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Kobayashi M, Ferreira JP, Matsue Y, Chikamori T, Ito S, Asakura M, Yamashina A, Kitakaze M. Effect of eplerenone on clinical stability of Japanese patients with acute heart failure. Int J Cardiol 2023; 374:73-78. [PMID: 36586516 DOI: 10.1016/j.ijcard.2022.12.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the EARLIER (Efficacy and Safety of Early Initiation of Eplerenone Treatment in Patients with Acute Heart Failure) trial, eplerenone did not reduce heart failure (HF) hospitalizations or all-cause mortality in 300 patients admitted for acute HF (AHF). However, the trial might have been underpowered for these endpoints, and a comprehensive overview of the effect of eplerenone on diuretic doses and patients' clinical stability is warranted. METHODS The EARLIER trial included Japanese patients hospitalized for AHF randomly assigned to eplerenone or placebo over 6 months. Cox proportional hazards and mixed-effects models were used for analyses. RESULTS Three hundred patients were included (mean age, 67 ± 13 years; 73% males). The median furosemide equivalent dose was 40 (20-62) mg at randomization. Patients with higher furosemide-equivalent doses had more severe signs and symptoms of congestion and a higher risk of all-cause mortality or HF hospitalization during 6-month follow-up (adjusted-hazard ratio per 10 mg/day increase = 1.25, 95% confidence interval: 1.05-1.49). Eplerenone significantly decreased furosemide-equivalent diuretic doses and b-type natriuretic levels throughout the follow-up (overall-joint-p < 0.05 for both) and reduced E/e' and inferior vena cava diameter at 4 weeks (both p < 0.05). Additionally, eplerenone significantly reduced left ventricular (LV) end-diastolic diameter at 24 weeks (p < 0.05). CONCLUSIONS Eplerenone treatment improved the clinical stability particularly during short period following hospitalization for AHF, translated by lower diuretic doses, natriuretic peptide levels, indirect markers of filling pressure and venous congestion, and a smaller LV volume.
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Affiliation(s)
| | - João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France; Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | | | - Shin Ito
- Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, Hyogo, Japan
| | - Akira Yamashina
- Department of Cardiology, Tokyo medical university, Tokyo, Japan; Department of Nursing, Kiryu University, Gunma, Japan
| | - Masafumi Kitakaze
- Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Osaka, Japan; Hanwa Memorial Hospital, Osaka, Japan.
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Asakura M, Ito S, Yamada T, Saito Y, Kimura K, Yamashina A, Hirayama A, Kobayashi Y, Hanatani A, Tsujimoto M, Yasuda S, Abe Y, Higashino Y, Tamaki Y, Sugino H, Niinuma H, Okuhara Y, Koitabashi T, Momomura SI, Asai K, Nomura A, Kawai H, Satoh Y, Yoshikawa T, Hirata KI, Yokoi Y, Tanaka J, Shibata Y, Maejima Y, Tamaki S, Kawata H, Iwahashi N, Kobayashi M, Higuchi Y, Kada A, Yamamoto H, Kitakaze M. Efficacy and safety of early initiation of eplerenone treatment in patients with acute heart failure (EARLIER trial): a multicenter, randomized, double-blind, placebo-controlled trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:108-117. [PMID: 33175088 DOI: 10.1093/ehjcvp/pvaa132] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/16/2020] [Accepted: 11/03/2020] [Indexed: 11/12/2022]
Abstract
AIMS A mineralocorticoid receptor antagonist (MRA) is effective in patients with chronic heart failure; however, the effects of the early initiation of an MRA in patients with acute heart failure (AHF) have not been elucidated. METHODS AND RESULTS In this multicenter, randomized, double-blind, placebo-controlled, parallel-group study, we focused on the safety and effectiveness of the treatment with eplerenone, a selective MRA in 300 patients with AHF, that is, 149 in the eplerenone group and 151 in the placebo group in 27 Japanese institutions. The key inclusion criteria were (1) patients aged 20 years or older and (2) those with left ventricular ejection fraction of ≤ 40%. The primary outcome was a composite of cardiac death or first re-hospitalization due to cardiovascular disease within 6 months. The mean age of the participants was 66.8 years, 27.3% were women, and the median levels of brain natriuretic peptide were 376.0 pg/mL. The incidences of the primary outcome were 19.5% in the eplerenone group and 17.2% in the placebo group (hazard ratio (HR): 1.09, 95% confidence interval (CI): 0.642-1.855). In prespecified secondary outcomes, HR for the composite endpoint, cardiovascular death, or first re-hospitalization due to heart failure (HF) within 6 months was 0.55 (95% CI: 0.213 to 1.434). The safety profile for eplerenone was as expected. CONCLUSION The early initiation of eplerenone in patients with AHF could safely be utilized. The reduction of the incidence of a composite of cardiovascular death or first re-hospitalization for cardiovascular diseases by eplerenone is inconclusive because of inadequate power.
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Affiliation(s)
- Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Hyogo, Japan
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shin Ito
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Nara Medical University Hospital, Nara, Japan
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Akira Yamashina
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Hirayama
- The Division of Cardiology, Department of Medicine, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Youichi Kobayashi
- Division of Cardiology, Department of Medicine, Showa University Hospital, Tokyo, Japan
| | - Akihisa Hanatani
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Mitsuru Tsujimoto
- Department of Cardiology, Cardiovascular Center, Veritas Hospital, Hyogo, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Yorihiko Higashino
- Department of Cardiology, Higashi Takarazuka Satoh Hospital, Hyogo, Japan
| | - Yodo Tamaki
- Department of Cardiology, Tenri Hospital, Nara, Tenri, Japan
| | - Hiroshi Sugino
- Department of Cardiac Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroyuki Niinuma
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Yoshitaka Okuhara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Toshimi Koitabashi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Tokyo, Japan
| | - Shin-Ichi Momomura
- Cardiovascular Division, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Akihiro Nomura
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medical Science, Ishikawa, Japan
| | - Hiroya Kawai
- Division of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center, Hyogo Brain and Heart Center, Hyogo, Japan
| | - Yasuhiro Satoh
- Department of Cardiology, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | | | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshiaki Yokoi
- Department of Medicine, Cardiac Arrhythmia Center, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Jun Tanaka
- Department of Cardiology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Yoshisato Shibata
- Department of Cardiology, Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Medical Hospital, Tokyo, Japan
| | - Shunsuke Tamaki
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Hiroyuki Kawata
- Department of Cardiovascular Medicine, Nara Medical University, Nara Medical University Hospital, Nara, Japan
| | - Noriaki Iwahashi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | | | - Yoshiharu Higuchi
- The Division of Cardiology, Department of Medicine, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Akiko Kada
- Department of Clinical Research Management, National Hospital Organization Nagoya Medical Center, Aichi, Japan
| | - Haruko Yamamoto
- Department of Advance Medical Technology Development, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi Suita 564-8565, Osaka, Japan
| | - Masafumi Kitakaze
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
- Hanwa Daini Senboku Hospital, 3176 Fukaikitamachi, Naka-ku Sakai City, Osaka 599-8271, Japan
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Abstract
Heart failure is common in adults, accounting for substantial morbidity and mortality worldwide. Its prevalence is increasing because of ageing of the population and improved treatment of acute cardiovascular events, despite the efficacy of many therapies for patients with heart failure with reduced ejection fraction, such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β blockers, and mineralocorticoid receptor antagonists, and advanced device therapies. Combined angiotensin receptor blocker neprilysin inhibitors (ARNIs) have been associated with improvements in hospital admissions and mortality from heart failure compared with enalapril, and guidelines now recommend substitution of ACE inhibitors or ARBs with ARNIs in appropriate patients. Improved safety of left ventricular assist devices means that these are becoming more commonly used in patients with severe symptoms. Antidiabetic therapies might further improve outcomes in patients with heart failure. New drugs with novel mechanisms of action, such as cardiac myosin activators, are under investigation for patients with heart failure with reduced left ventricular ejection fraction. Heart failure with preserved ejection fraction is a heterogeneous disorder that remains incompletely understood and will continue to increase in prevalence with the ageing population. Although some data suggest that spironolactone might improve outcomes in these patients, no therapy has conclusively shown a significant effect. Hopefully, future studies will address these unmet needs for patients with heart failure. Admissions for acute heart failure continue to increase but, to date, no new therapies have improved clinical outcomes.
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Affiliation(s)
- Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - John R Teerlink
- School of Medicine, University of California, San Francisco, CA, USA; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
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Takahama H, Kitakaze M. Pathophysiology of cardiorenal syndrome in patients with heart failure: potential therapeutic targets. Am J Physiol Heart Circ Physiol 2017; 313:H715-H721. [PMID: 28733448 DOI: 10.1152/ajpheart.00215.2017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/27/2017] [Accepted: 07/13/2017] [Indexed: 12/16/2022]
Abstract
Despite the development of pharmacological inventions and new nonpharmacological techniques to prevent and treat heart failure (HF), the mortality rate in patients with symptomatic HF remains high. To conquer these difficulties, the pathophysiology of HF should be considered within a wide range of views. Given the diverse mechanisms of HF pathophysiology, renal and cardiac functions have close and complementary interconnections. Recent studies have suggested that communication between the kidney and heart through bidirectional pathways causes significant pathological changes. This review summarizes the pathophysiology of cardiorenal syndrome (CRS) from three different viewpoints, namely, underlying chronic kidney disease, worsening renal function during hospitalization due to HF, and resistance to diuretics. We also summarize the presently available data on the pathophysiology of CRS, identify the challenges associated with some clinical approaches, and explore the potential therapeutic target for CRS.
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Affiliation(s)
- Hiroyuki Takahama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan; and
| | - Masafumi Kitakaze
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan; and.,Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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