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Tan SS, Hisham SA, Bin Abdul Malek AM, Lik CP, Lau GSK, Bin Abdul Ghapar AK. Impact of Multidisciplinary Heart Failure Clinic on Guideline-Directed Medical Therapy and Clinical Outcomes. Can J Hosp Pharm 2024; 77:e3364. [PMID: 38204512 PMCID: PMC10754400 DOI: 10.4212/cjhp.3364] [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: 07/21/2022] [Accepted: 07/10/2023] [Indexed: 01/12/2024]
Abstract
Background Heart failure (HF) is associated with recurrent hospital admissions and high mortality. Guideline-directed medical therapy has been shown to improve prognosis for patients who have HF with reduced ejection fraction (HFrEF). Despite the proven benefits of guideline-directed medical therapy, its utilization is less than optimal among patients with HF in Malaysia. Objective To determine the impact of a multidisciplinary team HF (MDT-HF) clinic on the use of guideline-directed medical therapy and patients' clinical outcomes at 1 year. Methods This retrospective study was conducted in a single cardiac centre in Malaysia. Patients with HFrEF who were enrolled in the MDT-HF clinic between November 2017 and June 2020 were compared with a matched control group who received the standard of care. Data were retrieved from the hospital electronic system and were analyzed using statistical software. Results A total of 54 patients were included in each group. Patients enrolled in the MDT-HF clinic had higher usage of renin-angiotensin system blockers (54 [100%] vs 47 [87%], p < 0.001) and higher attainment of the target dose for these agents (35 [65%] vs 5 [9%], p < 0.001). At 1 year, the mean left ventricular ejection fraction (LVEF) was significantly greater in the MDT-HF group (35.7% [standard deviation 12.3%] vs 26.2% [standard deviation 8.7%], p < 0.001), and care in the MDT-HF clinic was significantly associated with better functional class, with a lower proportion of patients categorized as having New York Heart Association class III HF at 1 year (1 [2%] vs 14 [26%], p = 0.001). Patients in the MDT-HF group also had a significantly lower rate of readmission for HF (4 [7%] vs 32 [59%], p < 0.001). Conclusions Patients who received care in the MDT-HF clinic had better use of guideline-directed medical therapy, greater improvement in LVEF, and a lower rate of readmission for HF at 1 year relative to patients who received the standard of care.
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Affiliation(s)
- Sie Sie Tan
- , BScPhm, RPh, MClinPharm, is a clinical pharmacist with Sultan Idris Shah Serdang Hospital, Selangor, Malaysia
| | - Shairyzah Ahmad Hisham
- , PhD, MedSc, is with the Faculty of Pharmacy, University of Cyberjaya, Selangor, Malaysia
| | - Abdul Muizz Bin Abdul Malek
- , MBBS, MMed (Internal Medicine), is a cardiologist with Sultan Idris Shah Serdang Hospital, Selangor, Malaysia
| | - Chua Ping Lik
- , MBBS, MRCP, is a cardiologist with Sultan Idris Shah Serdang Hospital, Selangor, Malaysia
| | - Glendon Seng Kiong Lau
- , MBBS, MRCP, is a cardiologist with Sultan Idris Shah Serdang Hospital, Selangor, Malaysia
| | - Abdul Kahar Bin Abdul Ghapar
- , MD, MMed (Internal Medicine), is Head of the Cardiology Department, Sultan Idris Shah Serdang Hospital, Selangor, Malaysia
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Meani P, Pagnoni M, Mondellini GM, Fiorenza S, Brunner-La Rocca HP. Impact of loop diuretic dosage in a population of patients with acute heart failure: a retrospective analysis. Front Cardiovasc Med 2023; 10:1267042. [PMID: 38075974 PMCID: PMC10701382 DOI: 10.3389/fcvm.2023.1267042] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/31/2023] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Loop diuretics are essential for managing congestion in acute heart failure (AHF) patients, but concerns exist about their dosing and administration. This study aims to explore the relationship between aggressive diuretic treatment and clinical outcomes in AHF patients. METHODS We randomly selected 370 AHF patients from admissions at Maastricht University Medical Center between January 2011 and March 2017. Patients were divided into four quartiles based on diuretic doses administrated during index hospitalization. The primary endpoint was a composite of cardiovascular (CV) rehospitalization or death at 1 year. RESULTS 42.4% of patients experimented the primary outcome The composite endpoint rates were 35.4%, 41.6%, 38.5%, and 54.9%, respectively, from lowest to highest dose quartiles (p = 0.033). In univariate analysis, the outcome was significantly lower in the first three quartiles as compared to the fourth quartile. One-year CV mortality was 9.1%, 10.1%, 20.9% and 27.2%, respectively (p = 0.002). After adjusting for confounders, the association between loop diuretic dosage disappeared for both the primary outcome and one-year CV mortality. Most secondary outcomes and endpoints at 3 months, including worsening renal function, showed no significant differences between groups, while hypokaliemia occurrence, length of hospital stay and weight loss at index admission were higher in the fourth quartile compared to the first one. CONCLUSIONS High loop diuretic doses are associated with poor outcomes in AHF patients, reflecting disease severity rather than harm from aggressive diuretic use. Furthermore, high diuretic doses do not seem to negatively affect kidney function.
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Affiliation(s)
- P. Meani
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht (MUMC), Maastricht, Netherlands
| | - M. Pagnoni
- Division of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - G. M. Mondellini
- Division of Cardiology, Università Degli Studi di Milano, Milan, Italy
| | - S. Fiorenza
- Division of Cardiology, Istituto Clinico Città Studi, Milan, Italy
| | - H. P. Brunner-La Rocca
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
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Aklilu AM, Kumar S, Yamamoto Y, Moledina DG, Sinha F, Testani JM, Wilson FP. Outcomes Associated with Sodium-Glucose Cotransporter-2 Inhibitor Use in Acute Heart Failure Hospitalizations Complicated by AKI. KIDNEY360 2023; 4:1371-1381. [PMID: 37644648 PMCID: PMC10615381 DOI: 10.34067/kid.0000000000000250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
Key Points In a multicenter retrospective cohort study of adults hospitalized with acute heart failure, exposure to sodium-glucose cotransporter-2 inhibitor during AKI was associated with lower risk of 30-day mortality. Exposure to sodium-glucose cotransporter-2 inhibitor during acute heart failure–associated AKI was associated with no difference in time to renal recovery. The findings were reproducible in inverse probability-weighted analysis. Background Although sodium-glucose cotransporter-2 inhibitor (SGLT2i) use during acute heart failure (AHF) hospitalizations is associated with symptomatic improvement, reduction in rehospitalizations, and mortality, these medications are often withheld during AKI because of concerns about worsening GFR. We aimed to investigate the safety of SGLT2i exposure during AKI among patients hospitalized with AHF. We hypothesized that SGLT2i exposure would not worsen mortality but may prolong return of creatinine to baseline. Methods This was a retrospective study of adults hospitalized across five Yale New Haven Health System hospitals between January 2020 and May 2022 with AHF complicated by Kidney Disease Improving Global Outcomes–defined AKI. Patients with stage 5 CKD and those with potential contraindications to SGLT2i were excluded. We tested the association of SGLT2i use with kidney function recovery at 14 days and death at 30 days using time-varying, multivariable Cox-regression analyses. Results Of 3305 individuals hospitalized with AHF and AKI, 356 received SGLT2i after AKI diagnosis either as initiation or continuation. The rate of renal recovery was not significantly different among those exposed and unexposed to SGLT2i after AKI (adjusted hazard ratio, 0.94; 95% confidence interval, 0.79 to 1.11; P = 0.46). SGLT2i exposure was associated with lower risk of 30-day mortality (adjusted hazard ratio, 0.45; 95% confidence interval, 0.23 to 0.87; P = 0.02). Sensitivity analyses using an inverse probability-weighted time-varying Cox regression analysis and using alternate definitions of AHF with different NT-proBNP cutoffs yielded similar results. Rates of renal recovery were similar between the exposed and unexposed cohorts regardless of the proximity of SGLT2i exposure to AKI diagnosis. Conclusion In adults experiencing AHF-associated AKI, exposure to SGLT2i was associated with decreased mortality and no delay in renal recovery. Prospective studies are needed to elucidate the effect of SGLT2i exposure during AKI, particularly during heart failure hospitalizations.
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Affiliation(s)
- Abinet M. Aklilu
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
| | - Sanchit Kumar
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
| | - Dennis G. Moledina
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
| | - Frederick Sinha
- Department of Internal Medicine II, University Medical Center Regensburg, Germany
| | - Jeffrey M. Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - F. Perry Wilson
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut
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Price N, Wood AF. Acute kidney injury in the critical care setting. Nurs Stand 2023; 38:45-50. [PMID: 37458070 DOI: 10.7748/ns.2023.e12063] [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] [Accepted: 11/22/2022] [Indexed: 07/18/2023]
Abstract
Acute kidney injury is a sudden reduction in renal function which impairs the kidneys' ability to maintain fluid, electrolyte and acid-base balance. The syndrome often develops secondary to severe illness and is associated with a significant increase in morbidity and mortality rate in critically ill patients. This article gives an overview of the pathophysiology and aetiology of acute kidney injury, as well as the associated complications and clinical diagnostic signs. The authors also describe some common causes of the syndrome in critically ill patients, specifically sepsis, liver failure and cardiac failure, and discuss patient management in the critical care setting, with a focus on haemodynamic support and continuous renal replacement therapy.
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Affiliation(s)
- Natasha Price
- division of nursing and paramedic science, school of health sciences, Queen Margaret University, Edinburgh, Scotland
| | - Alison Fiona Wood
- programme lead for independent prescribing, division of nursing and paramedic science, school of health sciences, Queen Margaret University, Edinburgh, Scotland
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Effect of Hypertonic Saline Solution Combined with Furosemide on Acute Heart Failure: A Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5728967. [PMID: 36188107 PMCID: PMC9519297 DOI: 10.1155/2022/5728967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Background The efficacy of hypertonic saline solution (HSS) combined with furosemide in treating acute heart failure is controversial. This meta-analysis explores the efficacy of HSS combined with furosemide for the treatment of acute heart failure. Methods Literature were searched from databases, including PubMed, Web of Knowledge, Embase, Central, CMKI, Wanfang, and VIP. The inclusion criteria were as follows: (1) subjects: patients with acute heart failure; (2) the experimental group and the control group were properly set up; (3) intervention measures: patients in the experimental group were treated with HSS + furosemide, and patients in the control group were treated with furosemide; (4) the outcomes included at least one of the following indicators: readmission rate, mortality, 24 h urine volume, weight loss, and serum creatinine; and (5) randomized controlled trial (RCT). The method recommended by Cochrane Collaboration Network was used to evaluate the risk bias. The heterogeneity among the studies was evaluated through the chi-square test, and the publication bias was assessed by the Egger test. The results were described using risk ratio (RR), mean difference (MD), and 95% confidence interval (CI). Results The readmission rate in the HSS + furosemide group was lower than that in the furosemide group (RR = 0.53, 95% CI [0.46, 0.60], P < 0.00001), with no heterogeneity among the literature (P = 0.21, I2 = 29%). Patients in the HSS + furosemide group had a lower mortality rate than that in the furosemide group (RR = 0.55, 95% CI [0.46, 0.65], P < 0.00001). The chi-square test result indicated no heterogeneity among the literature (P = 0.25, I2 = 23%). Furthermore, the 24 h urine volume of patients in the HSS + furosemide group was higher than that in the furosemide group (MD = 497.29, 95% CI [457.61, 536.96], P < 0.00001). There was no heterogeneity among the literature (P = 0.58, I2 = 0%). In contrast, patients in the HSS + furosemide group demonstrated a lower serum creatinine level than those in the furosemide group (MD = −0.45, 95% CI [-0.51, -0.39], P < 0.00001). However, heterogeneity was observed among the literature (P < 0.00001, I2 = 81%). The weight loss in the HSS + furosemide group was higher than that in the furosemide group (MD = 1.83, 95% CI [1.51, 2.15], P < 0.00001). There was no heterogeneity among the literature (P = 0.42, I2 = 2%). Egger test showed no publication bias among the literature (P > 0.05). Conclusion Despite the heterogeneity and bias in our study, the combination of HSS with furosemide is promising in patients with acute heart failure. However, further research is still needed to confirm.
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Aronson D. The interstitial compartment as a therapeutic target in heart failure. Front Cardiovasc Med 2022; 9:933384. [PMID: 36061549 PMCID: PMC9428749 DOI: 10.3389/fcvm.2022.933384] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/15/2022] [Indexed: 12/23/2022] Open
Abstract
Congestion is the single most important contributor to heart failure (HF) decompensation. Most of the excess volume in patients with HF resides in the interstitial compartment. Inadequate decongestion implies persistent interstitial congestion and is associated with worse outcomes. Therefore, effective interstitial decongestion represents an unmet need to improve quality of life and reduce clinical events. The key processes that underlie incomplete interstitial decongestion are often ignored. In this review, we provide a summary of the pathophysiology of the interstitial compartment in HF and the factors governing the movement of fluids between the interstitial and vascular compartments. Disruption of the extracellular matrix compaction occurs with edema, such that the interstitium becomes highly compliant, and large changes in volume marginally increase interstitial pressure and allow progressive capillary filtration into the interstitium. Augmentation of lymph flow is required to prevent interstitial edema, and the lymphatic system can increase fluid removal by at least 10-fold. In HF, lymphatic remodeling can become insufficient or maladaptive such that the capacity of the lymphatic system to remove fluid from the interstitium is exceeded. Increased central venous pressure at the site of the thoracic duct outlet also impairs lymphatic drainage. Owing to the kinetics of extracellular fluid, microvascular absorption tends to be transient (as determined by the revised Starling equation). Therefore, effective interstitial decongestion with adequate transcapillary plasma refill requires a substantial reduction in plasma volume and capillary pressure that are prolonged and sustained, which is not always achieved in clinical practice. The critical importance of the interstitium in the congestive state underscores the need to directly decongest the interstitial compartment without relying on the lowering of intracapillary pressure with diuretics. This unmet need may be addressed by novel device therapies in the near future.
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Chen JJ, Lee TH, Kuo G, Yen CL, Chen SW, Chu PH, Fan PC, Chien-Chia Wu V, Chang CH. Acute Kidney Disease After Acute Decompensated Heart Failure. Kidney Int Rep 2022; 7:526-536. [PMID: 35257065 PMCID: PMC8897687 DOI: 10.1016/j.ekir.2021.12.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 12/09/2021] [Accepted: 12/28/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Acute kidney disease (AKD) represents a continuum of kidney injury for 7 to 90 days after acute kidney injury (AKI). The incidence and prognosis of AKD after acute decompensated heart failure (ADHF) are currently unclear. The aims of this study were to explore the incidence of AKD and the transition from AKI to AKD, to identify risk factors for AKD and develop a prediction model for any-stage AKD, and to evaluate the prognosis of AKD. Methods A total of 7519 patients admitted for ADHF between January 1, 2008, and December 31, 2018, from a multi-institutional database were identified. The composite outcomes after ADHF were stage 3 AKD and all-cause death. The prognosis impact of AKD, including major adverse kidney events (MAKEs), all-cause death, and heart failure hospitalization (HFH), during 5 years of follow-up was analyzed. Results The overall incidence of AKI and AKD after ADHF was 9% and 21.2%, respectively; 39.4% of the patients diagnosed with having AKI during ADHF subsequently developed AKD whereas 19.4% of the patients without an identified AKI episode subsequently developed AKD. The predictive scoring models revealed C-statistics of 0.726 (95% CI: 0.712–0.740) for any-stage AKD and 0.807 (95% CI: 0.793–0.821) for the composite of stage 3 AKD and death. Finally, AKD was associated with higher risks of all-cause death, MAKE, and HFH during the 5 years of follow-up (P < 0.001). Conclusion AKD after ADHF are associated with adverse outcomes. Our model could help in identification of patients at risk for AKD development, especially in those who did not have an index AKI episode.
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Ilges DT, Dermody ML, Blankenship C, Mansfield V, Van Tuyl JS. Impact of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers on Renal Function in Type 1 Cardiorenal Syndrome. J Cardiovasc Pharmacol Ther 2021; 26:611-618. [PMID: 34138673 DOI: 10.1177/10742484211022625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin receptor blocker (ARB) discontinuation during acute heart failure (AHF) is associated with increased mortality following hospitalization. Although the etiology of acute kidney injury (AKI) in type 1 cardiorenal syndrome (CRS) has been linked to renal venous congestion, ACE-I/ARB withdrawal (AW) theoretically promotes renal function recovery. ACE-I/ARBs are dose-reduced or withheld in approximately half of patients with CRS, but the subsequent impact on renal function remains largely uninvestigated. This study compared AW to ACE-I/ARB continuation (AC) during CRS. METHODS This was a retrospective, single-center chart review. Patients aged 18-89 years admitted from April 2018 to August 2019 with AHF and AKI were identified using discharge ICD-10 codes. All patients were treated with an ACE-I/ARB before admission. Key exclusion criteria included shock, pregnancy, and end-stage renal disease. The primary endpoint was change in serum creatinine (SCr) from admission through 72 hours. Data were analyzed utilizing chi-square and Mann-Whitney U tests with SPSS software. RESULTS A total of 111 admissions were included. AW occurred in 68 patients upon admission. AW patients presented with a higher blood urea nitrogen (P = 0.034), higher SCr (P = 0.021), and lower ejection fraction (P = 0.04). Median SCr change from admission to 72 hours did not differ between groups (AW -0.1 mg/dL vs AC 0.0 mg/dL, P = 0.05). There was no difference in SCr reduction ≥0.3 mg/dL at 72 hours, 30-day readmissions, or ACE-I/ARB prescription at discharge. CONCLUSIONS In patients with type 1 CRS, AW was not associated with improved renal function at 72 hours. A larger sample size is necessary to confirm these results.
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Affiliation(s)
- Daniel T Ilges
- Department of Pharmacy Services, 25213SSM Health Saint Louis University Hospital, St. Louis, MO, USA
| | - Morgan L Dermody
- Department of Pharmacy Practice, St. Louis College of Pharmacy at UHSP, St. Louis, MO, USA
| | - Caitlyn Blankenship
- Department of Pharmacy Practice, St. Louis College of Pharmacy at UHSP, St. Louis, MO, USA
| | - Valerie Mansfield
- Department of Pharmacy Services, 25213SSM Health Saint Louis University Hospital, St. Louis, MO, USA
| | - Joseph S Van Tuyl
- Department of Pharmacy Services, 25213SSM Health Saint Louis University Hospital, St. Louis, MO, USA.,Department of Pharmacy Practice, St. Louis College of Pharmacy at UHSP, St. Louis, MO, USA
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Carubelli V, Lombardi C, Specchia C, Peveri G, Oriecuia C, Tomasoni D, Di Pasquale M, Inciardi R, Garrafa E, Metra M. Adherence and optimization of angiotensin converting enzyme inhibitor/angiotensin II receptors blockers and beta-blockers in patients hospitalized for acute heart failure. ESC Heart Fail 2021; 8:1944-1953. [PMID: 33660949 PMCID: PMC8120409 DOI: 10.1002/ehf2.13223] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/17/2020] [Accepted: 01/07/2021] [Indexed: 12/28/2022] Open
Abstract
Aims Treatment with angiotensin converting enzyme inhibitor (ACEi)/angiotensin II receptors blockers (ARBs) and beta‐blockers is frequently suboptimal at discharge in patients hospitalized for acute heart failure (AHF). We investigated the prognostic significance of medical treatment at discharge and its changes during hospitalization. Methods and results In a retrospective analysis, we included 623 patients hospitalized for AHF with reduced left ventricular ejection fraction (<40%). The primary endpoint was all‐cause mortality and heart failure rehospitalization to Day 180 since hospital discharge. A total of 249 (42.4%) of patients received no ACEi/ARBs/BB or <50% target dose (TD) of these drugs, 249 (42.4%) had either ACEi/ARBs or BB ≥ 50% of TD, and 89 (15.2%) ACEi/ARBs and BB ≥ 50% of TD at discharge. The primary endpoint was significantly lower in patients receiving at least one drug ≥50% of TD compared with no or low‐dose treatment (ACEi/ARBs or BB ≥ 50% TD: adjusted hazard ratio (HR) 0.69, 95% confidence interval (CI) [0.49–0.98], P = 0.04; ACEi/ARBs and BB ≥ 50% TD: adjusted HR 0.54, 95% CI [0.30–0.96], P = 0.03). With regard to treatment changes from admission to discharge, therapy was decreased in 258 (44.6%) patients, stable in 194 (33.6%), and increased in 126 (21.8%). Compared with patients with stable therapy, treatment intensification was associated with a lower rate of the primary endpoint (adjusted HR 0.49, 95% CI [0.29–0.83]; P = 0.01). Conclusions In patients with AHF, prescription of ACEi/ARBs/BB ≥ 50% TD at the time of discharge, whether achieved or not through treatment intensification during the hospitalization, is associated with better post‐discharge outcomes.
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Affiliation(s)
- Valentina Carubelli
- Division of Cardiology, ASST Spedali Civili di Brescia, University and Civil Hospital of Brescia, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Carlo Lombardi
- Division of Cardiology, ASST Spedali Civili di Brescia, University and Civil Hospital of Brescia, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Claudia Specchia
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Giulia Peveri
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Chiara Oriecuia
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Division of Cardiology, ASST Spedali Civili di Brescia, University and Civil Hospital of Brescia, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Di Pasquale
- Division of Cardiology, ASST Spedali Civili di Brescia, University and Civil Hospital of Brescia, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Inciardi
- Division of Cardiology, ASST Spedali Civili di Brescia, University and Civil Hospital of Brescia, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Emirena Garrafa
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,Department of Laboratory Diagnostics, ASST Spedali Civili, Brescia, Italy
| | - Marco Metra
- Division of Cardiology, ASST Spedali Civili di Brescia, University and Civil Hospital of Brescia, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Lei L, Huang Y, Guo Z, Song F, He Y, Liu J, Sun G, Liu B, Chen P, Zhao J, Wu D, Xue Y, Yan W, Lin Z, Huang X, Chen G, Chen S, Liu Y, Chen J. Impact of contrast-induced acute kidney injury on the association between renin-angiotensin system inhibitors and long-term mortality in heart failure patients. J Renin Angiotensin Aldosterone Syst 2020; 21:1470320320979795. [PMID: 33319610 PMCID: PMC7745565 DOI: 10.1177/1470320320979795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Renin-angiotensin system inhibitors (RASi) reduce mortality among heart failure (HF) patients, but their effect among those complicating contrast-induced acute kidney injury (CI-AKI) remains unexplored. We aimed to investigate whether the relationship between RASi prescription at discharge and mortality differs between HF patients with or without CI-AKI following coronary angiography (CAG). METHODS About 596 HF patients from an observational cohort were divided into a CI-AKI group (n = 104) and a non-CI-AKI group (n = 492) based on whether they had CI-AKI following CAG. The endpoint was all-cause mortality. Multivariable Cox regression was performed in each group to explore the associations between RASi at discharge and mortality. RESULTS During the median follow-up time of 2.26 (1.70; 3.24) years, higher mortality rate was observed in the CI-AKI group compared to the non-CI-AKI group (18.3% vs 8.9%, p = 0.002). Among HF patients with CI-AKI, after adjusting for confounding factors, the association was not significant between RASi prescription at discharge and mortality (HR: 0.39, 95%CI: 0.12-1.31, p = 0.128), while it was among those without CI-AKI (HR: 0.39, 95%CI: 0.18-0.84, p = 0.016). CONCLUSION RASi prescription at discharge for HF patients complicating CI-AKI tended to be ineffective, while it benefited those without CI-AKI. Further randomized evidence is needed to confirm this trend.
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Affiliation(s)
- Li Lei
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China.,Department of Cardiology, Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Affiliated with South China University of Technology, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yulu Huang
- School of Pharmacy, Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Zhaodong Guo
- Department of Cardiology, Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Affiliated with South China University of Technology, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Feier Song
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yibo He
- Department of Cardiology, Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Affiliated with South China University of Technology, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Jin Liu
- Department of Cardiology, Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Affiliated with South China University of Technology, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Guoli Sun
- Department of Cardiology, Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Affiliated with South China University of Technology, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Bowen Liu
- Guangdong Provincial People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Pengyuan Chen
- Department of Cardiology, Guangdong General Hospital's Nanhai Hospital, The Second Hospital of Nanhai District Foshan City, Foshan, China
| | - Jianbin Zhao
- Department of Cardiology, Jiangmen Central Hospital, Jiangmen, Guangdong, China
| | - Dengxuan Wu
- Department of Cardiology, Panzhihua Central Hospital, Panzhihua, China
| | - Yan Xue
- Department of Cardiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Wenhe Yan
- Department of Cardiology, Maoming People's Hospital, Maoming, Guangdong, China
| | - Zefeng Lin
- Department of Neurology, Maoming People's Hospital, Maoming, Guangdong, China
| | - Xiuqiong Huang
- School of Pharmacy, Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Guanzhong Chen
- Guangdong Provincial People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Shiqun Chen
- Department of Cardiology, Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Affiliated with South China University of Technology, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yong Liu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China.,Department of Cardiology, Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Affiliated with South China University of Technology, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Jiyan Chen
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China.,Department of Cardiology, Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Affiliated with South China University of Technology, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
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11
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Simonavičius J, Maeder MT, Eurlings CGMJ, Aizpurua AB, Čelutkienė J, Barysienė J, Toggweiler S, Kaufmann BA, Brunner-La Rocca HP. Intensification of pharmacological decongestion but not the actual daily loop diuretic dose predicts worse chronic heart failure outcome: insights from TIME-CHF. Clin Res Cardiol 2020; 110:1221-1233. [PMID: 33216179 DOI: 10.1007/s00392-020-01779-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 11/02/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Both loop diuretics (LDs) and congestion have been related to worse heart failure (HF) outcome. The relationship between the cause and effect is unknown. The aim of this study was to investigate the interaction between congestion, diuretic use and HF outcome. METHODS Six hundred and twenty-two chronic HF patients from TIME-CHF were studied. Congestion was measured by means of a clinical congestion index (CCI). Loop diuretic dose was considered at baseline and month 6. Treatment intensification was defined as the increase in LD dose over 6 months or loop diuretic and thiazide or thiazide-like diuretic co-administration. The end-points were survival and HF hospitalisation-free survival. RESULTS High-LD dose at baseline and month 6 (≥ 80 mg of furosemide per day) was not identified as an independent predictor of outcome. CCI at baseline remained independently associated with impaired survival [hazard ratio (HR) 1.34, (95% confidence interval) (95% CI) (1.20-1.50), p < 0.001] and HF hospitalisation-free survival [HR 1.09, 95% CI (1.02-1.17), p = 0.015]. CCI at month 6 was independently associated with HF hospitalisation-free survival [HR 1.24, 95% CI (1.11-1.38), p < 0.001]. Treatment intensification was independently associated with survival [HR 1.75, 95% CI (1.19-1.38), p = 0.004] and HF hospitalisation-free survival [HR 1.69, 95% CI (1.22-2.35), p = 0.002]. Patients undergoing treatment intensification resulting in decongestion had better outcome than patients with persistent (worsening) congestion despite LD dose up-titration (p < 0.001). CONCLUSION Intensification of pharmacological decongestion but not the actual LD dose was related to poor outcome in chronic HF. If treatment intensification translated into clinical decongestion, outcome was better than in case of persistent or worsening congestion.
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Affiliation(s)
- Justas Simonavičius
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands. .,Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariskiu str. 2, 08406, Vilnius, Lithuania. .,The Faculty of Medicine of Vilnius University, Vilnius, Lithuania.
| | - Micha T Maeder
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Casper G M J Eurlings
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Jelena Čelutkienė
- Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Jūratė Barysienė
- Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Stefan Toggweiler
- Division of Cardiology, Heart Centre Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Beat A Kaufmann
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
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12
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Santos B, Sanz M, Muñoz Ramos P, Gilabert N, Costa R, Otero S, Carles P, Ruano P, Quiroga B. [Baseline characteristics of nonagenarians hospitalised due to acute kidney injury compared to other age groups]. Rev Esp Geriatr Gerontol 2020; 55:326-331. [PMID: 32718579 DOI: 10.1016/j.regg.2020.06.004] [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: 01/17/2020] [Revised: 06/07/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The increase in life expectancy leads to higher hospitalisation rates in elderly patients. The aim of this work is to study the characteristics of the population over 90 years of age that are admitted due to acute kidney injury (AKI). MATERIAL AND METHODS A cross-sectional study was conducted that included all patients admitted to hospital with AKI in the years 2013 and 2014. Epidemiological characteristics, comorbidity, medication and baseline analytical data were collected, and a comparison was made between patients with age over 90 years-old and the others. RESULTS A total of 1733 patients were included, of whom 264 (15%) were over 90 years-old. A significantly higher proportion of these patients were women. The most frequent cause of AKI in patients older than 90 years was functional (81%) (p < 0.001 compared to other age groups). The main cause of hospital admission was infection. In the group of over 90 years of age, a higher prevalence was found for arterial hypertension (p = 0.005), chronic kidney disease (p = 0.014), congestive heart failure (p = 0.006), and cognitive impairment (p < 0.0001). The baseline glomerular filtration rate by CKD-EPI was lower in the group of patients older than 90 years (p < 0.0001). Patients under 90 years admitted to hospital due to AKI, had a higher prevalence of diabetes mellitus (p < 0.001), dyslipidaemia (p < 0.001), history of neoplasia (p < 0.001), and a higher Barthel index (p < 0.0001). CONCLUSIONS Nonagenarians admitted due to AKI have functional aetiology as the most common factor. These patients have a higher prevalence of hypertension, heart failure, chronic kidney disease, low functional status, and more cognitive impairment.
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Affiliation(s)
- Begoña Santos
- Servicio de Nefrología, Hospital Universitario de La Princesa, Madrid, España
| | - Marta Sanz
- Servicio de Nefrología, Hospital Universitario de La Princesa, Madrid, España
| | | | - Noemi Gilabert
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, España
| | - Ramón Costa
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, España
| | - Silvia Otero
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, España
| | - Patricia Carles
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, España
| | - Pablo Ruano
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, España
| | - Borja Quiroga
- Servicio de Nefrología, Hospital Universitario de La Princesa, Madrid, España.
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Boulos J, Darawsha W, Abassi ZA, Azzam ZS, Aronson D. Treatment patterns of patients with acute heart failure who develop acute kidney injury. ESC Heart Fail 2018; 6:45-52. [PMID: 30569598 PMCID: PMC6351897 DOI: 10.1002/ehf2.12364] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/22/2018] [Accepted: 08/30/2018] [Indexed: 11/08/2022] Open
Abstract
AIMS In the present study, we aimed to determine the relationship between therapeutic decisions during the treatment of acute heart failure (AHF) patients who develop acute kidney injury (AKI) and subsequent renal and clinical outcomes. METHODS AND RESULTS We studied 277 patients with AHF and AKI, defined as an increase of >0.3 mg/dL in serum creatinine. The physician response to AKI was determined through a treatment composite score that captured changes in medical management in response to AKI, including a reduction (≥50%) or discontinuation of selected medication classes [angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACE-Is/ARBs), beta-blockers, and diuretics] and fluids administration. ACE-Is/ARBs, beta-blockers, and diuretics were reduced or discontinued in 103 (55.4%), 84 (38.9%), and 166 (61.5%), respectively. Fluids were administered to 130 (46.9%) patients. Discontinuation rates of ACE-Is/ARBs, beta-blockers, diuretics, and fluids administration were higher in patients with hypotension (systolic blood pressure < 90 mm Hg; P = 0.001). In a logistic regression model, a composite score > 1 was associated with greater likelihood of renal function recovery (odds ratio 3.47, 95% confidence interval 2.06-5.83; P < 0.0001) but with a smaller reduction in congestion index (P = 0.021). Unadjusted 6 months mortality was higher in patients with a composite treatment score > 1 (hazard ratio 1.71, 95% confidence interval 1.12-2.61; P = 0.01). After adjustments, the treatment composite score was no longer associated with mortality. CONCLUSIONS Discontinuation or dose reduction of diuretics or neurohormonal blockers may improve renal outcome at the price of less efficient decongestion. Our results emphasize the need for randomized clinical trials that address the treatment of AHF patients with AKI.
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Affiliation(s)
- Jubran Boulos
- Department of Cardiology, Rambam Medical Center, Bat Galim, Haifa, Israel
| | - Wisam Darawsha
- Department of Cardiology, Rambam Medical Center, Bat Galim, Haifa, Israel
| | - Zaid A Abassi
- Department of Physiology and Biophysics, Rambam Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Zaher S Azzam
- Department of Internal Medicine B, Rambam Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Doron Aronson
- Department of Cardiology, Rambam Medical Center, Bat Galim, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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