1
|
Rao VS, Turner JM, Griffin M, Mahoney D, Asher J, Jeon S, Yoo PS, Boutagy N, Feher A, Sinusas A, Wilson FP, Finkelstein F, Testani JM. First-in-Human Experience With Peritoneal Direct Sodium Removal Using a Zero-Sodium Solution: A New Candidate Therapy for Volume Overload. Circulation 2020; 141:1043-1053. [PMID: 31910658 DOI: 10.1161/circulationaha.119.043062] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Loop diuretics have well-described toxicities, and loss of response to these agents is common. Alternative strategies are needed for the maintenance of euvolemia in heart failure (HF). Nonrenal removal of sodium directly across the peritoneal membrane (direct sodium removal [DSR]) with a sodium-free osmotic solution should result in extraction of large quantities of sodium with limited off-target solute removal. METHODS This article describes the preclinical development and first-in-human proof of concept for DSR. Sodium-free 10% dextrose was used as the DSR solution. Porcine experiments were conducted to investigate the optimal dwell time, safety, and scalability and to determine the effect of experimental heart failure. In the human study, participants with end-stage renal disease on peritoneal dialysis (PD) underwent randomization and crossover to either a 2-hour dwell with 1 L DSR solution or standard PD solution (Dianeal 4.25% dextrose, Baxter). The primary end point was completion of the 2-hour dwell without significant discomfort or adverse events, and the secondary end point was difference in sodium removal between DSR and standard PD solution. RESULTS Porcine experiments revealed that 1 L DSR solution removed 4.1±0.4 g sodium in 2 hours with negligible off-target solute removal and overall stable serum electrolytes. Increasing the volume of DSR solution cycled across the peritoneum increased sodium removal and substantially decreased plasma volume (P=0.005). In the setting of experimental heart failure with elevated right atrial pressure, sodium removal was ≈4 times greater than in healthy animals (P<0.001). In the human proof-of-concept study, DSR solution was well tolerated and not associated with significant discomfort or adverse events. Plasma electrolyte concentrations were stable, and off-target solute removal was negligible. Sodium removal was substantially higher with DSR (4.5±0.4 g) compared with standard PD solution (1.0±0.3 g; P<0.0001). CONCLUSIONS DSR was well tolerated in both animals and human subjects and produced substantially greater sodium removal than standard PD solution. Additional research evaluating the use of DSR as a method to prevent and treat hypervolemia in heart failure is warranted. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03801226.
Collapse
Affiliation(s)
- Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine (V.S.R., M.G., D.M., N.B., J.M. Testani), Yale University School of Medicine, New Haven, CT
| | - Jeffrey M Turner
- Department of Medicine, Division of Nephrology (J.M. Turner, F.F.), Yale University School of Medicine, New Haven, CT
| | - Matthew Griffin
- Department of Internal Medicine, Section of Cardiovascular Medicine (V.S.R., M.G., D.M., N.B., J.M. Testani), Yale University School of Medicine, New Haven, CT
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiovascular Medicine (V.S.R., M.G., D.M., N.B., J.M. Testani), Yale University School of Medicine, New Haven, CT
| | - Jennifer Asher
- Department of Comparative Medicine (J.A.), Yale University School of Medicine, New Haven, CT
| | | | - Peter S Yoo
- Department of Surgery, Transplantation and Immunology (P.S.Y.), Yale University School of Medicine, New Haven, CT
| | - Nabil Boutagy
- Department of Internal Medicine, Section of Cardiovascular Medicine (V.S.R., M.G., D.M., N.B., J.M. Testani), Yale University School of Medicine, New Haven, CT
| | - Attila Feher
- Department of Internal Medicine (A.F.), Yale University School of Medicine, New Haven, CT
| | - Albert Sinusas
- Department of Medicine, Yale Translational Research Imaging Center, Section of Cardiovascular Medicine (A.S.), Yale University School of Medicine, New Haven, CT
| | - F Perry Wilson
- Program of Applied Translational Research (F.P.W.), Yale University School of Medicine, New Haven, CT
| | - Fredric Finkelstein
- Department of Medicine, Division of Nephrology (J.M. Turner, F.F.), Yale University School of Medicine, New Haven, CT
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine (V.S.R., M.G., D.M., N.B., J.M. Testani), Yale University School of Medicine, New Haven, CT
| |
Collapse
|
2
|
Jardim SI, Ramos dos Santos L, Araújo I, Marques F, Branco P, Gaspar A, Fonseca C. A 2018 overview of diuretic resistance in heart failure. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
|
3
|
Jardim SI, Ramos dos Santos L, Araújo I, Marques F, Branco P, Gaspar A, Fonseca C. A 2018 overview of diuretic resistance in heart failure. Rev Port Cardiol 2018; 37:935-945. [DOI: 10.1016/j.repc.2018.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/18/2018] [Accepted: 03/11/2018] [Indexed: 01/01/2023] Open
|
4
|
Rao VS, Planavsky N, Hanberg JS, Ahmad T, Brisco-Bacik MA, Wilson FP, Jacoby D, Chen M, Tang WHW, Cherney DZI, Ellison DH, Testani JM. Compensatory Distal Reabsorption Drives Diuretic Resistance in Human Heart Failure. J Am Soc Nephrol 2017; 28:3414-3424. [PMID: 28739647 DOI: 10.1681/asn.2016111178] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 06/19/2017] [Indexed: 12/31/2022] Open
Abstract
Understanding the tubular location of diuretic resistance (DR) in heart failure (HF) is critical to developing targeted treatment strategies. Rodents chronically administered loop diuretics develop DR due to compensatory distal tubular sodium reabsorption, but whether this translates to human DR is unknown. We studied consecutive patients with HF (n=128) receiving treatment with loop diuretics at the Yale Transitional Care Center. We measured the fractional excretion of lithium (FELi), the gold standard for in vivo assessment of proximal tubular and loop of Henle sodium handling, to assess sodium exit after loop diuretic administration and FENa to assess the net sodium excreted into the urine. The mean±SD prediuretic FELi was 16.2%±9.5%, similar to that in a control cohort without HF not receiving diuretics (n=52; 16.6%±9.2%; P=0.82). Administration of a median of 160 (interquartile range, 40-270) mg intravenous furosemide equivalents increased FELi by 12.6%±10.8% (P<0.001) but increased FENa by only 4.8%±3.3%. Thus, only 34% (interquartile range, 15.6%-75.7%) of the estimated diuretic-induced sodium release did not undergo distal reabsorption. After controlling for urine diuretic levels, the increase in FELi explained only 6.4% of the increase in FENa (P=0.002). These data suggest that administration of high-dose loop diuretics to patients with HF yields meaningful increases in sodium exit from the proximal tubule/loop of Henle. However, little of this sodium seems to reach the urine, consistent with findings from animal models that indicate that distal tubular compensatory sodium reabsorption is a primary driver of DR.
Collapse
Affiliation(s)
| | - Noah Planavsky
- Department of Geology and Geophysics, Yale University, New Haven, Connecticut
| | | | | | - Meredith A Brisco-Bacik
- Department of Medicine, Cardiovascular Division, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Francis P Wilson
- Department of Internal Medicine and.,Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut
| | | | | | - W H Wilson Tang
- Section of Heart Failure and Cardiac Transplantation, Cleveland Clinic, Cleveland, Ohio
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, Toronto General Hospital and Toronto General Hospital Research Institute, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada; and
| | - David H Ellison
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, Oregon
| | | |
Collapse
|
5
|
Spot urine sodium excretion as prognostic marker in acutely decompensated heart failure: the spironolactone effect. Clin Res Cardiol 2015; 105:489-507. [PMID: 26615605 DOI: 10.1007/s00392-015-0945-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Loop diuretic resistance characterized by inefficient sodium excretion complicates many patients with acutely decompensated heart failure (ADHF). Mineralocorticoid receptor antagonists (MRAs) in natriuretic doses may improve spot urine sodium excretion and outcomes. OBJECTIVE Our primary aim was to assess the association of high-dose spironolactone with short-term spot urine sodium excretion, and our secondary aim was to determine if this higher short-term spot urine sodium excretion is associated with reduction in the composite clinical outcome (of cardiovascular mortality and/or ADHF hospitalization) event rate at 180 days. METHODS Single-centre, non-randomized, open-label study enrolling 100 patients with ADHF. Patients were treated with standard ADHF therapy alone (n = 50) or oral spironolactone 100 mg/day plus standard ADHF therapy (n = 50). Spot urine samples were collected at day 1 and day 3 of hospitalization. RESULTS Spironolactone group had significantly higher spot urine sodium levels compared to standard care group at day 3 (84.13 ± 28.71 mmol/L vs 70.74 ± 34.43 mmol/L, p = 0.04). The proportion of patients with spot urinary sodium <60 mmol/L was lower in spironolactone group at day 3 (18.8 vs 45.7, p = 0.01). In multivariate analysis, spironolactone was independently associated with increased spot urinary sodium and urinary sodium/potassium ratio of >2 at day 3 (both, p < 0.05). Higher spot urine sodium levels were associated with a lower event rate [HR for urinary sodium >100 mmol/L = 0.16 (0.06-0.42), p < 0.01, compared to <60], and provided a significant prognostic gain measured by net reclassification indexes. CONCLUSION Spot urinary sodium levels >60 mmol/L and urinary sodium/potassium ratio >2 measured at day 3 of hospitalization for ADHF are associated with improved mid-term outcomes. Spironolactone is associated with increased spot urinary sodium and sodium/potassium ratio >2.
Collapse
|
6
|
Singh D, Shrestha K, Testani JM, Verbrugge FH, Dupont M, Mullens W, Tang WHW. Insufficient natriuretic response to continuous intravenous furosemide is associated with poor long-term outcomes in acute decompensated heart failure. J Card Fail 2014; 20:392-9. [PMID: 24704538 DOI: 10.1016/j.cardfail.2014.03.006] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/24/2014] [Accepted: 03/25/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND Treatment of acute decompensated heart failure (ADHF) with loop diuretics, such as furosemide, is frequently complicated by insufficient urine sodium excretion. We hypothesize that insufficient natriuretic response to diuretic therapy, characterized by lower urine sodium (UNa) and urine furosemide, is associated with subsequent inadequate decongestion, worsening renal function, and adverse long term events. METHODS AND RESULTS We enrolled 52 consecutive patients with ADHF and measured serum and urine sodium (UNa), urine creatinine (UCr), and urine furosemide (UFurosemide) levels on a spot sample taken after treatment with continuous intravenous furosemide, and followed clinical and renal variables as well as adverse long-term clinical outcomes (death, rehospitalizations, and cardiac transplantation). We observed similar correlations between UNa:UFurosemide ratio and UNa and fractional excretion of sodium (FENa) with 24-hour net urine output (r = 0.52-0.64, all P < .01) and 24-hour weight loss (r = 0.44-0.56; all P < .01). Interestingly, FENa (but not UNa or UNa:UFurosemide) were influenced by estimated glomerular filtration rate (eGFR). We observed an association between lower UNa:UFurosemide with greater likelihood of worsening renal function (hazard ratio [HR] 3.01; P = .02) and poorer adverse clinical outcomes (HR 1.63, P = .008) after adjusting for age and eGFR. Meanwhile, both diminished weight loss and net fluid output over 24 hours of continuous intravenous furosemide were observed when UNa:UFurosemide ratios were <2 mmol/mg or when UNa <50 mmol. CONCLUSION In patients with ADHF receiving continuous furosemide infusion, impaired natriuretic response to furosemide is associated with greater likelihood of worsening renal function and future adverse long-term outcomes, independently from and incrementally with decreasing intrinsic glomerular filtration.
Collapse
Affiliation(s)
- Dhssraj Singh
- Division of Cardiovascular Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas
| | - Kevin Shrestha
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey M Testani
- Department of Internal Medicine and Program of Applied Translational Research, Yale, University School of Medicine, New Haven, Connecticut
| | - Frederik H Verbrugge
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
7
|
Use of the loop diuretic torsemide in three dogs with advanced heart failure. J Vet Cardiol 2011; 13:287-92. [PMID: 22030290 DOI: 10.1016/j.jvc.2011.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 10/03/2011] [Accepted: 10/07/2011] [Indexed: 11/22/2022]
Abstract
Diuretics are a mainstay of therapy in dogs with heart failure. In dogs with advanced heart failure, moderate to high doses of loop diuretics such as furosemide are used with diminishing effects as profound activation of neuroendocrine systems promote signs of congestive heart failure. The loop diuretic torsemide has several characteristics that make it suitable for treatment of advanced heart failure including longer half-life, increased potency of diuretic action, and anti-aldosterone effects. This case report details the administration of torsemide in 3 dogs with advanced heart failure and apparent furosemide resistance.
Collapse
|
8
|
Martins J, Lourenço P, Araújo JP, Mascarenhas J, Lopes R, Azevedo A, Bettencourt P. Prognostic Implications of Diuretic Dose in Chronic Heart Failure. J Cardiovasc Pharmacol Ther 2011; 16:185-91. [DOI: 10.1177/1074248410388807] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Prognostic implications of diuretics dose are not completely understood. We aim to study the association between diuretic doses and long-term prognosis in patients with chronic stable heart failure (HF). Methods and Results: We conducted a retrospective cohort study of 244 patients followed at an outpatient HF clinic. Admission criteria were clinical stability in the previous 3 months and optimized medical therapy. Demographic characteristics, clinical, and laboratory parameters were recorded. Patients were followed for 2 years and the outcome was defined as all-cause death or hospital admission due to HF worsening. Patients on ≤80 mg furosemide were compared with those on higher doses. Patients were grouped according to furosemide dose (≤80 mg and >80 mg/d) and according to volemia as assessed by the sodium retention score: <3 (euvolemia) versus ≥3 (hypervolemia). Patients on higher diuretic doses (n = 79) were older, more hypervolemic, and more symptomatic. Patients on >80 mg furosemide had a higher risk of death or hospital admission (hazard ratio [HR]: 2.07, 95% confidence interval [CI]: 1.37-3.1). For each 40-mg furosemide tablet, there was a 67% increase in risk of an adverse outcome within 2 years. The increase in risk was independent of other variables crudely associated with prognosis. Among euvolemic patients, those on ≤80 mg/d furosemide performed better than those on higher doses. Among hypervolemic patients, the diuretic dose had no prognostic implications. Conclusions: Higher diuretic doses associated strongly and independently with adverse long-term outcome in chronic HF. Possibly, in euvolemic patients, efforts should be made to reduce diuretic dose.
Collapse
Affiliation(s)
- João Martins
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| | - Patrícia Lourenço
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal,
| | - José Paulo Araújo
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| | - Joana Mascarenhas
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| | - Ricardo Lopes
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| | - Ana Azevedo
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal, Serviço de Higiene e Epidemiologia, Faculdade de Medicina da Universidade de Porto, Institute of Public Health-University of Porto (ISPUP), Porto, Portugal
| | - Paulo Bettencourt
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| |
Collapse
|
9
|
El-Refai M, Krivospitskaya O, Peterson EL, Wells K, Williams LK, Lanfear DE. Relationship of Loop Diuretic Dosing and Acute Changes in Renal Function during Hospitalization for Heart Failure. ACTA ACUST UNITED AC 2011; 2. [PMID: 23482899 DOI: 10.4172/2155-9880.1000164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Worsening renal function (WRF) during heart failure (HF) hospitalization is an accepted correlate of poor prognosis. Loop diuretics are increasingly being considered as a potential cause of worsened HF outcomes, perhaps via WRF. However, the magnitude of worsening in renal function attributable to loop diuretics has not been quantified. METHODS This was a retrospective cohort study of patients who received care from a large health system and had a primary hospital discharge diagnosis of HF between Jan 1, 2000 and June 30, 2008. Patients with preexisting end-stage renal disease were excluded. Daily creatinine (Cr) measurements, furosemide dosing (only loop diuretic on hospital formulary), and radiocontrast dye studies were collected using administrative data. Day-to-day changes in Cr and MDRD estimated glomerular filtration (eGFR) were calculated. The first Cr or eGFR value during hospitalization or in the emergency department was considered baseline. Generalized estimating equations were used to test the association furosemide exposure over previous 2 days to the daily change in Cr and eGFR. Covariates included undergoing radiocontrast study, age, race, gender, and baseline Cr or eGFR. RESULTS Among 6071 patients who met inclusion criteria there were a total of 20,645 observations. This cohort was 51% female, 68% African American, and baseline Cr was 1.36 mg/dl. Furosemide exposure was associated with an average daily increase in Cr of 0.021 mg/dL and decrease in eGFR of 0.72 ml/min/1.73m2 (per 100 mg furosemide daily, both p<0.001). Over a typical length of stay of 5 days this would amount to a Cr increase of 0.11 mg/dL or decrease in eGFR of 3.6 ml/min/1.73m2. Furosemide exposure accounted for only 0.4% and 0.1% of the variation in Cr and eGFR changes, respectively. Undergoing radiocontrast study, African American race, and higher age were associated with day-to-day creatinine increases (all p<0.01). Reanaysis after classifying furosemide exposure into low (<40mg/day), medium (40-100mg/day), and high (>100mg/day) and censoring patients-days after radiocontrast exposure did not significantly affect the magnitude of the worsening renal function. CONCLUSIONS While loop diuretic exposure is statistically associated with WRF among hospitalized HF patients, the associated magnitude of renal function change is very small, and loop diuretics explain little of the variability in renal function during hospitalization. More important explanatory factors likely exist but remain unidentified.
Collapse
Affiliation(s)
- Mostafa El-Refai
- Department of Internal Medicine, Henry Ford Hospital, Detroit MI, 48202, USA
| | | | | | | | | | | |
Collapse
|
10
|
Ritzema J, Troughton R, Melton I, Crozier I, Doughty R, Krum H, Walton A, Adamson P, Kar S, Shah PK, Richards M, Eigler NL, Whiting JS, Haas GJ, Heywood JT, Frampton CM, Abraham WT. Physician-directed patient self-management of left atrial pressure in advanced chronic heart failure. Circulation 2010; 121:1086-95. [PMID: 20176990 DOI: 10.1161/circulationaha.108.800490] [Citation(s) in RCA: 223] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Previous studies suggest that management of ambulatory hemodynamics may improve outcomes in chronic heart failure. We conducted a prospective, observational, first-in-human study of a physician-directed patient self-management system targeting left atrial pressure. METHODS AND RESULTS Forty patients with reduced or preserved left ventricular ejection fraction and a history of New York Heart Association class III or IV heart failure and acute decompensation were implanted with an investigational left atrial pressure monitor, and readings were acquired twice daily. For the first 3 months, patients and clinicians were blinded as to these readings, and treatment continued per usual clinical assessment. Thereafter, left atrial pressure and individualized therapy instructions guided by these pressures were disclosed to the patient. Event-free survival was determined over a median follow-up of 25 months (range 3 to 38 months). Survival without decompensation was 61% at 3 years, and events tended to be less frequent after the first 3 months (hazard ratio 0.16 [95% confidence interval 0.04 to 0.68], P=0.012). Mean daily left atrial pressure fell from 17.6 mm Hg (95% confidence interval 15.8 to 19.4 mm Hg) in the first 3 months to 14.8 mm Hg (95% confidence interval 13.0 to 16.6 mm Hg; P=0.003) during pressure-guided therapy. The frequency of elevated readings (>25 mm Hg) was reduced by 67% (P<0.001). There were improvements in New York Heart Association class (-0.7+/-0.8, P<0.001) and left ventricular ejection fraction (7+/-10%, P<0.001). Doses of angiotensin-converting enzyme/angiotensin-receptor blockers and beta-blockers were uptitrated by 37% (P<0.001) and 40% (P<0.001), respectively, whereas doses of loop diuretics fell by 27% (P=0.15). CONCLUSIONS Physician-directed patient self-management of left atrial pressure has the potential to improve hemodynamics, symptoms, and outcomes in advanced heart failure. Clinical Trial Registration Information- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00547729.
Collapse
Affiliation(s)
- Jay Ritzema
- University of Otago, Christchurch, New Zealand
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Haas GJ, Pestritto VM, Abraham WT. Ultrafiltration for Volume Control in Decompensated Heart Failure. Heart Fail Clin 2008; 4:519-34. [DOI: 10.1016/j.hfc.2008.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
12
|
Pasquale PD, Sarullo FM, Paterna S. Novel strategies: challenge loop diuretics and sodium management in heart failure--Part I. ACTA ACUST UNITED AC 2007; 13:93-8. [PMID: 17392613 DOI: 10.1111/j.1527-5299.2007.06022.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This is the first of a 2-part series. This article reviews the relationships among diuretics, neurohormonal activation, renal function, fluid and Na management, the cardiorenal syndrome, and heart failure. Part II will describe novel therapies based on these relationships, focusing particularly on vasopressin antagonists and treatment using hypertonic saline solution with high-dose loop diuretics. Heart failure (HF) is a complex hemodynamic disorder characterized by chronic and progressive pump failure and fluid accumulation. Diuretics are a vital component of symptomatic management, and enhancing diuretic response in the setting of diuretic resistance is therefore pivotal. In HF patients treated with diuretics, compensatory pathophysiologic mechanisms to maintain vascular resistance, such as nonosmotic stimulation of vasopressin secretion and activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, promote renal Na and water reabsorption. Thus, there remains a need to develop novel therapies for HF patients who are refractory to conventional medical treatment. The conflicting results of diuretic treatments in HF and the importance of Na management in the context of the cardiorenal syndrome and neurohormonal activation have suggested novel and counterintuitive strategies, focusing primarily on the use of vasopressin antagonists and hypertonic saline solution with high doses of loop diuretics and neurohormonal interference. The authors review the current evidence for these therapies and suggest hypothetical bases for their efficacy.
Collapse
Affiliation(s)
- Pietro Di Pasquale
- Division of Cardiology "Paolo Borsellino", G.F. Ingrassia Hospital, Palermo, Italy.
| | | | | |
Collapse
|
13
|
Abstract
Diuretics are an established foundation of therapy for patients with chronic heart failure (HF) as well as for those hospitalized for treatment of acute HF syndromes. Despite the accepted use of diuretics in acute HF syndromes, treatment patterns with diuretics vary widely, and there are no data from randomized studies on the benefit of diuretics on morbidity or mortality in patients hospitalized with acute HF syndromes. Additional pharmacologic therapies that complement or replace diuretics in this setting, especially in patients with diuretic resistance, include positive inotropes, nitrovasodilators, and natriuretic peptides, but data are likewise lacking on important clinical outcomes. Ultrafiltration has also been used as a nonpharmacologic strategy to treat patients with acute HF syndromes who exhibit resistance to diuretics. Effective monitoring of volume status with newer modalities may allow more selective use of diuretics and diuretic-like modalities, but additional randomized trial data are clearly needed to establish ideal strategies to promote volume removal in acute HF syndromes.
Collapse
Affiliation(s)
- James A Hill
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA.
| | | | | |
Collapse
|
14
|
Simmonds J, Franklin O, Burch M. Understanding the pathophysiology of paediatric heart failure and its treatment. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.cupe.2006.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|