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Pintalhao M, Vasques-Nóvoa F, Barros AS, Lourenço P, Couto-Viana B, Leite-Moreira A, Bettencourt P, Castro-Chaves P. Prognostic association of circulating relaxin-2 in acute heart failure. Int J Cardiol 2024:132358. [PMID: 39002802 DOI: 10.1016/j.ijcard.2024.132358] [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: 02/14/2024] [Revised: 05/29/2024] [Accepted: 07/10/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Despite the increasing interest in the study of the endogenous relaxin system in heart failure (HF), its role as a prognostic marker in acute HF remains unclear. We aimed to evaluate the association of relaxin-2 circulating levels with 6 months' mortality in acute HF. METHODS We evaluated relaxin-2 serum levels at admission in a cohort of patients with acute HF (n = 202) using an enzyme immunoassay. The ability of relaxin-2 to predict all-cause death (primary outcome) and HF-specific death (secondary outcome) at 6 months was assessed using Cox-regression analysis. RESULTS The median age was 79 (70-85) years old, 44% of the patients were male, and 43% had preserved ejection fraction (≥50%). Median serum relaxin-2 level was 25 pg/mL. Patients with higher relaxin-2 levels had more peripheral oedemas, higher sodium retention score, higher pulmonary artery pressures, higher prevalence of right ventricle dysfunction and lower inferior vena cava collapse at inspiration. Conversely, there was no association with left chambers parameters or with B-type natriuretic peptide (BNP). Higher relaxin-2 concentrations were associated with a higher risk of all-cause death [HR 1.15; 95%CI 1.01,1.30; P = 0.030] and HF-specific death [HR 1.21; 95% CI 1.03-1.42; P = 0.018], after adjustment for classical prognostic factors such as age, sex and BNP. CONCLUSIONS In our acute HF population, relaxin-2 circulating levels were associated with clinical and echocardiographic markers of systemic congestion and with 6-months' mortality, independently of BNP. These results lay the groundwork for future investigations on the potential of relaxin-2 as an auxiliary biomarker in HF.
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Affiliation(s)
- Mariana Pintalhao
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Internal Medicine Department, Unidade Local de Saúde de São João, Porto, Portugal.
| | - Francisco Vasques-Nóvoa
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Internal Medicine Department, Unidade Local de Saúde de São João, Porto, Portugal
| | - António S Barros
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Patrícia Lourenço
- UnIC@RISE, Department of Medicine, Faculty of Medicine of the University of Porto, Internal Medicine Department, Unidade Local de Saúde de São João, Porto, Portugal
| | - Benedita Couto-Viana
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Paulo Bettencourt
- UnIC@RISE, Department of Medicine, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Paulo Castro-Chaves
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Internal Medicine Department, Unidade Local de Saúde de São João, Porto, Portugal
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Pellicori P, Cleland JGF, Borentain M, Taubel J, Graham FJ, Khan J, Bruzzese D, Kessler P, McMurray JJV, Voors AA, O'Connor CM, Teerlink JR, Felker GM. Impact of vasodilators on diuretic response in patients with congestive heart failure: A mechanistic trial of cimlanod (BMS-986231). Eur J Heart Fail 2024; 26:142-151. [PMID: 37990754 DOI: 10.1002/ejhf.3077] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/04/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023] Open
Abstract
AIM To investigate the effects of Cimlanod, a nitroxyl donor with vasodilator properties, on water and salt excretion after an administration of an intravenos bolus of furosemide. METHODS AND RESULTS In this randomized, double-blind, mechanistic, crossover trial, 21 patients with left ventricular ejection fraction <45%, increased plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and receiving loop diuretics were given, on separate study days, either an 8 h intravenous (IV) infusion of cimlanod (12 μg/kg/min) or placebo. Furosemide was given as a 40 mg IV bolus four hours after the start of infusion. The primary endpoint was urine volume in the 4 h after the bolus of furosemide during infusion of cimlanod compared with placebo. Median NT-proBNP at baseline was 1487 (interquartile range: 847-2665) ng/L. Infusion of cimlanod increased cardiac output and reduced blood pressure without affecting cardiac power index consistent with its vasodilator effects. Urine volume in the 4 h post-furosemide was lower with cimlanod (1032 ± 393 ml) versus placebo (1481 ± 560 ml) (p = 0.002), as were total sodium excretion (p = 0.004), fractional sodium excretion (p = 0.016), systolic blood pressure (p < 0.001), estimated glomerular filtration rate (p = 0.012), and haemoglobin (p = 0.010), an index of plasma volume expansion. CONCLUSIONS For patients with heart failure and congestion, vasodilatation with agents such as cimlanod reduces the response to diuretic agents, which may offset any benefit from acute reductions in cardiac preload and afterload.
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Affiliation(s)
- Pierpaolo Pellicori
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - John G F Cleland
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | | | - Jorg Taubel
- Richmond Pharmacology Ltd, St. George's University of London, London, UK
| | - Fraser J Graham
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Javed Khan
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Dario Bruzzese
- Department of Public Health, University of Naples 'Federico II', Naples, Italy
| | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - G Michael Felker
- Duke University School of Medicine and the Duke Clinical Research Institute, Durham, NC, USA
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3
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Kallash M, Mahan JD. Mechanisms and management of edema in pediatric nephrotic syndrome. Pediatr Nephrol 2021; 36:1719-1730. [PMID: 33216218 DOI: 10.1007/s00467-020-04779-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 08/18/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
Edema is the abnormal accumulation of fluid in the interstitial compartment of tissues within the body. In nephrotic syndrome, edema is often seen in dependent areas such as the legs, but it can progress to cause significant accumulation in other areas leading to pulmonary edema, ascites, and/or anasarca. In this review, we focus on mechanisms and management of edema in children with nephrotic syndrome. We review the common mechanisms of edema, its burden in pediatric patients, and then present our approach and algorithm for management of edema in pediatric patients. The extensive body of experience accumulated over the last 5 decades means that there are many options, and clinicians may choose among these options based on their experience and careful monitoring of responses in individual patients.
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Affiliation(s)
- Mahmoud Kallash
- Division of Pediatric Nephrology, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205, USA. .,The Ohio State University College of Medicine, Columbus, OH, USA.
| | - John D Mahan
- Division of Pediatric Nephrology, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205, USA.,The Ohio State University College of Medicine, Columbus, OH, USA
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4
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Massari F, Scicchitano P, Iacoviello M, Valle R, Sanasi M, Piscopo A, Guida P, Mastropasqua F, Caldarola P, Ciccone MM. Serum biochemical determinants of peripheral congestion assessed by bioimpedance vector analysis in acute heart failure. Heart Lung 2019; 48:395-399. [PMID: 31113676 DOI: 10.1016/j.hrtlng.2019.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/21/2019] [Accepted: 04/23/2019] [Indexed: 01/09/2023]
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Kobayashi M, Watanabe M, Coiro S, Bercker M, Paku Y, Iwasaki Y, Chikamori T, Yamashina A, Duarte K, Ferreira JP, Rossignol P, Zannad F, Girerd N. Mid-term prognostic impact of residual pulmonary congestion assessed by radiographic scoring in patients admitted for worsening heart failure. Int J Cardiol 2019; 289:91-98. [DOI: 10.1016/j.ijcard.2019.01.091] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 12/03/2018] [Accepted: 01/25/2019] [Indexed: 12/28/2022]
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6
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Shoaib A, Mamas MA, Ahmad QS, McDonagh TM, Hardman SM, Rashid M, Butler R, Duckett S, Satchithananda D, Nolan J, Dargie HJ, Clark AL, Cleland JG. Characteristics and outcome of acute heart failure patients according to the severity of peripheral oedema. Int J Cardiol 2019; 285:40-46. [DOI: 10.1016/j.ijcard.2019.03.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/10/2019] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
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Effect of intravenous carperitide versus nitrates as first-line vasodilators on in-hospital outcomes in hospitalized patients with acute heart failure: Insight from a nationwide claim-based database. Int J Cardiol 2019; 280:104-109. [DOI: 10.1016/j.ijcard.2019.01.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/05/2018] [Accepted: 01/14/2019] [Indexed: 12/28/2022]
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Keeble TR, Karamasis GV, Rothman MT, Ricksten SE, Ferrari M, Hullin R, Scherstén F, Reitan O, Kirking ST, Cleland JG, Smith EJ. Percutaneous haemodynamic and renal support in patients presenting with decompensated heart failure: A multi-centre efficacy study using the Reitan Catheter Pump (RCP). Int J Cardiol 2019; 275:53-58. [DOI: 10.1016/j.ijcard.2018.09.085] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 09/07/2018] [Accepted: 09/24/2018] [Indexed: 01/11/2023]
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Fudim M, Parikh KS, Dunning A, DeVore AD, Mentz RJ, Schulte PJ, Armstrong PW, Ezekowitz JA, Tang WHW, McMurray JJV, Voors AA, Drazner MH, O'Connor CM, Hernandez AF, Patel CB. Relation of Volume Overload to Clinical Outcomes in Acute Heart Failure (From ASCEND-HF). Am J Cardiol 2018; 122:1506-1512. [PMID: 30172362 DOI: 10.1016/j.amjcard.2018.07.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 07/15/2018] [Accepted: 07/18/2018] [Indexed: 01/01/2023]
Abstract
We aimed to study whether jugular venous distension (JVD) and peripheral edema were associated with worse outcomes in patients with acute heart failure in the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure trial. Of 7,141 patients in Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure, 7,135 had complete data on baseline JVD and peripheral edema status. Patients were grouped according to baseline examination findings: (1) no JVD or peripheral edema; (2) JVD only; (3) peripheral edema only; (4) JVD and peripheral edema. We used unadjusted and adjusted logistic or Cox regression analyses to assess associations between groups and the outcomes of index length of stay (LOS), in-hospital mortality, 30- and 180-day all-cause mortality. Patients with peripheral edema (Groups 3 and 4) had higher body mass index, NT-proBNP and BNP values, and more co-morbid disease, and reduced left ventricular ejection fraction compared with patients in Groups 1-2. The median (25th-75th) LOS for Groups 1-4 was 6 (4-9), 5 (4-8), 7 (4-11), and 6 days (4-10), respectively. For the 30-day and 180-day outcomes, adjusted analyses found no significant difference in risk for patients presenting with JVD only or peripheral edema only as compared with patients without evidence of JVD or peripheral edema (p >0.05 for all). The presence of both JVD and peripheral edema was associated with an adjusted 24% increase in risk for all-cause mortality at 30 days, but no risk difference at 180 days. In conclusion, in patients with heart failure presenting to the hospital with dyspnea, the presence of peripheral edema is associated with a longer hospital LOS, but no difference in short- and long-term clinical outcomes when compared with patients wihout peripheral edema. The combination of peripheral edema and JVD identifies the highest risk cohort for poor clinical outcomes.
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Affiliation(s)
- Marat Fudim
- Duke Clinical Research Institute, Durham, North Carolina.
| | | | | | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta
| | | | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, the Netherlands
| | - Mark H Drazner
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Chetan B Patel
- Duke Clinical Research Institute, Durham, North Carolina
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Shoaib A, Farag M, Nolan J, Rigby A, Patwala A, Rashid M, Kwok CS, Perveen R, Clark AL, Komajda M, Cleland JGF. Mode of presentation and mortality amongst patients hospitalized with heart failure? A report from the First Euro Heart Failure Survey. Clin Res Cardiol 2018; 108:510-519. [PMID: 30361818 PMCID: PMC6484773 DOI: 10.1007/s00392-018-1380-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/25/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Heart failure is heterogeneous in aetiology, pathophysiology, and presentation. Despite this diversity, clinical trials of patients hospitalized for HF deal with this problem as a single entity, which may be one reason for repeated failures. METHODS The first EuroHeart Failure Survey screened consecutive deaths and discharges of patients with suspected heart failure during 2000-2001. Patients were sorted into seven mutually exclusive hierarchical presentations: (1) with cardiac arrest/ventricular arrhythmia; (2) with acute coronary syndrome; (3) with rapid atrial fibrillation; (4) with acute breathlessness; (5) with other symptoms/signs such as peripheral oedema; (6) with stable symptoms; and (7) others in whom the contribution of HF to admission was not clear. RESULTS The 10,701 patients enrolled were classified into the above seven presentations as follows: 260 (2%), 560 (5%), 799 (8%), 2479 (24%), 1040 (10%), 703 (7%), and 4691 (45%) for which index-admission mortality was 26%, 20%, 10%, 8%, 6%, 6%, and 4%, respectively. Compared to those in group 7, the hazard ratios for death during the index admission were 4.9 (p ≤ 0.001), 4.0 (p < 0.001), 2.2 (p < 0.001), 2.1 (p < 0.001), 1.4 (p < 0.04) and 1.4 (p = 0.04), respectively. These differences were no longer statistically significant by 12 weeks. CONCLUSION There is great diversity in the presentation of heart failure that is associated with very different short-term outcomes. Only a minority of hospitalizations associated with suspected heart failure are associated with acute breathlessness. This should be taken into account in the design of future clinical trials.
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Affiliation(s)
- Ahmad Shoaib
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences and Centre for Prognosis Research, Keele University, Stoke on Trent, UK.
- Department of Academic Cardiology, University of Hull, Kingston upon Hull, UK.
| | - M Farag
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK
| | - J Nolan
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences and Centre for Prognosis Research, Keele University, Stoke on Trent, UK
| | - A Rigby
- Department of Academic Cardiology, University of Hull, Kingston upon Hull, UK
| | - A Patwala
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences and Centre for Prognosis Research, Keele University, Stoke on Trent, UK
| | - M Rashid
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences and Centre for Prognosis Research, Keele University, Stoke on Trent, UK
| | - C S Kwok
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences and Centre for Prognosis Research, Keele University, Stoke on Trent, UK
| | - R Perveen
- Department of Academic Cardiology, University of Hull, Kingston upon Hull, UK
| | - A L Clark
- Department of Academic Cardiology, University of Hull, Kingston upon Hull, UK
| | - M Komajda
- Department of Cardiology, University of Pierre and Marie Curie Paris VI, La Pitié-Salpêtrière Hospital, Paris, France
| | - J G F Cleland
- Robertson Centre for Biostatistics, University of Glasgow and National Heart and Lung Institute, Imperial College London, London, UK
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Combined use of lung ultrasound, B-type natriuretic peptide, and echocardiography for outcome prediction in patients with acute HFrEF and HFpEF. Clin Res Cardiol 2018. [PMID: 29532155 DOI: 10.1007/s00392-018-1221-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Lung ultrasound (LUS) can be used to assess pulmonary congestion by imaging B-lines ('comets') for patients with acute heart failure (AHF). OBJECTIVES Investigate relationship of B-lines, plasma concentrations of B-type natriuretic peptide (BNP), and echocardiographic left ventricular (LV) function measured at admission and discharge and their relationship to prognosis for AHF with preserved (HFpEF) or reduced (HFrEF) LV ejection fraction. METHODS Patients with AHF had the above tests done at admission and discharge. The primary outcome was re-hospitalization for heart failure or death at 6 months. RESULTS Of 162 patients enrolled, 95 had HFrEF and 67 had HFpEF, median age was 80 [77-85] years, and 85 (52%) were women. The number of B-lines at admission (median 31 [27-36]) correlated with respiratory rate (r = 0.75; p < 0.001), BNP (r = 0.43; p < 0.001), clinical congestion score (r = 0.25; p = 0.001), and systolic pulmonary artery pressure (r = 0.42; p < 0.001). At discharge, B-lines were also correlated with BNP (r = 0.69; p < 0.001) and congestion score (r = 0.57; p < 0.001). B-line count at discharge predicted outcome (AUC 0.83 [0.77-0.90]; univariate HR 1.12 [1.09-1.16]; p < 0.001; multivariable HR 1.16 [1.11-1.21]; p < 0.001). Results were similar for HFpEF and HFrEF. CONCLUSIONS LUS appears a useful method to assess severity and monitor the resolution of lung congestion. At hospital admission, B-lines are strongly related to respiratory rate, which may be a key component of the sensation of dyspnea. Measurement of lung congestion at discharge provides prognostic information for patients with either HFpEF or HFrEF.
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