (BNP group: 287.503 days vs 402.475 days, p ≤0.0001; control group 248.698 days vs 399.035 days, p = 0.0009).

Conclusion

Use of CDT is associated with earlier time to hospitalization, though no association was identified with increased all-cause mortality. Further prospective studies are likely needed to determine the true risk and benefits of combination diuretic therapy.

Heart Failure and Erectile Dysfunction: a Review of the Current Evidence and Clinical Implications

PURPOSE OF REVIEW

Heart failure (HF) and erectile dysfunction (ED) are two common conditions that affect millions of men worldwide and impair their quality of life. ED is a frequent complication of HF, as well as a possible predictor of cardiovascular events and mortality. ED deserves more attention from clinicians and researchers.

RECENT FINDINGS

The pathophysiology of ED in HF involves multiple factors, such as endothelial dysfunction, reduced cardiac output, neurohormonal activation, autonomic imbalance, oxidative stress, inflammation, and drug side effects. The diagnosis of ED in HF patients should be based on validated questionnaires or objective tests, as part of the routine cardiovascular risk assessment. The therapeutic management of ED in HF patients should be individualized and multidisciplinary, considering the patient's preferences, expectations, comorbidities, and potential drug interactions. The first-line pharmacological treatment for ED in HF patients with mild to moderate symptoms (NYHA class I-II) is phosphodiesterase type 5 inhibitors (PDE5Is), which improve both sexual function and cardiopulmonary parameters. PDE5Is are contraindicated in patients who use nitrates or nitric oxide donors for angina relief, and these patients should be advised to avoid sexual activity or to use alternative treatments for ED. Non-pharmacological treatments for ED, such as psychotherapy or couples therapy, should also be considered if there are significant psychosocial factors affecting the patient's sexual function or relationship. This review aims to summarize the most recent evidence regarding the prevalence of ED, the pathophysiology of this condition with an exhaustive analysis of factors involved in ED development in HF patients, a thorough discussion on diagnosis and management of ED in HF patients, providing practical recommendations for clinicians.

Management of Heart Failure in Patients with Chronic Kidney Disease

Chronic kidney disease (CKD) is increasingly prevalent in patients with heart failure (HF) and HF is one of the leading causes of hospitalisation, morbidity and mortality in patients with impaired renal function. Currently, there is strong evidence to support the symptomatic and prognostic benefits of β-blockers, renin-angiotensin-aldosterone inhibitors (RAASis), angiotensin receptor-neprilysin inhibitors (ARNIs) and mineralocorticoid receptor antagonists (MRA) in patients with HF and CKD stages 1-3. However, ARNIs, RAASis and MRAs are often suboptimally prescribed for patients with CKD owing to concerns about hyperkalaemia and worsening renal function. There is growing evidence for the use of sodium-glucose co-transporter 2 inhibitors and IV iron therapy in the management of HF in patients with CKD. However, few studies have included patients with CKD stages 4-5 and patients receiving dialysis, limiting the assessment of the safety and efficacy of these therapies in advanced CKD. Interdisciplinary input from HF and renal specialists is required to provide integrated care for the growing number of patients with HF and CKD.

Hypertensive Heart Failure in Asia

Hypertension (HT) is an important risk factor for heart failure (HF). The prevalence of HT among the HF population is higher in Asia than in other regions around the world. In Asia, HT is the most common cause of HF after ischemic heart disease. Hypertensive HF (HHF) results from structural and functional adaptations of the heart, which lead to left ventricular (LV) hypertrophy (LVH). Hypertensive LVH can cause ventricular diastolic dysfunction and becomes a risk factor for myocardial infarction, which is a well-known cause of LV systolic dysfunction. Asymptomatic systolic and diastolic LV dysfunction easily progress to clinically overt HF with other precipitating factors. Although the precise pathophysiology of HHF is still unclear, we have known that HHF can be reversed by effective control of blood pressure (BP). Thus, HT control is essential not only for primary prevention but also for the secondary prevention of HF. Here, we reviewed the epidemiology, pathophysiology, outcome, and implication of BP management in HHF patients, especially in the Asian population.

Stroke risk scores to predict hospitalization for acute decompensated heart failure in atrial fibrillation patients

Introduction. Atrial fibrillation (AF) is the most frequent hospitalized arrhythmia. It associates increased risk of death, stroke and heart failure (HF). Stroke risk scores, especially CHA₂DS₂-VASc, have been applied also for populations with different diseases. There is, however, limited data focusing on the ability of these scores to predict HF decompensation.Methods. We conducted a retrospective observational study on a cohort of 204 patients admitted for cardiovascular pathology to the Cardiology Ward of our tertiary University Hospital. We aimed to determine whether the stroke risk scores could predict hospitalisations for acute decompensated HF in AF patients.Results. C-statistics for CHADS₂ and R₂CHADS₂ showed a modest predictive ability for hospitalisation with decompensated HF (CHADS₂: AUC 0.631 p = 0.003; 95%CI 0.560-0.697. R₂CHADS₂: AUC 0.619; 95%CI 0.548-0.686; p = 0.004), a marginal correlation for CHA₂DS_2-VASc (AUC 0.572 95%CI 0.501-0.641 with a p value of only 0.09, while the other scores failed to show a correlation. A CHADS₂ ≥ 2 showed a RR = 2.96, p<0.0001 for decompensated HF compared to a score <2. For R₂CHADS₂ ≥ 2, RR = 2.41, p = 0.001 compared to a score <2. For CHA₂DS_2-VASc ≥ 2 RR = 2.18 p = 0.1, compared to CHA₂DS₂-VASc <2. The correlation coefficients showed a weak correlation for CHADS₂ (r = 0.216; p = 0.001) and even weaker for R₂CHADS₂ (r = 0.197; p = 0.0047 and CHA₂DS₂-VASc (r = 0.14; p = 0.035).Conclusions. Among AF patients, CHADS_2, CHA₂DS₂-VASc and R₂CHADS₂ were associated with the risk of hospitalisation for decompensated HF while ABC and ATRIA failed to show an association. However, predictive accuracy was modest and the clinical utility for this outcome remains to be determined.

Evolving understanding of cardiovascular protection by SGLT2 inhibitors: focus on renal protection, myocardial effects, uric acid, and magnesium balance

Robust clinical data indicate that inhibitors of the sodium/glucose cotransporter 2 (SGLT2) dramatically improve clinical outcomes in diabetes, especially heart failure and progression of kidney disease. Factors that may contribute to these findings include: 1) improved glycemic control, 2) diuresis and reduced extracellular fluid volume, 3) reduced serum uric acid levels, 3) direct myocardial effects, 4) reduction in proteinuria and preservation of kidney function, and 5) correction of diabetic magnesium deficiency. Understanding the mechanisms by which SGLT2 inhibitors improve cardiovascular outcomes has the potential to improve clinical management not only of diabetes, but also of other cardiovascular disorders such as heart failure and chronic kidney disease.