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Miró Ò, Núñez J, Trullàs JC, Lopez-Ayala P, Llauger L, Alquézar-Arbé A, Miñana G, Mollar A, de la Espriella R, Lorenzo M, Jacob J, Espinosa B, Garcés-Horna V, Aguirre A, Fortuny MJ, Martínez-Nadal G, Gil V, Mueller C, Llorens P. Combining loop with thiazide diuretics in patients discharged home after a heart failure decompensation: Association with 30-day outcomes. Eur J Intern Med 2024:S0953-6205(24)00213-9. [PMID: 38763846 DOI: 10.1016/j.ejim.2024.05.009] [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: 01/05/2024] [Revised: 04/11/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE To investigate the association of the addition of thiazide diuretic on top of loop diuretic and standard of care with short-term outcomes of patients discharged after surviving an acute heart failure (AHF) episode. METHODS This is a secondary analysis of 14,403 patients from three independent cohorts representing the main departments involved in AHF treatment for whom treatment at discharge was recorded and included loop diuretics. Patients were divided according to whether treatment included or not thiazide diuretics. Short-term outcomes consisted of 30-day all-cause mortality, hospitalization (with a separate analysis for hospitalization due to AHF or to other causes) and the combination of death and hospitalization. The association between thiazide diuretics on short-term outcomes was explored by Cox regression and expressed as hazard ratios (HR) with 95 % confidence intervals, which were adjusted for 18 patient-related variables and 9 additional drugs (aside from loop and thiazide diuretics) prescribed at discharge. RESULTS The median age was 81 (interquartile range=73-86) years, 53 % were women, and patients were mainly discharged from the cardiology (42 %), internal medicine or geriatric department (29 %) and emergency department (19 %). There were 1,367 patients (9.5 %) discharged with thiazide and loop diuretics, while the rest (13,036; 90.5 %) were discharged with only loop diuretics on top of the remaining standard of care treatments. The combination of thiazide and loop diuretics showed a neutral effect on all outcomes: death (adjusted HR 1.149, 0.850-1.552), hospitalization (0.898, 0.770-1.048; hospitalization due to AHF 0.799, 0.599-1.065; hospitalization due to other causes 1.136, 0.756-1.708) and combined event (0.934, 0.811-1.076). CONCLUSION The combination of thiazide and loop diuretics was not associated with changes in risk of death, hospitalization or a combination of both.
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Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain; The GREAT network, Rome, Italy
| | - Julio Núñez
- Cardiology Department, Hospital Clínico de Valencia, INCLIVA, Valencia, Spain
| | - Joan Carles Trullàs
- Internal Medicine Department, Hospital d'Olot, Girona, Catalonia, Spain. Laboratori de Reparació i Regeneració Tissular (TR2Lab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Vic, Barcelona, Catalonia, Spain
| | - Pedro Lopez-Ayala
- The GREAT network, Rome, Italy; Cardiology Department, University Hospital of Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
| | - Lluís Llauger
- Emergency Department, Althaia Xarxa Assistencial Universitaria, Manresa, Catalonia, Spain
| | - Aitor Alquézar-Arbé
- Emergency Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico de Valencia, INCLIVA, Valencia, Spain
| | - Anna Mollar
- Cardiology Department, Hospital Clínico de Valencia, INCLIVA, Valencia, Spain
| | | | - Miguel Lorenzo
- Cardiology Department, Hospital Clínico de Valencia, INCLIVA, Valencia, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Begoña Espinosa
- Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain
| | - Vanesa Garcés-Horna
- Internal Medicine Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Alfons Aguirre
- Emergency Department, Hospital del Mar, Barcelona, Catalonia, Spain
| | | | - Gemma Martínez-Nadal
- Emergency Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
| | - Víctor Gil
- Emergency Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
| | - Christian Mueller
- The GREAT network, Rome, Italy; Cardiology Department, University Hospital of Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
| | - Pere Llorens
- Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain.
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Trullàs JC, Casado J, Cobo-Marcos M, Formiga F, Morales-Rull JL, Núñez J, Manzano L. Combinational Diuretics in Heart Failure. Curr Heart Fail Rep 2024:10.1007/s11897-024-00659-9. [PMID: 38589570 DOI: 10.1007/s11897-024-00659-9] [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] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW Diuretics are the cornerstone therapy for acute heart failure (HF) and congestion. Patients chronically exposed to loop diuretics may develop diuretic resistance as a consequence of nephron remodelling, and the combination of diuretics will be necessary to improve diuretic response and achieve decongestion. This review integrates data from recent research and offers a practical approach to current pharmacologic therapies to manage congestion in HF with a focus on combinational therapy. RECENT FINDINGS Until recently, combined diuretic treatment was based on observational studies and expert opinion. Recent evidence from clinical trials has shown that combined diuretic treatment can be started earlier without escalating the doses of loop diuretics with an adequate safety profile. Diuretic combination is a promising strategy for overcoming diuretic resistance in HF. Further studies aiming to get more insights into the pathophysiology of diuretic resistance and large clinical trials confirming the safety and efficacy over standard diuretics regimens are warranted.
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Affiliation(s)
- Joan Carles Trullàs
- Internal Medicine Department, Hospital d'Olot I Comarcal de La Garrotxa, Avinguda Dels Països Catalans 86, 17800, Olot, Girona, Spain.
- Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IrisCC), Ctra. de Roda, 70 08500 Vic, Barcelona, Spain.
| | - Jesús Casado
- Internal Medicine Department, Hospital Universitario de Getafe, Carretera de Madrid - Toledo, Km 12,500, 28905, Madrid, Spain
| | - Marta Cobo-Marcos
- Cardiology Department, Hospital Universitario Puerta de Hierro Majadahonda (IDIPHISA), Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Francesc Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, Carrer de La Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - José Luís Morales-Rull
- Internal Medicine Department, Heart Failure Unit, Hospital Universitari Arnau de Villanova, Institut de Recerca Biomédica (IRBLleida), Avinguda Alcalde Rovira Roure, 80, 25198, Lleida, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Madrid, Spain
| | - Luís Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, M-607, 9, 100, 28034, Madrid, Spain
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3
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Trullàs JC, Casado J. [Diuretic resistance in heart failure]. Med Clin (Barc) 2024; 162:19-21. [PMID: 37919121 DOI: 10.1016/j.medcli.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Joan Carles Trullàs
- Servicio de Medicina Interna, Hospital d'Olot i Comarcal de la Garrotxa, Girona, Catalunya, España; Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Barcelona, Catalunya, España; Grupo de Trabajo de Insuficiencia Cardiaca y Fibrilación Auricular de la Sociedad Española de Medicina Interna, Madrid, España.
| | - Jesús Casado
- Grupo de Trabajo de Insuficiencia Cardiaca y Fibrilación Auricular de la Sociedad Española de Medicina Interna, Madrid, España; Servicio de Medicina Interna, Hospital Universitario de Getafe, Madrid, España
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Fernandez Hazim C, Duarte G, Urena AP, Jain S, Mishra R, Vittorio TJ, Rodriguez-Guerra M. Diuretic resistance and the role of albumin in congestive heart failure. Drugs Context 2023; 12:2023-6-5. [PMID: 38188263 PMCID: PMC10768781 DOI: 10.7573/dic.2023-6-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Diuresis with loop diuretics is the mainstay treatment for volume optimization in patients with congestive heart failure, in which perfusion and volume expansion play a crucial role. There are robust guidelines with extensive evidence for the management of heart failure; however, clear guidance is needed for patients who do not respond to standard diuretic treatment. Diuretic resistance (DR) can be defined as an insufficient quantity of natriuresis with proper diuretic therapy. A combination of diuretic regimens is used to overcome DR and, more recently, SGLT2 inhibitors have been shown to improve diuresis. Despite DR being relatively common, it is challenging to treat and there remains a notable lack of substantial data guiding its management. Moreover, DR has been linked with poor prognosis. This review aims to expose the multiple approaches for treatment of patients with DR and the importance of intravascular volume expansion in the response to therapy.
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Affiliation(s)
| | | | - Ana P Urena
- Medicina Cardiovascular Asociada, Santo Domingo, Dominican Republic
| | - Swati Jain
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rishabh Mishra
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy J Vittorio
- BronxCare Health System, Icahn School of Medicine at Mt. Sinai, Bronx, NY, USA
| | - Miguel Rodriguez-Guerra
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Marques M, Cobo M, López-Sánchez P, García-Magallón B, Salazar MLS, López-Ibor JV, Janeiro D, García E, Briales PS, Montero E, Illazquez MVL, Gómez TS, Citores YM, Peral AM, Segovia J, Portolés J. Multidisciplinary approach to patients with heart failure and kidney disease: preliminary experience of an integrated cardiorenal unit. Clin Kidney J 2023; 16:2100-2107. [PMID: 37915925 PMCID: PMC10616440 DOI: 10.1093/ckj/sfad169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Indexed: 11/03/2023] Open
Abstract
Background Cardiorenal programs have emerged to improve the management of cardiorenal disease (CRD). Evidence about the benefits of these programs is still scarce. This work aims to evaluate the performance of a novel cardiorenal program and describe the clinical profile and outcomes of patients with CRD. Methods We conducted a retrospective observational study of patients with CRD attended in a cardiorenal unit (CRU) from February 2021 to February 2022. Demographics and laboratory tests were collected and events (all-cause death and cardiovascular hospitalizations) were evaluated. Optimization of comorbidities and protective therapies was also assessed. Results Eighty-two patients were included, with a mean age of 76.8 years [standard deviation (SD) 8.5] and 72% were men. A total of 58.5% (n = 47) had left ventricular ejection fraction <50%. The mean follow-up was 11 months (SD 4.0). Almost 54% of the patients (n = 44) required hospitalization, 30.5% for heart failure (HF) decompensation. Total hospitalizations significantly decreased after CRU inclusion: 0.70 versus 0.45 admissions/year (P < .02). Global mortality was 17.1% (n = 14). The percentage of patients with HF with reduced ejection fraction on quadruple therapy increased by 20%, and up to 60% of the patients were on three drugs. A total of 39% of the patients with HF and preserved ejection fraction started treatment with sodium-glucose co-transporter inhibitors. Hyperkalaemia required the use of potassium binders in 12.2% of the patients and treatment of secondary hyperparathyroidism was started in 42.7% and renal anaemia in 23.2%. Renal replacement therapy was initiated in 10% of the patients (n = 8). Conclusion CRD confers a considerable risk of adverse outcomes. Cardiorenal programs may improve cardiorenal syndrome management by optimizing therapies, treating comorbidities and reducing hospitalizations.
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Affiliation(s)
- María Marques
- Nephrology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
- Medicine Department, Facultad de Medicina, Universidad Autónoma Madrid , Madrid, Spain
| | - Marta Cobo
- Cardiology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Paula López-Sánchez
- Nephrology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
| | - Belén García-Magallón
- Cardiology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
| | - María Luisa Serrano Salazar
- Nephrology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
- RETIC ISCIII REDinREN 16/009/009
| | - Jorge V López-Ibor
- Cardiology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
| | - Darío Janeiro
- Nephrology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
- RETIC ISCIII REDinREN 16/009/009
| | - Estefanya García
- Nephrology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
- RETIC ISCIII REDinREN 16/009/009
| | - Paula Sánchez Briales
- Nephrology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
| | - Esther Montero
- Internal Medicine Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
| | | | - Teresa Soria Gómez
- Cardiology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
| | | | - Ana Martínez Peral
- Nephrology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
| | - Javier Segovia
- Cardiology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
- Medicine Department, Facultad de Medicina, Universidad Autónoma Madrid , Madrid, Spain
| | - José Portolés
- Nephrology Department, Hospital Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
- Medicine Department, Facultad de Medicina, Universidad Autónoma Madrid , Madrid, Spain
- RETIC ISCIII REDinREN 16/009/009
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6
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Chen S, Wang H, Ning B. Efficacy and safety of early ultrafiltration in patients with acute decompensated heart failure: a meta-analysis. Front Cardiovasc Med 2023; 10:1234092. [PMID: 37920175 PMCID: PMC10619751 DOI: 10.3389/fcvm.2023.1234092] [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: 06/03/2023] [Accepted: 09/19/2023] [Indexed: 11/04/2023] Open
Abstract
Objective The objective of this study is to investigate the efficacy and safety of early ultrafiltration in patients with acute decompensated heart failure. Methods A systematic search was conducted on PubMed, Cochrane Library, and EMbase databases from inception to April 2023 to identify randomized controlled trials that compared the efficacy and safety of early ultrafiltration and conventional diuretics in patients with acute decompensated heart failure. Two investigators independently screened all eligible studies and extracted relevant data. The primary outcomes of interest were changes in body weight and creatinine levels, as well as the rate of readmission and mortality within 30 days. Meta-analysis was conducted using RevMan 5.4 software. Results This meta-analysis included eight studies and found that early ultrafiltration was effective in reducing body weight in patients with acute decompensated heart failure (RR = 1.45, 95% CI: 0.54-2.35, P = 0.002), but it also increased serum creatinine (RR = 0.1, 95% CI: 0.03-0.17, P = 0.003). However, it did not reduce the 30-day rehospitalization rate or mortality rate (30-day rehospitalization rate: RR = 0.84, 95% CI: 0.62-1.14, P = 0.28; Mortality: RR = 0.90, 95% CI: 0.57-1.44, P = 0.67). Conclusion Although early ultrafiltration is more effective in reducing body weight in patients with acute decompensated heart failure, it is associated with an increase in serum creatinine levels and does not reduce the rate of readmission or mortality within 30 days. Systematic Review Registration identifier: CRD42023416152.
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Affiliation(s)
- Shuai Chen
- Department of Cardiovascular Medicine, Fuyang People's Hospital Affiliated to Anhui Medical University, Fuyang, China
| | - Hongqi Wang
- Department of Cardiovascular Medicine, Fuyang People's Hospital Affiliated to Anhui Medical University, Fuyang, China
| | - Bin Ning
- Department of Cardiovascular Medicine, Fuyang People's Hospital Affiliated to Anhui Medical University, Fuyang, China
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Rodríguez-Álvarez A, Piñeiro-Fernández JC, Guerrero-Sande H, Chaos-González MP, Pérez-López A, González-Tabara L, Millan-Díaz B, Cerqueiro-González JM. Peritoneal ultrafiltration in older adult patients with advanced heart failure. Intern Emerg Med 2023; 18:1665-1671. [PMID: 37261558 DOI: 10.1007/s11739-023-03323-7] [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: 03/08/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
Advanced heart failure (HF) with congestive symptoms refractory to diuretic treatment worsens the patient's prognosis and quality of life. Peritoneal ultrafiltration (PUF) attempts to improve symptoms and reduce HF-related events. This study analyzes the impact of PUF on older adult patients with significant comorbidity and advanced HF. Eighteen patients with advanced HF attended to in the Internal Medicine HF Unit of the Lucus Augusti University Hospital of Lugo, Spain, who started PUF between 2014 and 2021 were analyzed. The number of admissions and instances in which diuretic rescue treatment was used in the year before and after starting PUF were compared. The evolution of renal function, complications secondary to the technique, and survival were also analyzed. The median age was 80 (SD 5.8) years and 72.2% were men. Comparing the year after starting PUF to the year before starting PUF, hospital admissions due to HF (4 vs 20, p = 0.01) and the use of intravenous diuretic rescue treatment declined (4 vs 118, p < 0.001). There was no significant deterioration in renal function during the first year of follow-up or major complications associated with the technique. Survival was 72% at 1 year. In older adult patients with comorbidity, advanced HF, and refractory congestive symptoms, PUF reduced hospital admissions and the use of intravenous diuretic rescue treatment, without major complications.
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Affiliation(s)
- Ana Rodríguez-Álvarez
- Heart Failure Unit, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain.
| | | | - Héctor Guerrero-Sande
- Heart Failure Unit, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain
| | - María Pilar Chaos-González
- Heart Failure Unit, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain
| | - Antía Pérez-López
- Heart Failure Unit, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain
| | - Lourdes González-Tabara
- Department of Nephrology, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain
| | - Beatriz Millan-Díaz
- Department of Nephrology, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain
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Trullàs JC, Morales-Rull JL, Casado J, Carrera-Izquierdo M, Sánchez-Marteles M, Conde-Martel A, Dávila-Ramos MF, Llácer P, Salamanca-Bautista P, Pérez-Silvestre J, Plasín MÁ, Cerqueiro JM, Gil P, Formiga F, Manzano L. Combining loop with thiazide diuretics for decompensated heart failure: the CLOROTIC trial. Eur Heart J 2023; 44:411-421. [PMID: 36423214 DOI: 10.1093/eurheartj/ehac689] [Citation(s) in RCA: 93] [Impact Index Per Article: 93.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/26/2022] [Accepted: 11/10/2022] [Indexed: 11/27/2022] Open
Abstract
AIMS To evaluate whether the addition of hydrochlorothiazide (HCTZ) to intravenous furosemide is a safe and effective strategy for improving diuretic response in acute heart failure (AHF). METHODS AND RESULTS A prospective, double-blind, placebo-controlled trial, including patients with AHF randomized to receive HCTZ or placebo in addition to an intravenous furosemide regimen. The coprimary endpoints were changes in body weight and patient-reported dyspnoea 72 h after randomization. Secondary outcomes included metrics of diuretic response and mortality/rehospitalizations at 30 and 90 days. Safety outcomes (changes in renal function and/or electrolytes) were also assessed. Two hundred and thirty patients (48 women, 83 years) were randomized. Patients assigned to HCTZ were more likely to lose weight at 72 h than those assigned to placebo [2.3 vs. 1.5 kg; adjusted estimated difference (notionally 95 confidence interval) 1.14 (1.84 to 0.42); P 0.002], but there were no significant differences in patient-reported dyspnoea (area under the curve for visual analogue scale: 960 vs. 720; P 0.497). These results were similar 96 h after randomization. Patients allocated to HCTZ showed greater 24 h diuresis (1775 vs. 1400 mL; P 0.05) and weight loss for each 40 mg of furosemide (at 72 and at 96 h) (P 0.001). Patients assigned to HCTZ more frequently presented impaired renal function (increase in creatinine 26.5 moL/L or decrease in eGFR 50; 46.5 vs. 17.2; P 0.001), but hypokalaemia and hypokalaemia were similar between groups. There were no differences in mortality or rehospitalizations. CONCLUSION The addition of HCTZ to loop diuretic therapy improved diuretic response in patients with AHF.
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Affiliation(s)
- Joan Carles Trullàs
- Internal Medicine Department, Hospital dOlot i comarcal de la Garrotxa, Girona, Av dels Pasos Catalans, 86, 17800 CA, Spain
- Laboratori de Reparaci i Regeneraci Tissular (TR2Lab), Facultat de Medicina, Universitat de VicUniversitat Central de Catalunya, Carretera de Roda, 70, 08500 Vic, Barcelona, CA, Spain
| | - José Luis Morales-Rull
- Internal Medicine Department, Heart Failure Unit, Hospital Universitari Arnau de Villanova, Institut de Recerca Biomdica (IRBLleida), Avinguda Alcalde Rovira Roure, 80, 25198 Lleida, Spain
| | - Jesús Casado
- Internal Medicine Department, Hospital Universitario de Getafe, Carretera de Madrid - Toledo, Km 12,500, 28905 Madrid, Spain
| | | | - Marta Sánchez-Marteles
- Internal Medicine Department, Hospital Clnico Universitario Lozano Blesa, Calle de San Juan Bosco, 15, 50009 Zaragoza, Spain
| | - Alicia Conde-Martel
- Internal Medicine Department, Hospital Universitario de Gran Canaria Dr. Negrn, C. Pl. Barranco de la Ballena, s/n, 35010 Las Palmas de Gran Canaria, Spain
| | - Melitón Francisco Dávila-Ramos
- Internal Medicine Department, Hospital Universitario Nuestra Seora de la Candelaria, Carretera Gerenal del Rosario, 145, 38010 Santa Cruz de Tenerife, Spain
| | - Pau Llácer
- Internal Medicine Department, Hospital de Manises, Avinguda de la Generalitat Valenciana, 50, 46940 Manises, Valencia, Spain
| | - Prado Salamanca-Bautista
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Avenida Dr. Fedriani, 3, 41009 Sevilla, Spain
| | - José Pérez-Silvestre
- Internal Medicine Department, Consorcio Hospital General Universitario de Valencia, Avinguda de les Tres Creus, 2, 46014 Valencia, Spain
| | - Miguel Ángel Plasín
- Internal Medicine Department, Mollet University Hospital, Ronda dels Pinetons, 6, 08100 Mollet Del Valles, Barcelona, Spain
| | - José Manuel Cerqueiro
- Internal Medicine Department, Hospital Universitario Lucus Augusti, Ra Dr. Ulises Romero, 1, 27003 Lugo, Spain
| | - Paloma Gil
- Internal Medicine Department, La Princesa University Hospital, Calle de Diego de Len, 62, 28006 Madrid, Spain
| | - Francesc Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, Carrer de la Feixa Llarga, s/n, 08907 LHospitalet de Llobregat, Barcelona, Spain
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramn y Cajal, IRYCIS, Universidad de Alcal, M-607, 9, 100, 28034 Madrid, Spain
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Sinagra G, Fabris E. Ultrafiltration in decompensated heart failure: Is time to look forward? Eur J Intern Med 2022; 104:37-38. [PMID: 35985954 DOI: 10.1016/j.ejim.2022.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/10/2022] [Indexed: 12/29/2022]
Affiliation(s)
- Gianfranco Sinagra
- Cardiothoracovascular Department, University of Trieste, Trieste, Italy.
| | - Enrico Fabris
- Cardiothoracovascular Department, University of Trieste, Trieste, Italy
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Wei J, Zhao M, Meng K, Xia G, Pan Y, Li C, Zhang W. The Diuretic Effects of Coconut Water by Suppressing Aquaporin and Renin–Angiotensin–Aldosterone System in Saline-Loaded Rats. Front Nutr 2022; 9:930506. [PMID: 35811978 PMCID: PMC9262403 DOI: 10.3389/fnut.2022.930506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
The acute and prolonged diuretic effects of coconut water (CW) and the underlying mechanism were investigated with a saline-loaded rat model. In an acute diuretic experiment, CW could significantly increase urine excretion. In addition, the treatment of CW significantly increased urinary sodium and chloride ions, thereby considerably increasing the excretion of NaCl. However, the calcium concentration and pH value were not affected. In the prolonged diuretic experiment, CW dramatically increased the urine output and urine electrolyte concentrations (Na+, K+, and Cl–). Furthermore, CW could suppress the activation of renin–angiotensin–aldosterone system by decreasing serum antidiuretic hormone, angiotensin II, and aldosterone levels, and significantly increasing the serum atriopeptin level. CW treatment significantly reduced the mRNA expressions and protein levels of aquaporin 1 (AQP1), AQP2, and AQP 3. This report provided basic data for explaining the natural tropical beverage of CW as an alternative diuretic agent.
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Affiliation(s)
- Jing Wei
- Hainan Engineering Research Center of Aquatic Resources Efficient Utilization in South China Sea, Key Laboratory of Food Nutrition and Functional Food of Hainan Province, Key Laboratory of Seafood Processing of Haikou, College of Food Science and Engineering, Hainan University, Haikou, China
- Key Laboratory of Tropical Fruits and Vegetables Quality and Safety for State Market Regulation, Hainan Institute for Food Control, Haikou, China
| | - Mantong Zhao
- Hainan Engineering Research Center of Aquatic Resources Efficient Utilization in South China Sea, Key Laboratory of Food Nutrition and Functional Food of Hainan Province, Key Laboratory of Seafood Processing of Haikou, College of Food Science and Engineering, Hainan University, Haikou, China
| | - Keke Meng
- Hainan Engineering Research Center of Aquatic Resources Efficient Utilization in South China Sea, Key Laboratory of Food Nutrition and Functional Food of Hainan Province, Key Laboratory of Seafood Processing of Haikou, College of Food Science and Engineering, Hainan University, Haikou, China
| | - Guanghua Xia
- Hainan Engineering Research Center of Aquatic Resources Efficient Utilization in South China Sea, Key Laboratory of Food Nutrition and Functional Food of Hainan Province, Key Laboratory of Seafood Processing of Haikou, College of Food Science and Engineering, Hainan University, Haikou, China
- Key Laboratory of Tropical Fruits and Vegetables Quality and Safety for State Market Regulation, Hainan Institute for Food Control, Haikou, China
- *Correspondence: Guanghua Xia,
| | - Yonggui Pan
- Hainan Engineering Research Center of Aquatic Resources Efficient Utilization in South China Sea, Key Laboratory of Food Nutrition and Functional Food of Hainan Province, Key Laboratory of Seafood Processing of Haikou, College of Food Science and Engineering, Hainan University, Haikou, China
| | - Congfa Li
- Hainan Engineering Research Center of Aquatic Resources Efficient Utilization in South China Sea, Key Laboratory of Food Nutrition and Functional Food of Hainan Province, Key Laboratory of Seafood Processing of Haikou, College of Food Science and Engineering, Hainan University, Haikou, China
| | - Weimin Zhang
- Hainan Engineering Research Center of Aquatic Resources Efficient Utilization in South China Sea, Key Laboratory of Food Nutrition and Functional Food of Hainan Province, Key Laboratory of Seafood Processing of Haikou, College of Food Science and Engineering, Hainan University, Haikou, China
- Key Laboratory of Tropical Fruits and Vegetables Quality and Safety for State Market Regulation, Hainan Institute for Food Control, Haikou, China
- Weimin Zhang,
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11
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Kennelly P, Sapkota R, Azhar M, Cheema FH, Conway C, Hameed A. Diuretic therapy in congestive heart failure. Acta Cardiol 2022; 77:97-104. [PMID: 33653227 DOI: 10.1080/00015385.2021.1878423] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In heart failure, fluid overload is a major pathological mechanism leading to vascular congestion, pulmonary congestion and elevated jugular venous pressures. Diuretics play a significant role in the management of patients with congestive heart failure. It is used to relieve the congestive symptoms of heart failure. However, the appropriate use of diuretics remains challenging due to various complications like electrolyte abnormalities, worsening renal function and diuretic resistance. This has prompted towards the search of safer and effective alternatives. This review evaluates the use of diuretics in congestive heart failure and discusses the complications of different types of diuretics, which is essential for successful management of congestion in patients with heart failure and hence to optimise the outcome for the patients.
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Affiliation(s)
- Patrick Kennelly
- Graduate Entry Medicine, School of Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Rajju Sapkota
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Maimoona Azhar
- Graduate Entry Medicine, School of Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Department of Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Faisal Habib Cheema
- HCA Healthcare Gulf Coast Division, Houston, TX, USA
- College of Medicine, University of Houston, Houston, TX, USA
| | - Claire Conway
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Aamir Hameed
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Trinity Centre for Biomedical Engineering (TCBE), Trinity College Dublin (TCD), Dublin, Ireland
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12
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Blázquez‐Bermejo Z, Farré N, Caravaca Perez P, Llagostera M, Morán‐Fernández L, Fort A, de Juan Bagudá J, García‐Cosio MD, Ruiz‐Bustillo S, Delgado JF. Dose of furosemide before admission predicts diuretic efficiency and long-term prognosis in acute heart failure. ESC Heart Fail 2022; 9:656-666. [PMID: 34766460 PMCID: PMC8788037 DOI: 10.1002/ehf2.13696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/21/2021] [Accepted: 10/29/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS The outpatient diuretic dose is a marker of diuretic resistance and prognosis in chronic heart failure (HF). Still, the impact of the preadmission dose on diuretic efficiency (DE) and prognosis in acute HF is not fully known. METHODS AND RESULTS We conducted an observational and prospective study. All patients admitted for acute HF treated with intravenous diuretic and at least one criterion of congestion on admission were evaluated. Decongestion [physical examination, hemoconcentration, N-terminal pro-brain natriuretic peptide (NT-proBNP) change, and lung ultrasound], DE (weight loss and urine output per unit of 40 mg furosemide), and urinary sodium were monitored on the fifth day of admission. DE was dichotomized into high-low based on the median value. A multivariate Cox regression analysis was conducted to find predictors of HF readmission or mortality. A total of 105 patients were included between July 2017 and July 2019. Mean age was 74.5 ± 12.0 years, 64.8% were male, 33.3% had de novo HF, and mean left ventricular ejection fraction was 46 ± 17%. Median follow-up was 26 [15-35] months. Low DE based on weight loss was associated with a higher previous dose of furosemide (odds ratio [OR] 1.01 [1.00-1.02]), thiazide treatment before admission (OR 9.37 [2.19-40.14]), and lower diastolic blood pressure (OR 0.95 [0.91-0.98]) in the multivariate regression model. Only previous dose of furosemide (OR 1.01 [1.00-1.02]) and haemoglobin at admission (OR 0.76 [0.58-0.99]) were associated with low DE based on urine output in the multivariate analysis. The correlation between the previous dose of furosemide and DE based on weight loss was poor (r = -0.12; P = 0.209) and with DE based on urine output was weak to moderate (r = -0.33; P < 0.001). Low DE based on weight loss and urine output was associated with lesser decongestion measured by NT-proBNP (P = 0.011; P = 0.007), hemoconcentration (P = 0.006; P = 0.044), and lung ultrasound (P = 0.034; P = 0.029), but not by physical examination (P = 0.506; P = 0.560). Survival and event-free survival in acute decompensated HF (ADHF) were lower than in de novo HF; a preadmission dose of furosemide > 80 mg in ADHF identified patients with particularly poor prognosis (log-rank < 0.001). In ADHF, the preadmission dose of furosemide (hazard ratio [HR] 1.34 [1.08-1.67] per 40 mg) and NT-proBNP at admission (HR 1.03 [1.01-1.06] per 1000 pg/mL) were independently associated with mortality or HF readmission in the multivariate Cox regression analysis. CONCLUSIONS The outpatient dose of furosemide before acute HF admission predicts DE and must be taken into account when deciding on the initial diuretic dose. In ADHF, the outpatient dose of furosemide can predict long-term prognosis better than DE during hospitalization.
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Affiliation(s)
- Zorba Blázquez‐Bermejo
- Cardiology DepartmentHospital del MarBarcelonaSpain
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
| | - Nuria Farré
- Cardiology DepartmentHospital del MarBarcelonaSpain
- Biomedical Research Group on Heart Disease (GREC)Hospital del Mar Medical Research Group (IMIM)BarcelonaSpain
- Department of MedicineUniversidad Autónoma de BarcelonaBarcelonaSpain
| | - Pedro Caravaca Perez
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
- CIBER de Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | | | - Laura Morán‐Fernández
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
- CIBER de Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | - Aleix Fort
- Cardiology DepartmentHospital del MarBarcelonaSpain
| | - Javier de Juan Bagudá
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
- CIBER de Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | - María Dolores García‐Cosio
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
- CIBER de Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | - Sonia Ruiz‐Bustillo
- Cardiology DepartmentHospital del MarBarcelonaSpain
- Biomedical Research Group on Heart Disease (GREC)Hospital del Mar Medical Research Group (IMIM)BarcelonaSpain
- Department of MedicineUniversitat Pompeu FabraBarcelonaSpain
| | - Juan F. Delgado
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
- CIBER de Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
- Faculty of MedicineUniversidad Complutense de MadridMadridSpain
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13
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Shams E, Bonnice S, Mayrovitz HN. Diuretic Resistance Associated With Heart Failure. Cureus 2022; 14:e21369. [PMID: 35198282 PMCID: PMC8852330 DOI: 10.7759/cureus.21369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/18/2022] [Indexed: 11/05/2022] Open
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14
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Metolazone Add-On Therapy in Heart Failure: A Cohort Study from Persian Registry of Cardiovascular Disease/Heart Failure (PROVE/HF). Crit Care Res Pract 2021; 2021:3820292. [PMID: 34721901 PMCID: PMC8556116 DOI: 10.1155/2021/3820292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/12/2021] [Indexed: 11/30/2022] Open
Abstract
Background One of the strategies for overcoming diuretic resistance among heart failure (HF) patients is adding thiazide-type diuretics. The main aim of this article is to compare the adverse clinical outcomes, including death and re-hospitalization, among individuals suffering from severe acute decompensated HF (ADHF) that consumed furosemide or furosemide plus metolazone. Methods This retrospective cohort study was done in the context of the Persian registry of cardiovascular disease (PROVE) from September 2017 to September 2018. One thousand and four hundred thirty-eight individuals (furosemide: 972 and furosemide plus metolazone: 466) with the final diagnosis of severe ADHF (left ventricular ejection fraction < 30%) were selected and followed for 10.3 ± 7.8 months. The association between two groups, as mentioned above, with the incidence of death and re-admission, was evaluated with different models. Results The mean age of the study population was 68.19 ± 12.98 years. There was no significant relation in terms of death or re-hospitalization between patients with different diuretic regimens. After adjustment of potential confounders, we found that adding metolazone as an adjuvant HF therapy was not independently associated with death or re-hospitalization (hazard ratio (HR): 0.78,95% confidence interval (CI) = 0.59–1.03, P = 0.085, and odds ratio (OR): 0.80, 95% CI: 0.60–1.07, P = 0.135, respectively). Conclusion Our findings revealed that adding metolazone in patients with furosemide resistance is not associated with higher morbidity and mortality. Therefore, usage of these two therapeutic agents could be a helpful strategy for severe HF patients.
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15
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Empagliflozin in Patients With Heart Failure, Reduced Ejection Fraction, and Volume Overload: EMPEROR-Reduced Trial. J Am Coll Cardiol 2021; 77:1381-1392. [PMID: 33736819 DOI: 10.1016/j.jacc.2021.01.033] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Investigators have hypothesized that sodium-glucose cotransporter 2 (SGLT2) inhibitors exert diuretic effects that contribute to their ability to reduce serious heart failure events, and this action is particularly important in patients with fluid retention. OBJECTIVES This study sought to evaluate the effects of the SGLT2 inhibitor empagliflozin on symptoms, health status, and major heart failure outcomes in patients with and without recent volume overload. METHODS This double-blind randomized trial compared the effects of empagliflozin and placebo in 3,730 patients with heart failure and a reduced ejection fraction, with or without diabetes. Approximately 40% of the patients had volume overload in the 4 weeks before study enrollment. RESULTS Patients with recent volume overload were more likely to have been hospitalized for heart failure and to have received an intravenous diuretic agent in an outpatient setting in the previous 12 months, and to experience a heart failure event following randomization, even though they were more likely to be treated with high doses of a loop diuretic agent as an outpatient (all p < 0.001). When compared with placebo, empagliflozin reduced the composite risk of cardiovascular death or hospitalization for heart failure, decreased total hospitalizations for heart failure, and improved health status and functional class. Yet despite the predisposition of patients with recent volume overload to fluid retention, the magnitude of these benefits (even after 1 month of treatment) was not more marked in patients with recent volume overload (interaction p values > 0.05). Changes in body weight, hematocrit, and natriuretic peptides (each potentially indicative of a diuretic action of SGLT2 inhibitors) did not track each other closely in their time course or in individual patients. CONCLUSIONS Taken together, study findings do not support a dominant role of diuresis in mediating the physiological changes or clinical benefits of SGLT2 inhibitors on the course of heart failure in patients with a reduced ejection fraction. (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction [EMPEROR-Reduced]; NCT03057977).
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16
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In Vivo Diuretic Activity of Hydromethanolic Extract and Solvent Fractions of the Root Bark of Clerodendrum myricoides Hochst. (Lamiaceae). EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:1718708. [PMID: 33376495 PMCID: PMC7746458 DOI: 10.1155/2020/1718708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/26/2020] [Accepted: 11/30/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Clerodendrum myricoides (Lamiaceae) has been traditionally used for the treatment of various ailments, including body swelling and urine retention. The present study aimed to evaluate the diuretic activity of a crude extract and solvent fractions of the root bark of C. myricoides. Methodology. The coarsely powdered root bark of C. myricoides was extracted by a cold maceration method using 80% methanol. A portion of the extract was fractionated based on the polarity index of solvents to obtain chloroform, ethyl acetate, and aqueous fractions. To investigate the diuretic activity of the plant, rats were divided into fifteen groups. The normal control groups received either water or 2% tween 80, the standard group received furosemide (10 mg/kg), and the test groups were administered the hydromethanolic extract and solvent fractions at the doses of 100, 200, and 400 mg/kg by the oral route. The urine volume, urine pH, urine, and serum electrolytes were determined and compared with the standard and normal control groups. RESULTS The crude hydromethanolic extract, ethyl acetate, and chloroform fractions induced significant diuresis at a dose of 400 mg/kg (P < 0.001) compared to the aqueous fraction. The hydromethanolic extract at 200 mg/kg and 400 mg/kg also caused noticeable diuresis (P < 0.001) compared to the standard, furosemide. Rats treated with hydromethanolic extract, ethyl acetate, and chloroform fractions showed delayed onset and prolonged diuresis in a dose-dependent fashion compared to the aqueous fraction (P < 0.05). The hydromethanolic extract and solvent fractions produced the highest saliuretic and natriuretic index compared to the standard, furosemide. The crude hydromethanolic extract also failed to produce any sign of toxicity up to 2000 mg/kg. CONCLUSION From this study, the hydromethanolic extract and ethyl acetate fraction of the root bark of C. myricoides produced a prominent diuretic effect in rats.
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17
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Simonavičius J, Maeder MT, Eurlings CGMJ, Aizpurua AB, Čelutkienė J, Barysienė J, Toggweiler S, Kaufmann BA, Brunner-La Rocca HP. Intensification of pharmacological decongestion but not the actual daily loop diuretic dose predicts worse chronic heart failure outcome: insights from TIME-CHF. Clin Res Cardiol 2020; 110:1221-1233. [PMID: 33216179 DOI: 10.1007/s00392-020-01779-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 11/02/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Both loop diuretics (LDs) and congestion have been related to worse heart failure (HF) outcome. The relationship between the cause and effect is unknown. The aim of this study was to investigate the interaction between congestion, diuretic use and HF outcome. METHODS Six hundred and twenty-two chronic HF patients from TIME-CHF were studied. Congestion was measured by means of a clinical congestion index (CCI). Loop diuretic dose was considered at baseline and month 6. Treatment intensification was defined as the increase in LD dose over 6 months or loop diuretic and thiazide or thiazide-like diuretic co-administration. The end-points were survival and HF hospitalisation-free survival. RESULTS High-LD dose at baseline and month 6 (≥ 80 mg of furosemide per day) was not identified as an independent predictor of outcome. CCI at baseline remained independently associated with impaired survival [hazard ratio (HR) 1.34, (95% confidence interval) (95% CI) (1.20-1.50), p < 0.001] and HF hospitalisation-free survival [HR 1.09, 95% CI (1.02-1.17), p = 0.015]. CCI at month 6 was independently associated with HF hospitalisation-free survival [HR 1.24, 95% CI (1.11-1.38), p < 0.001]. Treatment intensification was independently associated with survival [HR 1.75, 95% CI (1.19-1.38), p = 0.004] and HF hospitalisation-free survival [HR 1.69, 95% CI (1.22-2.35), p = 0.002]. Patients undergoing treatment intensification resulting in decongestion had better outcome than patients with persistent (worsening) congestion despite LD dose up-titration (p < 0.001). CONCLUSION Intensification of pharmacological decongestion but not the actual LD dose was related to poor outcome in chronic HF. If treatment intensification translated into clinical decongestion, outcome was better than in case of persistent or worsening congestion.
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Affiliation(s)
- Justas Simonavičius
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands. .,Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariskiu str. 2, 08406, Vilnius, Lithuania. .,The Faculty of Medicine of Vilnius University, Vilnius, Lithuania.
| | - Micha T Maeder
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Casper G M J Eurlings
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Jelena Čelutkienė
- Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Jūratė Barysienė
- Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Stefan Toggweiler
- Division of Cardiology, Heart Centre Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Beat A Kaufmann
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
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Kristjánsdóttir I, Thorvaldsen T, Lund LH. Congestion and Diuretic Resistance in Acute or Worsening Heart Failure. Card Fail Rev 2020; 6:e25. [PMID: 33042585 PMCID: PMC7539143 DOI: 10.15420/cfr.2019.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 05/07/2020] [Indexed: 12/20/2022] Open
Abstract
Hospitalisation for acute heart failure (AHF) is associated with high mortality and high rehospitalisation rates. In the absence of evidence-based therapy, treatment is aimed at stabilisation and symptom relief. The majority of AHF patients have signs and symptoms of fluid overload, and, therefore, decongestion is the number one treatment goal. Diuretics are the cornerstone of therapy in AHF, but the treatment effect is challenged by diuretic resistance and poor diuretic response throughout the spectrum of chronic to worsening to acute to post-worsening HF. Adequate dosing and monitoring and evaluation of diuretic effect are important for treatment success. Residual congestion at discharge is a strong predictor of worse outcomes. Therefore, achieving euvolaemia is crucial despite transient worsening renal function.
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Affiliation(s)
- Ingibjörg Kristjánsdóttir
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden; and Karolinska University Hospital, Heart and Vascular Theme Stockholm, Sweden
| | - Tonje Thorvaldsen
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden; and Karolinska University Hospital, Heart and Vascular Theme Stockholm, Sweden
| | - Lars H Lund
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden; and Karolinska University Hospital, Heart and Vascular Theme Stockholm, Sweden
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Blázquez-Bermejo Z, Farré N, Llagostera M, Caravaca Perez P, Morán-Fernández L, Fort A, De-Juan J, Ruiz S, Delgado JF. The development of chronic diuretic resistance can be predicted during a heart-failure hospitalization. Results from the REDIHF registry. PLoS One 2020; 15:e0240098. [PMID: 33007024 PMCID: PMC7531800 DOI: 10.1371/journal.pone.0240098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/19/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Diuretic resistance (DR) is a common condition during a heart failure (HF) hospitalization, and is related to worse prognosis. Although the risk factors for DR during a HF hospitalization are widely described, we do not know whether the risk of chronic DR could be predicted during admission. Material and methods We conducted a multicenter, prospective observational study between July 2017 and July 2019. All patients admitted for acute HF with intravenous diuretic treatment and at least one criterion of congestion on admission were invited to participate. Patients on renal replacement therapy, under intravenous diuretic treatment for >72 hours before screening and those who were unable to sign the informed consent were excluded. We monitored decongestion (physical exam, hemoconcentration, NTproBNP change and lung ultrasound) and DR (diuresis and weight loss per unit of 40mg furosemide and fractional excretion of sodium) on the fifth day of admission. Chronic DR was evaluate two months after hospitalization and was defined as persistent signs of congestion despite ≥80 mg furosemide per day. We compared variables from the hospitalization between patients with and without chronic DR. A multivariate logistic regression analysis was conducted to find predictors of chronic DR. Results A total of 105 patients were included in the study. Mean age was 74.5±12.0 years, 64.8% were male and mean LVEF was 46±17%. In the two months follow-up, five patients have died and one patient has had a heart transplant. Of the 99 remaining patients, 21 patients (21.2%) had chronic DR. The dose of furosemide before admission and the decrease in NT-proBNP ≤30% during admission were predictors of chronic DR in the multivariate analysis. Conclusions We can predict during a HF hospitalization which patients will develop chronic DR. The dose of furosemide before admission and the change in NT-proBNP are independent predictors of chronic DR.
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Affiliation(s)
| | - Nuria Farré
- Cardiology Department, Hospital del Mar, Barcelona, Spain
- Biomedical Research Group on Heart Disease (GREC), Hospital del Mar Medical Research Group (IMIM), Barcelona, Spain
- Department of Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Pedro Caravaca Perez
- Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Laura Morán-Fernández
- Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Aleix Fort
- Cardiology Department, Hospital del Mar, Barcelona, Spain
| | - Javier De-Juan
- Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Sonia Ruiz
- Cardiology Department, Hospital del Mar, Barcelona, Spain
- Biomedical Research Group on Heart Disease (GREC), Hospital del Mar Medical Research Group (IMIM), Barcelona, Spain
| | - Juan F. Delgado
- Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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20
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Patoulias D, Papadopoulos C, Zografou I, Doumas M. Acute heart failure, type 2 diabetes and loop diuretic use: any adjunct role for sodium-glucose cotransporter-2 inhibitors? J Cardiovasc Med (Hagerstown) 2020; 21:343. [PMID: 31977537 DOI: 10.2459/jcm.0000000000000938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Christodoulos Papadopoulos
- Third Department of Cardiology, Aristotle University of Thessaloniki, General Hospital 'Hippokration', Thessaloniki, Greece
| | | | - Michael Doumas
- Second Propedeutic Department of Internal Medicine.,Veterans ffairs Medical Center, George Washington University, Washington, District of Columbia, USA
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21
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Trullàs JC, Formiga F, Manzano L. The use of thiazide and thiazide‐like diuretics in heart failure with congestion. Eur J Heart Fail 2019; 21:948. [DOI: 10.1002/ejhf.1455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 02/15/2019] [Indexed: 11/09/2022] Open
Affiliation(s)
- Joan Carles Trullàs
- Internal Medicine Service, Hospital de Olot Olot Girona Spain
- Medical Sciences DepartmentUniversitat de Girona Girona Spain
- Heart Failure Working Group of the Spanish Society of Internal Medicine
| | - Francesc Formiga
- Heart Failure Working Group of the Spanish Society of Internal Medicine
- Internal Medicine Service, Hospital Universitari de BellvitgeIDIBELL L'Hospitalet de Llobregat Barcelona Spain
| | - Luis Manzano
- Heart Failure Working Group of the Spanish Society of Internal Medicine
- Internal Medicine Service, Hospital Universitario Ramón y CajalUniversidad de Alcalá (IRYCIS) Madrid Spain
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22
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Marra AM, Proietti M. Diuretic resistance in decompensated chronic heart failure: trying to get out of the "loop". Intern Emerg Med 2019; 14:497-498. [PMID: 31049784 DOI: 10.1007/s11739-019-02083-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 03/25/2019] [Indexed: 10/26/2022]
Affiliation(s)
| | - Marco Proietti
- Laboratory of Quality Assessment of Geriatric Therapies and Services, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Giuseppe La Masa 19, 20156, Milan, Italy.
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23
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Carrizales-Sepúlveda EF, Vera-Pineda R, Jiménez-Castillo RA, Benavides-González MA, Ordaz-Farías A. Prevalence and outcome of diuretic resistance in heart failure: comment. Intern Emerg Med 2019; 14:631-632. [PMID: 30788652 DOI: 10.1007/s11739-019-02050-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/11/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Edgar Francisco Carrizales-Sepúlveda
- Internal Medicine Department, Hospital Universitario, Universidad Autónoma de Nuevo León, Madero and Gonzalitos Av. N/N, Col. Mitras Centro, 64460, Monterrey, Nuevo León, Mexico.
| | - Raymundo Vera-Pineda
- Internal Medicine Department, Hospital Universitario, Universidad Autónoma de Nuevo León, Madero and Gonzalitos Av. N/N, Col. Mitras Centro, 64460, Monterrey, Nuevo León, Mexico
| | - Raúl Alberto Jiménez-Castillo
- Internal Medicine Department, Hospital Universitario, Universidad Autónoma de Nuevo León, Madero and Gonzalitos Av. N/N, Col. Mitras Centro, 64460, Monterrey, Nuevo León, Mexico
| | - Mario Alberto Benavides-González
- Echocardiography Laboratory, Cardiology Service, Hospital Universitario, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - Alejandro Ordaz-Farías
- Echocardiography Laboratory, Cardiology Service, Hospital Universitario, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
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24
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Trullàs JC, Casado J, Morales-Rull JL, Formiga F, Manzano L. Prevalence and outcome of diuretic resistance in heart failure: reply. Intern Emerg Med 2019; 14:633-634. [PMID: 30840188 DOI: 10.1007/s11739-019-02064-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 02/26/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Joan-Carles Trullàs
- Internal Medicine Service, Hospital de Olot, Av. Dels Països Catalans, 86, 17800, Olot, Girona, Spain.
- Medical Sciences Department, Universitat de Girona, Girona, Spain.
| | - Jesús Casado
- Internal Medicine Service, Hospital Universitario de Getafe, Madrid, Spain
| | - Jose-Luís Morales-Rull
- Internal Medicine Service, Hospital Universitario "Arnau de Vilanova", IRBLleida, Lleida, Spain
| | - Francesc Formiga
- Internal Medicine Service, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Luis Manzano
- Internal Medicine Service, Hospital Universitario Ramón Y Cajal, Universidad de Alcalá (IRYCIS), Madrid, Spain
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