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Liu X, Wang Y, Yiu K, Zhang Y, Wang J. Synergistic effect of spironolactone/ARB on cardiovascular endpoints in heart failure patients with preserved ejection. Eur J Intern Med 2024; 126:113-116. [PMID: 38637197 DOI: 10.1016/j.ejim.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Xiao Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China; Guangdong Province Key Laboratory of Arrhythmia and Electrophysiology, Guangzhou, Guangdong Province, China; Guangzhou Key Laboratory of Molecular Mechanism and Translation in Major Cardiovascular Disease, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Yue Wang
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China; Guangdong Province Key Laboratory of Arrhythmia and Electrophysiology, Guangzhou, Guangdong Province, China
| | - Kaihang Yiu
- Cardiology Division, Department of Medicine, The University of Hong Kong-Shen Zhen Hospital, Shenzhen City, Guangdong Province, China; Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
| | - Yuling Zhang
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China; Guangdong Province Key Laboratory of Arrhythmia and Electrophysiology, Guangzhou, Guangdong Province, China; Guangzhou Key Laboratory of Molecular Mechanism and Translation in Major Cardiovascular Disease, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China.
| | - Jingfeng Wang
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China; Guangdong Province Key Laboratory of Arrhythmia and Electrophysiology, Guangzhou, Guangdong Province, China; Guangzhou Key Laboratory of Molecular Mechanism and Translation in Major Cardiovascular Disease, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China.
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2
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Zahir Anjum D, Bonde AN, Fosbol E, Hartwell Garred C, Gislason G, Elmegaard M, Knigge P, Torp-Pedersen C, Andersson C, Pfeffer MA, Jhund PS, McMurray JJV, Petrie MC, Kober L, Schou M. Incidence of clinical outcomes in heart failure patients with and without advanced chronic kidney disease. ESC Heart Fail 2024. [PMID: 38978335 DOI: 10.1002/ehf2.14933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 05/13/2024] [Accepted: 06/14/2024] [Indexed: 07/10/2024] Open
Abstract
AIMS Chronic kidney disease (CKD) is a well-established risk factor for heart failure (HF); however, patients with an estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2 have been systematically excluded from clinical trials. This study investigated the incidence of HF and kidney outcomes in HF patients with and without advanced CKD, that is, eGFR < 30. METHODS From nationwide registries, HF patients were identified from 2014 to 2018 and categorized into three groups according to baseline eGFR (eGFR ≥ 60, 60 > eGFR ≥ 30 and eGFR < 30). The incidence of primary outcomes (all-cause mortality, HF hospitalization, end-stage kidney disease and sustained 50% eGFR decline) was estimated using cumulative incidence functions. RESULTS Of the 21 959 HF patients included, the median age was 73.9 years, and 30% of patients had an eGFR between 30 and 60 and 7% had an eGFR < 30. The 4 year incidence of all-cause mortality was highest for patients with eGFR < 30 (28.3% for patients with eGFR ≥ 60, 51.6% for patients with 60 > eGFR ≥ 30 and 72.2% for patients with eGFR < 30). The 4 year incidence of HF hospitalization was comparable between the groups (25.8%, 29.8% and 26.1% for patients with eGFR ≥ 60, 60 > eGFR ≥ 30 and eGFR < 30, respectively). For patients with eGFR < 30, kidney outcomes were four times more often the first event than patients with eGFR > 30 (4 year incidence of kidney outcome as the first event was 5.0% for eGFR ≥ 60, 4.8% for 60 > eGFR ≥ 30 and 20.1% for eGFR < 30). CONCLUSIONS Patients with advanced CKD had a higher incidence of mortality and poorer kidney outcomes than those without advanced CKD, but a similar incidence of HF hospitalizations.
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Affiliation(s)
- Deewa Zahir Anjum
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Anders N Bonde
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Emil Fosbol
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Mariam Elmegaard
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Pauline Knigge
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Christian Torp-Pedersen
- Department of Clinical Research and Cardiology, Nordsjællands Hospital, Hillerød, Denmark
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Charlotte Andersson
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Kober
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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3
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Bonacchi G, Rossi VA, Garofalo M, Mollace R, Uccello G, Pieragnoli P, Checchi L, Perrotta L, Voltolini L, Ricciardi G, Beltrami M. Pathophysiological Link and Treatment Implication of Heart Failure and Preserved Ejection Fraction in Patients with Chronic Kidney Disease. Biomedicines 2024; 12:981. [PMID: 38790943 PMCID: PMC11117953 DOI: 10.3390/biomedicines12050981] [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: 03/30/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) results from a complex interplay of age, genetic, cardiac remodeling, and concomitant comorbidities including hypertension, obesity, diabetes, and chronic kidney disease (CKD). Renal failure is an important comorbidity of HFpEF, as well as a major pathophysiological mechanism for those patients at risk of developing HFpEF. Heart failure (HF) and CKD are intertwined conditions sharing common disease pathways; the so-called "kidney tamponade", explained by an increase in intracapsular pressure caused by fluid retention, is only the latest model to explain renal injury in HF. Recognizing the different phenotypes of HFpEF remains a real challenge; the pathophysiological mechanisms of renal dysfunction may differ across the HF spectrum, as well as the prognostic role. A better understanding of the role of cardiorenal interactions in patients with HF in terms of symptom status, disease progression, and prognosis remains essential in HF management. Historically, patients with HF and CKD have been scarcely represented in clinical trial populations. Current concerns affect the practical approach to HF treatment, and, in this context, physicians are frequently hesitant to prescribe and titrate both new and old treatments. Therefore, the extensive application of HF drugs in diverse HF subtypes with numerous comorbidities and different renal dysfunction etiologies remains a controversial matter of discussion. Numerous recently introduced drugs, such as sodium-glucose-linked transporter 2 inhibitors (SGLT2i), constitute a new therapeutic option for patients with HF and CKD. Because of their protective vascular and hormonal actions, the use of these agents may be safely extended to patients with renal dysfunction in the long term. The present review delves into the phenotype of patients with HFpEF and CKD from a pathophysiological perspective, proposing a treatment approach that suggests a practical stepwise algorithm for the proper application of life-saving therapies in clinical practice.
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Affiliation(s)
- Giacomo Bonacchi
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy;
| | | | - Manuel Garofalo
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Rocco Mollace
- Department of Experimental Medicine, Tor Vergata University, 00133 Rome, Italy;
- Cardiology Unit, Humanitas Gavazzeni, 24125 Bergamo, Italy
| | - Giuseppe Uccello
- Division of Cardiology, “A. Manzoni” Hospital—ASST Lecco, 23900 Lecco, Italy;
| | - Paolo Pieragnoli
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Luca Checchi
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Laura Perrotta
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Luca Voltolini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
- Thoracic Surgery Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Giuseppe Ricciardi
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy;
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
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4
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Ostrominski JW, Vaduganathan M. Chapter 2: Clinical and Mechanistic Potential of Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors in Heart Failure with Preserved Ejection Fraction. Am J Med 2024; 137:S9-S24. [PMID: 37160196 DOI: 10.1016/j.amjmed.2023.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/18/2023] [Indexed: 05/11/2023]
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have emerged as an important approach for the treatment of heart failure in patients with or without diabetes. Although the precise mechanisms underpinning their clinical impact remain incompletely resolved, mechanistic studies and insights from major clinical trials have demonstrated the impact of SGLT2 inhibitors on numerous cardio-renal-metabolic pathways of relevance to heart failure with preserved ejection fraction (HFpEF), which, in the contemporary era, constitutes approximately half of all patients with heart failure. Despite rates of morbidity and mortality that are commensurate with those of heart failure with reduced ejection fraction, disease-modifying therapies have comparatively been severely lacking. As such, HFpEF remains among the greatest unmet needs in cardiovascular medicine. Within the past decade, HFpEF has been established as a highly integrated disorder, involving not only the cardiovascular system, but also the lungs, kidneys, skeletal muscle, and adipose tissue. Given their multisystem impact, SGLT2i offer unique promise in addressing the complex pathophysiology of HFpEF, and in recent randomized controlled trials, were shown to significantly reduce heart failure events and cardiovascular death in patients with HFpEF. Herein, we discuss several proposed mechanisms of clinical benefit of SGLT2i in HFpEF.
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Affiliation(s)
- John W Ostrominski
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass.
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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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6
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Guo L, Wu X. Worsening Renal Function and Adverse Outcomes in Patients with HFpEF with or without Atrial Fibrillation. Biomedicines 2023; 11:2484. [PMID: 37760925 PMCID: PMC10526122 DOI: 10.3390/biomedicines11092484] [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: 07/11/2023] [Revised: 08/26/2023] [Accepted: 08/27/2023] [Indexed: 09/29/2023] Open
Abstract
Since worsening renal function (WRF) and atrial fibrillation (AF) often coexist in preserved ejection fraction (HFpEF), we aimed to investigate the effect of WRF on the prognosis of HFpEF patients with and without AF. The study population of this study (n = 1763) was based on the subset of the Americas in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial (TOPCAT). We found that the cumulative probabilities of the primary composite outcome and cardiovascular death were significantly higher in AF patients post-WRF when compared to non-AF patients. In the time-dependent Cox proportional hazard model, WRF was significantly associated with higher risks of adverse outcomes (primary composite outcome: HR = 1.58 (95% CI, 1.19-2.11); all-cause death: HR = 1.50 (95% CI, 1.10-2.06); cardiovascular death: HR, 2.00 (95% CI, 1.34-3.00)) after adjustments for confounding factors at baseline in HFpEF patients with AF, whereas in HFpEF patients without AF, WRF was not significantly associated with any adverse outcome. p for interactions for the primary composite outcome, cardiovascular death, and AF were significant. In conclusion, these findings highlight that WRF was associated with a greater risk of the primary composite outcome, all-cause death, and cardiovascular death in HFpEF patients with AF.
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Affiliation(s)
- Linjuan Guo
- Department of Cardiology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang 330000, China
| | - Xiaojuan Wu
- Department of Gastroenterology, Ganzhou People’s Hospital, Ganzhou 341000, China
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7
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Vaduganathan M, Mentz RJ, Claggett BL, Miao ZM, Kulac IJ, Ward JH, Hernandez AF, Morrow DA, Starling RC, Velazquez EJ, Williamson KM, Desai AS, Zieroth S, Lefkowitz M, McMurray JJV, Braunwald E, Solomon SD. Sacubitril/valsartan in heart failure with mildly reduced or preserved ejection fraction: a pre-specified participant-level pooled analysis of PARAGLIDE-HF and PARAGON-HF. Eur Heart J 2023; 44:2982-2993. [PMID: 37210743 PMCID: PMC10424880 DOI: 10.1093/eurheartj/ehad344] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/23/2023] Open
Abstract
AIMS The PARAGLIDE-HF trial demonstrated reductions in natriuretic peptides with sacubitril/valsartan compared with valsartan in patients with heart failure (HF) with mildly reduced or preserved ejection fraction who had a recent worsening HF event, but was not adequately powered to examine clinical outcomes. PARAGON-HF included a subset of PARAGLIDE-HF-like patients who were recently hospitalized for HF. Participant-level data from PARAGLIDE-HF and PARAGON-HF were pooled to better estimate the efficacy and safety of sacubitril/valsartan in reducing cardiovascular and renal events in HF with mildly reduced or preserved ejection fraction. METHODS AND RESULTS Both PARAGLIDE-HF and PARAGON-HF were multicentre, double-blind, randomized, active-controlled trials of sacubitril/valsartan vs. valsartan in patients with HF with mildly reduced or preserved left ventricular ejection fraction (LVEF >40% in PARAGLIDE-HF and ≥45% in PARAGON-HF). In the pre-specified primary analysis, we pooled participants in PARAGLIDE-HF (all of whom were enrolled during or within 30 days of a worsening HF event) with a 'PARAGLIDE-like' subset of PARAGON-HF (those hospitalized for HF within 30 days). We also pooled the entire PARAGLIDE-HF and PARAGON-HF populations for a broader context. The primary endpoint for this analysis was the composite of total worsening HF events (including first and recurrent HF hospitalizations and urgent visits) and cardiovascular death. The secondary endpoint was the pre-specified renal composite endpoint for both studies (≥50% decline in estimated glomerular filtration rate from baseline, end-stage renal disease, or renal death). Compared with valsartan, sacubitril/valsartan significantly reduced total worsening HF events and cardiovascular death in both the primary pooled analysis of participants with recent worsening HF [n = 1088; rate ratio (RR) 0.78; 95% confidence interval (CI) 0.61-0.99; P = 0.042] and in the pooled analysis of all participants (n = 5262; RR 0.86; 95% CI: 0.75-0.98; P = 0.027). In the pooled analysis of all participants, first nominal statistical significance was reached by Day 9 after randomization, and treatment benefits were larger in those with LVEF ≤60% (RR 0.78; 95% CI 0.66-0.91) compared with those with LVEF >60% (RR 1.09; 95% CI 0.86-1.40; Pinteraction = 0.021). Sacubitril/valsartan was also associated with lower rates of the renal composite endpoint in the primary pooled analysis [hazard ratio (HR) 0.67; 95% CI 0.43-1.05; P = 0.080] and the pooled analysis of all participants (HR 0.60; 95% CI 0.44-0.83; P = 0.002). CONCLUSION In pooled analyses of PARAGLIDE-HF and PARAGON-HF, sacubitril/valsartan reduced cardiovascular and renal events among patients with HF with mildly reduced or preserved ejection fraction. These data provide support for use of sacubitril/valsartan in patients with HF with mildly reduced or preserved ejection fraction, particularly among those with an LVEF below normal, regardless of care setting.
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Affiliation(s)
- Muthiah Vaduganathan
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | | | - Brian L Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Zi Michael Miao
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Ian J Kulac
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | | | | | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Eric J Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Akshay S Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Eugene Braunwald
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
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Koike T, Ejima K, Kataoka S, Yazaki K, Higuchi S, Kanai M, Yagishita D, Shoda M, Hagiwara N. Prognostic significance of cardiorenal dysfunction within 1 year after atrial fibrillation ablation in patients with systolic dysfunction. Heart Vessels 2023; 38:77-89. [PMID: 35879440 DOI: 10.1007/s00380-022-02124-w] [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: 02/24/2022] [Accepted: 06/15/2022] [Indexed: 01/06/2023]
Abstract
Atrial fibrillation (AF) ablation can improve left ventricular ejection fraction (LVEF) and renal function and can even reduce mortality in patients with impaired LVEF. However, the effect of post-ablation cardiorenal dysfunction on the prognosis of patients with impaired LVEF who underwent AF ablation remains unclear. Of the 1243 consecutive patients undergoing AF ablation, the prognosis of 163 non-dialysis patients who underwent AF ablation with < 50% LVEF was evaluated. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, and a need for modification of the treatment for heart failure. During the median follow-up of 4.2 years after the first AF ablation procedure, the primary outcome occurred in 30 of 163 patients (18%). The receiver operating characteristic curve analysis demonstrated that the post-LVEF (LVEF within 1 year after the procedure, and before the occurrence of primary outcome) had larger areas under the curve (0.70) than the pre-LVEF (LVEF before the procedure), and the most optimal cutoff value was LVEF ≤ 42%. Multivariate analysis demonstrated that patients with post-LVEF ≤ 42% and worsening renal function (WRF; an absolute increase in serum creatinine [SCr] ≥ 0.3 mg/dL compared with the SCr at baseline within 1 year after the procedure and before the occurrence of primary outcome) had a 3.4- to 4.3-fold and 3.4- to 3.7-fold higher risk of the primary outcome compared with those without these predictors, respectively. Patients were categorized using post-LVEF ≤ 42% and WRF as follows: group 1 (post-LVEF > 42% without WRF), group 2 (post-LVEF ≤ 42% without WRF), group 3 (post-LVEF > 42% with WRF), and group 4 (post-LVEF ≤ 42% with WRF). Group 4 had a 15.8-fold (P = 0.0001) higher risk of the primary outcome compared with group 1 after adjusting for pre-procedural factors. In patients with impaired LVEF undergoing AF ablation, post-LVEF ≤ 42% and WRF were independent predictors of poor prognosis. The combination of post-LVEF ≤ 42% and WRF is strongly associated with a poor prognosis in patients with AF undergoing ablation, who with these post-ablation cardiorenal dysfunction may have to be treated more intensively after AF ablation.
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Affiliation(s)
- Toshiharu Koike
- Department of Cardiology, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Koichiro Ejima
- Department of Cardiology, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan. .,Clinical Research Division for Heart Rhythm Management, Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Shohei Kataoka
- Department of Cardiology, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kyoichiro Yazaki
- Department of Cardiology, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Satoshi Higuchi
- Department of Cardiology, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Miwa Kanai
- Department of Cardiology, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Daigo Yagishita
- Department of Cardiology, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.,Clinical Research Division for Heart Rhythm Management, Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.,Clinical Research Division for Heart Rhythm Management, Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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9
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Guo Y, Ren M, Wang T, Wang Y, Pu T, Li X, Yu L, Wang L, Liu P, Tang L. Effects of sacubitril/valsartan in ESRD patients undergoing hemodialysis with HFpEF. Front Cardiovasc Med 2022; 9:955780. [PMID: 36440034 PMCID: PMC9681904 DOI: 10.3389/fcvm.2022.955780] [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: 05/29/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Heart failure with preserved ejection fraction (HFpEF), which is a common co-morbidity in patients with maintenance hemodialysis (MHD), results in substantial mortality and morbidity. However, there are still no effective therapeutic drugs available for HFpEF currently. Sacubitril/valsartan has been shown to significantly improve clinical outcomes and reverse myocardial remodeling among patients with heart failure with reduced ejection fraction (HFrEF). The effect of sacubitril/valsartan in MHD patients with HFpEF remains unclear. Our study was designed to assess the efficacy and safety of sacubitril/valsartan in MHD patients with HFpEF. Methods A total of 247 MHD patients with HFpEF treated with sacubitril/valsartan were included in this retrospective study. Patients were followed up regularly after medication treatment. The alterations in clinical, biochemical, and echocardiographic parameters before and after taking sacubitril/valsartan were collected. In addition, the safety of the sacubitril/valsartan treatment was also assessed. Among those 247 patients with MHD, 211 patients were already in treatment with angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs) before being treated with sacubitril/valsartan. We also performed an analysis to compare the differences between the 211 patients who had previously received ACEi/ARB treatment and the 36 patients who were sacubitril/valsartan naive. Results Among those 247 patients with MHD, compared with baseline levels, systolic blood pressure (BP) (149.7 ± 23.6 vs. 137.2 ± 21.0 mmHg, P < 0.001), diastolic BP (90.2 ± 16.1 vs. 84.5 ± 14.1 mmHg, P < 0.001), heart rate (83.5 ± 12.5 vs. 80.0 ± 8.7 bpm, P < 0.001), N-terminal B-type natriuretic peptide precursor (NT-proBNP) [29125.0 (11474.5, 68532.0) vs. 12561.3 (4035.0, 37575.0) pg/ml, P < 0.001], and cardiac troponin I [0.044 (0.025, 0.078) vs. 0.0370 (0.020, 0.064) μg/L, P = 0.009] were markedly decreased after treatment with sacubitril/valsartan. New York Heart Association (NYHA) functional class showed a notable trend of improvement after 3–12 months of follow-up. Echocardiographic parameters including left ventricular posterior wall thickness (LVPWT) (11.8 ± 2.0 vs. 10.8 ± 1.9 mm, P < 0.001), intraventricular septal thickness in diastole (11.8 ± 2.0 vs. 11.2 ± 2.0 mm, P < 0.001), left ventricular end-diastolic diameter (53.8 ± 6.9 vs. 51.2 ± 7.1 mm, P < 0.001), left atrial diameter (LAD) (40.5 ± 6.2 vs. 37.2 ± 7.2 mm, P < 0.001), left ventricular end-diastolic volume (LVEDV) [143.0 (111.5, 174.0) vs. 130.0 (105.0, 163.0) ml, P < 0.001], left ventricular end-systolic volume (LVESV) [57.0 (43.0, 82.5) vs. 48.0 (38.0, 74.0) ml, P < 0.001], and pulmonary arterial systolic pressure [39.0 (30.5, 50.0) vs. 28.0 (21.0, 37.5) mmHg, P < 0.001] were significantly reduced after initiating the treatment of sacubitril/valsartan. The parameters of left ventricular diastolic function including E/A ratio [0.8 (0.7, 1.3) vs. 0.9 (0.8, 1.3), P = 0.008], maximal tricuspid regurgitation velocity [2.7 (2.5, 3.2) vs. 2.4 (2.0, 2.8) m/s, P < 0.001], septal e’wave velocity (8.0 ± 0.6 vs. 8.2 ± 0.5 cm/s, P = 0.001), lateral e’ wave velocity (9.9 ± 0.8 vs. 10.2 ± 0.7 cm/s, P < 0.001), E/e’ [8.3 (6.4, 11.8) vs. 7.2 (6.1, 8.9), P < 0.001], and left atrial volume index (37.9 ± 4.2 vs. 36.4 ± 4.1 ml/m2, P < 0.001) were significantly improved by sacubitril/valsartan. Among 211 patients who were already in treatment with ACEi/ARB and 36 patients who were sacubitril/valsartan naive, the improvement of cardiac function demonstrated by clinical outcomes and echocardiographic parameters were similar to the previous one of the 247 MHD patients with HFpEF. During the follow-up, none of the patients showed severe adverse drug reactions. Conclusion Our study suggested that sacubitril/valsartan treatment in MHD patients with HFpEF was effective and safe.
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Affiliation(s)
- Yanhong Guo
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingjing Ren
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tingting Wang
- Department of Gastroenterology, Wenxian People’s Hospital, Jiaozuo, China
| | - Yulin Wang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tian Pu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaodan Li
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lu Yu
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Liuwei Wang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peipei Liu
- Clinical Systems Biology Laboratories, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Peipei Liu,
| | - Lin Tang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Lin Tang,
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10
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Mc Causland FR, Lefkowitz MP, Claggett B, Packer M, Senni M, Gori M, Jhund PS, McGrath MM, Rouleau JL, Shi V, Swedberg K, Vaduganathan M, Zannad F, Pfeffer MA, Zile M, McMurray JJV, Solomon SD. Angiotensin-neprilysin inhibition and renal outcomes across the spectrum of ejection fraction in heart failure. Eur J Heart Fail 2022; 24:1591-1598. [PMID: 34989105 PMCID: PMC9253196 DOI: 10.1002/ejhf.2421] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/01/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022] Open
Abstract
AIMS Patients with heart failure are at higher risk of progression to end-stage renal disease (ESRD), regardless of ejection fraction (EF). We assessed the renal effects of angiotensin-neprilysin inhibition in a pooled analysis of 13 195 patients with heart failure with reduced and preserved EF. METHODS AND RESULTS We combined data from PARADIGM-HF (EF ≤40%; n = 8399) and PARAGON-HF (EF ≥45%; n = 4796) in a pre-specified pooled analysis. We assessed the effect of treatment (sacubitril/valsartan vs. enalapril or valsartan) on a composite of either ≥50% reduction in estimated glomerular filtration rate (eGFR), ESRD, or death from renal causes, in addition to changes in eGFR slope. We assessed whether baseline renal function or EF modified the effect of therapy on renal outcomes. At randomization, eGFR was 68 ± 20 ml/min/1.73 m2 in PARADIGM-HF and 63 ± 19 ml/min/1.73 m2 in PARAGON-HF. The composite renal outcome occurred in 70 of 6594 patients (1.1%) in the sacubitril/valsartan group and in 123 of 6601 patients (1.9%) in the valsartan or enalapril group (hazard ratio 0.56, 95% confidence interval [CI] 0.42-0.75; p < 0.001). The mean eGFR change was -1.8 (95% CI -1.9 to -1.7) ml/min/1.73 m2 /year for the sacubitril/valsartan group, compared with -2.4 (95% CI -2.5 to -2.2) ml/min/1.73 m2 /year for the valsartan or enalapril group. The treatment effect on the composite renal endpoint was not modified by categories of baseline eGFR (p-interaction = 0.64), but was most pronounced in those with baseline EF between 30% and 60% (p-interaction = 0.001). CONCLUSIONS In patients with heart failure, sacubitril/valsartan reduced the risk of serious adverse renal outcomes and slowed decline in eGFR, compared with valsartan or enalapril, independent of baseline renal function.
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Affiliation(s)
- Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Brian Claggett
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Michele Senni
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Mauro Gori
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Martina M. McGrath
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jean L. Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Canada
| | - Victor Shi
- Novartis Pharmaceuticals, East Hanover, NJ, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden
| | - Muthiah Vaduganathan
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm CIC1433, CHRU de Nancy, France
| | - Marc A. Pfeffer
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Michael Zile
- Medical University of South Carolina, Charleston, South Carolina, USA
- Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | - John J. V. McMurray
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Scott D. Solomon
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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11
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Vaduganathan M, Ferreira JP, Rossignol P, Neuen BL, Claggett BL, Pfeffer MA, McMurray JJV, Pitt B, Zannad F, Solomon SD. Effects of Steroidal Mineralocorticoid Receptor Antagonists on Acute and Chronic Estimated Glomerular Filtration Rate Slopes in Patients with Chronic Heart Failure. Eur J Heart Fail 2022; 24:1586-1590. [PMID: 35867859 DOI: 10.1002/ejhf.2635] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS Steroidal mineralocorticoid receptor antagonists (MRAs) form a cornerstone of the management of heart failure (HF), but little is known about the long-term effects of MRA therapy on kidney function. We evaluated acute and chronic estimated glomerular function (eGFR) slopes in the 2 largest completed trials testing steroidal MRAs in chronic HF. METHODS AND RESULTS We conducted parallel post hoc eGFR slope analyses in 2 multinational, double-blind randomized, placebo-controlled trials of steroidal MRAs in chronic HF with reduced ejection fraction (EMPHASIS-HF) and preserved ejection fraction (TOPCAT Americas region). GFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation. Annual slopes of eGFR were assessed by generalized random coefficient models. Least square mean differences of eGFR slopes between steroidal MRA and placebo arms. Median follow-up was 1.8 years (EMPHASIS-HF) and 3.3 years (TOPCAT Americas). From baseline to month 4-6 ("acute eGFR slope"), compared to placebo, MRA treatment led to an acute decline in eGFR of -2.4 mL/min/1.73m2 (95% CI -3.4 to -1.4; P <0.001) and -2.0 mL/min/1.73m2 (95% CI -3.0 to -1.8; P <0.001) in EMPHASIS-HF and TOPCAT Americas, respectively. From month 4-6 to end of study, there was no difference in "chronic eGFR slope" between MRA and placebo arms (-0.3 mL/min/1.73m2 /year [95% CI -1.3 to 0.7; P =0.53] and 0.1 mL/min/1.73m2 /year [95% CI -1.4 to 1.7; P =0.86]) in EMPHASIS-HF and TOPCAT Americas, respectively. CONCLUSIONS Steroidal MRAs result in acute declines in eGFR but do not modify long-term kidney disease trajectories in chronic HF with reduced or preserved ejection fraction. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - João Pedro Ferreira
- Université de Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Nancy, France
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Patrick Rossignol
- Université de Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Nancy, France
- Department of Medical specialties and Nephrology-Hemodialysis, Princess Grace Hospital, Monaco, and Centre d'Hémodialyse Privé de Monaco, Monaco
| | - Brendon L Neuen
- George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
| | - Brian L Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Nancy, France
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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12
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Ilieșiu AM, Hodorogea AS, Balahura AM, Bădilă E. Non-Invasive Assessment of Congestion by Cardiovascular and Pulmonary Ultrasound and Biomarkers in Heart Failure. Diagnostics (Basel) 2022; 12:962. [PMID: 35454010 PMCID: PMC9024731 DOI: 10.3390/diagnostics12040962] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 02/04/2023] Open
Abstract
Worsening chronic heart failure (HF) is responsible for recurrent hospitalization and increased mortality risk after discharge, irrespective to the ejection fraction. Symptoms and signs of pulmonary and systemic congestion are the most common cause for hospitalization of acute decompensated HF, as a consequence of increased cardiac filling pressures. The elevated cardiac filling pressures, also called hemodynamic congestion, may precede the occurrence of clinical congestion by days or weeks. Since HF patients often have comorbidities, dyspnoea, the main symptom of HF, may be also caused by respiratory or other illnesses. Recent studies underline the importance of the diagnosis and treatment of hemodynamic congestion before HF symptoms worsen, reducing hospitalization and improving prognosis. In this paper we review the role of integrated evaluation of biomarkers and imaging technics, i.e., echocardiography and pulmonary ultrasound, for the diagnosis, prognosis and treatment of congestion in HF patients.
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Affiliation(s)
- Adriana Mihaela Ilieșiu
- Cardiology and Internal Medicine Department, Theodor Burghele Clinical Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Andreea Simona Hodorogea
- Cardiology and Internal Medicine Department, Theodor Burghele Clinical Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Ana-Maria Balahura
- Internal Medicine Department, Bucharest Clinical Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.-M.B.); (E.B.)
| | - Elisabeta Bădilă
- Internal Medicine Department, Bucharest Clinical Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.-M.B.); (E.B.)
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13
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Beldhuis IE, Lam CSP, Testani JM, Voors AA, Van Spall HGC, Ter Maaten JM, Damman K. Evidence-Based Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction and Chronic Kidney Disease. Circulation 2022; 145:693-712. [PMID: 35226558 PMCID: PMC9074837 DOI: 10.1161/circulationaha.121.052792] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease (CKD) as identified by a reduced estimated glomerular filtration rate (eGFR) is a common comorbidity in patients with heart failure with reduced ejection fraction (HFrEF). The presence of CKD is associated with more severe heart failure, and CKD itself is a strong independent risk factor of poor cardiovascular outcome. Furthermore, the presence of CKD often influences the decision to start, uptitrate, or discontinue possible life-saving HFrEF therapies. Because pivotal HFrEF randomized clinical trials have historically excluded patients with stage 4 and 5 CKD (eGFR <30 mL/min/1.73 m2), information on the efficacy and tolerability of HFrEF therapies in these patients is limited. However, more recent HFrEF trials with novel classes of drugs included patients with more severe CKD. In this review on medical therapy in patients with HFrEF and CKD, we show that for both all-cause mortality and the combined end point of cardiovascular death or heart failure hospitalization, most drug classes are safe and effective up to CKD stage 3B (eGFR minimum 30 mL/min/1.73 m2). For more severe CKD (stage 4), there is evidence of safety and efficacy of sodium glucose cotransporter 2 inhibitors, and to a lesser extent, angiotensin-converting enzyme inhibitors, vericiguat, digoxin and omecamtiv mecarbil, although this evidence is restricted to improvement of cardiovascular death/heart failure hospitalization. Data are lacking on the safety and efficacy for any HFrEF therapies in CKD stage 5 (eGFR < 15 mL/min/1.73 m2 or dialysis) for either end point. Last, although an initial decline in eGFR is observed on initiation of several HFrEF drug classes (angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers/mineralocorticoid receptor antagonists/angiotensin receptor blocker neprilysin inhibitors/sodium glucose cotransporter 2 inhibitors), renal function often stabilizes over time, and the drugs maintain their clinical efficacy. A decline in eGFR in the context of a stable or improving clinical condition should therefore not be cause for concern and should not lead to discontinuation of life-saving HFrEF therapies.
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Affiliation(s)
- Iris E Beldhuis
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (I.E.B., C.S.P.L., A.A.V., J.M.t.M., K.D.)
| | - Carolyn S P Lam
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (I.E.B., C.S.P.L., A.A.V., J.M.t.M., K.D.)
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT (J.M.T.)
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (I.E.B., C.S.P.L., A.A.V., J.M.t.M., K.D.)
| | - Harriette G C Van Spall
- Department of Medicine (H.G.C.V.S.), McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact (H.G.C.V.S.), McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada (H.G.C.V.S.)
| | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (I.E.B., C.S.P.L., A.A.V., J.M.t.M., K.D.)
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (I.E.B., C.S.P.L., A.A.V., J.M.t.M., K.D.)
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14
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Peikert A, Vaduganathan M, McCausland F, Claggett BL, Chatur S, Packer M, Pfeffer MA, Zannad F, Lefkowitz MP, Pieske B, Düngen HD, McMurray JJV, Solomon SD. Effects of Sacubitril/Valsartan Versus Valsartan on Renal Function in Patients with and without Diabetes and Heart Failure with Preserved Ejection Fraction: Insights From PARAGON-HF. Eur J Heart Fail 2022; 24:794-803. [PMID: 35119183 PMCID: PMC9305963 DOI: 10.1002/ejhf.2450] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/18/2022] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Diabetes is associated with a faster rate of renal function decline in patients with heart failure (HF). Sacubitril/valsartan attenuates the deterioration of renal function to a greater extent in patients with diabetes and HF with reduced ejection fraction compared with renin-angiotensin-system inhibitors alone. We assessed whether the same may be true in HF with preserved ejection fraction (HFpEF). METHODS AND RESULTS In the PARAGON-HF trial in patients with HF and LVEF of 45% or greater (n=4,796), we characterized the effects of sacubitril/valsartan on changes in estimated glomerular filtration rate (eGFR) over a period of 192 weeks, and on the prespecified renal composite outcome (eGFR reduction of ≥50%, end-stage renal disease, or death attributable to renal causes) in patients with (n=2,388) and without diabetes (n=2,408). The decline in eGFR was greater in patients with diabetes than in those without (-2.6 vs. -1.7 mL/min per 1·73 m2 per year, p<0.001), regardless of treatment assignment. Sacubitril/valsartan attenuated decline in eGFR similarly in patients with (-2.2 vs. -2.9 mL/min per 1·73 m2 per year, p=0.001) and without diabetes (-1.5 vs. -2.0 mL/min per 1·73 m2 per year, p=0.006) (Pinteraction for difference in eGFR slopes = 0.40). Compared with valsartan, sacubitril/valsartan reduced the renal composite outcome similarly in patients without diabetes (HR 0.42 (95% CI 0.19-0.91) and those with diabetes (HR 0.54 (95% CI 0.33-0.89); Pinteraction =0.59), as well as across a range of baseline HbA1c (Pinteraction =0.71). CONCLUSION Sacubitril/valsartan, compared with valsartan, attenuates the decline of eGFR and reduces clinically relevant kidney events similarly among patients with HFpEF with and without diabetes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexander Peikert
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Finnian McCausland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Safia Chatur
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Milton Packer
- Baylor Heart and Vascular Hospital, Baylor University Medical Center, Dallas, TX, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Hans-Dirk Düngen
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - John J V McMurray
- New British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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15
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Bujo C, Amiya E, Hatano M, Ishida J, Tsuji M, Kakuda N, Narita K, Saito A, Yagi H, Ando M, Shimada S, Kimura M, Kinoshita O, Ono M, Komuro I. Long-Term renal function after implantation of continuous-flow left ventricular assist devices: A single center study. IJC HEART & VASCULATURE 2021; 37:100907. [PMID: 34765720 PMCID: PMC8571723 DOI: 10.1016/j.ijcha.2021.100907] [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] [Received: 07/20/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 11/28/2022]
Abstract
Background Implantable continuous-flow left ventricular assist device (LVAD) improve renal function in advanced heart failure. However, the long-term effects of LVAD on renal function have not been investigated thoroughly. We aimed to assess long-term renal function in patients with LVAD support and to identify predictors for late deterioration in renal function (LDRF). Methods One hundred patients underwent LVAD implantation as a bridge to transplant at the University of Tokyo Hospital between May 2011 and December 2018. We assessed renal function at intervals (preoperative, 1, 6, 12, 18, 24 and 30 months after LVAD implantation). We divided patients into two groups: “with LDRF,” whose renal function at 30 months had decreased by >25% compared with preoperatively (n = 14), and “without LDRF” (n = 55). Results Renal function improved at 1 month, returned to preoperative levels at 6 months, and remained there up to 30 months after LVAD implantation. However, renal function impairment became evident in patients with LDRF 18 months after LVAD implantation. A ratio of right atrial pressure/pulmonary artery wedge pressure > 0.57 and left ventricular dimension diastole ≤ 67 mm were preoperative independent risk factors for LDRF. In addition, the incidence of perioperative acute kidney injury, ventricular arrhythmia, aortic insufficiency, and late right ventricular failure was significantly higher in patients with LDRF. Conclusion LDRF after LVAD implantation corresponded to several risk factors, including a small left ventricle and LVAD-related complications, such as right ventricular failure.
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Affiliation(s)
- Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Nobutaka Kakuda
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Koichi Narita
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Akihito Saito
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hiroki Yagi
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masahiko Ando
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Shogo Shimada
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Mitsutoshi Kimura
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Osamu Kinoshita
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
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16
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Yuan S, Liu Y, He W, Jin J, Liu L, He Q. Association between early worsening of kidney function and poor outcomes in patients treated with renin angiotensin system inhibitors: A meta-analysis. Nephrology (Carlton) 2021; 26:772-781. [PMID: 34165226 DOI: 10.1111/nep.13915] [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: 01/09/2021] [Revised: 05/27/2021] [Accepted: 06/15/2021] [Indexed: 11/28/2022]
Abstract
AIM As renin angiotensin system inhibitors (RASi) are widely used in the clinic, early worsening of kidney function (EWKF) after RASi therapy deserves attention, as its clinical significance is unknown. The aim was to evaluate the relationship between EWKF and long-term outcomes including all-cause mortality, kidney and cardiovascular events, in all the patients treated with RASi. METHODS We searched PubMed, Embase, and the Cochrane databases for controlled trials that compared the outcomes of patients with and without EWKF after RASi treatment. Our primary outcome was all-cause mortality, and secondary outcomes were kidney and cardiovascular events. We pooled data using a random effects model. RESULTS A total of ten studies were enrolled, of which eight were randomized trials (including 33 454 patients) and two were observational studies (including 148 144 patients). Of the eight randomized trials, 4996 patients with type 2 diabetes, 19 118 with heart failure (HF), and 9340 with atherosclerotic vascular disease and diabetes with end-organ damage. Both observational studies investigated all kinds of patients with initial RASi treatment. In patients with RASi, the EWKF group had a higher risk of all-cause mortality than the no-EWKF group in the randomized studies (n = 13 581; RR, 1.22; 95% CI, 1.04-1.42; P = .02) and in observational studies (n = 148 144; OR, 1.70; 95% CI, 1.43-2.01; P < .00001). In patients who experienced EWKF, no statistically significant difference was found between the efficacy of RASi and placebo in all-cause mortality (n = 1762; RR, 0.85; 95% CI, 0.68-1.06; P = .14). CONCLUSION RASi treatment led to an increased incidence of EWKF which was associated with poorer long-term outcomes. As the benefit of RAS blockade to patients with EWKF was limited, we suggest clinicians use RASi with caution when EWKF occurs.
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Affiliation(s)
- Shizhu Yuan
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Zhejiang, China.,Department of Nephrology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Zhejiang, China
| | - Yueming Liu
- Department of Nephrology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Zhejiang, China
| | - Wenfang He
- Department of Nephrology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Zhejiang, China
| | - Juan Jin
- Department of Nephrology, the First People's Hospital of Hangzhou Lin'an District, Affiliated Lin'an People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Lin Liu
- Department of Nephrology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Zhejiang, China
| | - Qiang He
- Department of Nephrology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Zhejiang, China
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17
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Martin N, Manoharan K, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2021; 5:CD012721. [PMID: 34022072 PMCID: PMC8140651 DOI: 10.1002/14651858.cd012721.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction (LVEF); a review of the evidence is required to determine whether these treatments are beneficial for people with heart failure with preserved ejection fraction (HFpEF). OBJECTIVES To assess the effects of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with HFpEF. SEARCH METHODS We updated searches of CENTRAL, MEDLINE, Embase, and one clinical trial register on 14 May 2020 to identify eligible studies, with no language or date restrictions. We checked references from trial reports and review articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials with a parallel group design, enrolling adults with HFpEF, defined by LVEF greater than 40%. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 41 randomised controlled trials (231 reports), totalling 23,492 participants across all comparisons. The risk of bias was frequently unclear and only five studies had a low risk of bias in all domains. Beta-blockers (BBs) We included 10 studies (3087 participants) investigating BBs. Five studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 30 years to 81 years. A possible reduction in cardiovascular mortality was observed (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; number needed to treat for an additional benefit (NNTB) 25; 1046 participants; three studies), however, the certainty of evidence was low. There may be little to no effect on all-cause mortality (RR 0.82, 95% CI 0.67 to 1.00; 1105 participants; four studies; low-certainty evidence). The effects on heart failure hospitalisation, hyperkalaemia, and quality of life remain uncertain. Mineralocorticoid receptor antagonists (MRAs) We included 13 studies (4459 participants) investigating MRA. Eight studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 54.5 to 80 years. Pooled analysis indicated that MRA treatment probably reduces heart failure hospitalisation (RR 0.82, 95% CI 0.69 to 0.98; NNTB = 41; 3714 participants; three studies; moderate-certainty evidence). However, MRA treatment probably has little or no effect on all-cause mortality (RR 0.91, 95% CI 0.78 to 1.06; 4207 participants; five studies; moderate-certainty evidence) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11; 4070 participants; three studies; moderate-certainty evidence). MRA treatment may have little or no effect on quality of life measures (mean difference (MD) 0.84, 95% CI -2.30 to 3.98; 511 participants; three studies; low-certainty evidence). MRA treatment was associated with a higher risk of hyperkalaemia (RR 2.11, 95% CI 1.77 to 2.51; number needed to treat for an additional harmful outcome (NNTH) = 11; 4291 participants; six studies; high-certainty evidence). Angiotensin-converting enzyme inhibitors (ACEIs) We included eight studies (2061 participants) investigating ACEIs. Three studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 70 to 82 years. Pooled analyses with moderate-certainty evidence suggest that ACEI treatment likely has little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 945 participants; two studies), all-cause mortality (RR 1.04, 95% CI 0.75 to 1.45; 1187 participants; five studies) and heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 1019 participants; three studies), and may result in little or no effect on the quality of life (MD -0.09, 95% CI -3.66 to 3.48; 154 participants; two studies; low-certainty evidence). The effects on hyperkalaemia remain uncertain. Angiotensin receptor blockers (ARBs) Eight studies (8755 participants) investigating ARBs were included. Five studies used a placebo comparator and in three the comparator was usual care. The mean age of participants ranged from 61 to 75 years. Pooled analyses with high certainty of evidence suggest that ARB treatment has little or no effect on cardiovascular mortality (RR 1.02, 95% 0.90 to 1.14; 7254 participants; three studies), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 7964 participants; four studies), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 7254 participants; three studies), and quality of life (MD 0.41, 95% CI -0.86 to 1.67; 3117 participants; three studies). ARB was associated with a higher risk of hyperkalaemia (RR 1.88, 95% CI 1.07 to 3.33; 7148 participants; two studies; high-certainty evidence). Angiotensin receptor neprilysin inhibitors (ARNIs) Three studies (7702 participants) investigating ARNIs were included. Two studies used ARBs as the comparator and one used standardised medical therapy, based on participants' established treatments at enrolment. The mean age of participants ranged from 71 to 73 years. Results suggest that ARNIs may have little or no effect on cardiovascular mortality (RR 0.96, 95% CI 0.79 to 1.15; 4796 participants; one study; moderate-certainty evidence), all-cause mortality (RR 0.97, 95% CI 0.84 to 1.11; 7663 participants; three studies; high-certainty evidence), or quality of life (high-certainty evidence). However, ARNI treatment may result in a slight reduction in heart failure hospitalisation, compared to usual care (RR 0.89, 95% CI 0.80 to 1.00; 7362 participants; two studies; moderate-certainty evidence). ARNI treatment was associated with a reduced risk of hyperkalaemia compared with valsartan (RR 0.88, 95% CI 0.77 to 1.01; 5054 participants; two studies; moderate-certainty evidence). AUTHORS' CONCLUSIONS There is evidence that MRA and ARNI treatment in HFpEF probably reduces heart failure hospitalisation but probably has little or no effect on cardiovascular mortality and quality of life. BB treatment may reduce the risk of cardiovascular mortality, however, further trials are needed. The current evidence for BBs, ACEIs, and ARBs is limited and does not support their use in HFpEF in the absence of an alternative indication. Although MRAs and ARNIs are probably effective at reducing the risk of heart failure hospitalisation, the treatment effect sizes are modest. There is a need for improved approaches to patient stratification to identify the subgroup of patients who are most likely to benefit from MRAs and ARNIs, as well as for an improved understanding of disease biology, and for new therapeutic approaches.
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Affiliation(s)
- Nicole Martin
- Institute of Health Informatics Research, University College London, London, UK
| | | | - Ceri Davies
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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18
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Patel RB, Fonarow GC, Greene SJ, Zhang S, Alhanti B, DeVore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Vaduganathan M. Kidney Function and Outcomes in Patients Hospitalized With Heart Failure. J Am Coll Cardiol 2021; 78:330-343. [PMID: 33989713 DOI: 10.1016/j.jacc.2021.05.002] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Few contemporary data exist evaluating care patterns and outcomes in heart failure (HF) across the spectrum of kidney function. OBJECTIVES This study sought to characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction. METHODS Guideline-directed medical therapies were evaluated among patients hospitalized with HF at 418 sites in the GWTG-HF (Get With The Guidelines-Heart Failure) registry from 2014 to 2019 by discharge CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)-derived estimated glomerular filtration rate (eGFR). We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality. RESULTS Among 365,494 hospitalizations (age 72 ± 15 years, left ventricular ejection fraction [EF]: 43 ± 17%), median discharge eGFR was 51 ml/min/1.73 m2 (interquartile range: 34 to 72 ml/min/1.73 m2), 234,332 (64%) had eGFR <60 ml/min/1.73 m2, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014 to 2019. Among 157,439 patients with HF with reduced EF (≤40%), discharge guideline-directed medical therapies, including beta-blockers, were lowest in discharge eGFR <30 mL/min/1.73 m2 or dialysis (p < 0.001). "Triple therapy" with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor + beta-blocker + mineralocorticoid receptor antagonist was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60 to 89, 45 to 59, 30 to 44, <30 ml/min/1.73 m2, and dialysis, respectively; p < 0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; p < 0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger for HF with reduced EF compared with HF with mid-range or preserved EF (pinteraction = 0.045). CONCLUSIONS Despite facing elevated risks of mortality, patients with comorbid HF with reduced EF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.
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Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA. https://twitter.com/RBPatelMD
| | - Gregg C Fonarow
- Ahmanson-University of California, Los Angeles Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA.
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/SJGreene_md
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/_adevore
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA. https://twitter.com/JavedButler1
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, California, USA. https://twitter.com/MKIttlesonMD
| | - Karen E Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri, USA. https://twitter.com/kejoynt
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. https://twitter.com/tikuowens
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA; Department of Medicine, Anschutz Medical Center, Aurora, Colorado, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/scottdsolomon
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, University of Minnesota, Minnesota, USA. https://twitter.com/orlyvardeny
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/mvaduganathan
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19
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Okina Y, Miura T, Senda K, Taki M, Kobayashi M, Kanai M, Okuma Y, Yanagisawa T, Hashizume N, Otagiri K, Shoin K, Watanabe N, Ebisawa S, Karube K, Nakajima H, Saigusa T, Miyashita Y, Kashiwagi D, Machida K, Abe N, Tachibana T, Kanzaki Y, Maruyama T, Nomi H, Sakai T, Yui H, Mochidome T, Kobayashi T, Kasai T, Ikeda U, Kuwahara K. Prognostic ability of mid-term worsening renal function after percutaneous coronary intervention: findings from the SHINANO registry. Heart Vessels 2021; 36:1496-1505. [PMID: 33825976 PMCID: PMC8379120 DOI: 10.1007/s00380-021-01837-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/15/2021] [Indexed: 12/03/2022]
Abstract
Chronic kidney disease is a prognostic factor for cardiovascular disease. Worsening renal function (WRF), specifically, is an important predictor of mortality in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention (PCI). We evaluate the prognostic impact of mid-term WRF after PCI on future cardiovascular events. We examined the renal function data of 1086 patients in the first year after PCI using the SHINANO 5-year registry. Patients were divided into two groups, mid-term WRF and non-mid-term WRF, and primary outcomes were major adverse cardiovascular events (MACE) and death. Mid-term WRF was defined as an increase in creatinine (≥ 0.3 mg/dL) in the first year after PCI. Mid-term WRF was found in 101 patients (9.3%), and compared to non-mid-term WRF, it significantly increased the incidence of MACE (p < 0.001), and all-cause death (p < 0.001), myocardial infarction (p = 0.001). Furthermore, mid-term WRF patients had higher incidence of future heart failure (p < 0.001) and new-onset atrial fibrillation (p = 0.01). Patients with both mid-term WRF and chronic kidney disease had increased MACE compared to patients with either condition alone (p < 0.001). Similarly, patients with mid-term WRF and acute kidney injury had increased MACE compared to patients with either condition alone (p < 0.001). Multivariate Cox regression analysis revealed mid-term WRF as a strong predictor of MACE (hazard ratio: 2.50, 95% confidence interval 1.57–3.98, p < 0.001). Mid-term WRF after PCI negatively affects MACE, as well as future admission due to heart failure and new-onset atrial fibrillation, chronic kidney disease, and acute kidney injury.
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Affiliation(s)
- Yoshiteru Okina
- Department of Cardiology, Nagano Municipal Hospital, 1333-1 Tomitake, Nagano, 381-0006, Japan.
| | - Takashi Miura
- Department of Cardiology, Nagano Municipal Hospital, 1333-1 Tomitake, Nagano, 381-0006, Japan
| | - Keisuke Senda
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Minami Taki
- Department of Cardiology, Shinshu Ueda Medical Center, Ueda, Japan
| | | | - Masafumi Kanai
- Department of Cardiology, Nagano Red Cross Hospital, Nagano, Japan
| | - Yukari Okuma
- Epartment of Cardiology, Suwa Red Cross Hospital, Suwa, Japan
| | | | - Naoto Hashizume
- Department of Cardiology, Shinonoi General Hospital, Nagano, Japan
| | | | - Kyoko Shoin
- Department of Cardiology, Aizawa Hospital, Matsumoto, Japan
| | - Noboru Watanabe
- Department of Cardiology, Hokushin General Hospital, Nagano, Japan
| | - Soichiro Ebisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Kenichi Karube
- Department of Cardiology, Okaya Municipal Hospital, Okaya, Japan
| | - Hiroyuki Nakajima
- Department of Cardiology, Matsushiro General Hospital, Nagano, Japan
| | - Tatsuya Saigusa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Yusuke Miyashita
- Department of Cardiology, Nagano Red Cross Hospital, Nagano, Japan
| | - Daisuke Kashiwagi
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | | | - Naoyuki Abe
- Department of Cardiology, Nagano Red Cross Hospital, Nagano, Japan
| | | | - Yusuke Kanzaki
- Department of Cardiology, Shinonoi General Hospital, Nagano, Japan
| | - Takuya Maruyama
- Department of Cardiology, Shinonoi General Hospital, Nagano, Japan
| | - Hidetomo Nomi
- Department of Cardiology, Saku Central Hospital, Saku, Japan
| | - Takahiro Sakai
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Hisanori Yui
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Tomoaki Mochidome
- Department of Cardiology, Nagano Municipal Hospital, 1333-1 Tomitake, Nagano, 381-0006, Japan
| | - Takahiro Kobayashi
- Department of Cardiology, Nagano Municipal Hospital, 1333-1 Tomitake, Nagano, 381-0006, Japan
| | - Toshio Kasai
- Department of Cardiology, Nagano Municipal Hospital, 1333-1 Tomitake, Nagano, 381-0006, Japan
| | - Uichi Ikeda
- Department of Cardiology, Nagano Municipal Hospital, 1333-1 Tomitake, Nagano, 381-0006, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
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20
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Beldhuis IE, Myhre PL, Bristow M, Claggett B, Damman K, Fang JC, Fleg JL, McKinlay S, Lewis EF, O'Meara E, Pitt B, Shah SJ, Vardeny O, Voors AA, Pfeffer MA, Solomon SD, Desai AS. Spironolactone in Patients With Heart Failure, Preserved Ejection Fraction, and Worsening Renal Function. J Am Coll Cardiol 2021; 77:1211-1221. [PMID: 33663739 DOI: 10.1016/j.jacc.2020.12.057] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Treatment of heart failure with preserved ejection fraction (HFpEF) with spironolactone is associated with lower risk of heart failure hospitalization (HFH) but increased risk of worsening renal function (WRF). The prognostic implications of spironolactone-associated WRF in HFpEF patients are not well understood. OBJECTIVES The purpose of this study was to investigate the association between WRF, spironolactone treatment, and clinical outcomes in patients with HFpEF. METHODS In 1,767 patients randomized to spironolactone or placebo in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial)-Americas study, we examined the incidence of WRF (doubling of serum creatinine) by treatment assignment. Associations between incident WRF and subsequent risk for the primary study endpoint of cardiovascular (CV) death, HFH, or aborted cardiac arrest and key secondary outcomes, including CV death, HFH, and all-cause mortality according to treatment assignment, were examined in time-updated Cox proportional hazards models with an interaction term. RESULTS WRF developed in 260 (14.7%) patients with higher rates in those assigned to spironolactone compared to placebo (17.8% vs. 11.6%; odds ratio: 1.66; 95% confidence interval: 1.27 to 2.17; p < 0.001). Regardless of treatment, incident WRF was associated with increased risk for the primary endpoint (hazard ratio: 2.04; 95% confidence interval: 1.52 to 2.72; p < 0.001) after multivariable adjustment. Although there was no statistical interaction between treatment assignment and WRF regarding the primary endpoint (interaction p = 0.11), spironolactone-associated WRF was associated with lower risk of CV death (interaction p = 0.003) and all-cause mortality (interaction p = 0.001) compared with placebo-associated WRF. CONCLUSIONS Among HFpEF patients enrolled in TOPCAT-Americas, spironolactone increased risk of WRF compared with placebo. Rates of CV death were lower with spironolactone in both patients with and without WRF.
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Affiliation(s)
- Iris E Beldhuis
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA; University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands. https://twitter.com/iebeldhuis
| | - Peder L Myhre
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Medicine, Akershus University Hospital, Lorenskog, Norway. https://twitter.com/pmyhre
| | - Michael Bristow
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - James C Fang
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sonja McKinlay
- New England Research Institutes, Watertown, Massachusetts, USA
| | - Eldrin F Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adriaan A Voors
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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21
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Deferrari G, Cipriani A, La Porta E. Renal dysfunction in cardiovascular diseases and its consequences. J Nephrol 2021; 34:137-153. [PMID: 32870495 PMCID: PMC7881972 DOI: 10.1007/s40620-020-00842-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022]
Abstract
It is well known that the heart and kidney and their synergy is essential for hemodynamic homeostasis. Since the early XIX century it has been recognized that cardiovascular and renal diseases frequently coexist. In the nephrological field, while it is well accepted that renal diseases favor the occurrence of cardiovascular diseases, it is not always realized that cardiovascular diseases induce or aggravate renal dysfunctions, in this way further deteriorating cardiac function and creating a vicious circle. In the same clinical field, the role of venous congestion in the pathogenesis of renal dysfunction is at times overlooked. This review carefully quantifies the prevalence of chronic and acute kidney abnormalities in cardiovascular diseases, mainly heart failure, regardless of ejection fraction, and the consequences of renal abnormalities on both organs, making cardiovascular diseases a major risk factor for kidney diseases. In addition, with regard to pathophysiological aspects, we attempt to substantiate the major role of fluid overload and venous congestion, including renal venous hypertension, in the pathogenesis of acute and chronic renal dysfunction occurring in heart failure. Furthermore, we describe therapeutic principles to counteract the major pathophysiological abnormalities in heart failure complicated by renal dysfunction. Finally, we underline that the mild transient worsening of renal function after decongestive therapy is not usually associated with adverse prognosis. Accordingly, the coexistence of cardiovascular and renal diseases inevitably means mediating between preserving renal function and improving cardiac activity to reach a better outcome.
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Affiliation(s)
- Giacomo Deferrari
- Department of Cardionephrology, Istituto Clinico Ligure Di Alta Specialità (ICLAS), GVM Care and Research, Via Mario Puchoz 25, 16035, Rapallo, GE, Italy.
- Department of Internal Medicine (DiMi), University of Genoa, Genoa, Italy.
| | - Adriano Cipriani
- Grown-Up Congentital Heart Disease Center (GUCH Center), Istituto Clinico Ligure Di Alta Specialità (ICLAS), GVM Care and Research, Rapallo, GE, Italy
| | - Edoardo La Porta
- Department of Cardionephrology, Istituto Clinico Ligure Di Alta Specialità (ICLAS), GVM Care and Research, Via Mario Puchoz 25, 16035, Rapallo, GE, Italy
- Department of Internal Medicine (DiMi), University of Genoa, Genoa, Italy
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22
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Jhund PS, Solomon SD, Docherty KF, Heerspink HJL, Anand IS, Böhm M, Chopra V, de Boer RA, Desai AS, Ge J, Kitakaze M, Merkley B, O'Meara E, Shou M, Tereshchenko S, Verma S, Vinh PN, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Bengtsson O, Langkilde AM, Sjöstrand M, McMurray JJV. Efficacy of Dapagliflozin on Renal Function and Outcomes in Patients With Heart Failure With Reduced Ejection Fraction: Results of DAPA-HF. Circulation 2020; 143:298-309. [PMID: 33040613 PMCID: PMC7834909 DOI: 10.1161/circulationaha.120.050391] [Citation(s) in RCA: 194] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Supplemental Digital Content is available in the text. Many patients with heart failure and reduced ejection fraction (HFrEF) have chronic kidney disease that complicates pharmacological management and is associated with worse outcomes. We assessed the safety and efficacy of dapagliflozin in patients with HFrEF, according to baseline kidney function, in the DAPA-HF trial (Dapagliflozin and Prevention of Adverse-outcomes in Heart Failure). We also examined the effect of dapagliflozin on kidney function after randomization.
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Affiliation(s)
- Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (P.S.J., K.F.D., J.J.V.M.)
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S., A.S.D.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (P.S.J., K.F.D., J.J.V.M.)
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology (H.J.L.H.), University Medical Center Groningen, University of Groningen, The Netherlands
| | - Inder S Anand
- Department of Cardiology, University of Minnesota, Minneapolis (I.S.A.)
| | - Michael Böhm
- Department of Medicine, Saarland University Hospital, Homburg-Saar, Germany (M.B.)
| | - Vijay Chopra
- Department of Cardiology, Max Super Speciality Hospital, Saket, New Delhi, India (V.C.)
| | - Rudolf A de Boer
- Department of Cardiology (R.A.d.B.), University Medical Center Groningen, University of Groningen, The Netherlands
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S., A.S.D.)
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease and Zhongshan Hospital Fudan University, China (J.G.)
| | - Masafumi Kitakaze
- Cardiovascular Division of Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (M.K.)
| | - Bela Merkley
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.)
| | - Eileen O'Meara
- Department of Cardiology, Montreal Heart Institute, Canada (E.O.)
| | - Morten Shou
- Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (M. Shou)
| | - Sergey Tereshchenko
- Department of Myocardial Disease and Heart Failure, National Medical Research Center of Cardiology, Moscow, Russia (S.T.)
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Canada (S.V.)
| | - Pham Nguyen Vinh
- Department of Internal Medicine, Tan Tao University, Tan Duc, Vietnam (P.N.V.)
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, CT (S.E.I.)
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (L.K.)
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City (M.N.K.).,The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | | | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Poland (P.P.)
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital, Boston, MA (M.S.S.)
| | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (O.B., A.M.L., M. Sjöstrand)
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (O.B., A.M.L., M. Sjöstrand)
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (O.B., A.M.L., M. Sjöstrand)
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (P.S.J., K.F.D., J.J.V.M.)
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23
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Feng S, Janwanishstaporn S, Teerlink JR, Metra M, Cotter G, Davison B, Felker GM, Filippatos G, Pang P, Ponikowski P, Sama IE, Voors AA, Greenberg B. Association of left ventricular ejection fraction with worsening renal function in patients with acute heart failure: insights from the RELAX-AHF-2 study. Eur J Heart Fail 2020; 23:58-67. [PMID: 32964537 DOI: 10.1002/ejhf.2012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/12/2020] [Accepted: 08/26/2020] [Indexed: 12/15/2022] Open
Abstract
AIMS Whether risk of worsening renal function (WRF) during acute heart failure (AHF) hospitalization or the association between in-hospital WRF and post-discharge outcomes vary according to left ventricular ejection fraction (LVEF) is uncertain. We assessed incidence of WRF, factors related to its development and impact of WRF on post-discharge outcomes across the spectrum of LVEF in patients enrolled in RELAX-AHF-2. METHODS AND RESULTS A total of 6112 patients who had LVEF measured on admission and renal function determined prospectively during hospitalization were included. WRF, defined as a rise in serum creatinine ≥0.3 mg/dL from baseline through day 5, occurred in 1722 patients (28.2%). Incidence increased progressively from lowest to highest LVEF quartile (P < 0.001). After baseline adjustment, WRF risk in Q4 (LVEF >50%) remained significantly greater than in Q1 (LVEF ≤29%; hazard ratio 1.2, 95% confidence interval 1-1.43; P = 0.050). Age and comorbidity burden including chronic kidney disease increased as LVEF increased. Neither admission haemodynamic abnormalities, extent of diuresis during hospitalization nor residual congestion explained the increased incidence of WRF in patients with higher LVEF. Serelaxin treatment and diuretic responsiveness were associated with reduced risk of WRF in all LVEF quartiles. WRF in patients in the upper three LVEF quartiles increased risk of post-discharge events. CONCLUSIONS Worsening renal function incidence during AHF hospitalization increases progressively with LVEF. Greater susceptibility of patients with higher LVEF to WRF appears more related to their advanced age and worse underlying kidney function rather than haemodynamic or treatment effects. WRF is associated with increased risk of post-discharge events except in patients in the lowest LVEF quartile.
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Affiliation(s)
- Siting Feng
- Division of Cardiology, University of California, San Diego, CA, USA.,Emergency & Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Satit Janwanishstaporn
- Division of Cardiology, University of California, San Diego, CA, USA.,Faculty of Medicine Siriraj Hospital, Mahidol University, Salaya, Thailand
| | - 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
| | | | | | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Gerasimos Filippatos
- School of Medicine, University of Cyprus, Nicosia, Cyprus.,National and Kapidistrian University of Athens, School of Medicine, Athens, Greece
| | - Peter Pang
- Department of Emergency Medicine, Indiana University School of Medicine, and the Regenstrief Institute, Indianapolis, IN, USA
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Military Hospital, Wrocław, Poland
| | - Iziah E Sama
- University of Groningen, Groningen, The Netherlands
| | | | - Barry Greenberg
- Division of Cardiology, University of California, San Diego, CA, USA
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24
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Benefits of peritoneal ultrafiltration in HFpEF and HFrEF patients. BMC Nephrol 2020; 21:179. [PMID: 32410664 PMCID: PMC7222460 DOI: 10.1186/s12882-020-01777-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 03/20/2020] [Indexed: 01/18/2023] Open
Abstract
Background Peritoneal ultrafiltration (pUF) in refractory heart failure (HF) reduces the incidence of decompensation episodes, which is of particular significance as each episode incrementally adds to mortality. Nevertheless, there are insufficient data about which patient cohort benefits the most. The objective of this study was to compare pUF in HFrEF and HFpEF, focusing on functional status, hospitalizations, surrogate endpoints and mortality. Methods This study involves 143 patients, who could be classified as either HFpEF (n = 37, 25.9%) or HFrEF (n = 106, 74.1%) and who received pUF due to refractory HF. Results Baseline eGFR was similar in HFrEF (23.1 ± 10.6 mg/dl) and HFpEF (27.8 ± 13.2 mg/dl). Significant improvements in NYHA class were found in HFpEF (3.19 ± 0.61 to 2.72 ± 0.58, P < 0.001) and HFrEF (3.45 ± 0.52 to 2.71 ± 0.72, P < 0.001). CRP decreased in HFrEF (19.4 ± 17.6 mg/l to 13.7 ± 21.4 mg/l, P = 0.018) and HFpEF (33.7 ± 52.6 mg/l to 17.1 ± 26.3 mg/l, P = 0.004). Body weight was significantly reduced in HFrEF (81.1 ± 14.6 kg to 77.2 ± 15.6 kg, P = 0.003) and HFpEF (86.9 ± 15.8 kg to 83.1 ± 15.9 kg, P = 0.005). LVEF improved only in HFrEF (25.9 ± 6.82% to 30.4 ± 12.2%, P = 0.046). BCR decreased significantly in HFrEF and HFpEF (55.7 ± 21.9 to 34.3 ± 17.9 P > 0.001 and 50.5 ± 68.9 to 37.6 ± 21.9, P = 0.006). Number of hospitalization episodes as well as number of hospitalization days decreased significantly only in HFpEF (total number 2.88 ± 1.62 to 1.25 ± 1.45, P < 0.001, days 40.4 ± 31.7 to 18.3 ± 22.5 days, P = 0.005). Conclusions pUF offers various benefits in HFpEF and HFrEF, but there are also substantial differences. In particular, hospitalization rates were found to be significantly reduced in HFpEF patients, indicating a greater medical and economical advantage. However, LVEF was only found to be improved in HFrEF patients. While pUF can now be regarded as an option to supplement classical HF therapy, further studies are desirable to obtain specifications about pUF in HFpEF, HFmEF and HFrEF patients.
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25
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Agrawal A, Naranjo M, Kanjanahattakij N, Rangaswami J, Gupta S. Cardiorenal syndrome in heart failure with preserved ejection fraction-an under-recognized clinical entity. Heart Fail Rev 2020; 24:421-437. [PMID: 31127482 DOI: 10.1007/s10741-018-09768-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiorenal syndrome (CRS) results from the complex and bidirectional interaction between the failing heart and the kidneys. Limited information exists about the pathophysiology and treatment options for worsening kidney function in the setting of heart failure with preserved ejection fraction (HFpEF). This review summarizes the salient pathophysiological pathways in CRS in patients with HFpEF, with emphasis on type 1 and type 2 phenotypes, and outlines diagnostic and therapeutic strategies that are applicable in this population. Elevated central venous and intra-abdominal pressure, left ventricular hypertrophy, LV strain, RAAS activation, oxidative injury, pulmonary hypertension, and RV dysfunction play key roles in the pathogenesis of CRS in the backdrop of HFpEF. The availability of biomarkers of renal and cardiac injury offer a new dimension in accurately diagnosing and quantifying end organ damage in CRS and will improve the accuracy of goal-directed therapies in this population. Novel targeted therapies such as the development of angiotensin/neprilysin inhibitors and sodium-glucose cotransporter-2 (SGLT-2) inhibitors offer new territory in realizing potential benefits in reduction of cardio-renal adverse outcomes in this population. Future studies focusing exclusively on renal outcomes in patients with HFpEF are crucial in delivering optimal therapies in this subset of patients.
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Affiliation(s)
- Akanksha Agrawal
- Department of Internal Medicine, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, 19141, USA.
| | - Mario Naranjo
- Department of Internal Medicine, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, 19141, USA
| | - Napatt Kanjanahattakij
- Department of Internal Medicine, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, 19141, USA
| | - Janani Rangaswami
- Department of Nephrology, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Shuchita Gupta
- Department of Cardiology, Albert Einstein Medical Center, Philadelphia, PA, USA
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26
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Kubo I, Izawa KP, Kajisa N, Ogura A, Kanai M, Matsumoto D. Factors delaying the progress of early rehabilitation of elderly Japanese patients with heart failure. Aging Clin Exp Res 2020; 32:399-406. [PMID: 31076966 DOI: 10.1007/s40520-019-01213-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/29/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Although intervention with early cardiac rehabilitation (CR) is recommended for elderly patients treated for acute heart failure (HF), there are patients in whom the progress of early CR will be delayed. The aim of this study was to clarify factors related to the progress of early CR. METHODS We enrolled 180 Japanese inpatients aged ≥ 65 years with HF in the present retrospective cohort study. We set a short-term goal of 30 m of walking at 1 week after the start of early CR. We divided the patients into two groups according to whether this goal was achieved (Achievement group, n = 124) or not (Non-achievement group, n = 56) and compared patients' characteristics and clinical parameters. RESULTS There was a significant difference (p < 0.05) between the groups for age, length of hospital stay, Functional Independence Measure at discharge, walking level before hospitalization, rate of co-existence of diabetes mellitus, chronic renal failure, orthopedic disease, use of diuretics, creatinine, Prognostic Nutritional Index, hemoglobin, C-reactive protein, and estimated glomerular filtration rate (eGFR). Furthermore, logistic regression analysis showed that walking level before hospitalization (odds ratio [OR]: 3.144, p = 0.0001) and eGFR (OR: 0.971, p = 0.009) were factors related to the inability to achieve the short-term goal. CONCLUSION Our findings suggest that walking level before hospitalization and renal function on admission are factors related to delayed progress in early CR of elderly Japanese patients with HF.
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Affiliation(s)
- Ikko Kubo
- Department of Rehabilitation, Yodogawa Christian Hospital, Osaka, Japan
- Department of Public Health, Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma, Kobe, 654-0142, Japan
| | - Kazuhiro P Izawa
- Department of Public Health, Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma, Kobe, 654-0142, Japan.
| | - Nozomu Kajisa
- Department of Rehabilitation, Yodogawa Christian Hospital, Osaka, Japan
| | - Asami Ogura
- Department of Public Health, Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma, Kobe, 654-0142, Japan
| | - Masashi Kanai
- Department of Public Health, Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma, Kobe, 654-0142, Japan
| | - Daisuke Matsumoto
- Department of Cardiovascular Medicine, Yodogawa Christian Hospital, Osaka, Japan
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27
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GFM, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Marinella Ruospo
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Patrizia Natale
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Robert R Quinn
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Paul E Ronksley
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical CenterDepartment of Medicine3459 Fifth AvenuePittsburghPAUSA15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of OtagoDepartment of Medicine, NephrologistChristchurchNew Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Pietro Ravani
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
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Kocabas U, Altay H, Ozkalayci F, Yildirimturk O, Kulah E, Pehlivanoglu S. Prognostic value of worsening renal function in patients with acute decompensated heart failure with preserved ejection fraction and its association with increased inflammatory state. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2020. [DOI: 10.4103/ijca.ijca_38_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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30
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Ahn MS, Yoo BS, Yoon J, Lee SH, Kim JY, Ahn SG, Youn YJ, Lee JW, Son JW, Kim HS, Kang DR, Cho HJ, Lee HY, Jeon ES, Kang SM, Choi DJ, Cho MC. Guideline-directed therapy at discharge in patients with heart failure and atrial fibrillation. Heart 2019; 106:292-298. [PMID: 31492703 PMCID: PMC7027027 DOI: 10.1136/heartjnl-2019-315240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/08/2019] [Accepted: 07/24/2019] [Indexed: 01/28/2023] Open
Abstract
Objectives This study evaluated the relationship between guideline adherence for recommended therapy on discharge and relevant 60-day and 1-year clinical outcomes in patients with acute heart failure (HF) with reduced ejection fraction and atrial fibrillation (AF). Methods Of 5625 acute patients with HF in the Korean Acute Heart Failure registry, 986 patients with HF and documented AF were analysed. Guideline adherence scores were calculated for the prescription of ACE inhibitors, angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists and anticoagulants. Results In patients with HF with AF, there was a significant trend of reduced 60-day and 1-year mortality rates and the composite end point with guideline adherence. According to the Cox proportion hazard model, poor adherence was associated with a significantly higher risk of 60-day mortality (HR 4.75; 95% CI 1.77 to 12.74) and the composite end point (HR 2.36; 95% CI 1.33 to 4.18) compared with good adherence. Furthermore, poor adherence was associated with a significantly higher risk of 1-year mortality compared with moderate (HR 1.64; 95% CI 1.15 to 2.33) and good adherence (HR 2.34; 95% CI 1.39 to 3.97) and with a higher risk of the 1-year composite end point compared with good adherence (HR 1.58; 95% CI 1.07 to 2.33). Conclusion Better adherence to guidelines was associated with better 60-day and 1-year prognoses in patients with HF with AF.
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Affiliation(s)
- Min-Soo Ahn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Byung Su Yoo
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Junghan Yoon
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Seung-Hwan Lee
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Jang Young Kim
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Sung Gyun Ahn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Young Jin Youn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Jun-Won Lee
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Jung-Woo Son
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Hye Sim Kim
- Center of Biomedical Data Science, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Dae Ryong Kang
- Center of Biomedical Data Science, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea
| | - Hyun-Jai Cho
- Division of Cardiology, Department of Internal Medicine/Cardiovascular Center, Seoul National University Hospital, Jongno-gu, Seoul, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun Seok Jeon
- Division of Cardiology, Sungkyunkwan University College of Medicine, Seoul, Republic of Korea
| | - Seok-Min Kang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Wonju College of Medicine, Seoul, Republic of Korea
| | - Dong-Ju Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Myeong-Chan Cho
- Chungbuk National University Hospital, Chungju-si, Republic of Korea
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McCallum W, Tighiouart H, Ku E, Salem D, Sarnak MJ. Trends in Kidney Function Outcomes Following RAAS Inhibition in Patients With Heart Failure With Reduced Ejection Fraction. Am J Kidney Dis 2019; 75:21-29. [PMID: 31303349 DOI: 10.1053/j.ajkd.2019.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/03/2019] [Indexed: 01/06/2023]
Abstract
RATIONALE & OBJECTIVE Angiotensin-converting enzyme (ACE) inhibitors are beneficial in heart failure with reduced ejection fraction (HFrEF). We sought to describe longitudinal trends in estimated glomerular filtration rate (eGFR) in HFrEF and how ACE-inhibitor therapy influences these changes. STUDY DESIGN Post hoc analysis of trial data. SETTINGS & PARTICIPANTS Symptomatic (Treatment Trial, n=2,423) and asymptomatic (Prevention Trial, n=4,094) patients from the Studies of Left Ventricular Dysfunction (SOLVD). EXPOSURE Enalapril versus placebo. OUTCOMES Early and long-term eGFR slope (ie, within and after the first 6 weeks) and 4 kidney end points: (1) serum creatinine level increase by≥0.3mg/dL, (2)>30% eGFR decline, (3)>40% eGFR decline, and (4) incident eGFR<30mL/min/1.73m2. ANALYTICAL APPROACH Shared parameter models, multivariable Cox regression models. RESULTS Baseline mean eGFR was lower in the Treatment Trial than in the Prevention Trial, 69.5±19.8 (SD) versus 76.2±18.6mL/min/1.73m2. Following randomization, an early eGFR decline occurred in the enalapril group; however, slopes during the median 3-year follow-up were not statistically different by randomization arm in either the Treatment Trial (-0.84 in enalapril vs-1.36mL/min/1.73m2 per year in placebo; P=0.08) or Prevention Trial (-1.27 in enalapril vs-1.36mL/min/1.73m2 per year in placebo; P=0.7). Random assignment to enalapril treatment increased the risk for all 4 outcomes in the Treatment Trial in the first 6-week period (HRs were 1.48 [95% CI, 1.10-1.99] for creatinine increase by≥0.3mg/dL; 1.38 [95% CI, 0.98-1.94] for eGFR decline> 30%; 2.60 [95% CI, 1.30-5.21] for eGFR decline> 40%; and 4.71 [95% CI, 1.78-12.50] for eGFR<30mL/min/1.73m2), but after the first year was not significantly associated with increased risk. A similar albeit less pronounced pattern was observed in the Prevention Trial, with risks present only in the early period. LIMITATIONS Creatinine results were not blinded, making it possible that ACE-inhibitor/placebo dosing was influenced by creatinine level. CONCLUSION Kidney function decline is slow in HFrEF. Although random assignment to enalapril treatment results in a statistically increased risk for kidney surrogates, the risk is limited to the early phase and late eGFR slopes and risks are not different by randomly assigned group.
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Affiliation(s)
- Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Elaine Ku
- Division of Nephrology and Pediatric Nephrology, University of California San Francisco, San Francisco, CA
| | - Deeb Salem
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, MA.
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House AA, Wanner C, Sarnak MJ, Piña IL, McIntyre CW, Komenda P, Kasiske BL, Deswal A, deFilippi CR, Cleland JGF, Anker SD, Herzog CA, Cheung M, Wheeler DC, Winkelmayer WC, McCullough PA. Heart failure in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2019; 95:1304-1317. [PMID: 31053387 DOI: 10.1016/j.kint.2019.02.022] [Citation(s) in RCA: 208] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/13/2019] [Accepted: 02/21/2019] [Indexed: 12/24/2022]
Abstract
The incidence and prevalence of heart failure (HF) and chronic kidney disease (CKD) are increasing, and as such a better understanding of the interface between both conditions is imperative for developing optimal strategies for their detection, prevention, diagnosis, and management. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened an international, multidisciplinary Controversies Conference titled Heart Failure in CKD. Breakout group discussions included (i) HF with preserved ejection fraction (HFpEF) and nondialysis CKD, (ii) HF with reduced ejection fraction (HFrEF) and nondialysis CKD, (iii) HFpEF and dialysis-dependent CKD, (iv) HFrEF and dialysis-dependent CKD, and (v) HF in kidney transplant patients. The questions that formed the basis of discussions are available on the KDIGO website http://kdigo.org/conferences/heart-failure-in-ckd/, and the deliberations from the conference are summarized here.
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Affiliation(s)
- Andrew A House
- Division of Nephrology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada.
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Mark J Sarnak
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ileana L Piña
- Division of Cardiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Christopher W McIntyre
- Division of Nephrology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Paul Komenda
- Department of Internal Medicine, Section of Nephrology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Medicine, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Community Health Sciences, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Anita Deswal
- Section of Cardiology, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK, German Centre for Cardiovascular Research), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA; Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Peter A McCullough
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, Texas, USA; Department of Internal Medicine, Division of Cardiology, Baylor Heart and Vascular Institute, Dallas, Texas, USA.
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Grossekettler L, Schmack B, Meyer K, Brockmann C, Wanninger R, Kreusser MM, Frankenstein L, Kihm LP, Zeier M, Katus HA, Remppis A, Schwenger V. Peritoneal dialysis as therapeutic option in heart failure patients. ESC Heart Fail 2019; 6:271-279. [PMID: 30815994 PMCID: PMC6437425 DOI: 10.1002/ehf2.12411] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 01/06/2019] [Indexed: 12/30/2022] Open
Abstract
Aims Each episode of acute decompensated heart failure (HF) incrementally adds to mortality. Peritoneal dialysis (PD) offers an alternative therapeutic option in refractory HF and reduces the incidence of decompensation episodes. The objective of this study was to determine the efficacy of PD, in terms of functional status, surrogate endpoints, rate of hospitalizations, and mortality. Methods and results This study is based on the registry of the German Society of Nephrology, involving 159 patients receiving PD treatment due to refractory HF between January 2010 and December 2014. Body weight was reduced by PD (82.2 ± 14.9 to 78.4 ± 14.8 kg, P < 0.001), and significant improvements in New York Heart Association functional class (3.38 ± 0.55 to 2.85 ± 0.49, P < 0.001) were found already after 3 months. Left ventricular ejection fraction did not change (31.5 ± 13.8 to 34.0 ± 15.7%, P = 0.175). C‐reactive protein improved with PD treatment (33.7 ± 52.6 to 17.1 ± 26.3 mg/L, P = 0.004). Blood urea nitrogen/creatinine ratio decreased significantly (148.7 ± 68.3 to 106.7 ± 44.8 mg/dL, P < 0.001). Hospitalization rates decreased significantly (total number 2.86 ± 1.88 to 1.90 ± 1.78, P = 0.001, and 39.2 ± 30.7 to 27.1 ± 25.2 days, P = 0.004). One year mortality was 39.6% in end‐stage HF patients treated with PD. Conclusions Peritoneal dialysis offers an additional therapeutic option in end‐stage HF and is associated with improved New York Heart Association classification and reduced hospitalization. Although PD treatment was associated with various benefits, further studies are necessary to identify which patients benefit the most from PD.
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Affiliation(s)
- Leonie Grossekettler
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Bastian Schmack
- Clinic for Cardiac Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Katrin Meyer
- Clinic for Cardiology, Heart and Vascular Center, Bad Bevensen, Germany
| | | | | | - Michael M Kreusser
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Lutz Frankenstein
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Lars P Kihm
- Department of Internal Medicine I, Endocrinology and Nephrology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Department of Internal Medicine I, Endocrinology and Nephrology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Andrew Remppis
- Clinic for Cardiology, Heart and Vascular Center, Bad Bevensen, Germany
| | - Vedat Schwenger
- Department of Internal Medicine I, Endocrinology and Nephrology, University Hospital of Heidelberg, Heidelberg, Germany.,Department of Kidney, Blood Pressure and Autoimmune Diseases, Katharinenhospital, Klinikum Stuttgart, Stuttgart, Germany
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Association of Abnormal Left Ventricular Functional Reserve With Outcome in Heart Failure With Preserved Ejection Fraction. JACC Cardiovasc Imaging 2018; 11:1737-1746. [DOI: 10.1016/j.jcmg.2017.07.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/07/2017] [Accepted: 07/24/2017] [Indexed: 11/18/2022]
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Dinatolo E, Sciatti E, Anker MS, Lombardi C, Dasseni N, Metra M. Updates in heart failure: what last year brought to us. ESC Heart Fail 2018; 5:989-1007. [PMID: 30570225 PMCID: PMC6300825 DOI: 10.1002/ehf2.12385] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- Elisabetta Dinatolo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Edoardo Sciatti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Markus S. Anker
- Division of Cardiology and Metabolism, Department of Cardiology, Berlin‐Brandenburg Center for Regenerative Therapies (BCRT), DZHK (German Centre for Cardiovascular Research), partner site BerlinCharité—Universitätsmedizin BerlinBerlinGermany
| | - Carlo Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Nicolò Dasseni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
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Kasahara S, Sakata Y, Nochioka K, Tay WT, Claggett BL, Abe R, Oikawa T, Sato M, Aoyanagi H, Miura M, Shiroto T, Takahashi J, Sugimura K, Teng THK, Miyata S, Shimokawa H. The 3A3B score: The simple risk score for heart failure with preserved ejection fraction - A report from the CHART-2 Study. Int J Cardiol 2018; 284:42-49. [PMID: 30413304 DOI: 10.1016/j.ijcard.2018.10.076] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/01/2018] [Accepted: 10/22/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Few simple risk models, without echocardiography have been developed for patients with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) (HFpEF). METHODS To develop a risk score to predict all-cause death for HFpEF patients, we examined 1277 HF patients with LVEF ≥50% and BNP ≥100 pg/ml in the CHART-2 Study, a large-scale prospective cohort study for HF in Japan. We selected the optimal subset of covariates for the score with Cox proportional hazard models and random survival forests (RSF). RESULTS During the median 5.7-year follow-up, 576 deaths occurred. Cox models and RSF analyses consistently indicated age ≥75 years, albumin <3.7 g/dl, anemia, BMI <22 kg/m2, BNP ≥300 pg/ml (or NT-proBNP ≥1400 pg/ml), and BUN ≥25 mg/dl, as the important 6 prognostic variables. Incorporating these 6 variables, we developed a scoring system (3A3B score, with 2 points given to age ≥75 years and 1 point to the others based on the hazard ratios. The discrimination ability of the risk score was excellent (c-index 0.708). Regarding model goodness-of-fit, the overall gradient in 5-year risk was well captured by the score. The predictive accuracy of the 3A3B score was confirmed in the external validation cohorts from the TOPCAT trial (N = 835, c-index 0.652) and the ASIAN-HF registry (N = 170, c-index 0.741). CONCLUSIONS We developed a simple risk score to predict long-term prognosis of HFpEF patients. The 3A3B score, comprising 6 commonly available parameters in daily practice, has potential utility in the risk stratification and management of HFpEF patients.
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Affiliation(s)
- Shintaro Kasahara
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiko Sakata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; The Big Data Medicine Center, Tohoku University, Sendai, Japan.
| | - Kotaro Nochioka
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | | | - Ruri Abe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takuya Oikawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masayuki Sato
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hajime Aoyanagi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masanobu Miura
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Koichiro Sugimura
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Satoshi Miyata
- Department of Evidence-based Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; The Big Data Medicine Center, Tohoku University, Sendai, Japan; Department of Evidence-based Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Aoki T, Ishii H, Tanaka A, Suzuki S, Ichimiya S, Kanashiro M, Murohara T. Influence of chronic kidney disease and worsening renal function on clinical outcomes in patients undergoing primary percutaneous coronary intervention. Clin Exp Nephrol 2018; 23:182-188. [PMID: 30218297 DOI: 10.1007/s10157-018-1622-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/21/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The combined influence of CKD and worsening renal function (WRF) on clinical outcomes in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) has not been fully understood. METHODS We analyzed 443 patients diagnosed with AMI who underwent primary PCI. Based on their estimated glomerular filtration rate (eGFR), they were classified into two groups: a high eGFR group (eGFR ≥ 45 mL/min/1.73 m2, n = 381) and a low eGFR group (eGFR < 45 mL/min/1.73 m2, n = 63). WRF was defined as an increase in serum creatinine levels ≥ 0.3 mg/dL above the admission value during the course of hospitalization. The primary end-point was set as all-cause mortality. RESULTS WRF was observed in 88 patients (19.8%). The median follow-up duration was 769 (interquartile range 397-1314) days. The all-cause mortality rate was significantly lower in the high eGFR than in the low eGFR group (5.5 vs. 28.6%, respectively, at 1500 days, P < 0.001). In patients with WRF, the all-cause and cardiac mortality rates were significantly higher than in patients without WRF, and these results were consistent between the high and low eGFR sub-groups. Multivariate Cox proportional hazards model analysis showed that low eGFR and WRF remained independent predictors of all-cause mortality [(hazard ratio 2.61, 95% confidence interval 1.27-5.36, P = 0.009) and (hazard ratio 2.59, 95% confidence interval 1.34-5.01, P = 0.005), respectively]. CONCLUSIONS Both eGFR at baseline and WRF were observed to be important predictors of mortality in patients with AMI undergoing primary PCI. WRF showed a significant effect on mortality even in patients with high eGFR.
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Affiliation(s)
- Toshijiro Aoki
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Susumu Suzuki
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Satoshi Ichimiya
- Department of Cardiology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Masaaki Kanashiro
- Department of Cardiology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Hollinger A, Cerlinskaite K, Bastian K, Mebazaa A. Biomarkers of increased intraventricular pressure: are we ready? Eur Heart J Suppl 2018. [DOI: 10.1093/eurheartj/suy025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Alexa Hollinger
- Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue A. Paré, Paris, France
- Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, Paris Cedex 10, France
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Kamile Cerlinskaite
- Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue A. Paré, Paris, France
- Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, Paris Cedex 10, France
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Santariškių g. 2, Vilnius, Lithuania
| | - Kathleen Bastian
- Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue A. Paré, Paris, France
- Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, Paris Cedex 10, France
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Alexandre Mebazaa
- Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue A. Paré, Paris, France
- Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, Paris Cedex 10, France
- University Paris Diderot, 5 rue Thomas Mann, Paris, France
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Okubo Y, Sairaku A, Morishima N, Ogi H, Matsumoto T, Kinoshita H, Kihara Y. Increased Urinary Liver-Type Fatty Acid-Binding Protein Level Predicts Worsening Renal Function in Patients With Acute Heart Failure. J Card Fail 2018; 24:520-524. [PMID: 30026130 DOI: 10.1016/j.cardfail.2018.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 05/01/2018] [Accepted: 07/08/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Urinary liver-type fatty acid-binding protein (L-FABP) is a potential biomarker for acute kidney injury, and it in turn increases cardiovascular mortality. We tested whether the urinary L-FABP level predicted short- and mid-term outcomes in patients with acute heart failure. METHODS AND RESULTS We enrolled consecutive patients with acute heart failure, and measured their urinary L-FABP levels before acute treatment. Worsening renal function (WRF), defined as both an absolute increase in the serum creatinine level of ≥0.3mg/dL and a ≥25% relative increase in its level from baseline, occurred in 37 (26.8%) of 138 patients. Patients with a urinary L-FABP level above the upper normal limit (8.4 µg/g creatinine) (n = 49; 35.5%) were more likely than those with a urinary L-FABP level within normal limits (n = 89; 64.5%) to develop WRF (n = 26 [53.1%] vs n = 11 [12.4%]; P < .001). A urinary L-FABP level above the upper limit was independently associated with WRF (hazard ratio 1.8; P = .01). During 1 year of follow-up, 12 patients (8.7%) died, and urinary L-FABP level had no association with all-cause mortality. There was, however, a tendency toward a higher readmission rate in patients with a urinary L-FABP level above the upper normal limit who survived the index hospitalization (n = 46) than in those without an abnormal L-FABP level (n = 88; n = 13 [28.3%] vs n = 13 [14.8%]; log-rank P = .06). CONCLUSIONS Increased urinary L-FABP level before treatment may predict WRF in patients with acute heart failure. Further investigation is warranted for its predictive ability of adverse outcomes.
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Affiliation(s)
- Yousaku Okubo
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan; Department of Cardiology, Onomichi General Hospital, Onomichi, Japan
| | - Akinori Sairaku
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan; Department of Cardiology, Onomichi General Hospital, Onomichi, Japan.
| | | | - Hiroshi Ogi
- Department of Cardiology, Onomichi General Hospital, Onomichi, Japan
| | - Takeshi Matsumoto
- Department of Cardiology, Onomichi General Hospital, Onomichi, Japan
| | - Hiroki Kinoshita
- Department of Cardiology, Onomichi General Hospital, Onomichi, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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Martin N, Manoharan K, Thomas J, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2018; 6:CD012721. [PMID: 29952095 PMCID: PMC6513293 DOI: 10.1002/14651858.cd012721.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction. There is uncertainty whether these treatments are beneficial for people with heart failure with preserved ejection fraction and a comprehensive review of the evidence is required. OBJECTIVES To assess the effects of beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with heart failure with preserved ejection fraction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trial registries on 25 July 2017 to identify eligible studies. Reference lists from primary studies and review articles were checked for additional studies. There were no language or date restrictions. SELECTION CRITERIA We included randomised controlled trials with a parallel group design enrolling adult participants with heart failure with preserved ejection fraction, defined by a left ventricular ejection fraction of greater than 40 percent. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion and extracted data. The outcomes assessed included cardiovascular mortality, heart failure hospitalisation, hyperkalaemia, all-cause mortality and quality of life. Risk ratios (RR) and, where possible, hazard ratios (HR) were calculated for dichotomous outcomes. For continuous data, mean difference (MD) or standardised mean difference (SMD) were calculated. We contacted trialists where neccessary to obtain missing data. MAIN RESULTS 37 randomised controlled trials (207 reports) were included across all comparisons with a total of 18,311 participants.Ten studies (3087 participants) investigating beta-blockers (BB) were included. A pooled analysis indicated a reduction in cardiovascular mortality (15% of participants in the intervention arm versus 19% in the control arm; RR 0.78; 95% confidence interval (CI) 0.62 to 0.99; number needed to treat to benefit (NNTB) 25; 1046 participants; 3 studies). However, the quality of evidence was low and no effect on cardiovascular mortality was observed when the analysis was limited to studies with a low risk of bias (RR 0.81; 95% CI 0.50 to 1.29; 643 participants; 1 study). There was no effect on all-cause mortality, heart failure hospitalisation or quality of life measures, however there is uncertainty about these effects given the limited evidence available.12 studies (4408 participants) investigating mineralocorticoid receptor antagonists (MRA) were included with the quality of evidence assessed as moderate. MRA treatment reduced heart failure hospitalisation (11% of participants in the intervention arm versus 14% in the control arm; RR 0.82; 95% CI 0.69 to 0.98; NNTB 41; 3714 participants; 3 studies; moderate-quality evidence) however, little or no effect on all-cause and cardiovascular mortality and quality of life measures was observed. MRA treatment was associated with a greater risk of hyperkalaemia (16% of participants in the intervention group versus 8% in the control group; RR 2.11; 95% CI 1.77 to 2.51; 4291 participants; 6 studies; high-quality evidence).Eight studies (2061 participants) investigating angiotensin converting enzyme inhibitors (ACEI) were included with the overall quality of evidence assessed as moderate. The evidence suggested that ACEI treatment likely has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. Data for the effect of ACEI on hyperkalaemia were only available from one of the included studies.Eight studies (8755 participants) investigating angiotensin receptor blockers (ARB) were included with the overall quality of evidence assessed as high. The evidence suggested that treatment with ARB has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. ARB was associated with an increased risk of hyperkalaemia (0.9% of participants in the intervention group versus 0.5% in the control group; RR 1.88; 95% CI 1.07 to 3.33; 7148 participants; 2 studies; high-quality evidence).We identified a single ongoing placebo-controlled study investigating the effect of angiotensin receptor neprilysin inhibitors (ARNI) in people with heart failure with preserved ejection fraction. AUTHORS' CONCLUSIONS There is evidence that MRA treatment reduces heart failure hospitalisation in heart failure with preserverd ejection fraction, however the effects on mortality related outcomes and quality of life remain unclear. The available evidence for beta-blockers, ACEI, ARB and ARNI is limited and it remains uncertain whether these treatments have a role in the treatment of HFpEF in the absence of an alternative indication for their use. This comprehensive review highlights a persistent gap in the evidence that is currently being addressed through several large ongoing clinical trials.
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Affiliation(s)
- Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Karthick Manoharan
- John Radcliffe HospitalEmergency Department3 Sherwood AvenueLondonMiddlesexUKUb6 0pg
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of EducationLondonUK
| | - Ceri Davies
- Barts Heart Centre, St Bartholomew's HospitalDepartment of CardiologyWest SmithfieldLondonUKEC1A 7BE
| | - R Thomas Lumbers
- University College LondonInstitute of Health InformaticsLondonUK
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Rosano GM. Cardiovascular pharmacotherapy a growing sub-speciality across all areas of cardiology. J Cardiovasc Med (Hagerstown) 2018; 19:263-266. [DOI: 10.2459/jcm.0000000000000640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Vergaro G, Iacoviello M. Is there a "renal paradox" in chronic heart failure? Int J Cardiol 2018; 267:139-140. [PMID: 29859710 DOI: 10.1016/j.ijcard.2018.05.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 05/22/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Giuseppe Vergaro
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Massimo Iacoviello
- University Cardiology Unit, Cardiothoracic Department, Policlinic University Hospital, Bari, Italy.
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Formiga F, Moreno-Gonzalez R, Chivite D, Casado J, Escrihuela-Vidal F, Corbella X. Clinical characteristics and one-year mortality according to admission renal function in patients with a first acute heart failure hospitalization. Rev Port Cardiol 2018; 37:159-165. [PMID: 29501214 DOI: 10.1016/j.repc.2017.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/20/2017] [Accepted: 06/26/2017] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Chronic kidney disease is related to poor outcomes in patients with heart failure (HF). Few studies have assessed whether renal function influences one-year mortality risk in patients admitted for the first time for acute HF. METHODS We reviewed the medical records of all patients aged >50 years admitted within a two-year period for a first episode of decompensated HF. The sample was divided according to the patients' estimated glomerular filtration rate (eGFR) on admission into three groups (eGFR >60, 30-60 and <30 ml/min/1.73 m2). Index admission and one-year all-cause mortality rates were compared between groups using Cox regression analysis. RESULTS A total of 985 patients were included in the study, mean age 78.4±9 years, and with mean admission eGFR of 60.5±26 ml/min/1.73 m2. Of these, 516 (52.3%) patients had eGFR <60 ml/min/1.73 m2. One-year all-cause mortality was 25.4%, with a significant association between worse eGFR category and mortality (p<0.0001). Cox regression analysis assessing eGFR as a categorical variable confirmed this association (HR 1.378; p=0.030), together with older age (HR 1.066; p<0.001), previous diagnosis of hypertension (HR 0.527; p<0.001), and both lower systolic blood pressure (HR 0.993; p=0.009) and higher serum potassium on admission (HR 1.471; p <0.001). CONCLUSIONS Renal impairment is common in HF patients, even at the time of first admission. In this group of HF patients the presence of renal impairment was associated with higher mid-term (one-year) mortality risk.
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Affiliation(s)
- Francesc Formiga
- Geriatric Unit, Internal Medicine Department, Bellvitge University Hospital, Barcelona, Spain.
| | - Rafael Moreno-Gonzalez
- Geriatric Unit, Internal Medicine Department, Bellvitge University Hospital, Barcelona, Spain
| | - David Chivite
- Geriatric Unit, Internal Medicine Department, Bellvitge University Hospital, Barcelona, Spain
| | - Jesús Casado
- Internal Medicine Department, Getafe University Hospital, Madrid, Spain
| | | | - Xavier Corbella
- Geriatric Unit, Internal Medicine Department, Bellvitge University Hospital, Barcelona, Spain; Hestia Chair in Integrated Health and Social Care, Faculty of Medicine and Health Sciences, Catalunya International University, Barcelona, Spain
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Clinical characteristics and one-year mortality according to admission renal function in patients with a first acute heart failure hospitalization. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Carubelli V, Metra M, Lund LH. Negotiating renal dysfunction when treating patients with heart failure. Expert Rev Cardiovasc Ther 2018; 16:113-122. [PMID: 29292652 DOI: 10.1080/14779072.2018.1422178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Chronic kidney disease (CKD) is one of the most prevalent comorbidities in HF, and no specific treatment is still available for the so-called cardiorenal syndrome. Areas covered: The aim of this review is to describe the interaction of heart and kidney function and the consequences of cardiorenal syndrome, focusing on the use of available therapeutics. Expert commentary: The presence of CKD has been associated with adverse outcomes in HF regardless of ejection fraction. On the other hand, cardiovascular events are the most common causes of morbidity and mortality among CKD patients, reflecting the close pathophysiological crosstalk between these organs. Multiple mechanisms are involved in the development of cardiorenal syndrome, including hemodynamic, neurohormonal and inflammatory mediators. The management of several HF drugs is a challenge in the presence of CKD mainly due to blunted diuretic response and increased risk of worsening of kidney function. Therefore, finding a balance between the optimization of cardiac and renal outcomes is a real negotiation in the everyday clinical practice.
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Affiliation(s)
- Valentina Carubelli
- a Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health , University and Civil Hospital of Brescia , Brescia , Italy
| | - Marco Metra
- a Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health , University and Civil Hospital of Brescia , Brescia , Italy
| | - Lars H Lund
- b Unit of Cardiology, Department of Medicine , Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital , Solna , Sweden
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Al‐Naher A, Wright D, Devonald MAJ, Pirmohamed M. Renal function monitoring in heart failure - what is the optimal frequency? A narrative review. Br J Clin Pharmacol 2018; 84:5-17. [PMID: 28901643 PMCID: PMC5736847 DOI: 10.1111/bcp.13434] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/31/2017] [Accepted: 09/05/2017] [Indexed: 12/29/2022] Open
Abstract
The second most common cause of hospitalization due to adverse drug reactions in the UK is renal dysfunction due to diuretics, particularly in patients with heart failure, where diuretic therapy is a mainstay of treatment regimens. Therefore, the optimal frequency for monitoring renal function in these patients is an important consideration for preventing renal failure and hospitalization. This review looks at the current evidence for optimal monitoring practices of renal function in patients with heart failure according to national and international guidelines on the management of heart failure (AHA/NICE/ESC/SIGN). Current guidance of renal function monitoring is in large part based on expert opinion, with a lack of clinical studies that have specifically evaluated the optimal frequency of renal function monitoring in patients with heart failure. Furthermore, there is variability between guidelines, and recommendations are typically nonspecific. Safer prescribing of diuretics in combination with other antiheart failure treatments requires better evidence for frequency of renal function monitoring. We suggest developing more personalized monitoring rather than from the current medication-based guidance. Such flexible clinical guidelines could be implemented using intelligent clinical decision support systems. Personalized renal function monitoring would be more effective in preventing renal decline, rather than reacting to it.
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Affiliation(s)
- Ahmed Al‐Naher
- The Wolfson Centre for Personalised MedicineThe University of LiverpoolLiverpoolUK
| | - David Wright
- Institute of Cardiovascular Medicine and ScienceLiverpool Heart and Chest HospitalLiverpoolUK
| | | | - Munir Pirmohamed
- The Wolfson Centre for Personalised MedicineThe University of LiverpoolLiverpoolUK
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Ruocco G, Nuti R, Giambelluca A, Evangelista I, De Vivo O, Daniello C, Palazzuoli A. The paradox of transient worsening renal function in patients with acute heart failure. J Cardiovasc Med (Hagerstown) 2017; 18:851-858. [DOI: 10.2459/jcm.0000000000000546] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Lam PH, Dooley DJ, Fonarow GC, Butler J, Bhatt DL, Filippatos GS, Deedwania P, Forman DE, White M, Fletcher RD, Arundel C, Blackman MR, Adamopoulos C, Kanonidis IE, Aban IB, Patel K, Aronow WS, Allman RM, Anker SD, Pitt B, Ahmed A. Similar clinical benefits from below-target and target dose enalapril in patients with heart failure in the SOLVD Treatment trial. Eur J Heart Fail 2017; 20:359-369. [PMID: 28980368 DOI: 10.1002/ejhf.937] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/05/2017] [Accepted: 06/08/2017] [Indexed: 12/28/2022] Open
Abstract
AIMS To examine associations of below-target and target dose of enalapril, an angiotensin-converting enzyme (ACE) inhibitor, with outcomes in patients with heart failure and reduced ejection fraction (HFrEF) in the Studies of Left Ventricular Dysfunction (SOLVD) Treatment trial. METHODS AND RESULTS Two thousand five hundred and sixty-nine patients with HFrEF (ejection fraction ≤35%) were randomized to below-target (5-10 mg/day) dose placebo (n = 1284) or enalapril (n = 1285). One month post-randomization, blind up-titration to target (20 mg/day) dose was attempted for both study drugs in 2458 patients. Among the 1444 patients who achieved dose up-titration (placebo, n = 748; enalapril, n = 696; mean dose for both groups, 20.0 mg/day), target dose enalapril (vs. target dose placebo) was associated with a 9% absolute lower risk of the combined endpoint of heart failure hospitalization or all-cause mortality [adjusted hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.60-0.81; P < 0.001] during 4 years of follow-up. Among the 1014 patients who could not achieve target dose (placebo, n = 486; enalapril, n = 528; mean dose for both groups, 8.8 mg/day), below-target dose enalapril (vs. below-target dose placebo) was associated with a 12% absolute lower risk of the combined endpoint of heart failure hospitalization or all-cause mortality (adjusted HR 0.68; 95% CI 0.57-0.81; P < 0.001). Among the 1224 patients receiving enalapril, target (vs. below-target) dose had no association with the combined endpoint of heart failure hospitalization or all-cause mortality (adjusted HR 1.04; 95% CI 0.87-1.23; P = 0.695). CONCLUSION In patients with HFrEF, the clinical benefits of ACE inhibitors appear to be similar at both below-target and target doses.
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Affiliation(s)
- Phillip H Lam
- Veterans Affairs Medical Center, Washington, DC, USA.,Georgetown University/MedStar Washington Hospital Center, Washington, DC, USA
| | - Daniel J Dooley
- Veterans Affairs Medical Center, Washington, DC, USA.,Georgetown University/MedStar Washington Hospital Center, Washington, DC, USA
| | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Boston, MA, USA
| | | | | | - Daniel E Forman
- University of Pittsburgh and VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | - Ross D Fletcher
- Veterans Affairs Medical Center, Washington, DC, USA.,Georgetown University, Washington, DC, USA
| | - Cherinne Arundel
- Veterans Affairs Medical Center, Washington, DC, USA.,George Washington University, Washington, DC, USA
| | - Marc R Blackman
- Veterans Affairs Medical Center, Washington, DC, USA.,Georgetown University, Washington, DC, USA.,George Washington University, Washington, DC, USA
| | | | | | | | - Kanan Patel
- University of California, San Francisco, CA, USA
| | - Wilbert S Aronow
- Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Richard M Allman
- Department of Veterans Affairs, Geriatrics and Extended Care, Washington, DC, USA
| | - Stefan D Anker
- Division of Cardiology and Metabolism - Heart Failure, Cachexia and Sarcopenia, Department of Cardiology (CVK); and Berlin-Brandenburg Center for Regenerative Therapies (BCRT); Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) Berlin, Charité Universitätsmedizin Berlin, Germany.,Department of Cardiology and Pneumology, University Medicine Göttingen, Germany
| | | | - Ali Ahmed
- Veterans Affairs Medical Center, Washington, DC, USA.,George Washington University, Washington, DC, USA.,University of Alabama at Birmingham, Birmingham, AL, USA
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Beldhuis IE, Streng KW, Ter Maaten JM, Voors AA, van der Meer P, Rossignol P, McMurray JJV, Damman K. Renin-Angiotensin System Inhibition, Worsening Renal Function, and Outcome in Heart Failure Patients With Reduced and Preserved Ejection Fraction: A Meta-Analysis of Published Study Data. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003588. [PMID: 28209765 DOI: 10.1161/circheartfailure.116.003588] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/03/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Renin-angiotensin aldosterone system (RAAS) inhibitors significantly improve outcome in heart failure (HF) patients with reduced ejection fraction (HFREF), irrespective of the occurrence of worsening renal function (WRF). However, in HF patients with preserved ejection fraction (HFPEF), RAAS inhibitors have not been shown to improve outcome but are still frequently prescribed. METHODS AND RESULTS Random effect meta-analysis was performed to investigate the relationship between RAAS inhibitor therapy, WRF in both HF phenotypes, and mortality. Studies were selected based on literature search in MEDLNE and included randomized, placebo controlled trials of RAAS inhibitors in chronic HF. The primary outcome consisted of the interaction analysis for the association between RAAS inhibition-induced WRF, HF phenotype and outcome. A total of 8 studies (6 HFREF and 2 HFPEF, including 28 961 patients) were included in our analysis. WRF was more frequent in the RAAS inhibitor group, compared with the placebo group, in both HFREF and HFPEF. In HFREF, WRF induced by RAAS inhibitor therapy was associated with a less increased relative risk of mortality (relative risk, 1.19 (1.08-1.31); P<0.001), compared with WRF induced by placebo (relative risk, 1.48 (1.35-1.62); P<0.001; P for interaction 0.005). In contrast, WRF induced by RAAS inhibitor therapy was strongly associated with worse outcomes in HFPEF (relative risk, 1.78 (1.43-2.21); P<0.001), whereas placebo-induced WRF was not (relative risk, 1.25 (0.88-1.77); P=0.21; P for interaction 0.002). CONCLUSIONS RAAS inhibitors induce renal dysfunction in both HFREF and HFPEF. However, in contrast to patients with HFREF where mortality increase with WRF is small, HFPEF patients with RAAS inhibitor-induced WRF have an increased mortality risk, without experiencing improved outcome with RAAS inhibition.
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Affiliation(s)
- Iris E Beldhuis
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (I.E.B., K.W.S., J.M.T.M., A.A.V., P.v.d.M., K.D.); Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Inserm U1116; CHRU Nancy, France (P.R.); Université de Lorraine, F-CRIN INI-CRCT Network, Nancy, France (P.R.); and British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.M.)
| | - Koen W Streng
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (I.E.B., K.W.S., J.M.T.M., A.A.V., P.v.d.M., K.D.); Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Inserm U1116; CHRU Nancy, France (P.R.); Université de Lorraine, F-CRIN INI-CRCT Network, Nancy, France (P.R.); and British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.M.)
| | - Jozine M Ter Maaten
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (I.E.B., K.W.S., J.M.T.M., A.A.V., P.v.d.M., K.D.); Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Inserm U1116; CHRU Nancy, France (P.R.); Université de Lorraine, F-CRIN INI-CRCT Network, Nancy, France (P.R.); and British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.M.)
| | - Adriaan A Voors
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (I.E.B., K.W.S., J.M.T.M., A.A.V., P.v.d.M., K.D.); Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Inserm U1116; CHRU Nancy, France (P.R.); Université de Lorraine, F-CRIN INI-CRCT Network, Nancy, France (P.R.); and British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.M.)
| | - Peter van der Meer
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (I.E.B., K.W.S., J.M.T.M., A.A.V., P.v.d.M., K.D.); Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Inserm U1116; CHRU Nancy, France (P.R.); Université de Lorraine, F-CRIN INI-CRCT Network, Nancy, France (P.R.); and British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.M.)
| | - Patrick Rossignol
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (I.E.B., K.W.S., J.M.T.M., A.A.V., P.v.d.M., K.D.); Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Inserm U1116; CHRU Nancy, France (P.R.); Université de Lorraine, F-CRIN INI-CRCT Network, Nancy, France (P.R.); and British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.M.)
| | - John J V McMurray
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (I.E.B., K.W.S., J.M.T.M., A.A.V., P.v.d.M., K.D.); Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Inserm U1116; CHRU Nancy, France (P.R.); Université de Lorraine, F-CRIN INI-CRCT Network, Nancy, France (P.R.); and British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.M.)
| | - Kevin Damman
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (I.E.B., K.W.S., J.M.T.M., A.A.V., P.v.d.M., K.D.); Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Inserm U1116; CHRU Nancy, France (P.R.); Université de Lorraine, F-CRIN INI-CRCT Network, Nancy, France (P.R.); and British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.M.).
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Deep Phenotyping of Systemic Arterial Hemodynamics in HFpEF (Part 2): Clinical and Therapeutic Considerations. J Cardiovasc Transl Res 2017; 10:261-274. [PMID: 28401511 DOI: 10.1007/s12265-017-9736-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/30/2017] [Indexed: 01/09/2023]
Abstract
Multiple phase III trials over the last few decades have failed to demonstrate a clear benefit of various pharmacologic interventions in heart failure with a preserved left ventricular (LV) ejection fraction (HFpEF). Therefore, a better understanding of its pathophysiology is important. An accompanying review describes key technical and physiologic aspects regarding the deep phenotyping of arterial hemodynamics in HFpEF. This review deals with the potential of this approach to enhance our clinical, translational, and therapeutic approach to HFpEF. Specifically, the role of arterial hemodynamics is discussed in relation to (1) the pathophysiology of left ventricular diastolic dysfunction, remodeling, and fibrosis, (2) impaired oxygen delivery to peripheral skeletal muscle, which affects peripheral oxygen extraction, (3) the frequent presence of comorbidities, such as renal failure and dementia in this population, and (4) the potential to enhance precision medicine approaches. A therapeutic approach to target arterial hemodynamic abnormalities that are prevalent in this population (particularly, with inorganic nitrate/nitrite) is also discussed.
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