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Roca LN, García MC, Germán JB, Becerra AJB, Otero JMR, Chapel JAE, López CR, Lázaro AMP, Urquía MT, Tuñón J. Use and Benefit of Sacubitril/Valsartan in Elderly Patients with Heart Failure with Reduced Ejection Fraction. J Clin Med 2024; 13:4772. [PMID: 39200914 PMCID: PMC11355447 DOI: 10.3390/jcm13164772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/08/2024] [Accepted: 08/11/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Heart failure (HF) is a highly prevalent syndrome in elderly subjects. Currently, multiple drugs have shown clinical benefits in patients with HF and reduced ejection fraction (HFrEF). However, evidence is scarce in elderly patients (beyond 75 years old), even more so for the latest drugs, such as angiotensin receptor-neprilysin inhibitors (ARNIs). This study aims to evaluate the use and benefits of ARNIs in elderly patients with HFrEF. Methods: A prospective observational cohort study was designed. Patients with left ventricular systolic dysfunction (defined by left ventricular ejection fraction [LVEF] < 40%) and age ≥ 75 years from January 2016 to December 2020 were prospectively included. Patients with an indication for ARNIs at inclusion or throughout follow-up were selected. Clinical, electrocardiographic and echocardiographic variables were collected. Results: A total of 616 patients were included, 34.4% of them female, with a mean age of 83.3 years, mean LVEF of 28.5% and ischemic etiology in 53.9% of patients. Only 14.3% of patients were taking ARNIs. After a mean follow-up of 34 months, 50.2% of patients died, and 62.2% had a cardiac event (total mortality or hospital admission due to HF). Multivariate Cox regression analysis showed that the use of ARNIs was independently and significantly associated with lower rates of mortality [HR 0.36 (95% CI 0.21-0.61)], with similar results in relation to all-cause mortality in a propensity-score-matched analysis [HR 0.33 (95% CI 0.19-0.57)]. Conclusions: We observed an important underuse of ARNIs in a cohort of elderly HFrEF patients, in which treatment with ARNIs was associated with a significant reduction in mortality. Greater implementation of clinical practice guidelines in this group of patients could improve their prognosis.
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Affiliation(s)
- Luis Nieto Roca
- Cardiology Department, Son Espases University Hospital, 07120 Balearic Islands, Spain;
| | - Marcelino Cortés García
- Cardiology Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain (J.T.)
| | - Jorge Balaguer Germán
- Cardiology Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain (J.T.)
| | | | - José María Romero Otero
- Cardiology Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain (J.T.)
| | | | - Carlos Rodríguez López
- Cardiology Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain (J.T.)
| | - Ana María Pello Lázaro
- Cardiology Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain (J.T.)
| | - Mikel Taibo Urquía
- Cardiology Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain (J.T.)
| | - José Tuñón
- Cardiology Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain (J.T.)
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Pina PMR, Arcon LC, Zatz R, Moysés RMA, Elias RM. Older patients are less prone to fast decline of renal function: a propensity-matched study. Int Urol Nephrol 2023; 55:3245-3252. [PMID: 37160835 DOI: 10.1007/s11255-023-03610-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/24/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE Despite CKD is common among older patients, and although factors associated with CKD progression have been explored over decades, little is known about the decline of renal function specifically in older individuals. METHODS We included adult patients with CKD on conservative management in a propensity-score matched study 1:1 older (> 65 year) and young (≤ 65 yr). Factors associated with the slope of the decline of eGFR such as proteinuria, initial eGFR, diabetes, sex, and use of angiotensin-converting enzyme inhibitor/angiotensin receptor block (ACEI/ARB) were analyzed. Inclusion criteria were at least two consultations in the service and an initial eGFR lower than 45 ml/min/m2, in the period between January 2012 and December 2017. RESULTS Crude analysis of eGFR decline shows a slower progression of older patients when compared to younger patients in both absolute change [- 2.0 (- 4.5, - 1.0) vs. -3.0 (- 7.0, - 1.0) ml/min/1.73m2, p < 0.001] and slope of eGFR reduction [- 2.2 (- 4.4, - 1.0) vs. 3.1 (- 6.7, - 1.2)) ml/min/1.73m2, p < 0.001]. Patients considered fast progressors (> 5 ml/min/1.73 m2/year decline in eGFR) were less likely to be older (35.2% young vs. 22.0% older, p < 0.001). Adjusted logistic multivariate regression confirmed that older patients had less odds ratio of eGFR decline, independently of the presence of proteinuria, diabetes, ACEI/ARB use, sex, baseline eGFR, baseline phosphate and baseline 25(OH) vitamin D. CONCLUSION Older patients present slower CKD progression even after multiple adjustments. This information should be taken into consideration while treating these patients on conservative management and should be kept in mind while planning dialysis start.
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Affiliation(s)
- Paula M R Pina
- LIM 16, Faculdade de Medicina da Universidade de São Paulo, Serviço de Nefrologia, Rua Dr. Enéas de Carvalho Aguiar 255, 7º Andar, São Paulo, SP, CEP, 05403-000, Brazil
| | - Luis Carlos Arcon
- LIM 16, Faculdade de Medicina da Universidade de São Paulo, Serviço de Nefrologia, Rua Dr. Enéas de Carvalho Aguiar 255, 7º Andar, São Paulo, SP, CEP, 05403-000, Brazil
| | - Roberto Zatz
- LIM 16, Faculdade de Medicina da Universidade de São Paulo, Serviço de Nefrologia, Rua Dr. Enéas de Carvalho Aguiar 255, 7º Andar, São Paulo, SP, CEP, 05403-000, Brazil
| | - Rosa M A Moysés
- LIM 16, Faculdade de Medicina da Universidade de São Paulo, Serviço de Nefrologia, Rua Dr. Enéas de Carvalho Aguiar 255, 7º Andar, São Paulo, SP, CEP, 05403-000, Brazil
| | - Rosilene M Elias
- Universidade Nove de Julho (UNINOVE), Sao Paulo, Brazil.
- LIM 16, Faculdade de Medicina da Universidade de São Paulo, Serviço de Nefrologia, Rua Dr. Enéas de Carvalho Aguiar 255, 7º Andar, São Paulo, SP, CEP, 05403-000, Brazil.
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Folkerts K, Millier A, Smela B, Olewinska E, Schmedt N, Mernagh P, Kovesdy CP. Real-world evidence for steroidal mineralocorticoid receptor antagonists in patients with chronic kidney disease. J Nephrol 2022; 36:1135-1167. [DOI: 10.1007/s40620-022-01492-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022]
Abstract
Abstract
Background
Mineralocorticoid receptor antagonists (MRAs) were shown to delay chronic kidney disease (CKD) progression in patients with hypertension and/or heart failure (HF) and proteinuria.
Objective
We conducted a systematic literature review on real-world evidence to identify the literature gaps related to the efficacy and safety outcomes of MRAs administered to CKD patients.
Results
A total of 751 records were identified of which, 23 studies (26 publications) were analyzed. Studies included heterogeneous populations, including the overall CKD, CKD and diabetes, CKD and HF, and CKD and a history of cardiovascular disease. Most of the studies were small and non-rigorous, resulting in a notable lack of evidence in these populations. In the overall CKD population, steroidal MRAs resulted in a significant or sustained eGFR reduction but no efficacy in delaying progression to end-stage kidney disease. No cardiovascular protection was found. Results for all-cause mortality and hospitalization for HF were inconsistent; however, the longest follow-up studies indicate similar or lower incidence for spironolactone non-users. Most results consistently reported a higher incidence of hyperkalemia among patients on steroidal MRAs in all CKD stages, and side effects led to high discontinuation rates in the real-world setting.
Conclusions
Despite the limited availability of evidence on the effectiveness and safety of steroidal MRAs in CKD patients and subgroups with diabetes, HF or history of cardiovascular disease, MRAs were shown to have a limited effect on renal and cardiovascular outcomes. Gaps in the evidence regarding the efficacy and safety of MRAs are particularly relevant in diabetic CKD patients; therefore, further research is warranted.
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Wang B, Zhang L, Hu S, Bai X, Li X, Li J, Zheng X. Use of angiotensin receptor blocker is associated with improved 1 year mortality in heart failure with mid-range ejection fraction. ESC Heart Fail 2021; 8:1438-1445. [PMID: 33619915 PMCID: PMC8006710 DOI: 10.1002/ehf2.13229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/29/2020] [Accepted: 01/18/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS Current evidence about the effect of angiotensin receptor blocker (ARB) on the outcome of heart failure with mid-range ejection fraction (HFmrEF) is lacking. We aim to assess the association between use of ARB and 1 year all-cause mortality after hospitalization for HFmrEF. METHODS AND RESULTS We analysed the data of patients with ejection fraction of 40-49% in China Patient-centred Evaluative Assessment of Cardiac Events Prospective Heart Failure Study; 4907 patients hospitalized for heart failure from 52 Chinese hospitals were enrolled from August 2016 to May 2018. Use of ARB was determined by prescriptions at discharge. Patients who died during hospitalization or were using angiotensin-converting enzyme inhibitors at discharge were excluded. The association between the use of ARB and outcome was assessed using stabilized inverse probability of treatment weighting-adjusted Kaplan-Meier and Cox regression analyses. A total of 701 patients with HFmrEF were included for analysis. The mean age was 66.4 ± 12.8 years, and 267 (38.1%) were female. Of them, 244 were treated (34.8%) with ARB. During the 1 year follow-up period, patients treated with ARB had lower all-cause mortality compared with untreated patients (11.5% vs. 21.9%, P = 0.0005). Inverse probability of treatment weighting-adjusted Cox regression analysis showed that use of ARB was associated with significantly reduced all-cause mortality (adjusted hazard ratio 0.44, 95% confidence interval 0.28-0.69, P = 0.0004). CONCLUSIONS Among patients hospitalized for HFmrEF, the use of ARB was associated with lower 1 year mortality after discharge.
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Affiliation(s)
- Bin Wang
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBuilding C, Fengcunxili 15, Mentougou DistrictBeijingChina
| | - Lihua Zhang
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBuilding C, Fengcunxili 15, Mentougou DistrictBeijingChina
| | - Shuang Hu
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBuilding C, Fengcunxili 15, Mentougou DistrictBeijingChina
| | - Xueke Bai
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBuilding C, Fengcunxili 15, Mentougou DistrictBeijingChina
| | - Xi Li
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBuilding C, Fengcunxili 15, Mentougou DistrictBeijingChina
| | - Jing Li
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBuilding C, Fengcunxili 15, Mentougou DistrictBeijingChina
| | - Xin Zheng
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBuilding C, Fengcunxili 15, Mentougou DistrictBeijingChina
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Beta-blocker therapy in elderly patients with renal dysfunction and heart failure. J Geriatr Cardiol 2021; 18:20-29. [PMID: 33613656 PMCID: PMC7868915 DOI: 10.11909/j.issn.1671-5411.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the role of beta-blockers (BB) in patients with chronic kidney disease (CKD) aged ≥ 75 years. METHODS AND RESULTS From January 2008 to July 2014, we included 390 consecutive patients ≥ 75 years of age with ejection fraction ≤ 35% and glomerular filtration rate (GFR) ≤ 60 mL/min per 1.73 m2. We analyzed the relationship between treatment with BB and mortality or cardiovascular events. The mean age of our population was 82.6 ± 4.1 years. Mean ejection fraction was 27.9% ± 6.5%. GFR was 60-45 mL/min per 1.73 m2 in 50.3% of patients, 45-30 mL/min per 1.73 m2 in 37.4%, and < 30 mL/min per 1.73 m 2 in 12.3%. At the conclusion of follow-up, 67.4% of patients were receiving BB. The median follow-up was 28.04 (IR: 19.41-36.67) months. During the study period, 211 patients (54.1%) died and 257 (65.9%) had a major cardiovascular event (death or hospitalization for heart failure). BB use was significantly associated with a reduced risk of death (HR = 0.51, 95% CI: 0.35-0.74;P < 0.001). Patients receiving BB consistently showed a reduced risk of death across the different stages of CKD: stage IIIa (GFR = 30-45 mL/min per 1.73 m 2; HR = 0.47, 95% CI: 0.26-0.86,P < 0.0001), stage IIIb (GFR 30-45 mL/min per 1.73 m 2; HR = 0.55, 95% CI: 0.26-1.06,P = 0.007), and stages IV and V (GFR < 30 mL/min per 1.73 m 2; HR = 0.29, 95% CI: 0.11-0.76;P = 0.047). CONCLUSIONS The use of BB in elderly patients with HFrEF and renal impairment was associated with a better prognosis. Use of BB should be encouraged when possible.
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Singhania N, Bansal S, Mohandas S, Nimmatoori DP, Ejaz AA, Singhania G. Role of renin-angiotensin-aldosterone system inhibitors in heart failure and chronic kidney disease. Drugs Context 2020; 9:dic-2020-7-3. [PMID: 33240389 PMCID: PMC7673621 DOI: 10.7573/dic.2020-7-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/11/2022] Open
Abstract
Renin–angiotensin–aldosterone system (RAAS) inhibitors are the key medications for patients with heart failure and chronic kidney disease. Multiple randomized controlled trials have demonstrated their benefits in an outpatient setting for the treatment of chronic heart failure. Additional advantages in acute heart failure treatment during inpatient hospitalization are less clear but a small number of non-randomized studies have favored their use. Conditions that result in stoppage of RAAS inhibitors during inpatient stay are an increase in serum creatinine, hyperkalemia, and hemodynamic instability such as hypotension. The role of RAAS inhibitors in chronic kidney disease has also been documented in multiple randomized controlled trials, with their use in hypertension and proteinuria being unambiguous. This narrative review summarizes the role of RAAS inhibitors in acute and chronic heart failure and chronic kidney disease.
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Affiliation(s)
- Namrata Singhania
- Department of Hospital Medicine, Mount Carmel East Hospital, Columbus, OH, USA
| | - Saurabh Bansal
- Department of Internal Medicine, University of Illinois at Peoria, Peoria, IL, USA
| | | | | | - Abutaleb A Ejaz
- Division of Nephrology and Hypertension, University of Florida, Gainesville, FL, USA
| | - Girish Singhania
- Division of Hospital Medicine, CHI St Vincent Infirmary, Little Rock, AR, USA.,Department of Nephrology and Hypertension, University of Utah, Salt Lake City, UT, USA
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Roy L, Zappitelli M, White-Guay B, Lafrance JP, Dorais M, Perreault S. Agreement Between Administrative Database and Medical Chart Review for the Prediction of Chronic Kidney Disease G category. Can J Kidney Health Dis 2020; 7:2054358120959908. [PMID: 33101698 PMCID: PMC7549183 DOI: 10.1177/2054358120959908] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 08/12/2020] [Indexed: 01/13/2023] Open
Abstract
Background Chronic kidney disease (CKD) is a major health issue and cardiovascular risk factor. Validity assessment of administrative data for the detection of CKD in research for drug benefit and risk using real-world data is important. Existing algorithms have limitations and we need to develop new algorithms using administrative data, giving the importance of drug benefit/risk ratio in real world. Objective The aim of this study was to validate a predictive algorithm for CKD GFR category 4-5 (eGFR < 30 mL/min/1.73 m2 but not receiving dialysis or CKD G4-5ND) using the administrative databases of the province of Quebec relative to estimated glomerular filtration rate (eGFR) as a reference standard. Design This is a retrospective cohort study using chart collection and administrative databases. Setting The study was conducted in a community outpatient medical clinic and pre-dialysis outpatient clinic in downtown Montreal and rural area. Patients Patient medical files with at least 2 serum creatinine measures (up to 1 year apart) between September 1, 2013, and June 30, 2015, were reviewed consecutively (going back in time from the day we started the study). We excluded patients with end-stage renal disease on dialysis. The study was started in September 2013. Measurement Glomerular filtration rate was estimated using the CKD Epidemiological Collaboration (CKD-EPI) from each patient's file. Several algorithms were developed using 3 administrative databases with different combinations of physician claims (diagnostics and number of visits) and hospital discharge data in the 5 years prior to the cohort entry, as well as specific drug use and medical intervention in preparation for dialysis in the 2 years prior to the cohort entry. Methods Chart data were used to assess eGFR. The validity of various algorithms for detection of CKD groups was assessed with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results A total of 434 medical files were reviewed; mean age of patients was 74.2 ± 10.6 years, and 83% were older than 65 years. Sensitivity of algorithm #3 (diagnosis within 2-5 years and/or specific drug use within 2 years and nephrologist visit ≥4 within 2-5 years) in identification of CKD G4-5ND ranged from 82.5% to 89.0%, specificity from 97.1% to 98.9% with PPV and NPV ranging from 94.5% to 97.7% and 91.1% to 94.2%, respectively. The subsequent subgroup analysis (diabetes, hypertension, and <65 and ≥65 years) and also the comparisons of predicted prevalence in a cohort of older adults relative to published data emphasized the accuracy of our algorithm for patients with severe CKD (CKD G4-5ND). Limitations Our cohort comprised mostly older adults, and results may not be generalizable to all adults. Participants with CKD without 2 serum creatinine measurements up to 1 year apart were excluded. Conclusions The case definition of severe CKD G4-5ND derived from an algorithm using diagnosis code, drug use, and nephrologist visits from administrative databases is a valid algorithm compared with medical chart reviews in older adults.
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Affiliation(s)
- Louise Roy
- Faculty of Medicine, University of Montreal, University of Montreal Hospital Center, QC, Canada
| | - Michael Zappitelli
- Faculty of Medicine, Department of Pediatrics, Pediatric Nephrology, Toronto Hospital for Sick Children, University of Toronto, ON, Canada
| | | | - Jean-Philippe Lafrance
- Faculty of Medicine, Department of Pharmacology and Physiology, University of Montreal, QC, Canada
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l'Île-Perrot, QC, Canada
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Khan T, Awadalla AF. Survival rates in elderly patients with heart failure. Eur J Heart Fail 2019; 22:566. [PMID: 31840348 DOI: 10.1002/ejhf.1712] [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: 10/06/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 11/06/2022] Open
Affiliation(s)
- Tahira Khan
- University College London Medical School, London, UK
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