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Andrade A. Exploring the evidence gap: Loop diuretic withdrawal in chronic heart failure. Rev Port Cardiol 2024; 43:523-524. [PMID: 39074533 DOI: 10.1016/j.repc.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Affiliation(s)
- Aurora Andrade
- Clínica de Insuficiência Cardíaca, Serviço de Cardiologia, Unidade Local de Saúde Tâmega e Sousa, Penafiel, Portugal.
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Rastogi T, Gargani L, Pellicori P, Lamiral Z, Ambrosio G, Bayés-Genis A, Domingo M, Lupon J, Simonovic D, Pugliese NR, Ruocco G, Duarte K, Coiro S, Palazzuoli A, Girerd N. Prognostic implication of lung ultrasound in heart failure: a pooled analysis of international cohorts. Eur Heart J Cardiovasc Imaging 2024; 25:1216-1225. [PMID: 38606932 DOI: 10.1093/ehjci/jeae099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
AIMS Lung ultrasound (LUS) is often used to assess congestion in heart failure (HF). In this study, we assessed the prognostic role of LUS in patients with HF at admission and hospital discharge, and in an outpatient setting, and explored whether clinical factors [age, sex, left ventricular ejection fraction (LVEF), and atrial fibrillation] impact the prognostic value of LUS findings. Further, we assessed the incremental prognostic value of LUS on top of the following two clinical risk scores: (i) the atrial fibrillation, haemoglobin, elderly, abnormal renal parameters, diabetes mellitus (AHEAD) and (ii) the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) clinical risk scores. METHODS AND RESULTS We pooled data on patients hospitalized for HF or followed up in outpatient clinics from international cohorts. We enrolled 1947 patients at admission (n = 578), discharge (n = 389), and in outpatient clinics (n = 980). The total LUS B-line count was calculated for the eight-zone scanning protocol. The primary outcome was a composite of rehospitalization for HF and all-cause death. Compared with those in the lower tertiles of B lines, patients in the highest tertiles were older, more likely to have signs of HF and had higher N-terminal pro b-type natriuretic peptide (NT-proBNP) levels. A higher number of B lines was associated with increased risk of primary outcome at discharge [Tertile 3 vs. Tertile 1: adjusted hazard ratio (HR): 5.74 (3.26-10.12), P < 0.0001] and in outpatients [Tertile 3 vs. Tertile 1: adjusted HR: 2.66 (1.08-6.54), P = 0.033]. Age and LVEF did not influence the prognostic capacity of LUS in different clinical settings. Adding B-line count to the MAGGIC and AHEAD scores improved net reclassification significantly in all three clinical settings. CONCLUSION A higher number of B lines in patients with HF was associated with an increased risk of morbidity and mortality, regardless of the clinical setting.
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Affiliation(s)
- Tripti Rastogi
- Centre d'Investigation Clinique Pierre Drouin-INSERM-Unité mixte de recherche U1116 DCAC-CHRU de Nancy, Institut lorrain du cœur et des vaisseaux Louis Mathieu, 4, rue du Morvan, 54500 Vandœuvre-Lès-Nancy, France
| | - Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Zohra Lamiral
- Centre d'Investigation Clinique Pierre Drouin-INSERM-Unité mixte de recherche U1116 DCAC-CHRU de Nancy, Institut lorrain du cœur et des vaisseaux Louis Mathieu, 4, rue du Morvan, 54500 Vandœuvre-Lès-Nancy, France
| | - Giuseppe Ambrosio
- Department of Cardiology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Antoni Bayés-Genis
- Heart Failure Clinic, Heart Institute, Hospital Universitari Germans Trias i Pujol, Department of Medicine, Autonomous University of Barcelona, CIBERCV, Barcelona, Spain
| | - Mar Domingo
- Heart Failure Clinic, Heart Institute, Hospital Universitari Germans Trias i Pujol, Department of Medicine, Autonomous University of Barcelona, CIBERCV, Barcelona, Spain
| | - Josep Lupon
- Heart Failure Clinic, Heart Institute, Hospital Universitari Germans Trias i Pujol, Department of Medicine, Autonomous University of Barcelona, CIBERCV, Barcelona, Spain
| | - Dejan Simonovic
- Institute for Treatment and Rehabilitation 'Niška Banja', Clinic of Cardiology, University of Niš School of Medicine, Niš, Serbia
| | | | - Gaetano Ruocco
- Cardiology Division, Regina Montis Regalis Hospital, ASL CN-1, Mondovì, Cuneo, Italy
| | - Kevin Duarte
- Centre d'Investigation Clinique Pierre Drouin-INSERM-Unité mixte de recherche U1116 DCAC-CHRU de Nancy, Institut lorrain du cœur et des vaisseaux Louis Mathieu, 4, rue du Morvan, 54500 Vandœuvre-Lès-Nancy, France
| | - Stefano Coiro
- Department of Cardiology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Cardio Thoracic and Vascular, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Nicolas Girerd
- Centre d'Investigation Clinique Pierre Drouin-INSERM-Unité mixte de recherche U1116 DCAC-CHRU de Nancy, Institut lorrain du cœur et des vaisseaux Louis Mathieu, 4, rue du Morvan, 54500 Vandœuvre-Lès-Nancy, France
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Wu L, Rodriguez M, El Hachem K, Krittanawong C. Diuretic Treatment in Heart Failure: A Practical Guide for Clinicians. J Clin Med 2024; 13:4470. [PMID: 39124738 PMCID: PMC11313642 DOI: 10.3390/jcm13154470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Congestion and fluid retention are the hallmarks of decompensated heart failure and the major reason for the hospitalization of patients with heart failure. Diuretics have been used in heart failure for decades, and they remain the backbone of the contemporary management of heart failure. Loop diuretics is the preferred diuretic, and it has been given a class I recommendation by clinical guidelines for the relief of congestion symptoms. Although loop diuretics have been used virtually among all patients with acute decompensated heart failure, there is still very limited clinical evidence to guide the optimized diuretics use. This is a sharp contrast to the rapidly growing evidence of the rest of the guideline-directed medical therapy of heart failure and calls for further studies. The loop diuretics possess a unique pharmacology and pharmacokinetics that lay the ground for different strategies to increase diuretic efficiency. However, many of these approaches have not been evaluated in randomized clinical trials. In recent years, a stepped and protocolized diuretics dosing has been suggested to have superior benefits over an individual clinician-based strategy. Diuretic resistance has been a major challenge to decongestion therapy for patients with heart failure and is associated with a poor clinical prognosis. Recently, therapy options have emerged to help overcome diuretic resistance to loop diuretics and have been evaluated in randomized clinical trials. In this review, we aim to provide a comprehensive review of the pharmacology and clinical use of loop diuretics in the context of heart failure, with attention to its side effects, and adjuncts, as well as the challenges and future direction.
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Affiliation(s)
- Lingling Wu
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Mario Rodriguez
- John T. Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY 10029, USA
| | - Chayakrit Krittanawong
- Section of Cardiology, Cardiology Division, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY 10016, USA
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Krychtiuk KA, Gersh BJ, Washam JB, Granger CB. When cardiovascular medicines should be discontinued. Eur Heart J 2024; 45:2039-2051. [PMID: 38838241 DOI: 10.1093/eurheartj/ehae302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/19/2024] [Accepted: 05/05/2024] [Indexed: 06/07/2024] Open
Abstract
An integral component of the practice of medicine is focused on the initiation of medications, based on clinical practice guidelines and underlying trial evidence, which usually test the addition of novel medications intended for life-long use in short-term clinical trials. Much less attention is given to the question of medication discontinuation, especially after a lengthy period of treatment, during which patients age gets older and diseases may either progress or new diseases may emerge. Given the paucity of data, clinical practice guidelines offer little to no guidance on when and how to deprescribe cardiovascular medications. Such decisions are often left to the discretion of clinicians, who, together with their patients, express concern of potential adverse effects of medication discontinuation. Even in the absence of adverse effects, the continuation of medications without any proven effect may cause harm due to drug-drug interactions, the emergence of polypharmacy, and additional preventable spending to already strained health systems. Herein, several cardiovascular medications or medication classes are discussed that in the opinion of this author group should generally be discontinued, either for the prevention of potential harm, for a lack of benefit, or for the availability of better alternatives.
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Affiliation(s)
- Konstantin A Krychtiuk
- Duke Clinical Research Institute, 300 W Morgan Street, Durham, NC 27701, USA
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Jeffrey B Washam
- Division of Clinical Pharmacology, Department of Medicine, Duke University, Durham, NC, USA
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Cuthbert JJ, Clark AL. Diuretic Treatment in Patients with Heart Failure: Current Evidence and Future Directions - Part I: Loop Diuretics. Curr Heart Fail Rep 2024; 21:101-114. [PMID: 38240883 PMCID: PMC10924023 DOI: 10.1007/s11897-024-00643-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE OF REVIEW Fluid retention or congestion is a major cause of symptoms, poor quality of life, and adverse outcome in patients with heart failure (HF). Despite advances in disease-modifying therapy, the mainstay of treatment for congestion-loop diuretics-has remained largely unchanged for 50 years. In these two articles (part I: loop diuretics and part II: combination therapy), we will review the history of diuretic treatment and the current trial evidence for different diuretic strategies and explore potential future directions of research. RECENT FINDINGS We will assess recent trials including DOSE, TRANSFORM, ADVOR, CLOROTIC, OSPREY-AHF, and PUSH-AHF amongst others, and assess how these may influence current practice and future research. There are few data on which to base diuretic therapy in clinical practice. The most robust evidence is for high dose loop diuretic treatment over low-dose treatment for patients admitted to hospital with HF, yet this is not reflected in guidelines. There is an urgent need for more and better research on different diuretic strategies in patients with HF.
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Affiliation(s)
- Joseph James Cuthbert
- Clinical Sciences Centre, Hull York Medical School, University of Hull, Cottingham Road, Kingston-Upon-Hull, East Yorkshire, UK.
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals Trust, Castle Road, Cottingham, East Yorkshire, UK.
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals Trust, Castle Road, Cottingham, East Yorkshire, UK
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Scholte NT, Aydin D, Linssen GC, Koudstaal S, Rademaker PC, Geerlings PR, van Gent MW, Aksoy I, Oosterom L, Boersma E, Brunner-La Rocca HP, Brugts JJ. Use of loop diuretics in patients with chronic heart failure: an observational overview. Open Heart 2023; 10:e002497. [PMID: 38011993 PMCID: PMC10685956 DOI: 10.1136/openhrt-2023-002497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION This study aimed to evaluate the use and dose of loop diuretics (LDs) across the entire ejection fraction (EF) spectrum in a large, 'real-world' cohort of chronic heart failure (HF) patients. METHODS A total of 10 366 patients with chronic HF from 34 Dutch outpatient HF clinics were analysed regarding diuretic use and diuretic dose. Data regarding daily diuretic dose were stratified by furosemide dose equivalent (FDE)>80 mg or ≤80 mg. Multivariable logistic regression models were used to assess the association between diuretic dose and clinical features. RESULTS In this cohort, 8512 (82.1%) patients used diuretics, of which 8179 (96.1%) used LDs. LD use was highest among HF with reduced EF (HFrEF) patients (81.1%) followed by HF with mild-reduced EF (76.1%) and HF with preserved ejection fraction EF (73.8%, p<0.001). Among all LDs users, the median FDE was 40 mg (IQR: 40-80). The results of the multivariable analysis showed that New York Heart Association classes III and IV and diabetes mellitus were one of the strongest determinants of an FDE >80 mg, across all HF categories. Renal impairment was associated with a higher FDE across the entire EF spectrum. CONCLUSION In this large registry of real-world HF patients, LD use was highest among HFrEF patients. Advanced symptoms, diabetes mellitus and worse renal function were significantly associated with a higher diuretic dose regardless of left ventricular ejection fraction.
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Affiliation(s)
- Niels Tb Scholte
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Dilan Aydin
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Gerard Cm Linssen
- Department of Cardiology, Hospital Group Twente, Almelo, The Netherlands
| | - Stefan Koudstaal
- Department of Cardiology, Groene Hart Hospital, Gouda, The Netherlands
| | | | - Peter R Geerlings
- Department of Cardiology, St. Jans Gasthuis Weert, Weert, The Netherlands
| | - Marco Wf van Gent
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Ismail Aksoy
- Department of Cardiology, Admiraal De Ruyter Hospital, Goes, The Netherlands
| | - Liane Oosterom
- Department of Cardiology, Dijklander Hospital, Hoorn, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | | | - Jasper J Brugts
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
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Gargani L, Girerd N, Platz E, Pellicori P, Stankovic I, Palazzuoli A, Pivetta E, Miglioranza MH, Soliman-Aboumarie H, Agricola E, Volpicelli G, Price S, Donal E, Cosyns B, Neskovic AN. Lung ultrasound in acute and chronic heart failure: a clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI). Eur Heart J Cardiovasc Imaging 2023; 24:1569-1582. [PMID: 37450604 PMCID: PMC11032195 DOI: 10.1093/ehjci/jead169] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Affiliation(s)
- Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, via Paradisa 2 5614, Pisa, Italy
| | - Nicolas Girerd
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, CHRU de Nancy, INSERM DCAC, F-CRIN INI-CRCT, Nancy, France
| | - Elke Platz
- Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Ivan Stankovic
- Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Serbia
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, Italy
| | - Emanuele Pivetta
- Medicina d'Urgenza-MECAU, Presidio Molinette, A.O.U. Città della Salute e della Scienza di Torino, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marcelo Haertel Miglioranza
- EcoHaertel - Hospital Mae de Deus, Porto Alegre, Brazil
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Hatem Soliman-Aboumarie
- Department of Cardiothoracic Anaesthesia and Critical Care, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, King’s College London, UK
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Giovanni Volpicelli
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Torino, Italy
| | - Susanna Price
- Departments of Cardiology & Intensive Care, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, Rennes, France
| | - Bernard Cosyns
- Department of Cardiology, Universitair Ziekenhuis Brussel, Jette, Brussels, Belgium
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Lu Y, Chen W, Guo Y, Wang Y, Wang L, Zhang Y. Risk factors for short-term mortality in elderly hip fracture patients with complicated heart failure in the ICU: A MIMIC-IV database analysis using nomogram. J Orthop Surg Res 2023; 18:829. [PMID: 37924144 PMCID: PMC10625197 DOI: 10.1186/s13018-023-04258-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/02/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Hip fracture is a prevalent and hazardous injury among the elderly population that often results in intensive care unit (ICU) admission due to various complications, despite advanced medical science. One common complication experienced in the ICU by elderly hip fracture patients is heart failure, which significantly impacts short-term survival rates. Currently, there is a deficit of adequate predictive models to forecast the short-term risk of death following heart failure for elderly hip fracture patients in the ICU. This study aims to identify independent risk factors for all-cause mortality within 30 days for elderly patients with hip fractures and heart failure while in the ICU in order to develop a predictive model. METHOD A total of 641 elderly patients with hip fractures combined with heart failure were recruited from the Medical Information Mart for Intensive Care IV dataset and randomized to the training and validation sets. The primary outcome was all-cause mortality within 30 days. The least absolute shrinkage and selection operator regression was used to reduce data dimensionality and select features. Multivariate logistic regression was used to build predictive models. Consistency index (C-index), receiver operating characteristic curve, and decision curve analysis (DCA) were used to measure the predictive performance of the nomogram. RESULT Our results showed that these variables including MCH, MCV, INR, monocyte percentage, neutrophils percentage, creatinine, and combined sepsis were independent factors for death within 30 days in elderly patients with hip fracture combined with heart failure in the ICU. The C-index was 0.869 (95% CI 0.823-0.916) and 0.824 (95% CI 0.749-0.900) for the training and validation sets, respectively. The results of the area under the curve and decision curve analysis (DCA) confirmed that the nomogram performed well in predicting elderly patients with hip fractures combined with heart failure in the ICU. CONCLUSION We developed a new nomogram model for predicting 30-day all-cause mortality in elderly patients with hip fractures combined with heart failure in the ICU, which could be a valid and useful clinical tool for clinicians for targeted treatment and prognosis prediction.
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Affiliation(s)
- Yining Lu
- Department of Orthopedic Research Center, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Wei Chen
- Department of Orthopedic Research Center, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Yuhui Guo
- Department of Orthopedic Research Center, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
- Department of Orthopedic Oncology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Yujing Wang
- Department of Orthopedic Research Center, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
- Department of Orthopedic Oncology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Ling Wang
- Department of Orthopedic Research Center, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.
- Department of Orthopedic Oncology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.
| | - Yingze Zhang
- Department of Orthopedic Research Center, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.
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Okoye C, Mazzarone T, Cargiolli C, Guarino D. Discontinuation of Loop Diuretics in Older Patients with Chronic Stable Heart Failure: A Narrative Review. Drugs Aging 2023; 40:981-990. [PMID: 37620655 PMCID: PMC10600299 DOI: 10.1007/s40266-023-01061-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 08/26/2023]
Abstract
Loop diuretics (LDs) represent the cornerstone treatment for relieving pulmonary congestion in patients with heart failure (HF). Their benefit is well-recognized in the short term because of their ability to eliminate fluid retention. However, long term, they could adversely influence prognosis due to activation of the neurohumoral mechanism, particularly in older, frail patients. Moreover, the advent of new drugs capable of improving outcomes and reducing pulmonary and systemic congestion signs in HF emphasizes the possibility of a progressive reduction and discontinuation of LD treatment. Nevertheless, few studies were aimed at investigating the safety of LDs withdrawal in older patients with chronic stable HF. This current review aims to approach current evidence regarding the safety and effectiveness of LDs discontinuation in patients with chronic stable HF, and is based on the material obtained via the PubMed and Scopus databases from January 2000 to November 2022. Our search yielded five relevant studies, including two randomized controlled trials. All participants presented stable HF at the time of study enrolment. Apart from one study, all the investigations were conducted in patients with HF with reduced ejection fraction. The most common outcomes examined were the need for diuretic resumption or the event of death and rehospitalization after diuretic withdrawal. As a whole, although based on a few investigations with a low grade of evidence, diuretic therapy discontinuation might be a safe strategy that deserves consideration for patients with stable HF. However, extensive investigations in older adults, accounting for frailty status, are warranted to confirm these data in this peculiar class of patients.
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Affiliation(s)
- Chukwuma Okoye
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa, 2, 56124, Pisa, Italy.
- Department of Neurobiology, Aging Research Center, Karolinska Institutet, Stockholm, Sweden.
| | - Tessa Mazzarone
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa, 2, 56124, Pisa, Italy
| | - Cristina Cargiolli
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa, 2, 56124, Pisa, Italy
| | - Daniela Guarino
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa, 2, 56124, Pisa, Italy
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Feng R, Zhang Z, Fan Q. Carbohydrate antigen 125 in congestive heart failure: ready for clinical application? Front Oncol 2023; 13:1161723. [PMID: 38023127 PMCID: PMC10644389 DOI: 10.3389/fonc.2023.1161723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Congestion is the permanent mechanism driving disease progression in patients with acute heart failure (AHF) and also is an important treatment target. However, distinguishing between the two different phenotypes (intravascular congestion and tissue congestion) for personalized treatment remains challenging. Historically, carbohydrate antigen 125 (CA125) has been a frequently used biomarker for the screening, diagnosis, and prognosis of ovarian cancer. Interestingly, CA125 is highly sensitive to tissue congestion and shows potential for clinical monitoring and optimal treatment of congestive heart failure (HF). Furthermore, in terms of right heart function parameters, CA125 levels are more advantageous than other biomarkers of HF. CA125 is expected to become a new biological alternative marker for congestive HF and thereby is expected be widely used in clinical practice.
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Affiliation(s)
- Rui Feng
- Department of Laboratory Medicine, Wuhan Asian Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
- School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Zhenlu Zhang
- Department of Laboratory Medicine, Wuhan Asian Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Qingkun Fan
- Department of Laboratory Medicine, Wuhan Asian Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
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Graham FJ, Pellicori P, Masini G, Cuthbert JJ, Clark AL, Cleland JGF. Influence of serum transferrin concentration on diagnostic criteria for iron deficiency in chronic heart failure. ESC Heart Fail 2023; 10:2826-2836. [PMID: 37400990 PMCID: PMC10567655 DOI: 10.1002/ehf2.14438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/23/2023] [Accepted: 05/29/2023] [Indexed: 07/05/2023] Open
Abstract
AIMS Transferrin saturation (TSAT), a marker of iron deficiency, reflects both serum concentrations of iron (SIC) and transferrin (STC). TSAT is susceptible to changes in each of these biomarkers. Little is known about determinants of STC and its influence on TSAT and mortality in patients with heart failure. Accordingly, we studied the relationship of STC to clinical characteristics, to markers of iron deficiency and inflammation and to mortality in chronic heart failure (CHF). METHODS AND RESULTS Prospective cohort of patients with CHF attending a clinic serving a large local population. A total of 4422 patients were included (median age 75 (68-82) years; 40% women; 32% with left ventricular ejection fraction ≤40%). STC ≤ 2.3 g/L (lowest quartile) was associated with older age, lower SIC and haemoglobin and higher high-sensitivity C-reactive protein, ferritin and N-terminal pro-brain natriuretic peptide compared with those with STC > 2.3 g/L. In the lowest STC quartile, 624 (52%) patients had SIC ≤13 μmol/L, of whom 38% had TSAT ≥20%. For patients in the highest STC quartile, TSAT was <20% when SIC was >13 μmol/L in 185 (17%) patients. STC correlated inversely with ferritin (r = -0.52) and high-sensitivity C-reactive protein (r = -0.17) and directly with albumin (r = 0.29); all P < 0.001. In models adjusted for age, N-terminal pro-brain natriuretic peptide and haemoglobin, both higher SIC (hazard ratio 0.87 [95% CI: 0.81-0.95]) and STC (hazard ratio 0.82 [95% CI: 0.73-0.91]) were associated with lower mortality. SIC was more strongly associated with both anaemia and mortality than either STC or TSAT. CONCLUSIONS Many patients with CHF and a low STC have low SIC even when TSAT is >20% and serum ferritin >100 μg/L; such patients have a high prevalence of anaemia and a poor prognosis and might have iron deficiency but are currently excluded from clinical trials of iron repletion.
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Affiliation(s)
- Fraser J. Graham
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Pierpaolo Pellicori
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Gabriele Masini
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | | | | | - John G. F. Cleland
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
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12
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Baudry G, Coutance G, Dorent R, Bauer F, Blanchart K, Boignard A, Chabanne C, Delmas C, D'Ostrevy N, Epailly E, Gariboldi V, Gaudard P, Goéminne C, Grosjean S, Guihaire J, Guillemain R, Mattei M, Nubret K, Pattier S, Vermes E, Sebbag L, Duarte K, Girerd N. Diuretic dose is a strong prognostic factor in ambulatory patients awaiting heart transplantation. ESC Heart Fail 2023; 10:2843-2852. [PMID: 37408178 PMCID: PMC10567662 DOI: 10.1002/ehf2.14467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023] Open
Abstract
AIMS The prognostic value of 'high dose' loop diuretics in advanced heart failure outpatients is unclear. We aimed to assess the prognosis associated with loop diuretic dose in ambulatory patients awaiting heart transplantation (HT). METHODS AND RESULTS All ambulatory patients (n = 700, median age 55 years and 70% men) registered on the French national HT waiting list between 1 January 2013 and 31 December 2019 were included. Patients were divided into 'low dose', 'intermediate dose', and 'high dose' loop diuretics corresponding to furosemide equivalent doses of ≤40, 40-250, and >250 mg, respectively. The primary outcome was a combined criterion of waitlist death and urgent HT. N-terminal pro-B-type natriuretic peptide, creatinine levels, pulmonary capillary wedge pressure, and pulmonary pressures gradually increased with higher diuretic dose. At 12 months, the risk of waitlist death/urgent HT was 7.4%, 19.2%, and 25.6% (P = 0.001) for 'low dose', 'intermediate dose', and 'high dose' patients, respectively. When adjusting for confounders, including natriuretic peptides, hepatic, and renal function, the 'high dose' group was associated with increased waitlist mortality or urgent HT [adjusted hazard ratio (HR) 2.23, 1.33 to 3.73; P = 0.002] and a six-fold higher risk of waitlist death (adjusted HR 6.18, 2.16 to 17.72; P < 0.001) when compared with the 'low dose' group. 'Intermediate doses' were not significantly associated with these two outcomes in adjusted models (P > 0.05). CONCLUSIONS A 'high dose' of loop diuretics is strongly associated with residual congestion and is a predictor of outcome in patients awaiting HT despite adjustment for classical cardiorenal risk factors. This routine variable may be helpful for risk stratification of pre-HT patients.
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Affiliation(s)
- Guillaume Baudry
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F‐CRIN INI‐CRCT, ReicatraVandoeuvre‐lès‐Nancy54500France
| | - Guillaume Coutance
- Department of Cardiac and Thoracic SurgeryCardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique‐Hôpitaux de Paris (AP‐HP). Sorbonne University Medical SchoolParisFrance
| | - Richard Dorent
- Department of Cardiac SurgeryCHU Bichat‐Claude Bernard, AP‐HP, Université Paris VIIParisFrance
| | - Fabrice Bauer
- Department of Cardiology and Cardiovascular SurgeryHospital Charles NicolleRouenFrance
| | - Katrien Blanchart
- Department of Cardiology and Cardiac SurgeryUniversity Hospital of Caen, University of CaenCaenFrance
| | - Aude Boignard
- Department of Cardiology and Cardiovascular SurgeryCHU MichallonGrenobleFrance
| | - Céline Chabanne
- Department of Thoracic and Cardiovascular SurgeryCHU Pontchaillou, Inserm U1099RennesFrance
| | - Clément Delmas
- Department of CardiologyCentre Hospitalier Universitaire de ToulouseToulouseFrance
| | - Nicolas D'Ostrevy
- Department of Cardiology and Cardiac SurgeryCHU Clermont‐FerrandClermont‐FerrandFrance
| | - Eric Epailly
- Department of Cardiology and Cardiovascular SurgeryHôpitaux Universitaires de StrasbourgStrasbourgFrance
| | - Vlad Gariboldi
- Department of Cardiac SurgeryLa Timone HospitalMarseilleFrance
| | - Philippe Gaudard
- Department of Cardiac Surgery, Anesthesiology and Critical Care MedicineArnaud de Villeneuve Hospital, CHRU MontpellierMontpellierFrance
| | - Céline Goéminne
- Department of Cardiac SurgeryCHU Lille, Institut Coeur‐PoumonsLilleFrance
| | - Sandrine Grosjean
- Department of Cardiology and Cardiac SurgeryDijon University HospitalDijonFrance
| | - Julien Guihaire
- Department of Cardiothoracic SurgeryMarie Lannelongue Hospital, University of Paris Sud, Inserm U999 (Pulmonary Hypertension: Pathophysiology and Novel Therapies [PAH])Le Plessis RobinsonFrance
| | - Romain Guillemain
- Department of Cardiology and Cardiac SurgeryEuropean Georges Pompidou HospitalParisFrance
| | - Mathieu Mattei
- Department of Cardiology and Cardiac SurgeryCHU de Nancy, Hopital de BraboisNancyFrance
| | - Karine Nubret
- Department of Thoracic and Cardiovascular SurgeryHôpital Cardiologique du Haut‐Lévêque, Université Bordeaux IIBordeauxFrance
| | - Sabine Pattier
- Department of Cardiology and Heart Transplantation UnitCHU NantesNantesFrance
| | - Emmanuelle Vermes
- Department of Cardiothoracic SurgeryTours University HospitalToursFrance
| | - Laurent Sebbag
- Department of Heart Failure and TransplantationHôpital Cardiovasculaire Louis Pradel, Hospices Civils de LyonBronFrance
| | - Kevin Duarte
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F‐CRIN INI‐CRCT, ReicatraVandoeuvre‐lès‐Nancy54500France
| | - Nicolas Girerd
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F‐CRIN INI‐CRCT, ReicatraVandoeuvre‐lès‐Nancy54500France
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13
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Iaconelli A, Cuthbert J, Kazmi S, Maffia P, Clark AL, Cleland JGF, Pellicori P. Inferior vena cava diameter is associated with prognosis in patients with chronic heart failure independent of tricuspid regurgitation velocity. Clin Res Cardiol 2023; 112:1077-1086. [PMID: 36894788 PMCID: PMC10359207 DOI: 10.1007/s00392-023-02178-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/22/2023] [Indexed: 03/11/2023]
Abstract
AIMS A high, Doppler-derived, tricuspid regurgitation velocity (TRV) indicates pulmonary hypertension, which may contribute to right ventricular dysfunction and worsening tricuspid regurgitation leading to systemic venous congestion, reflected by an increase in inferior vena cava (IVC) diameter. We hypothesized that venous congestion rather than pulmonary hypertension would be more strongly associated with prognosis. METHODS AND RESULTS 895 patients with chronic heart failure (CHF) (median (25th and 75th centile) age 75 (67-81) years, 69% men, LVEF 44 (34-55)% and NT-proBNP 1133 (423-2465) pg/ml) were enrolled. Compared to patients with normal IVC (< 21 mm) and TRV (≤ 2.8 m/s; n = 504, 56%), those with high TRV but normal IVC (n = 85, 9%) were older, more likely to be women and to have LVEF ≥ 50%, whilst those with dilated IVC but normal TRV (n = 142, 16%) had more signs of congestion and higher NT-proBNP. Patients (n = 164, 19%) with both dilated IVC and high TRV had the most signs of congestion and the highest NT-proBNP. During follow-up of 860 (435-1121) days, 239 patients died. Compared to those with both normal IVC and TRV (reference), patients with high TRV but normal IVC did not have a significantly increased mortality (HR: 1.41; CI: 0.87-2.29; P = 0.16). Risk was higher for patients with a dilated IVC but normal TRV (HR: 2.51; CI: 1.80-3.51; P < 0.001) or both a dilated IVC and elevated TRV (HR: 3.27; CI: 2.40-4.46; P < 0.001). CONCLUSION Amongst ambulatory patients with CHF, a dilated IVC is more closely associated with an adverse prognosis than an elevated TRV.
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Affiliation(s)
- Antonio Iaconelli
- School of Cardiovascular & Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Joe Cuthbert
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston-Upon-Hull, East Riding of Yorkshire, HU6 7RX, UK
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals Trust, Castle Road, Cottingham, Kingston-Upon-Hull, East Riding of Yorkshire, HU6 5JQ, UK
| | - Syed Kazmi
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston-Upon-Hull, East Riding of Yorkshire, HU6 7RX, UK
| | - Pasquale Maffia
- School of Cardiovascular & Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- School of Infection & Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals Trust, Castle Road, Cottingham, Kingston-Upon-Hull, East Riding of Yorkshire, HU6 5JQ, UK
| | - John G F Cleland
- School of Cardiovascular & Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Pierpaolo Pellicori
- School of Cardiovascular & Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
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14
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Graham FJ, Iaconelli A, Sonecki P, Campbell RT, Hunter D, Cleland JGF, Pellicori P. Defining Heart Failure Based on Imaging the Heart and Beyond. Card Fail Rev 2023; 9:e10. [PMID: 37427007 PMCID: PMC10326661 DOI: 10.15420/cfr.2022.29] [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: 10/26/2022] [Accepted: 02/19/2023] [Indexed: 07/11/2023] Open
Abstract
Water and salt retention, in other words congestion, are fundamental to the pathophysiology of heart failure and are important therapeutic targets. Echocardiography is the key tool with which to assess cardiac structure and function in the initial diagnostic workup of patients with suspected heart failure and is essential for guiding treatment and stratifying risk. Ultrasound can also be used to identify and quantify congestion in the great veins, kidneys and lungs. More advanced imaging methods might further clarify the aetiology of heart failure and its consequences for the heart and periphery, thereby improving the efficiency and quality of care tailored with greater precision to individual patient need.
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Affiliation(s)
- Fraser J Graham
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
| | - Antonio Iaconelli
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
| | | | - Ross T Campbell
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
| | - David Hunter
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
| | - John GF Cleland
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
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15
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Yaku H, Kato T, Morimoto T, Kaneda K, Nishikawa R, Kitai T, Inuzuka Y, Tamaki Y, Yamazaki T, Kitamura J, Ezaki H, Nagao K, Yamamoto H, Isotani A, Takeshi A, Izumi C, Sato Y, Nakagawa Y, Matoba S, Sakata Y, Kuwahara K, Kimura T. Rationale and study design of the GOREISAN for heart failure (GOREISAN-HF) trial: A randomized clinical trial. Am Heart J 2023; 260:18-25. [PMID: 36841318 DOI: 10.1016/j.ahj.2023.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/15/2023] [Accepted: 02/18/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND The decongestion strategy using loop diuretics is essential for improving signs and symptoms of heart failure (HF). However, chronic use of loop diuretics in HF has been linked to worsening renal function and adverse clinical outcomes in a dose-dependent manner. Goreisan, a traditional Japanese herbal medicine, has a long history of use in Japan for regulating body fluid homeostasis and has been recognized as causing less adverse outcomes such as dehydration in contrast to loop diuretics in clinical practice. Therefore, we designed the GOREISAN-HF trial to evaluate the long-term effects of a new decongestion strategy adding Goreisan to usual care in patients with HF and volume overload. METHODS The GOREISAN-HF trial is an investigator-initiated, multicenter, pragmatic, randomized, comparative effectiveness trial in which we will enroll 2,192 patients hospitalized for HF at 68 hospitals in Japan. All study participants will be randomly assigned to either a decongestion strategy that adds Goreisan at a dose of 7.5 g daily on top of usual care or usual care alone. Investigators have the flexibility to change the existing diuretic regimen in both groups. The primary end point is the improvement rate of cardiac edema at 12-month follow-up, and the co-primary end point is a composite of all-cause death or hospitalization up to the end of the planned follow-up period. Secondary end points include longitudinal changes in patient-reported outcomes, loop diuretics dose, and renal function. CONCLUSIONS The GOREISAN-HF is the first large-scale randomized pragmatic trial to assess the efficacy and safety of a new congestion control strategy adding Goreisan to usual care in patients with HF and volume overload. REGISTRATION NUMBER NCT04691700.
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Affiliation(s)
- Hidenori Yaku
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Morimoto
- Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazuhisa Kaneda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yasutaka Inuzuka
- Department of Cardiovascular Medicine, Shiga General Hospital, Moriyama, Japan
| | - Yodo Tamaki
- Division of Cardiology, Tenri Hospital, Nara, Japan
| | - Taketoshi Yamazaki
- Department of Internal Medicine, Rakuwakai Otowa Rehabilitation Hospital, Kyoto, Japan
| | - Jun Kitamura
- Department of Internal Medicine, Kobe Kaisei Hospital, Kobe, Japan
| | - Hirotaka Ezaki
- Department of Cardiology, Tokorozawa Heart Center, Tokorozawa, Japan
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hiromi Yamamoto
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Akihiro Isotani
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Arita Takeshi
- Division of Cardiovascular Medicine Heart & Neuro-Vascular Center, Fukuoka Wajiro, Fukuoka, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University Graduate School of Medicine, Nagano, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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16
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Khan J, Graham FJ, Masini G, Iaconelli A, Friday JM, Lang CC, Pellicori P. Congestion and Use of Diuretics in Heart Failure and Cardiomyopathies: a Practical Guide. Curr Cardiol Rep 2023; 25:411-420. [PMID: 37074565 DOI: 10.1007/s11886-023-01865-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE OF REVIEW Heart failure is a highly prevalent condition caused by many different aetiologies and characterised by cardiac dysfunction and congestion. Once developed, congestion leads to signs (peripheral oedema) and symptoms (breathlessness on exertion), adverse cardiac remodelling, and an increased risk of hospitalisation and premature death. This review summarises strategies that could enable early identification and a more objective management of congestion in patients with heart failure. RECENT FINDINGS For patients with suspected or diagnosed heart failure, combining an echocardiogram with assessment of great veins, lungs, and kidneys by ultrasound might facilitate recognition and quantification of congestion, the management of which is still difficult and highly subjective. Congestion is a one of the key drivers of morbidity and mortality in patients with heart failure and is often under-recognised. The use of ultrasound allows for a timely, simultaneous identification of cardiac dysfunction and multiorgan congestion; ongoing and future studies will clarify how to tailor diuretic treatments in those with or at risk of heart failure.
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Affiliation(s)
| | - Fraser J Graham
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Gabriele Masini
- Cardiothoracic and Vascular Department, University of Pisa, Pisa, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Antonio Iaconelli
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Jocelyn M Friday
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Chim C Lang
- NHS Tayside, Dundee, UK
- Department of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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17
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Maeda D, Matsue Y, Dotare T, Sunayama T, Iso T, Yatsu S, Ishiwata S, Nakamura Y, Akama Y, Tsujimura Y, Suda S, Kato T, Hiki M, Kasai T, Minamino T. Clinical and prognostic implications of hyaluronic acid in hospitalized patients with heart failure. Heart Vessels 2023:10.1007/s00380-023-02269-2. [PMID: 37079067 DOI: 10.1007/s00380-023-02269-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/12/2023] [Indexed: 04/21/2023]
Abstract
We investigated the clinical and prognostic implications of hyaluronic acid, a liver fibrosis marker, in patients with heart failure. We measured hyaluronic acid levels on admission in 655 hospitalized patients with heart failure between January 2015 and December 2019. Patients were stratified into three groups according to hyaluronic acid level: low (< 84.3 ng/mL, n = 219), middle (84.3-188.2 ng/mL, n = 218), and high (≥ 188.2 ng/mL, n = 218). The primary endpoint was all-cause death. The high hyaluronic acid group had higher N-terminal pro-brain-type natriuretic peptide levels, larger inferior vena cava, and shorter tricuspid annular plane systolic excursion than the other two groups. During the follow-up period (median 485 days), 132 all-cause deaths were observed: 27 (12.3%) in the low, 37 (17.0%) in the middle, and 68 (31.2%) in the high hyaluronic acid (P < 0.001) groups. Cox proportional hazards analysis revealed that higher log-transformed hyaluronic acid levels were significantly associated with all-cause death (hazard ratio, 1.38; 95% confidence interval, 1.15-1.66; P < 0.001). No significant interaction was observed between hyaluronic acid level and reduced/preserved left ventricular ejection fraction on all-cause death (P = 0.409). Hyaluronic acid provided additional prognostic predictability to pre-existing prognostic factors, including the fibrosis-4 index (continuous net reclassification improvement, 0.232; 95% confidence interval, 0.022-0.441; P = 0.030). In hospitalized patients with heart failure, hyaluronic acid was associated with right ventricular dysfunction and congestion and was independently associated with prognosis regardless of left ventricular ejection fraction.
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Affiliation(s)
- Daichi Maeda
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan.
| | - Taishi Dotare
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Tsutomu Sunayama
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Takashi Iso
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Shoichiro Yatsu
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Sayaki Ishiwata
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yutaka Nakamura
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yuka Akama
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yuichiro Tsujimura
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Shoko Suda
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Takao Kato
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Masaru Hiki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
- Japan Agency for Medical Research and Development-Core Research for Evolutionary Medical Science and Technology (AMED-CREST), Japan Agency for Medical Research and Development, Tokyo, Japan
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18
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Diuretic dose trajectories in dilated cardiomyopathy: prognostic implications. Clin Res Cardiol 2023; 112:419-430. [PMID: 36385396 PMCID: PMC9998319 DOI: 10.1007/s00392-022-02126-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND For patients with heart failure, prescription of loop diuretics (LD) and of higher doses are associated with an adverse prognosis. We investigated LD dose trajectories and their associations with outcomes in patients with dilated cardiomyopathy (DCM). METHODS Associations between outcomes and both furosemide-equivalent dose (FED) at enrolment and change in FED in the subsequent 24 months were evaluated. According to FED trajectory, patients were classified as (i) dose↑ (FED increase by ≥ 50% or newly initiated); (ii) dose↓ (FED decrease by ≥ 50%); (iii) stable dose (change in FED by < 50%); and (iv) never-users. The primary outcome was all-cause-death/heart transplantation/ventricular-assist-device/heart failure hospitalization. The secondary outcome was all-cause-death/heart transplantation/ventricular-assist-device. RESULTS Of 1,131 patients enrolled, 738 (65%) were prescribed LD at baseline. Baseline FED was independently associated with outcome (HR per 20 mg increase: 1.12 [95% CI 1.04-1.22], p = 0.003). Of the 908 with information on FED within 24 months from enrolment, 31% were never-users; 29% were dose↓; 26% were stable dose and 14% were dose↑. In adjusted models, compared to never-users, stable dose had a higher risk of the primary outcome (HR 2.42 [95% CI 1.19-4.93], p = 0.015), while dose↑ had the worst prognosis (HR 2.76 [95% CI 1.27-6.03], p = 0.011). Results were similar for the secondary outcome. Compared to patients who remained on LD, discontinuation of LD (143, 24%) was associated with an improved outcome (HR 0.43 [95% CI 0.28-0.65], p < 0.001). CONCLUSIONS In patients with DCM, LD use and increasing FED are powerful markers of adverse outcomes. Patients who never receive LD have an excellent prognosis. Among 1131 DCM patients 65% received loop diuretics at enrolment (upper left side). The bar chart on the upper right side shows the categorization in never-users/ dose↓/stable dose/ dose↑ over 24 months of follow-up. At the bottom is reported on the left side of each panel (observation period) the trajectory of LD dose in the four groups (left panel) and in patients who have their LD suspended vs those who continue LD (right panel) in the first two years. On the right side of each panel is shown the incidence of primary outcomes during the subsequent follow-up in the subgroups (outcome assessment).
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19
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Gladysheva IP, Sullivan RD, Pellicori P. Editorial: Edema in heart failure with reduced ejection fraction. Front Cardiovasc Med 2023; 10:1141937. [PMID: 36824450 PMCID: PMC9941704 DOI: 10.3389/fcvm.2023.1141937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/23/2023] [Indexed: 02/10/2023] Open
Affiliation(s)
- Inna P. Gladysheva
- Department of Internal Medicine and Translational Cardiovascular Research Center, University of Arizona College of Medicine – Phoenix, Phoenix, AZ, United States,*Correspondence: Inna P. Gladysheva ✉
| | - Ryan D. Sullivan
- Department of Internal Medicine and Translational Cardiovascular Research Center, University of Arizona College of Medicine – Phoenix, Phoenix, AZ, United States,Ryan D. Sullivan ✉
| | - Pierpaolo Pellicori
- College of Medical, Veterinary and Life Sciences, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom,Pierpaolo Pellicori ✉
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20
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Baudry G, Coutance G, Dorent R, Bauer F, Blanchart K, Boignard A, Chabanne C, Delmas C, D'Ostrevy N, Epailly E, Gariboldi V, Gaudard P, Goéminne C, Grosjean S, Guihaire J, Guillemain R, Mattei M, Nubret K, Pattier S, Pozzi M, Rossignol P, Vermes E, Sebbag L, Girerd N. Prognosis value of Forrester's classification in advanced heart failure patients awaiting heart transplantation. ESC Heart Fail 2022; 9:3287-3297. [PMID: 35801277 PMCID: PMC9715881 DOI: 10.1002/ehf2.14037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/04/2022] [Accepted: 06/03/2022] [Indexed: 11/09/2022] Open
Abstract
AIMS The value of Forrester's perfusion/congestion profiles assessed by invasive catheter evaluation in non-inotrope advanced heart failure patients listed for heart transplant (HT) is unclear. We aimed to assess the value of haemodynamic evaluation according to Forrester's profiles to predict events on the HT waitlist. METHODS AND RESULTS All non-inotrope patients (n = 837, 79% ambulatory at listing) registered on the French national HT waiting list between 1 January 2013 and 31 December 2019 with right heart catheterization (RHC) were included. The primary outcome was a combined criteria of waitlist death, delisting for aggravation, urgent HT or left ventricular assist device implantation. Secondary outcome was waitlist death. The 'warm-dry', 'cold-dry', 'warm-wet', and 'cold-wet' profiles represented 27%, 18%, 27%, and 28% of patients, respectively. At 12 months, the respective rates of primary outcome were 15%, 17%, 25%, and 29% (P = 0.008). Taking the 'warm-dry' category as reference, a significant increase in the risk of primary outcome was observed only in the 'wet' categories, irrespectively of 'warm/cold' status: hazard ratios, 1.50; 1.06-2.13; P = 0.024 in 'warm-wet' and 1.77; 1. 25-2.49; P = 0.001 in 'cold-wet'. CONCLUSIONS Haemodynamic assessment of advanced HF patients using perfusion/congestion profiles predicts the risk of the combine endpoint of waitlist death, delisting for aggravation, urgent heart transplantation, or left ventricular assist device implantation. 'Wet' patients had the worst prognosis, independently of perfusion status, thus placing special emphasis on the cardinal prominence of persistent congestion in advanced HF.
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Affiliation(s)
- Guillaume Baudry
- Department of heart failure and transplantationHôpital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon69500BronFrance
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F‐CRIN INI‐CRCTUniversité de Lorraine54500Vandoeuvre‐lès‐NancyNancyFrance
| | - Guillaume Coutance
- Department of Cardiac and Thoracic Surgery, Cardiology InstitutePitié Salpêtrière Hospital, Assistance Publique‐Hôpitaux de Paris (AP‐HP). Sorbonne University Medical SchoolParisFrance
| | - Richard Dorent
- Department of Cardiac Surgery, CHU Bichat‐Claude Bernard, AP‐HPUniversité Paris VII75877ParisFrance
| | - Fabrice Bauer
- Department of Cardiology and Cardiovascular SurgeryHospital Charles NicolleRouenFrance
| | - Katrien Blanchart
- Department of Cardiology and Cardiac SurgeryUniversity Hospital of Caen, University of CaenCaenFrance
| | - Aude Boignard
- Department of Cardiology and Cardiovascular SurgeryCHU MichallonGrenobleFrance
| | - Céline Chabanne
- Department of Thoracic and Cardiovascular SurgeryCHU Pontchaillou, Inserm U109935000RennesFrance
| | - Clément Delmas
- Department of CardiologyCentre Hospitalier Universitaire de ToulouseToulouseFrance
| | - Nicolas D'Ostrevy
- Cardiology and Cardiac Surgery DepartmentCHU Clermont‐FerrandClermont‐FerrandFrance
| | - Eric Epailly
- Department of Cardiology and Cardiovascular SurgeryHôpitaux Universitaires de StrasbourgStrasbourgFrance
| | - Vlad Gariboldi
- Department of Cardiac SurgeryLa Timone HospitalMarseilleFrance
| | - Philippe Gaudard
- Department of Cardiac Surgery, Anesthesiology and Critical Care MedicineArnaud de Villeneuve Hospital, CHRU MontpellierMontpellierFrance
| | - Céline Goéminne
- Department of Cardiac SurgeryCHU Lille, Institut Coeur PoumonsLilleFrance
| | - Sandrine Grosjean
- Department of Cardiology and Cardiac SurgeryUniversity Hospital of DijonDijonFrance
| | - Julien Guihaire
- Department of Cardiothoracic SurgeryMarie Lannelongue Hospital, University of Paris Sud, Inserm U999 [Pulmonary Hypertension: Pathophysiology and Novel Therapies (PAH)]92350Le Plessis RobinsonFrance
| | - Romain Guillemain
- Cardiology and Cardiac Surgery DepartmentEuropean Georges Pompidou HospitalParisFrance
| | - Mathieu Mattei
- Department of Cardiology and Cardiac SurgeryCHU de Nancy, Hopital de BraboisNancyFrance
| | - Karine Nubret
- Department of Thoracic and Cardiovascular SurgeryHôpital Cardiologique du Haut‐Lévêque, Université Bordeaux IIBordeauxFrance
| | - Sabine Pattier
- Department of Cardiology and Heart Transplantation UnitCHU de NantesNantesFrance
| | - Matteo Pozzi
- Department of heart failure and transplantationHôpital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon69500BronFrance
| | - Patrick Rossignol
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F‐CRIN INI‐CRCTUniversité de Lorraine54500Vandoeuvre‐lès‐NancyNancyFrance
| | - Emmanuelle Vermes
- Cardiothoracic Surgery DepartmentTours University HospitalToursFrance
| | - Laurent Sebbag
- Department of heart failure and transplantationHôpital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon69500BronFrance
| | - Nicolas Girerd
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F‐CRIN INI‐CRCTUniversité de Lorraine54500Vandoeuvre‐lès‐NancyNancyFrance
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Cooper TJ, Pellicori P, Ushakova A, Dickstein K. Reply to the letter “Particular Challenges in the Use of Pulmonary Vasodilating Therapy for Patients with Pulmonary Hypertension Secondary to Left Heart Diseases”. Eur J Heart Fail 2022; 24:1990-1992. [DOI: 10.1002/ejhf.2690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 11/07/2022] Open
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22
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Non-Invasive Estimation of Right Atrial Pressure Using a Semi-Automated Echocardiographic Tool for Inferior Vena Cava Edge-Tracking. J Clin Med 2022; 11:jcm11123257. [PMID: 35743330 PMCID: PMC9224556 DOI: 10.3390/jcm11123257] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 12/07/2022] Open
Abstract
The non-invasive estimation of right atrial pressure (RAP) would be a key advancement in several clinical scenarios, in which the knowledge of central venous filling pressure is vital for patients’ management. The echocardiographic estimation of RAP proposed by Guidelines, based on inferior vena cava (IVC) size and respirophasic collapsibility, is exposed to operator and patient dependent variability. We propose novel methods, based on semi-automated edge-tracking of IVC size and cardiac collapsibility (cardiac caval index—CCI), tested in a monocentric retrospective cohort of patients undergoing echocardiography and right heart catheterization (RHC) within 24 h in condition of clinical and therapeutic stability (170 patients, age 64 ± 14, male 45%, with pulmonary arterial hypertension, heart failure, valvular heart disease, dyspnea, or other pathologies). IVC size and CCI were integrated with other standard echocardiographic features, selected by backward feature selection and included in a linear model (LM) and a support vector machine (SVM), which were cross-validated. Three RAP classes (low < 5 mmHg, intermediate 5−10 mmHg and high > 10 mmHg) were generated and RHC values used as comparator. LM and SVM showed a higher accuracy than Guidelines (63%, 71%, and 61% for LM, SVM, and Guidelines, respectively), promoting the integration of IVC and echocardiographic features for an improved non-invasive estimation of RAP.
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23
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Rossignol P, Silva-Cardoso J, Kosiborod MN, Brandenburg, Cleland JG, Hadimeri H, Hullin R, Makela S, Mörtl D, Paoletti E, Pollock C, Vogt L, Jadoul M, Butler J. Pragmatic Diagnostic and Therapeutic Algorithms to Optimize New Potassium Binder use in Cardiorenal Disease. Pharmacol Res 2022; 182:106277. [PMID: 35662631 DOI: 10.1016/j.phrs.2022.106277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/16/2022] [Accepted: 05/22/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pivotal randomized trials demonstrating efficacy, safety and good tolerance, of two new potassium binders (patiromer and sodium zirconium cyclosilicate) led to their recent approval. A major hurdle to the implementation of these potassium-binders is understanding how to integrate them safely and effectively into the long-term management of cardiovascular and kidney disease patients using renin angiotensin aldosterone system inhibitors (RAASi), the latter being prone to induce hyperkalaemia. METHODS a multidisciplinary academic panel including nephrologists and cardiologists was convened to develop consensus therapeutic algorithm(s) aimed at optimizing the use of the two novel potassium binders (patiromer and sodium zirconium cyclosilicate) in stable adults who require treatment with RAASi and experience(d) hyperkalaemia in a non-emergent setting. RESULTS Two dedicated pragmatic algorithms are proposed. The lowest intervention threshold (i.e. 5.1mmol/L or greater) was the one used in the patiromer and sodium zirconium cyclosilicate) pivotal trials, both drugs being indicated to treat hyperkalaemia in a non -emergent setting. Acknowledging the heterogeneity across specialty guidelines in hyperkalaemia definition and thresholds to intervene when facing hyperkalaemia, we have been mindful to use soft language i.e. "it is to consider", not necessarily "to do". CONCLUSIONS Providing the clinical community with pragmatic algorithms may help optimize the management of high-risk patients by avoiding the risks of both hyper and hypokalaemia and of suboptimal RAASi therapy.
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Affiliation(s)
- P Rossignol
- Université de Lorraine, INSERM CIC Plurithématique 1433, Nancy CHRU, Inserm U1116, FCRIN INI-CRCT, Nancy, France.
| | - J Silva-Cardoso
- Heart Failure and Transplant Clinic, Cardiology Service, São João University Hospital Centre, Faculty of Medicine, University of Porto, CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal
| | - M N Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri; The George Institute for Global Health, and University of New South Wales, Sydney, New South Wales, Australia
| | - Brandenburg
- Department of Cardiology and Nephrology, Rhein-Maas Klinikum, Würselen, Germany
| | - J G Cleland
- Robertson Centre for Biostatistics & Clinical Trials, University of Glasgow & National Heart & Lung Institute, Imperial College, London, United Kingdom
| | - H Hadimeri
- Department of Nephrology, Skaraborgs sjukhus, Skövde, Sweden
| | - R Hullin
- Service de Cardiologie, Département Coeur-Vaisseaux, Centre Hospitalier Universitaire Vaudois, Université de Lausanne, Lausanne, Suisse
| | - S Makela
- Department of Internal Medicine, Kidney Unit, Tampere University Hospital, Tampere, Finland
| | - D Mörtl
- Department of Internal Medicine 3, University Hospital St. Pölten, St. Pölten, Austria
| | - E Paoletti
- Nephrology, Dialysis, and Transplantation, Policlinico San Martino, Genova, Italy
| | - C Pollock
- Renal Research Laboratory, Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
| | - L Vogt
- Department of Internal Medicine, section Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - M Jadoul
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium;; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - J Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
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25
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Pellicori P, Cleland JGF. Heart failure: age is no excuse for complacency. Eur J Heart Fail 2022; 24:1063-1065. [PMID: 35481861 DOI: 10.1002/ejhf.2517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Pierpaolo Pellicori
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - John G F Cleland
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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26
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Girerd N, Mewton N, Tartière JM, Guijarro D, Jourdain P, Damy T, Lamblin N, Bayes-Génis A, Pellicori P, Januzzi J, Rossignol P, Roubille F. Practical outpatient management of worsening chronic heart failure. Eur J Heart Fail 2022; 24:750-761. [PMID: 35417093 PMCID: PMC9325366 DOI: 10.1002/ejhf.2503] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/04/2022] [Accepted: 04/10/2022] [Indexed: 11/12/2022] Open
Abstract
Management of worsening heart failure (WHF) has traditionally been hospital‐based, but with the rising burden of heart failure (HF), the pressure on healthcare systems exerted by this disease necessitates a different strategy than long (and costly) hospital stays. A strategy for outpatient intravenous (IV) diuretic treatment of WHF has been developed in certain American centres in the past 10 years, whereas European centres have been mostly favouring ‘classic’ in‐hospital management of WHF. Embracing novel, outpatient approaches for treating WHF could substantially reduce the burden on healthcare systems while improving patient's satisfaction and quality of life. The present article is intended to provide essential knowledge and practical guidelines aimed at helping clinicians implement these new ambulatory approaches using day hospital and/or at‐home hospitalization. The topics addressed by our group of HF experts include the pathophysiological background of diuretic therapy, the most suitable profile of WHF that may be managed in an ambulatory setting, the pharmacological protocols that can be used, as well as a detailed description of healthcare structures that can be proposed to deliver these ambulatory care interventions. The practical aspects of day hospital and hospital‐at‐home IV diuretic administration are specifically emphasized. The algorithm provided along with the practical IV diuretic protocols should assist HF clinicians in implementing this new approach in their local clinical setting.
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Affiliation(s)
- Nicolas Girerd
- Université de Lorraine, Centre d'Investigation Clinique- Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Nathan Mewton
- Hôpital Cardiovasculaire Louis Pradel Hospices Civils de Lyon Heart Failure Department Clinical Investigation Center Inserm 1407 CarMeN Inserm 1060, University Claude Bernard Lyon 1 28 Avenue Doyen Lépine 69500, Bron
| | | | - Damien Guijarro
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, F-44000, France
| | - Patrick Jourdain
- Covidom regional telemedicine platform, Assistance Publique-Hôpitaux de Paris, Paris, France; Cardiology Department, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Kremlin Bicêtre, France
| | - Thibaud Damy
- Réseau cardiogen, Department of Cardiology, centre français de référence de l'amylose cardiaque (CRAC), CHU d'Henri-Mondor, AP-HP, 94000, Créteil, France
| | - Nicolas Lamblin
- Department of Cardiology, Université de Lille, 59000, Lille, France
| | - Antoni Bayes-Génis
- CIBERCV; Servicio de Cardiología. Hospital Germans Trias i Pujol. Universitat Autònoma de Barcelona. Barcelona., Spain
| | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - James Januzzi
- Cardiology Division, Massachusetts General Hospital, Baim Institute for Clinical Research, Harvard Medical School, Boston, MA, USA
| | - Patrick Rossignol
- Université de Lorraine, Centre d'Investigation Clinique- Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - François Roubille
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, CHU de Montpellier, France
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27
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Albani S, Mesin L, Roatta S, De Luca A, Giannoni A, Stolfo D, Biava L, Bonino C, Contu L, Pelloni E, Attena E, Russo V, Antonini-Canterin F, Pugliese NR, Gallone G, De Ferrari GM, Sinagra G, Scacciatella P. Inferior Vena Cava Edge Tracking Echocardiography: A Promising Tool with Applications in Multiple Clinical Settings. Diagnostics (Basel) 2022; 12:427. [PMID: 35204518 PMCID: PMC8871248 DOI: 10.3390/diagnostics12020427] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/29/2022] [Indexed: 01/25/2023] Open
Abstract
Ultrasound (US)-based measurements of the inferior vena cava (IVC) diameter are widely used to estimate right atrial pressure (RAP) in a variety of clinical settings. However, the correlation with invasively measured RAP along with the reproducibility of US-based IVC measurements is modest at best. In the present manuscript, we discuss the limitations of the current technique to estimate RAP through IVC US assessment and present a new promising tool developed by our research group, the automated IVC edge-to-edge tracking system, which has the potential to improve RAP assessment by transforming the current categorical classification (low, normal, high RAP) in a continuous and precise RAP estimation technique. Finally, we critically evaluate all the clinical settings in which this new tool could improve current practice.
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Affiliation(s)
- Stefano Albani
- Division of Cardiology, Umberto Parini Regional Hospital, 11100 Aosta, Italy; (L.B.); (C.B.); (L.C.); (E.P.); (P.S.)
- Cardio-Thoraco-Vascular Department, Division of Cardiology and Postgraduate School in Cardiovascular Sciences, University of Trieste, 34127 Trieste, Italy; (A.D.L.); (D.S.); (G.S.)
| | - Luca Mesin
- Mathematical Biology & Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, 10129 Torino, Italy;
| | - Silvestro Roatta
- Integrative Physiology Lab, Department of Neuroscience, University of Turin, 10125 Turin, Italy;
| | - Antonio De Luca
- Cardio-Thoraco-Vascular Department, Division of Cardiology and Postgraduate School in Cardiovascular Sciences, University of Trieste, 34127 Trieste, Italy; (A.D.L.); (D.S.); (G.S.)
| | - Alberto Giannoni
- Scuola Superiore Sant’Anna, 56127 Pisa, Italy;
- Fondazione Toscana G. Monasterio, 56124 Pisa, Italy
| | - Davide Stolfo
- Cardio-Thoraco-Vascular Department, Division of Cardiology and Postgraduate School in Cardiovascular Sciences, University of Trieste, 34127 Trieste, Italy; (A.D.L.); (D.S.); (G.S.)
| | - Lorenza Biava
- Division of Cardiology, Umberto Parini Regional Hospital, 11100 Aosta, Italy; (L.B.); (C.B.); (L.C.); (E.P.); (P.S.)
| | - Caterina Bonino
- Division of Cardiology, Umberto Parini Regional Hospital, 11100 Aosta, Italy; (L.B.); (C.B.); (L.C.); (E.P.); (P.S.)
| | - Laura Contu
- Division of Cardiology, Umberto Parini Regional Hospital, 11100 Aosta, Italy; (L.B.); (C.B.); (L.C.); (E.P.); (P.S.)
| | - Elisa Pelloni
- Division of Cardiology, Umberto Parini Regional Hospital, 11100 Aosta, Italy; (L.B.); (C.B.); (L.C.); (E.P.); (P.S.)
| | - Emilio Attena
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli-Monaldi Hospital—A.O.R.N. Dei Colli, 80131 Naples, Italy; (E.A.); (V.R.)
| | - Vincenzo Russo
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli-Monaldi Hospital—A.O.R.N. Dei Colli, 80131 Naples, Italy; (E.A.); (V.R.)
| | | | | | - Guglielmo Gallone
- Division of Cardiology, Città della Salute e della Scienza, University of Turin, 10124 Turin, Italy; (G.G.); (G.M.D.F.)
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Città della Salute e della Scienza, University of Turin, 10124 Turin, Italy; (G.G.); (G.M.D.F.)
| | - Gianfranco Sinagra
- Cardio-Thoraco-Vascular Department, Division of Cardiology and Postgraduate School in Cardiovascular Sciences, University of Trieste, 34127 Trieste, Italy; (A.D.L.); (D.S.); (G.S.)
| | - Paolo Scacciatella
- Division of Cardiology, Umberto Parini Regional Hospital, 11100 Aosta, Italy; (L.B.); (C.B.); (L.C.); (E.P.); (P.S.)
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Mesin L, Albani S, Policastro P, Pasquero P, Porta M, Melchiorri C, Leonardi G, Albera C, Scacciatella P, Pellicori P, Stolfo D, Grillo A, Fabris B, Bini R, Giannoni A, Pepe A, Ermini L, Seddone S, Sinagra G, Antonini-Canterin F, Roatta S. Assessment of Phasic Changes of Vascular Size by Automated Edge Tracking-State of the Art and Clinical Perspectives. Front Cardiovasc Med 2022; 8:775635. [PMID: 35127855 PMCID: PMC8814097 DOI: 10.3389/fcvm.2021.775635] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/14/2021] [Indexed: 12/25/2022] Open
Abstract
Assessment of vascular size and of its phasic changes by ultrasound is important for the management of many clinical conditions. For example, a dilated and stiff inferior vena cava reflects increased intravascular volume and identifies patients with heart failure at greater risk of an early death. However, lack of standardization and sub-optimal intra- and inter- operator reproducibility limit the use of these techniques. To overcome these limitations, we developed two image-processing algorithms that quantify phasic vascular deformation by tracking wall movements, either in long or in short axis. Prospective studies will verify the clinical applicability and utility of these methods in different settings, vessels and medical conditions.
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Affiliation(s)
- Luca Mesin
- Mathematical Biology and Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, Turin, Italy
- *Correspondence: Luca Mesin
| | - Stefano Albani
- SC Cardiologia Ospedale Regionale U. Parini, Aosta, Italy
- Department of Medical, Surgical and Health Sciences, Universitá di Trieste, Trieste, Italy
| | - Piero Policastro
- Mathematical Biology and Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, Turin, Italy
| | - Paolo Pasquero
- Department of Medical Sciences, Universitá di Torino, Turin, Italy
| | - Massimo Porta
- Department of Medical Sciences, Universitá di Torino, Turin, Italy
| | | | | | - Carlo Albera
- Department of Medical Sciences, Universitá di Torino, Turin, Italy
| | | | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics, Research Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Davide Stolfo
- Department of Medical, Surgical and Health Sciences, Universitá di Trieste, Trieste, Italy
| | - Andrea Grillo
- Department of Medical, Surgical and Health Sciences, Universitá di Trieste, Trieste, Italy
| | - Bruno Fabris
- Department of Medical, Surgical and Health Sciences, Universitá di Trieste, Trieste, Italy
| | - Roberto Bini
- Chirurgia Generale e Trauma Team GOM Niguarda, Milan, Italy
| | - Alberto Giannoni
- Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Antonio Pepe
- Highly Specialized in Rehabilitation Hospital-ORAS S.p.A., Motta di Livenza, Italy
- Ospedale Unico di Santorso, AULSS7 Pedemontana, Italy
| | - Leonardo Ermini
- Integrative Physiology Lab, Department of Neuroscience, Universitá di Torino, Turin, Italy
| | - Stefano Seddone
- Integrative Physiology Lab, Department of Neuroscience, Universitá di Torino, Turin, Italy
| | - Gianfranco Sinagra
- Robertson Centre for Biostatistics, Research Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | | | - Silvestro Roatta
- Integrative Physiology Lab, Department of Neuroscience, Universitá di Torino, Turin, Italy
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Impact of Loop Diuretic on Outcomes in Patients with Heart Failure and Reduced Ejection Fraction. Curr Heart Fail Rep 2022; 19:15-25. [PMID: 35037162 DOI: 10.1007/s11897-021-00538-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Loop diuretics are the cornerstone of the treatment of congestion in heart failure patients. The manuscript aims to summarize the most updated information regarding the use of loop diuretics in heart failure. RECENT FINDINGS Diuretic response can be highly variable between patients and needs to be carefully evaluated during and after the hospitalization. Diuretic resistance can lead to residual congestion which affects prognosis and can be difficult to detect. The effect of loop diuretics on long-term prognosis remains uncertain but patients with advanced heart failure typically have renal dysfunction and are more inclined to develop loop diuretic resistance, which may lead to an incomplete decongestion and thus to a worse prognosis. Loop diuretics are the most potent diuretics available and their use is recommended in order to alleviate symptoms, improve exercise capacity, and reduce hospitalizations in patients with heart failure. Their use should be limited to the lowest dose necessary to maintain euvolemia because a low dose does not increase the risk of decompensation but reduce the risk of adverse effects and allow the up-titration of disease-modifying drugs.
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Vecchi AL, Muccioli S, Marazzato J, Mancinelli A, Iacovoni A, De Ponti R. Prognostic Role of Subclinical Congestion in Heart Failure Outpatients: Focus on Right Ventricular Dysfunction. J Clin Med 2021; 10:jcm10225423. [PMID: 34830705 PMCID: PMC8625381 DOI: 10.3390/jcm10225423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/01/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND subclinical pulmonary and peripheral congestion is an emerging concept in heart failure, correlated with a worse prognosis. Very few studies have evaluated its prognostic impact in an outpatient setting and its relationship with right-ventricular dysfunction. The study aims to investigate subclinical congestion in chronic heart failure outpatients, exploring the close relationship between the right heart-pulmonary unit and peripheral congestion. MATERIALS AND METHODS in this observational study, 104 chronic HF outpatients were enrolled. The degree of congestion and signs of elevated filling pressures of the right ventricle were evaluated by physical examination and a transthoracic ultrasound to define multiparametric right ventricular dysfunction, estimate the right atrial pressure and the pulmonary artery systolic pressure. Outcome data were obtained by scheduled visits and phone calls. RESULTS ultrasound signs of congestion were found in 26% of patients and, among this cohort, half of them presented as subclinical, affecting their prognosis, revealing a linear correlation between right ventricular/arterial coupling, the right-chambers size and ultrasound congestion. Right ventricular dysfunction, TAPSE/PAPS ratio, clinical and ultrasound signs of congestion have been confirmed to be useful predictors of outcome. CONCLUSIONS subclinical congestion is widespread in the heart failure outpatient population, significantly affecting prognosis, especially when right ventricular dysfunction also occurs, suggesting a strict correlation between the heart-pulmonary unit and volume overload.
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Affiliation(s)
- Andrea Lorenzo Vecchi
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (R.D.P.)
- Correspondence:
| | - Silvia Muccioli
- Department of Cardiology, Mauriziano Umberto I Hospital, 10128 Torino, Italy;
| | - Jacopo Marazzato
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (R.D.P.)
| | - Antonella Mancinelli
- Department of Cardiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (A.M.); (A.I.)
| | - Attilio Iacovoni
- Department of Cardiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (A.M.); (A.I.)
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (R.D.P.)
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Khan MS, Greene SJ, Hellkamp AS, DeVore AD, Shen X, Albert NM, Patterson JH, Spertus JA, Thomas LE, Williams FB, Hernandez AF, Fonarow GC, Butler J. Diuretic Changes, Health Care Resource Utilization, and Clinical Outcomes for Heart Failure With Reduced Ejection Fraction: From the Change the Management of Patients With Heart Failure Registry. Circ Heart Fail 2021; 14:e008351. [PMID: 34674536 DOI: 10.1161/circheartfailure.121.008351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diuretics are a mainstay therapy for the symptomatic treatment of heart failure. However, in contemporary US outpatient practice, the degree to which diuretic dosing changes over time and the associations with clinical outcomes and health care resource utilization are unknown. METHODS Among 3426 US outpatients with chronic heart failure with reduced ejection fraction in the Change the Management of Patients with Heart Failure registry with complete medication data and who were prescribed a loop diuretic, diuretic dose increase was defined as: (1) change to a total daily dose higher than their previous total daily dose, (2) addition of metolazone to the regimen, (3) change from furosemide to either bumetanide or torsemide, and the change persists for at least 7 days. Adjusted hazard ratios or rate ratios along with 95% CIs were reported for clinical outcomes among patients with an increase in oral diuretic dose versus no increase in diuretic dose. RESULTS Overall, 796 (23%) had a diuretic dose increase (18 episodes per 100 patient-years). The proportion of patients with dyspnea at rest (38% versus 26%), dyspnea at exertion (79% versus 67%), orthopnea (32% versus 21%), edema (60% versus 43%), and weight gain (40% versus 23%) were significantly (all P <0.001) higher in the diuretic increase group. Baseline angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (hazard ratio, 0.75 [95% CI, 0.65-0.87]) use were associated with lower likelihood of diuretic increase over time. Patients with a diuretic dose increase had a significantly higher number of heart failure hospitalizations (rate ratio, 2.53 [95% CI, 2.10-3.05]), emergency department visits (rate ratio, 1.84 [95% CI, 1.56-2.17]), and home health visits (rate ratio, 1.88 [95% CI, 1.39-2.54]), but not all-cause mortality (hazard ratio, 1.10 [95% CI, 0.89-1.36]). Similarly, greater furosemide dose equivalent increases were associated with greater resource utilization but not with mortality, compared with smaller increases. CONCLUSIONS In this contemporary US registry, 1 in 4 patients with heart failure with reduced ejection fraction had outpatient escalation of diuretic therapy over longitudinal follow-up, and these patients were more likely to have sign/symptoms of congestion. Outpatient diuretic dose escalation of any magnitude was associated with heart failure hospitalizations and resource utilization, but not all-cause mortality.
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Affiliation(s)
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.).,Department of Biostatistics and Bioinformatics (A.S.H., L.E.T.), Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (X.S.)
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, OH (N.M.A.)
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City (J.A.S.)
| | - Laine E Thomas
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.).,Department of Biostatistics and Bioinformatics (A.S.H., L.E.T.), Duke University School of Medicine, Durham, NC
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson (J.B.)
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Palazzuoli A, Ruocco G, Severino P, Gennari L, Pirrotta F, Stefanini A, Tramonte F, Feola M, Mancone M, Fedele F. Effects of Metolazone Administration on Congestion, Diuretic Response and Renal Function in Patients with Advanced Heart Failure. J Clin Med 2021; 10:jcm10184207. [PMID: 34575318 PMCID: PMC8465476 DOI: 10.3390/jcm10184207] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Advanced heart failure (HF) is a condition often requiring elevated doses of loop diuretics. Therefore, these patients often experience poor diuretic response. Both conditions have a detrimental impact on prognosis and hospitalization. Aims: This retrospective, multicenter study evaluates the effect of the addition of oral metolazone on diuretic response (DR), clinical congestion, NTproBNP values, and renal function over hospitalization phase. Follow-up analysis for a 6-month follow-up period was performed. Methods: We enrolled 132 patients with acute decompensated heart failure (ADHF) in advanced NYHA class with reduced ejection fraction (EF < 40%) taking a mean furosemide amount of 250 ± 120 mg/day. Sixty-five patients received traditional loop diuretic treatment plus metolazone (Group M). The mean dose ranged from 7.5 to 15 mg for one week. Sixty-seven patients continued the furosemide (Group F). Congestion score was evaluated according to the ESC recommendations. DR was assessed by the formula diuresis/40 mg of furosemide. Results: Patients in Group M and patients in Group F showed a similar prevalence of baseline clinical congestion (3.1 ± 0.7 in Group F vs. 3 ± 0.8 in Group M) and chronic kidney disease (CKD) (51% in Group M vs. 57% in Group F; p = 0.38). Patients in Group M experienced a better congestion score at discharge compared to patients in Group F (C score: 1 ± 1 in Group M vs. 3 ± 1 in Group F p > 0.05). Clinical congestion resolution was also associated with weight reduction (−6 ± 2 in Group M vs. −3 ± 1 kg in Group F, p < 0.05). Better DR response was observed in Group M compared to F (940 ± 149 mL/40 mgFUROSEMIDE/die vs. 541 ± 314 mL/40 mgFUROSEMIDE/die; p < 0.01), whereas median ΔNTproBNP remained similar between the two groups (−4819 ± 8718 in Group M vs. −3954 ± 5560 pg/mL in Group F NS). These data were associated with better daily diuresis during hospitalization in Group M (2820 ± 900 vs. 2050 ± 1120 mL p < 0.05). No differences were found in terms of WRF development and electrolyte unbalance at discharge, although Group M had a significant saline solution administration during hospitalization. Follow-up analysis did not differ between the group but a reduced trend for recurrent hospitalization was observed in the M group (26% vs. 38%). Conclusions: Metolazone administration could be helpful in patients taking an elevated loop diuretics dose. Use of thiazide therapy is associated with better decongestion and DR. Current findings could suggest positive insights due to the reduced amount of loop diuretics in patients with advanced HF.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, 53100 Siena, Italy; (L.G.); (F.P.); (A.S.); (F.T.)
- Correspondence: ; Tel.: +39-577585363 or +39-577585461; Fax: +39-577233480
| | - Gaetano Ruocco
- Cardiology Unit, Riuniti of Valdichiana Hospital, USL SUD-EST Toscana, Montepulciano, 53045 Siena, Italy;
| | - Paolo Severino
- Department of Clinical, Internal Anesthesiology and Cardiovascular Sciences, University La Sapienza, 00185 Rome, Italy; (P.S.); (M.M.); (F.F.)
| | - Luigi Gennari
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, 53100 Siena, Italy; (L.G.); (F.P.); (A.S.); (F.T.)
| | - Filippo Pirrotta
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, 53100 Siena, Italy; (L.G.); (F.P.); (A.S.); (F.T.)
| | - Andrea Stefanini
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, 53100 Siena, Italy; (L.G.); (F.P.); (A.S.); (F.T.)
| | - Francesco Tramonte
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, 53100 Siena, Italy; (L.G.); (F.P.); (A.S.); (F.T.)
| | - Mauro Feola
- Cardiology Unit, Regina Montis Regalis Hospital, 12084 Mondovì, Italy;
| | - Massimo Mancone
- Department of Clinical, Internal Anesthesiology and Cardiovascular Sciences, University La Sapienza, 00185 Rome, Italy; (P.S.); (M.M.); (F.F.)
| | - Francesco Fedele
- Department of Clinical, Internal Anesthesiology and Cardiovascular Sciences, University La Sapienza, 00185 Rome, Italy; (P.S.); (M.M.); (F.F.)
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Lombardi CM, Cimino G, Pellicori P, Bonelli A, Inciardi RM, Pagnesi M, Tomasoni D, Ravera A, Adamo M, Carubelli V, Metra M. Congestion in Patients with Advanced Heart Failure: Assessment and Treatment. Heart Fail Clin 2021; 17:575-586. [PMID: 34511206 DOI: 10.1016/j.hfc.2021.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Heart failure (HF) is characterized by frequent hospital admissions due to acute decompensation and shortened life span with a progressive clinical course leading to an advanced stage where traditional therapies become ineffective. Due to aging of the population and improved therapies, only a small of proportion of patients with advanced HF are candidates for surgical treatments, such as mechanical circulatory support or heart transplantation. In most cases, prompt identification and management of congestion is paramount to improving symptoms and quality of life and avoiding progression to severe multiorgan dysfunction and death.
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Affiliation(s)
- Carlo Mario Lombardi
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Giuliana Cimino
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Andrea Bonelli
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Maria Inciardi
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alice Ravera
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Valentina Carubelli
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
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Cleland JGF, Pellicori P. To master heart failure, first master congestion. Lancet 2021; 398:935-936. [PMID: 34461039 DOI: 10.1016/s0140-6736(21)01914-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/12/2021] [Indexed: 12/26/2022]
Affiliation(s)
- John G F Cleland
- Robertson Centre for Biostatistics and Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow Royal Infirmary, Glasgow G12 8QQ, UK; National Heart and Lung Institute, Imperial College London, London, UK.
| | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics and Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow Royal Infirmary, Glasgow G12 8QQ, UK
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35
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Diuretic therapy as prognostic enrichment factor for clinical trials in patients with heart failure with reduced ejection fraction. Clin Res Cardiol 2021; 110:1308-1320. [PMID: 33956209 DOI: 10.1007/s00392-021-01851-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: 11/10/2020] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Loop diuretics are the mainstay of congestion treatment in patients with heart failure (HF). We assessed the association between baseline loop diuretic use and outcome. We also compared the increment in risk related to diuretic dose with conventional prognostic enrichment criteria used in the EMPHASIS-HF trial, which included patients with systolic HF and mild symptoms, such as prior hospitalization and elevated natriuretic peptides. METHODS Individual analyses were performed according to baseline loop diuretic usage (furosemide-equivalent dose > 40 mg, 1-40 mg, and no furosemide), and according to enrichment criteria adopted in the trial [i.e. recent hospitalization (< 30 days or 30 to 180 days prior to randomization) due to HF or other cardiovascular cause, or elevated natriuretic peptides]. The primary endpoint was a composite of cardiovascular death or HF hospitalization. RESULTS Loop diuretic usage at baseline (HR for > 40 mg furosemide-equivalent dose = 3.16, 95% CI 2.43-4.11; HR for 1-40 mg = 2.06, 95% CI 1.60-2.65) was significantly associated with a higher risk for the primary endpoint in a stepwise manner when compared to no baseline loop diuretic usage. In contrast, the differences in outcome rates were more modest when using history of hospitalization and/or BNP: all HR ranged from 1 (reference, non-HF related CV hospitalization > 30 days) to 2.04 (HF hospitalization < 30 days). The effect of eplerenone on the primary endpoint was consistent across subgroups in both analyses (P for interaction ≥ 0.2 for all). CONCLUSIONS Loop diuretic usage (especially at doses > 40 mg) identified patients at higher risk than history of HF hospitalization and/or high BNP blood concentrations.
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Veenis JF, Radhoe SP, Hooijmans P, Brugts JJ. Remote Monitoring in Chronic Heart Failure Patients: Is Non-Invasive Remote Monitoring the Way to Go? SENSORS (BASEL, SWITZERLAND) 2021; 21:887. [PMID: 33525556 PMCID: PMC7865348 DOI: 10.3390/s21030887] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 11/16/2022]
Abstract
Heart failure (HF) is a major health care issue, and the incidence of HF is only expected to grow further. Due to the frequent hospitalizations, HF places a major burden on the available hospital and healthcare resources. In the future, HF care should not only be organized solely at the clinical ward and outpatient clinics, but remote monitoring strategies are urgently needed to guide, monitor, and treat chronic HF patients remotely from their homes as well. The intuitiveness and relatively low costs of non-invasive remote monitoring tools make them an appealing and emerging concept for developing new medical apps and devices. The recent COVID-19 pandemic and the associated transition of patient care outside the hospital will boost the development of remote monitoring tools, and many strategies will be reinvented with modern tools. However, it is important to look carefully at the inconsistencies that have been reported in non-invasive remote monitoring effectiveness. With this review, we provide an up-to-date overview of the available evidence on non-invasive remote monitoring in chronic HF patients and provide future perspectives that may significantly benefit the broader group of HF patients.
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Affiliation(s)
- Jesse F. Veenis
- Erasmus MC, University Medical Center Rotterdam, Thorax Center, Department of Cardiology, 3000 Rotterdam, The Netherlands; (S.P.R.); (P.H.); (J.J.B.)
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Effect of frailty on treatment, hospitalisation and death in patients with chronic heart failure. Clin Res Cardiol 2021; 110:1249-1258. [PMID: 33399955 PMCID: PMC8318949 DOI: 10.1007/s00392-020-01792-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 12/09/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Frailty is common in patients with chronic heart failure (CHF) and is associated with poor outcomes. The natural history of frail patients with CHF is unknown. METHODS Frailty was assessed using the clinical frailty scale (CFS) in 467 consecutive patients with CHF (67% male, median age 76 years, median NT-proBNP 1156 ng/L) attending a routine follow-up visit. Those with CFS > 4 were classified as frail. We investigated the relation between frailty and treatments, hospitalisation and death in patients with CHF. RESULTS 206 patients (44%) were frail. Of 291 patients with HF with reduced ejection fraction (HeFREF), those who were frail (N = 117; 40%) were less likely to receive optimal treatment, with many not receiving a renin-angiotensin-aldosterone system inhibitor (frail: 25% vs. non-frail: 4%), a beta-blocker (16% vs. 8%) or a mineralocorticoid receptor antagonist (50% vs 41%). By 1 year, there were 56 deaths and 322 hospitalisations, of which 25 (45%) and 198 (61%), respectively, were due to non-cardiovascular (non-CV) causes. Most deaths (N = 46, 82%) and hospitalisations (N = 215, 67%) occurred in frail patients. Amongst frail patients, 43% of deaths and 64% of hospitalisations were for non-CV causes; 58% of cardiovascular (CV) deaths were due to advancing HF. Among non-frail patients, 50% of deaths and 57% of hospitalisations were for non-CV causes; all CV deaths were due to advancing HF. CONCLUSION Frailty in patients with HeFREF is associated with sub-optimal medical treatment. Frail patients are more likely to die or be admitted to hospital, but whether frail or not, many events are non-CV.
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Pellicori P, Platz E, Dauw J, Ter Maaten JM, Martens P, Pivetta E, Cleland JGF, McMurray JJV, Mullens W, Solomon SD, Zannad F, Gargani L, Girerd N. Ultrasound imaging of congestion in heart failure: examinations beyond the heart. Eur J Heart Fail 2020; 23:703-712. [PMID: 33118672 DOI: 10.1002/ejhf.2032] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/12/2020] [Accepted: 10/22/2020] [Indexed: 12/15/2022] Open
Abstract
Congestion, related to pressure and/or fluid overload, plays a central role in the pathophysiology, presentation and prognosis of heart failure and is an important therapeutic target. While symptoms and physical signs of fluid overload are required to make a clinical diagnosis of heart failure, they lack both sensitivity and specificity, which might lead to diagnostic delay and uncertainty. Over the last decades, new ultrasound methods for the detection of elevated intracardiac pressures and/or fluid overload have been developed that are more sensitive and specific, thereby enabling earlier and more accurate diagnosis and facilitating treatment strategies. Accordingly, we considered that a state-of-the-art review of ultrasound methods for the detection and quantification of congestion was timely, including imaging of the heart, lungs (B-lines), kidneys (intrarenal venous flow), and venous system (inferior vena cava and internal jugular vein diameter).
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Affiliation(s)
- Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Elke Platz
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jeroen Dauw
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium.,Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Jozine M Ter Maaten
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium.,Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium.,Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Emanuele Pivetta
- Division of Emergency Medicine and High Dependency Unit, AOU Città della Salute e della Scienza di Torino, Cancer Epidemiology Unit and CPO Piemonte, Department of Medical Sciences, University of Turin, Turin, Italy
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
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Yurista SR, Silljé HHW, van Goor H, Hillebrands JL, Heerspink HJL, de Menezes Montenegro L, Oberdorf-Maass SU, de Boer RA, Westenbrink BD. Effects of Sodium-Glucose Co-transporter 2 Inhibition with Empaglifozin on Renal Structure and Function in Non-diabetic Rats with Left Ventricular Dysfunction After Myocardial Infarction. Cardiovasc Drugs Ther 2020; 34:311-321. [PMID: 32185580 PMCID: PMC7242237 DOI: 10.1007/s10557-020-06954-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background The use of sodium–glucose co-transporter 2 inhibitors (SGLT2i) is currently expanding to cardiovascular risk reduction in non-diabetic subjects, but renal (side-)effects are less well studied in this setting. Methods Male non-diabetic Sprague Dawley rats underwent permanent coronary artery ligation to induce MI, or sham surgery. Rats received chow containing empagliflozin (EMPA) (30 mg/kg/day) or control chow. Renal function and electrolyte balance were measured in metabolic cages. Histological and molecular markers of kidney injury, parameters of phosphate homeostasis and bone resorption were also assessed. Results EMPA resulted in a twofold increase in diuresis, without evidence for plasma volume contraction or impediments in renal function in both sham and MI animals. EMPA increased plasma magnesium levels, while the levels of glucose and other major electrolytes were comparable among the groups. Urinary protein excretion was similar in all treatment groups and no histomorphological alterations were identified in the kidney. Accordingly, molecular markers for cellular injury, fibrosis, inflammation and oxidative stress in renal tissue were comparable between groups. EMPA resulted in a slight increase in circulating phosphate and PTH levels without activating FGF23–Klotho axis in the kidney and bone mineral resorption, measured with CTX-1, was not increased. Conclusions EMPA exerts profound diuretic effects without compromising renal structure and function or causing significant electrolyte imbalance in a non-diabetic setting. The slight increase in circulating phosphate and PTH after EMPA treatment was not associated with evidence for increased bone mineral resorption suggesting that EMPA does not affect bone health. Electronic supplementary material The online version of this article (10.1007/s10557-020-06954-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Salva R Yurista
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Herman H W Silljé
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, Division of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Luuk Hillebrands
- Department of Pathology and Medical Biology, Division of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Luiz de Menezes Montenegro
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Silke U Oberdorf-Maass
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - B Daan Westenbrink
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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40
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Liu C, Lai Y, Guan T, Shen Y, Pan Y, Wu D. Outcomes of diuretics in rheumatic heart disease with compensated chronic heart failure: a retrospective study. ESC Heart Fail 2020; 7:3929-3941. [PMID: 32945144 PMCID: PMC7754903 DOI: 10.1002/ehf2.12987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/26/2020] [Accepted: 08/13/2020] [Indexed: 01/17/2023] Open
Abstract
Aims The purpose of this retrospective propensity score‐matched study was to evaluate the superiority of different application approaches [continuous diuretics use (CDU) vs. intermittent diuretics use (IDU)] and types [loop diuretics (LDs) vs. thiazide diuretics (TDs)] of diuretics on long‐term outcomes for rheumatic heart disease (RHD) patients with compensated chronic heart failure (CHF). Methods and results A total of 494 RHD patients with compensated CHF were analysed after propensity score matching. Cox proportional hazards regression model was used to investigate the associations of different diuretic application approaches and types with all‐cause mortality, cardiovascular death (CVD), and cerebrovascular death. Binary logistic regression analyses were used to evaluate the associations of different diuretic application approaches and types with 1‐, 3‐, and 5‐year heart failure (HF) re‐hospitalization as well as new‐onset atrial fibrillation (AF). In the comparison between IDU and CDU strategies for RHD patients with compensated CHF, CDU was associated with increased risks of all‐cause mortality [adjusted hazard ratio (HR) = 2.47, 95% confidence interval (CI): 1.54–3.97, P < 0.001] and CVD (adjusted HR = 3.67, 95% CI: 1.95–6.89, P < 0.001) except cerebrovascular death (adjusted HR = 1.07, 95% CI: 0.34–3.41, P = 0.905). CDU was also associated with increased risks of 3‐year [adjusted odds ratio (OR) = 1.80, 95% CI: 1.09–2.96, P = 0.022] and 5‐year (adjusted OR = 2.02, 95% CI: 1.18–3.45, P = 0.010) HF re‐hospitalization risk and new‐onset AF (adjusted OR = 2.34, 95% CI: 1.31–4.20, P = 0.004) except 1‐year HF re‐hospitalization risk (adjusted OR = 1.54, 95% CI: 0.88–2.70, P = 0.130). In the comparison between TDs and LDs among study participants receiving IDU strategy, LDs were only associated with decreased 1‐year HF re‐hospitalization risk (adjusted OR = 0.30, 95% CI: 0.12–0.77, P = 0.012) rather than all‐cause mortality, CVD, cerebrovascular death, 3‐ and 5‐year HF re‐hospitalization, and new‐onset AF (all adjusted P > 0.05). In the comparison between TDs and LDs among study participants receiving CDU strategy, LDs were not associated with cerebrovascular death and 1‐year HF re‐hospitalization (both adjusted P > 0.05) but with increased risks of all‐cause mortality (adjusted HR = 1.80, 95% CI: 1.09–2.99, P = 0.023), CVD (adjusted HR = 1.89, 95% CI: 1.04–3.44, P = 0.037), 3‐year (adjusted OR = 1.91, 95% CI: 1.06–3.43, P = 0.031) and 5‐year (adjusted OR = 2.16, 95% CI: 1.12–4.19, P = 0.022) HF re‐hospitalization, and new‐onset AF (adjusted OR = 2.66, 95% CI: 1.25–5.68, P = 0.012). Conclusions Continuous diuretics use (especially LDs) was associated with increased risks of all‐cause mortality, CVD, medium‐term/long‐term HF re‐hospitalization, and new‐onset AF in RHD patients with compensated CHF.
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Affiliation(s)
- Cheng Liu
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, #1 Panfu Road, Guangzhou, 510180, China.,Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yanxian Lai
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, #1 Panfu Road, Guangzhou, 510180, China
| | - Tianwang Guan
- Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yan Shen
- Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yichao Pan
- Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Deping Wu
- Guangzhou Center for Disease Control and Prevention, Guangzhou, China
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41
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Barrios V, Escobar C, Ortiz Cortés C, Cosín Sales J, Pascual Figal D, García-Moll Marimón X. Management of patients with heart failure treated in cardiology consultations: IC-BERG Study. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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42
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Barrios V, Escobar C, Ortiz Cortés C, Cosín Sales J, Pascual Figal D, García-Moll Marimón X. Manejo de los pacientes con insuficiencia cardiaca atendidos en la consulta de cardiología: Estudio IC-BERG. Rev Clin Esp 2020; 220:339-349. [DOI: 10.1016/j.rce.2019.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 10/24/2022]
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43
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Madelaire C, Gustafsson F, Stevenson LW, Kristensen SL, Køber L, Andersen J, D'Souza M, Biering-Sørensen T, Andersson C, Torp-Pedersen C, Gislason G, Schou M. One-Year Mortality After Intensification of Outpatient Diuretic Therapy. J Am Heart Assoc 2020; 9:e016010. [PMID: 32662300 PMCID: PMC7660734 DOI: 10.1161/jaha.119.016010] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Mortality is increased following a hospitalization for decompensated heart failure (HF), during which diuretics are usually intensified. It is unclear how risk is affected after outpatient intensification of diuretic therapy for HF. Methods and Results From nationwide administrative registers, we identified all Danish patients who were diagnosed with HF from 2001 to 2016 and received angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker and β blocker within 120 days. Subsequent follow‐up tracked progressive events of diuretic intensification and HF hospitalization. Intensification events were defined as new addition or doubling of loop diuretic or addition of thiazide to loop diuretic. These events were included in multivariable Cox regression models, calculating 1‐year mortality hazard after each year since inclusion. Patients with an intensification event or hospitalization were risk set matched to 2 nonworsened HF controls and absolute 1‐year mortality risks were calculated using Kaplan‐Meier estimates. We included 74 990 patients, their median age was 71 years, and 36% were women. Intensification events were associated with significantly increased mortality at all times during follow‐up. One‐year mortality was 18.0% after an intensification event, 22.6% after HF hospitalization, and 10.4% for matched controls with neither. In a multivariable Cox model adjusted for age, sex, ischemic heart disease, atrial fibrillation, chronic obstructive pulmonary disease, and diabetes mellitus, the hazard ratio for 1‐year death after an intensification event was 1.75 (95% CI, 1.66–1.85), and it was 2.28 (95% CI, 2.16–2.41) after HF hospitalization. Conclusions In a nationwide cohort of patients with HF, outpatient intensification events were associated with almost 2‐fold risk of mortality during the next year. Although HF hospitalization was associated with a higher risk, the need to intensify diuretics in the outpatient setting is a signal to review and intensify efforts to improve HF outcomes.
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Affiliation(s)
- Christian Madelaire
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
| | - Finn Gustafsson
- The Heart Centre Rigshospitalet University of Copenhagen Denmark.,Department of Clinical Medicine University of Copenhagen Denmark
| | | | | | - Lars Køber
- The Heart Centre Rigshospitalet University of Copenhagen Denmark
| | | | - Maria D'Souza
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
| | - Charlotte Andersson
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark.,Section of Cardiology Department of Medicine Boston Medical Center Boston MA
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Research Nordsjaellands Hospital Hilleroed Denmark.,Department of Cardiology Aalborg University Hospital Aalborg Denmark
| | - Gunnar Gislason
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark.,Danish Heart Foundation Copenhagen Denmark
| | - Morten Schou
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
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44
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Association of loop diuretics use and dose with outcomes in outpatients with heart failure: a systematic review and meta-analysis of observational studies involving 96,959 patients. Heart Fail Rev 2020; 27:147-161. [DOI: 10.1007/s10741-020-09995-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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45
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Cleland JGF, Clark RA, Pellicori P, Inglis SC. Caring for people with heart failure and many other medical problems through and beyond the COVID-19 pandemic: the advantages of universal access to home telemonitoring. Eur J Heart Fail 2020; 22:995-998. [PMID: 32385954 PMCID: PMC7273055 DOI: 10.1002/ejhf.1864] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/02/2020] [Indexed: 12/17/2022] Open
Affiliation(s)
- John G F Cleland
- Robertson Centre for Biostatistics & Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Robyn A Clark
- South Australian Health and Medical Research Institute (SAHMRI), Flinders University, Adelaide, Australia
| | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics & Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Sally C Inglis
- Faculty of Health, University of Technology Sydney, Sydney, Australia
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46
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Samuel M, Abrahamowicz M, Joza J, Essebag V, Pilote L. Population-Level Sex Differences and Predictors for Treatment With Catheter Ablation in Patients With Atrial Fibrillation and Heart Failure. CJC Open 2020; 2:85-93. [PMID: 32462121 PMCID: PMC7242511 DOI: 10.1016/j.cjco.2020.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/20/2020] [Indexed: 10/26/2022] Open
Abstract
Background Current guidelines are relatively general regarding the type of patient with heart failure (HF) who should be considered for catheter ablation (CA) of atrial fibrillation (AF). The aim of the present study was to identify clinical predictors and sex differences for treatment with CA in the AF-HF population. Methods A population-based AF-HF cohort was created using the Quebec administrative data (2000-2017). Patients were followed from the date of diagnosis of both diseases to the date of CA or death. Predictors for CA, represented by time-varying covariates, were assessed in a multivariable Cox model that accounted for the competing risk of death. Results Among 101,931 patients with AF-HF with medication information (median age, 80.7 years; interquartile range [IQR], 73.9-86.3; 51.4% were female, median CHA2DS2-VASc, 4; IQR, 3-4), only 432 (0.4%) underwent CA after a median of 0.8 years (IQR, 0.1-2.7). Independent of multiple comorbidities and advanced age, which were associated with a lower likelihood of CA, women were approximately half as likely to undergo a CA (26% were women; adjusted hazard ratio, 0.6; 95% confidence interval, 0.4-0.7). Prior use of direct-acting oral anticoagulants and antiarrhythmics, and the presence of an implantable cardioverter-defibrillator were also predictors for CA treatment (P < 0.05 for all). Conclusion In a real-world population, CA was infrequently used to treat AF among patients with HF, and the likelihood of CA was further reduced in women. Because patients with CA had few comorbidities, future studies need to be conducted to determine whether CA can be beneficial in subjects whose clinical characteristics are more representative of the AF-HF population.
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Affiliation(s)
- Michelle Samuel
- Division of Clinical Epidemiology, Research Institute McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Michal Abrahamowicz
- Division of Clinical Epidemiology, Research Institute McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Jacqueline Joza
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Louise Pilote
- Division of Clinical Epidemiology, Research Institute McGill University Health Centre, Montreal, Quebec, Canada.,Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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47
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Clark AL, Kalra PR, Petrie MC, Mark PB, Tomlinson LA, Tomson CR. Change in renal function associated with drug treatment in heart failure: national guidance. HEART (BRITISH CARDIAC SOCIETY) 2020; 105:904-910. [PMID: 31118203 PMCID: PMC6582720 DOI: 10.1136/heartjnl-2018-314158] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Revised: 01/22/2019] [Indexed: 12/11/2022]
Abstract
Inhibitors of the renin–angiotensin–aldosterone (RAAS) system are cornerstones of the management of patients with heart failure with reduced left ventricular ejection fraction (HFrEF). However, RAAS inhibitors may cause decline in renal function and/or hyperkalaemia, particularly during initiation and titration, intercurrent illness and during worsening of heart failure. There is very little evidence from clinical trials to guide the management of renal dysfunction. The Renal Association and British Society for Heart Failure have collaborated to describe the interactions between heart failure, RAAS inhibitors and renal dysfunction and give clear guidance on the use of RAAS inhibitors in patients with HFrEF. During initiation and titration of RAAS inhibitors, testing renal function is mandatory; a decline in renal function of 30% or more can be acceptable. During intercurrent illness, there is no evidence that stopping RAAS inhibitor is beneficial, but if potassium rises above 6.0 mmol/L, or creatinine rises more than 30%, RAAS inhibitors should be temporarily withheld. In patients with fluid retention, high doses of diuretic are needed and a decline in renal function is not an indication to reduce diuretic dose: if the patient remains congested, more diuretics are required. If a patient is hypovolaemic, diuretics should be stopped or withheld temporarily. Towards end of life, consider stopping RAAS inhibitors. RAAS inhibition has no known prognostic benefit in heart failure with preserved ejection fraction. Efforts should be made to initiate, titrate and maintain patients with HFrEF on RAAS inhibitor treatment, whether during intercurrent illness or worsening heart failure.
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Affiliation(s)
- Andrew L Clark
- Academic Cardiology, Hull York Medical School in the University of Hull, Hull, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Mark C Petrie
- University of Glasgow Institute of Cardiovascular and Medical Sciences, Glasgow, UK.,Golden Jubilee National Hospital, Golden Jubilee National Hospital, Clydebank, UK
| | - Patrick B Mark
- University of Glasgow Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Laurie A Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Charles Rv Tomson
- Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne, UK
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48
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Täger T, Fröhlich H, Seiz M, Katus HA, Frankenstein L. READY: relative efficacy of loop diuretics in patients with chronic systolic heart failure-a systematic review and network meta-analysis of randomised trials. Heart Fail Rev 2020; 24:461-472. [PMID: 30874955 DOI: 10.1007/s10741-019-09771-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The majority of patients with chronic heart failure (HF) receive long-term treatment with loop diuretics. The comparative effectiveness of different loop diuretics is unknown. We searched PubMed, clinicaltrials.gov , the Cochrane Central Register of Controlled Trials and the European Union Clinical Trials Register for randomised clinical trials exploring the efficacy of the loop diuretics azosemide, bumetanide, furosemide or torasemide in patients with HF. Comparators included placebo, standard medical care or any other active treatment. The primary endpoint was all-cause mortality. Secondary endpoints included cardiovascular mortality, HF-related hospitalisation and any combined endpoint thereof. Hypokalaemia and acute renal failure were defined as additional safety endpoints. Evidence was synthesised using network meta-analysis (NMA). Thirty-four trials reporting on 2647 patients were included. The overall quality of evidence was rated as moderate. NMA demonstrated no significant differences between loop diuretics with respect to all-cause mortality, cardiovascular mortality or hypokalaemia. In contrast, torasemide ranked best in terms of HF hospitalisation, and there was a trend towards benefits with torasemide with regard to occurrence of acute renal failure. Sensitivity analyses excluding trials with a follow-up < 6 months, trials with a cross-over design and those including < 25 patients confirmed the main results. We found no significant superiority of either loop diuretic with respect to mortality and safety endpoints. However, clinicians may prefer torasemide, as it was associated with fewer HF-related hospitalisations.
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Affiliation(s)
- Tobias Täger
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Hanna Fröhlich
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Mirjam Seiz
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Lutz Frankenstein
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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49
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Felker GM, Ellison DH, Mullens W, Cox ZL, Testani JM. Diuretic Therapy for Patients With Heart Failure. J Am Coll Cardiol 2020; 75:1178-1195. [DOI: 10.1016/j.jacc.2019.12.059] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/15/2019] [Accepted: 12/02/2019] [Indexed: 12/12/2022]
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50
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Pellicori P, Cleland JGF, Clark AL. Chronic Obstructive Pulmonary Disease and Heart Failure: A Breathless Conspiracy. Heart Fail Clin 2020; 16:33-44. [PMID: 31735313 DOI: 10.1016/j.hfc.2019.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are both common causes of breathlessness and often conspire to confound accurate diagnosis and optimal therapy. Risk factors (such as aging, smoking, and obesity) and clinical presentation (eg, cough and breathlessness on exertion) can be very similar, but the treatment and prognostic implications are very different. This review discusses the diagnostic challenges in individuals with exertional dyspnea. Also highlighted are the prevalence, clinical relevance, and therapeutic implications of a concurrent diagnosis of COPD and HF.
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Affiliation(s)
- Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK.
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School, University of Hull, Kingston upon Hull HU16 5JQ, UK
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