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Lukoschewitz JD, Miger KC, Olesen ASO, Caidi NOE, Jørgensen CK, Nielsen OW, Hassager C, Hove JD, Seven E, Møller JE, Jakobsen JC, Grand J. Vasodilators for Acute Heart Failure - A Systematic Review with Meta-Analysis. NEJM EVIDENCE 2024; 3:EVIDoa2300335. [PMID: 38804781 DOI: 10.1056/evidoa2300335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
BACKGROUND Acute heart failure is a public health concern. This study systematically reviewed randomized clinical trials (RCTs) to evaluate vasodilators in acute heart failure. METHODS The search was conducted across the databases of Medline, Embase, Latin American and the Caribbean Literature on Health Sciences, Web of Science, and the Cochrane Central Register of Controlled Trials. Inclusion criteria consisted of RCTs that compared vasodilators versus standard care, placebo, or cointerventions. The primary outcome was all-cause mortality; secondary outcomes were serious adverse events (SAEs), tracheal intubation, and length of hospital stay. Risk of bias was assessed in all trials. RESULTS The study included 46 RCTs that enrolled 28,374 patients with acute heart failure. Vasodilators did not reduce the risk of all-cause mortality (risk ratio, 0.95; 95% confidence interval [CI], 0.87 to 1.04; I2=9.51%; P=0.26). No evidence of a difference was seen in the risk of SAEs (risk ratio, 1.01; 95% CI, 0.97 to 1.05; I2=0.94%) or length of hospital stay (mean difference, -0.10; 95% CI, -0.28 to 0.08; I2=69.84%). Vasodilator use was associated with a lower risk of tracheal intubation (risk ratio, 0.54; 95% CI, 0.30 to 0.99; I2=51.96%) compared with no receipt of vasodilators. CONCLUSIONS In this systematic review with meta-analysis of patients with acute heart failure, vasodilators did not reduce all-cause mortality.
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Affiliation(s)
- Jasmin D Lukoschewitz
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
| | - Kristina C Miger
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
| | - Anne Sophie O Olesen
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
| | - Nora O E Caidi
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
| | - Caroline K Jørgensen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Olav W Nielsen
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Christian Hassager
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen
| | - Jens D Hove
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Ekim Seven
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
| | - Jacob E Møller
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen
- Department of Clinical Medicine, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johannes Grand
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
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2
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Grand J, Nielsen OW, Møller JE, Hassager C, Jakobsen JC. Vasodilators for acute heart failure – a protocol for a systematic review of randomized clinical trials with meta‐analysis and Trial Sequential Analysis. Acta Anaesthesiol Scand 2022; 66:1156-1164. [PMID: 36054782 PMCID: PMC9542024 DOI: 10.1111/aas.14130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/30/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Johannes Grand
- Department of Cardiology Copenhagen University Hospital Hvidovre and Amager‐Hospital, Kettegård Alle 30 Copenhagen Denmark
| | - Olav W. Nielsen
- Department of Cardiology Bispebjerg Hospital Copenhagen University Hospital, Rigshospitalet Bispebjerg Bakke 23 Copenhagen
- University of Copenhagen, Department of Clinical Medicine Copenhagen Denmark
| | - Jacob Eifer Møller
- The Heart Center, Copenhagen University Hospital Rigshospitalet, Department of Cardiology Copenhagen Denmark
- Odense University Hospital, Department of Cardiology, University of Southern Denmark, Department of Clinical Medicine Odense Denmark
| | - Christian Hassager
- The Heart Center, Copenhagen University Hospital Rigshospitalet, Department of Cardiology Copenhagen Denmark
- University of Copenhagen, Department of Clinical Medicine Copenhagen Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Department of Regional Health Research, Faculty of Health Sciences University of Southern Denmark Odense Denmark
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3
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Twiner MJ, Hennessy J, Wein R, Levy PD. Nitroglycerin Use in the Emergency Department: Current Perspectives. Open Access Emerg Med 2022; 14:327-333. [PMID: 35847764 PMCID: PMC9278720 DOI: 10.2147/oaem.s340513] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022] Open
Abstract
Nitroglycerin, a fast-acting vasodilator, is commonly used as a first-line agent for angina in the emergency department and to manage chest pain due to acute coronary syndromes. It is also a treatment option for other disease states such as acute heart failure, pulmonary edema, and aortic dissection. Nitroglycerin is converted to nitric oxide, a potent vasodilator, in the body, leading to venodilation at lower dosages and arteriodilation at higher dosages that results in both preload and afterload reduction, respectively. Although nitroglycerin has historically been administered as a sublingual tablet and/or spray, it is often given intravenously in the emergency department as this enables titration to effect with predictable pharmacokinetics. In this review article, we outline the indications, mechanism of action, contraindications, and adverse effects of nitroglycerin as well as review relevant literature and make general recommendations regarding the use of nitroglycerin in the emergency department.
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Affiliation(s)
- Michael J Twiner
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA.,Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - John Hennessy
- College of Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Rachel Wein
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA.,Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
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4
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Sax DR, Mark DG, Rana JS, Reed ME, Lindenfeld J, Stevenson LW, Storrow AB, Butler J, Pang PS, Collins SP. Current Emergency Department Disposition of Patients with Acute Heart Failure: An Opportunity for Improvement. J Card Fail 2022; 28:1545-1559. [DOI: 10.1016/j.cardfail.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/06/2022] [Accepted: 05/12/2022] [Indexed: 12/26/2022]
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Abstract
BACKGROUND Pharmacotherapies such as loop diuretics are the cornerstone treatment for acute heart failure (AHF), but resistance and poor response can occur. Ultrafiltration (UF) is an alternative therapy to reduce congestion, however its benefits, efficacy and safety are unclear. OBJECTIVES To assess the effects of UF compared to diuretic therapy on clinical outcomes such as mortality and rehospitalisation rates. SEARCH METHODS We undertook a systematic search in June 2021 of the following databases: CENTRAL, MEDLINE, Embase, Web of Science CPCI-S and ClinicalTrials.gov. We also searched the WHO ICTRP platform in October 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared UF to diuretics in adults with AHF. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for any further information, and language interpreters to translate texts. We assessed risk of bias in included studies using Risk of Bias 2 (RoB2) tool and assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 14 trials involving 1190 people. We included people who had clinical signs of acute hypervolaemia. We excluded critically unwell people such as those with ischaemia or haemodynamic instability. Mean age ranged from 57.5 to 75 years, and the setting was a mix of single and multi-centre. Two trials researched UF as a complimentary therapy to diuretics, while the remaining trials withheld diuretic use during UF. There was high risk of bias in some studies, particularly with deviations from the intended protocols from high cross-overs as well as missing outcome data for long-term follow-up. We are uncertain about the effect of UF on all-cause mortality at 30 days or less (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.13 to 2.85; 3 studies, 286 participants; very low-certainty evidence). UF may have little to no effect on all-cause mortality at the longest available follow-up (RR 1.00, 95% CI 0.73 to 1.36; 9 studies, 987 participants; low-certainty evidence). UF may reduce all-cause rehospitalisation at 30 days or less (RR 0.76, 95% CI 0.53 to 1.09; 3 studies, 337 participants; low-certainty evidence). UF may slightly reduce all-cause rehospitalisation at longest available follow-up (RR 0.91, 95% CI 0.79 to 1.05; 6 studies, 612 participants; low-certainty evidence). UF may reduce heart failure-related rehospitalisation at 30 days or less (RR 0.62, 95% CI 0.37 to 1.04; 2 studies, 395 participants; low-certainty evidence). UF probably reduces heart failure-related rehospitalisation at longest available follow-up, with a number needed to treat for an additional beneficial effect (NNTB) of 10 (RR 0.69, 95% CI 0.53 to 0.90; 4 studies, 636 participants; moderate-certainty evidence). No studies measured need for mechanical ventilation. UF may have little or no effect on serum creatinine change at 30 days since discharge (mean difference (MD) 14%, 95% CI -12% to 40%; 1 study, 221 participants; low-certainty evidence). UF may increase the risk of new initiation of renal replacement therapy at longest available follow-up (RR 1.42, 95% CI 0.42 to 4.75; 4 studies, 332 participants; low-certainty evidence). There is an uncertain effect of UF on the risk of complications from central line insertion in hospital (RR 4.16, 95% CI 1.30 to 13.30; 6 studies, 779 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: This review summarises the latest evidence on UF in AHF. Moderate-certainty evidence shows UF probably reduces heart failure-related rehospitalisation in the long term, with an NNTB of 10. UF may reduce all-cause rehospitalisation at 30 days or less and at longest available follow-up. The effect of UF on all-cause mortality at 30 days or less is unclear, and it may have little effect on all-cause mortality in the long-term. While UF may have little or no effect on serum creatinine change at 30 days, it may increase the risk of new initiation of renal replacement therapy in the long term. The effect on complications from central line insertion is unclear. There is insufficient evidence to determine the true impact of UF on AHF. Future research should evaluate UF as an adjunct therapy, focusing on outcomes such as heart failure-related rehospitalisation, cardiac mortality and renal outcomes at medium- to long-term follow-up.
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Affiliation(s)
- Mehul Srivastava
- Institute of Health Informatics Research, University College London, London, UK
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Nicholas Harrison
- Department of Emergency Medicine, Division of Research, Indiana University School of Medicine, Indianapolis, MI-Michigan, USA
| | | | - Audrey R Tan
- Institute of Health Informatics Research, University College London, London, UK
| | - Mandy Law
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
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6
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Martins RC, Pintalhão M, Leite-Moreira A, Castro-Chaves P. Relaxin and the Cardiovascular System: from Basic Science to Clinical Practice. Curr Mol Med 2021; 20:167-184. [PMID: 31642776 DOI: 10.2174/1566524019666191023121607] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 08/07/2019] [Accepted: 10/07/2019] [Indexed: 12/16/2022]
Abstract
The peptide hormone relaxin was originally linked to reproductive physiology, where it is believed to mediate systemic and renal hemodynamic adjustments to pregnancy. Recently, its broad range of effects in the cardiovascular system has been the focus of intensive research regarding its implications under pathological conditions and potential therapeutic potential. An understanding of the multitude of cardioprotective actions prompted the study of serelaxin, recombinant human relaxin-2, for the treatment of acute heart failure. Despite early promising results from phase II studies, recently revealed RELAX-AHF-2 outcomes were rather disappointing and the treatment for acute heart failure remains an unmet medical need. This article reviews the physiologic actions of relaxin on the cardiovascular system and its relevance in the pathophysiology of cardiovascular disease. We summarize the most updated clinical data and discuss future directions of serelaxin for the treatment of acute heart failure. This should encourage additional work to determine how can relaxin's beneficial effects be exploited for the treatment of cardiovascular disease.
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Affiliation(s)
- Rafael Clara Martins
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,Cardiovascular Research Centre, Porto, Portugal.,Internal Medicine Department, São João Hospital Centre, Porto, Portugal
| | - Mariana Pintalhão
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,Cardiovascular Research Centre, Porto, Portugal.,Internal Medicine Department, São João Hospital Centre, Porto, Portugal
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,Cardiovascular Research Centre, Porto, Portugal.,Cardiothoracic Surgery Department, São João Hospital Centre, Porto, Portugal
| | - Paulo Castro-Chaves
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,Cardiovascular Research Centre, Porto, Portugal.,Internal Medicine Department, São João Hospital Centre, Porto, Portugal
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7
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Gyory M, Abdallah S, Lagina A, Levy PD, Twiner MJ. Ultra-high dose intravenous nitroglycerin in an ESRD patient with acutely decompensated heart failure. J Am Coll Emerg Physicians Open 2021; 2:e12387. [PMID: 33718922 PMCID: PMC7926001 DOI: 10.1002/emp2.12387] [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: 12/21/2020] [Revised: 01/21/2021] [Accepted: 01/26/2021] [Indexed: 11/29/2022] Open
Abstract
Acute cardiogenic pulmonary edema is a highly unstable and potentially lethal condition that is most commonly associated with markedly elevated blood pressure (BP). Use of nitrates, diuretics, and non-invasive positive pressure ventilatory support are the mainstays of early intervention and stabilization. Use of high-dose bolus intravenous nitroglycerin, which causes both preload and afterload reduction, has shown significant promise in studies to date, reducing the need for endotracheal intubation (ETI) and intensive care unit admission. To date, the highest recorded total dose of nitroglycerin used during the initial stabilization of acute pulmonary edema has been 20 mg. Here, we describe a patient with end-stage renal disease who developed acute cardiogenic pulmonary edema and received a total of 59 mg nitroglycerin (56 mg push dose intravenous + 3 mg intravenous drip) over 41 minutes leading to successful stabilization and avoidance of ETI, facilitating rapid initiation of emergent hemodialysis.
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Affiliation(s)
- Michael Gyory
- Detroit Receiving HospitalWayne State UniversityDetroitMichiganUSA
| | | | - Anthony Lagina
- Department of Emergency MedicineIntegrative Biosciences CenterWayne State UniversityDetroitMichiganUSA
| | - Phillip D. Levy
- Department of Emergency MedicineIntegrative Biosciences CenterWayne State UniversityDetroitMichiganUSA
| | - Michael J. Twiner
- Department of Emergency MedicineIntegrative Biosciences CenterWayne State UniversityDetroitMichiganUSA
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8
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Harrison N, Pang P, Collins S, Levy P. Blood Pressure Reduction in Hypertensive Acute Heart Failure. Curr Hypertens Rep 2021; 23:11. [PMID: 33611627 DOI: 10.1007/s11906-021-01127-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To review the key clinical and research questions regarding blood pressure (BP) reduction with vasodilators in the early management of hypertensive acute heart failure (H-AHF). RECENT FINDINGS Despite numerous AHF vasodilator clinical trials in the past two decades, virtually none has studied a population where vasoconstriction is the predominant physiology, and with the agents and doses most commonly used in contemporary practice. AHF patients are remarkably heterogenous by vascular tone, and this heterogeneity is not always discernible through BP or clinical exam. Emerging data suggest that diastolic BP may be a stronger correlate of vascular tone in AHF than systolic BP, despite the latter historically serving as a key inclusion criterion for vasodilator clinical trials. Existing data are limited. A clinical trial that evaluates vasodilators in a manner of use consistent with contemporary practice, specifically within the subpopulation of patients with true H-AHF, is greatly needed. Until then, observational data supports long-standing vasodilators such as nitroglycerin, administered by IV bolus, and with goal reduction of SBP ≤25% as a safe first-line approach for patients with severe H-AHF presentations.
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Affiliation(s)
| | - Peter Pang
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sean Collins
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Phillip Levy
- Wayne State University School of Medicine, Detroit, MI, USA
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9
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Srivastava M, Harrison N, Caetano AFSMA, Tan AR, Law M. Ultrafiltration for acute heart failure. Hippokratia 2020. [DOI: 10.1002/14651858.cd013593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Mehul Srivastava
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Australia
| | - Nicholas Harrison
- Department of Emergency Medicine; Wayne State University; Detroit MI- MICHIGAN USA
| | | | - Audrey R Tan
- Institute of Health Informatics Research; University College London; London UK
| | - Mandy Law
- Department of Nephrology; Royal Melbourne Hospital; Parkville Australia
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10
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Tomasoni D, Lombardi CM, Sbolli M, Cotter G, Metra M. Acute heart failure: More questions than answers. Prog Cardiovasc Dis 2020; 63:599-606. [PMID: 32283133 DOI: 10.1016/j.pcad.2020.04.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/06/2020] [Indexed: 12/19/2022]
Abstract
Acute heart failure (AHF) is a life-threatening condition with a dramatic burden in terms of symptoms, morbidity and mortality. It is a specific syndrome requiring urgent, life-saving treatment. Multiple specific pathophysiologic mechanisms may be involved, including congestion, inflammation, and neurohormonal activation. This process eventually leads to symptoms, end-organ damage, and adverse outcomes. Clinical presentation varies, but it almost universally includes worsening of congestion associated with different degrees of hypoperfusion. Due to substantial early symptoms burden and high morbidity and mortality, patients with AHF require intensive monitoring and intravenous treatment. However, beyond variable improvement in congestion, none of the available intravenous therapies for AHF was shown to improve longer term outcomes. Although oral treatment with guideline-directed therapies for stable patients with HF and reduced ejection fraction (HFrEF) before discharge may fully prevent subsequent episodes, proof that this strategy may benefit patients is lacking. First, most patients with AHF have preserved EF (HFpEF) where no therapies have been shown to be effective. Second, all therapies developed for patients with HFrEF were tested for efficacy on outcomes in patients who were stable without recent AHF. Hence, the implementation of these chronic therapies during an AHF episode is untested. Third, the problem to better treat AHF patients in their early phase remains crucial with treatment strategies largely untested, yet. Further studies targeting AHF specific mechanisms, such as inflammation and end-organ damage, and finding effective intravenous drugs remain therefore warranted.
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Affiliation(s)
- Daniela Tomasoni
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, Cardiothoracic Department, Spedali Civili of Brescia, Brescia, Italy.
| | - Carlo Mario Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, Cardiothoracic Department, Spedali Civili of Brescia, Brescia, Italy
| | - Marco Sbolli
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, Cardiothoracic Department, Spedali Civili of Brescia, Brescia, Italy
| | | | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, Cardiothoracic Department, Spedali Civili of Brescia, Brescia, Italy
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Abstract
PURPOSE OF REVIEW This review summarizes current understanding of the pathophysiology of cardiogenic pulmonary edema, its causes and treatment. RECENT FINDINGS The pathobiology and classification of pulmonary edema is more complex than the hydrostatic vs. permeability dichotomy of the past. Mechanisms of alveolar fluid clearance and factors that affect the clearance rate are under intensive study to find therapeutic strategies. Patients need early stabilization of oxygenation and ventilation, preferably with high-flow nasal cannula oxygen or noninvasive ventilation whereas the diagnostic cause is quickly sought with echocardiography and other testing. SUMMARY Treatments must be initiated early, whereas evaluation still is occurring and requires multimodality intervention. The general treatment of cardiogenic pulmonary edema includes diuretics, possibly morphine and often nitrates. The appropriate use of newer approaches - such as, nesiritide, high-dose vasodilators, milrinone, and vasopressin receptor antagonists - needs larger clinical trials.
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12
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Lin X, Fang L. Pharmaceutical Treatment for Heart Failure. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1177:269-295. [PMID: 32246448 DOI: 10.1007/978-981-15-2517-9_7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) is defined as a clinical syndrome resulting from structural or functional impairment of ventricular fillings or ejections of blood. Currently, HF is divided into three groups which include HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF) and HF with midrange EF (HFmrEF). Even though major advances have been made in treating HFrEF during the past decades, heart failure is a fatal disease. In this review, we briefly summarize the current advances in pharmaceutical managements for heart failure, which includes drugs used in acute heart failure as well as those that prevent heart failure progression, in each category major clinical trials are also described. In addition, information about some of potential new drugs are also mentioned. Traditional Chinese medicine also shows its potential in treating HF, and we are still lack of medicine to treat HFpEF.
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Affiliation(s)
- Xue Lin
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ligang Fang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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13
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Early Treatment in Emergency Department Patients with Acute Heart Failure: Does Time Matter? Curr Heart Fail Rep 2019; 16:12-20. [PMID: 30828762 DOI: 10.1007/s11897-019-0419-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW Acute heart failure accounts for over one million hospital discharges annually. Current guidelines suggest treatments for AHF should begin "without delay" but this time interval has not been clearly defined. RECENT FINDINGS Data suggest that certain treatments such as earlier treatment with diuretics and vasodilators may improve patient symptom relief, morbidity, and mortality. Secondary analyses of clinical trials of novel treatments under development have not shown similar results. The data are equivocal regarding the impact of early treatment in AHF on in-hospital and long-term morbidity and mortality. Improved clinical trial designs will help answer when and if "early" treatment should begin and whether it impacts short- and long-term outcomes in AHF.
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15
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Shi J, Li Y, Xing C, Peng P, Shi H, Ding H, Zheng P, Ning G, Feng S. Urapidil, compared to nitroglycerin, has better clinical safety in the treatment of hypertensive patients with acute heart failure: a meta-analysis. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 13:161-172. [PMID: 30643384 PMCID: PMC6312052 DOI: 10.2147/dddt.s185972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objectives The application of urapidil for treating hypertensive patients with acute heart failure in the emergency department remains controversial. Our objective was to organize the relevant articles and assess the clinical indexes between urapidil and nitroglycerin. Materials and methods PubMed, EMBASE, the Cochrane Library and China National Knowledge Infrastructure were searched for randomized studies that compared urapidil treatment with nitroglycerin treatment for hypertensive patients with acute heart failure. The risk ratio, with 95% CI, was calculated by using a corresponding effects model, according to the value of I2. Results Seven randomized controlled trials were identified, in order to compare the clinical indexes. On comparing the clinical indexes, the urapidil group was found to be better than the nitroglycerin group in regard to left ventricular ejection fraction, systolic blood pressure, N-terminal prohormone of brain natriuretic peptide, left ventricular end-diastolic volume, cardiac index, ALT, AST and health complications (P<0.05), but the indexes of creatinine were worse in the urapidil group. Furthermore, the two methods of treatment were comparable in diastolic blood pressure, left ventricular end-systolic volume, left ventricular end-systolic dimension, heart rate, fasting plasma glucose and total cholesterol levels (P>0.05). Conclusion Based on the current evidence, urapidil treatment had better clinical safety features than the traditional pharmaceutical treatment with nitroglycerin. For those indicators with a small amount of data, a greater number of randomized, high-quality controlled trials should be conducted in order to further verify the findings, which could give researchers a more comprehensive evaluation of urapidil treatment.
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Affiliation(s)
- Jiaxiao Shi
- Department of Orthopaedics, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, PR China, ; .,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Heping District, Tianjin 300052, PR China, ;
| | - Yulin Li
- Department of Orthopaedics, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, PR China, ; .,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Heping District, Tianjin 300052, PR China, ;
| | - Cong Xing
- Department of Orthopaedics, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, PR China, ; .,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Heping District, Tianjin 300052, PR China, ;
| | - Peng Peng
- Department of Orthopaedics, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, PR China, ; .,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Heping District, Tianjin 300052, PR China, ;
| | - Hongyu Shi
- Department of Orthopaedics, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, PR China, ; .,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Heping District, Tianjin 300052, PR China, ;
| | - Han Ding
- Department of Orthopaedics, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, PR China, ; .,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Heping District, Tianjin 300052, PR China, ;
| | - Pengyuan Zheng
- Department of Orthopaedics, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, PR China, ; .,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Heping District, Tianjin 300052, PR China, ;
| | - Guangzhi Ning
- Department of Orthopaedics, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, PR China, ; .,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Heping District, Tianjin 300052, PR China, ;
| | - Shiqing Feng
- Department of Orthopaedics, Tianjin Medical University General Hospital, Heping District, Tianjin 300052, PR China, ; .,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Heping District, Tianjin 300052, PR China, ;
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16
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Verma AK, Sun JL, Hernandez A, Teerlink JR, Schulte PJ, Ezekowitz J, Voors A, Starling R, Armstrong P, O'Conner CM, Mentz RJ. Rate pressure product and the components of heart rate and systolic blood pressure in hospitalized heart failure patients with preserved ejection fraction: Insights from ASCEND-HF. Clin Cardiol 2018; 41:945-952. [PMID: 29781109 DOI: 10.1002/clc.22981] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Heart rate and systolic blood pressure (SBP) are prognostic markers in heart failure (HF) with reduced ejection fraction (HFrEF). Their combination in rate pressure product (RPP) as well as their role in heart failure with preserved ejection fraction (HFpEF) remains unclear. HYPOTHESIS RPP and its components are associated with HFpEF outcomes. METHODS We performed an analysis of Acute Study of Clinical Effectiveness of Nesiritide in Subjects With Decompensated Heart Failure (ASCEND-HF; http://www.clinicaltrials.gov NCT00475852), which studied 7141 patients with acute HF. HFpEF was defined as left ventricular ejection fraction ≥40%. Outcomes were assessed by baseline heart rate, SBP, and RPP, as well as the change of these variables using adjusted Cox models. RESULTS After multivariable adjustment, in-hospital change but not baseline heart rate, SBP, and RPP were associated with 30-day mortality/HF hospitalization (hazard ratio [HR]: 1.17 per 5-bpm heart rate, HR: 1.20 per 10-mm Hg SBP, and HR: 1.02 per 100 bpm × mm Hg RPP; all P < 0.05). Baseline SBP was associated with 180-day mortality (HR: 0.88 per 10-mm Hg, P = 0.028). Though change in RPP was associated with 30-day mortality/HF hospitalization, the RPP baseline variable did not provide additional associative information with regard to outcomes when compared with assessment of baseline heart rate and SBP variables alone. CONCLUSIONS An increase in heart rate and SBP from baseline to discharge was associated with increased 30-day mortality/HF hospitalization in HFpEF patients with acute exacerbation. These findings suggest value in monitoring the trend of vital signs during HFpEF hospitalization.
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Affiliation(s)
- Amanda K Verma
- Department of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jie-Lena Sun
- Department of Statistics, Duke University Medical Center, Durham, North Carolina
| | - Adrian Hernandez
- Department of Cardiology, Duke Clinical Research Institute, Duke Hospital, Durham, North Carolina
| | - John R Teerlink
- Department of Cardiology, School of Medicine, University of California, San Francisco
| | - Phillip J Schulte
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | | | - Adriaan Voors
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Paul Armstrong
- Division of Cardiology, University of Alberta, Edmonton, Canada
| | - Christopher M O'Conner
- Department of Cardiology, Duke Clinical Research Institute, Duke Hospital, Durham, North Carolina
| | - Robert J Mentz
- Department of Cardiology, Duke Clinical Research Institute, Duke Hospital, Durham, North Carolina
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17
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Kitai T, Tang WHW, Xanthopoulos A, Murai R, Yamane T, Kim K, Oishi S, Akiyama E, Suzuki S, Yamamoto M, Kida K, Okumura T, Kaji S, Furukawa Y, Matsue Y. Impact of early treatment with intravenous vasodilators and blood pressure reduction in acute heart failure. Open Heart 2018; 5:e000845. [PMID: 30018782 PMCID: PMC6045748 DOI: 10.1136/openhrt-2018-000845] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 05/25/2018] [Accepted: 06/13/2018] [Indexed: 01/19/2023] Open
Abstract
Objective Although vasodilators are used in acute heart failure (AHF) management, there have been no clear supportive evidence regarding their routine use. Recent European guidelines recommend systolic blood pressure (SBP) reduction in the range of 25% during the first few hours after diagnosis. This study aimed to examine clinical and prognostic significance of early treatment with intravenous vasodilators in relation to their subsequent SBP reduction in hospitalised AHF. Methods We performed post hoc analysis of 1670 consecutive patients enrolled in the Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure. Intravenous vasodilator use within 6 hours of hospital arrival and subsequent SBP changes were analysed. Outcomes were gauged by 1-year mortality and diuretic response (DR), defined as total urine output 6 hours posthospital arrival per 40 mg furosemide-equivalent diuretic use. Results Over half of the patients (56.0%) were treated with intravenous vasodilators within the first 6 hours. In this vasodilator-treated cohort, 554 (59.3%) experienced SBP reduction ≤25%, while 381 (40.7%) experienced SBP reduction >25%. In patients experiencing ≤25% drop in SBP, use of vasodilator was associated with greater DR compared with no vasodilators (p<0.001). Moreover, vasodilator treatment with ≤25% drop in SBP was independently associated with lower all-cause mortality compared with those treated without vasodilators (adjusted HR 0.74, 95% CI 0.57 to 0.96, p=0.028). Conclusions Intravenous vasodilator therapy was associated with greater DR and lower mortality, provided SBP reduction was less than 25%. Our results highlight the importance in early administration of intravenous vasodilators without causing excess SBP reduction in AHF management. Clinical trial registration URL: http://www.umin.ac.jp/ctr/ Unique identifier: UMIN000014105.
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Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Cellular and Molecular Medicine, Center for Microbiome and Human Health, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Center for Clinical Genomics, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrew Xanthopoulos
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ryosuke Murai
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takafumi Yamane
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shogo Oishi
- Department of Cardiology, Himeji Cardiovascular Center, Himeji, Japan
| | - Eiichi Akiyama
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Satoshi Suzuki
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Masayoshi Yamamoto
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Keisuke Kida
- Department of Cardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yuya Matsue
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Cardiovascular Medicine, Juntendo University, Tokyo, Japan
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18
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Li Z, Zhang Y, Yuan T. Clinical efficacy and safety of nuanxin capsule for chronic heart failure: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11339. [PMID: 29979410 PMCID: PMC6076094 DOI: 10.1097/md.0000000000011339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Chronic heart failure (CHF), the final phase of various heart diseases, is a serious public health problem resulting in high hospitalization rates, mortality, and increasing health care costs. Nuanxin capsule (NXC), a Chinese herbal formula, has been widely used in the treatment of CHF. However, the safety and efficacy of NXC used in patients with CHF has been uncertain and there has been no standard clinical trial published to confirm this. Thus, we conduct a study to evaluate the safety and efficacy of NXC for CHF. METHODS The reference lists of randomized controlled trials and 8 electronic databases will be independently and systematically searched by 2 review authors in May 2018. Four English databases (EMBASE, PubMed, Cumulative Index to Nursing and Allied Health Literature [CINAHL], and Cochrane Central Register of Controlled Trials [CENTRAL]) and 4 Chinese databases (Chinese Biomedical Literature Database [CBM], Chinese National Knowledge Infrastructure [CNKI], Wanfang Database, and VIP Database) will be included. The primary outcomes will be assessed according to the function classification of New York Heart Association (NYHA). Data synthesis will be precisely computed using the RevManV5.3 software when a data-analysis is allowed. Methodological quality will be assessed according to Cochrane Handbook. RESULTS This study will provide a high-quality synthesis of current evidence of NXC for CHF from different aspects including the mortality, the function classification of NYHA. CONCLUSION The conclusion of this systematic review will provide evidence to prove whether NXC is an effective therapeutic intervention for patient with CHF.PROSPERO registration number: PROSPERO CRD42018090003.
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Affiliation(s)
- Ziqing Li
- The Second Clinical School of Guangzhou University of Chinese Medicine
| | - Yu Zhang
- The Second Clinical School of Guangzhou University of Chinese Medicine
| | - Tie Yuan
- Guangdong Provincial Hospital of Chinese Medicine, The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
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19
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Singh A, Laribi S, Teerlink JR, Mebazaa A. Agents with vasodilator properties in acute heart failure. Eur Heart J 2018; 38:317-325. [PMID: 28201723 DOI: 10.1093/eurheartj/ehv755] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 12/14/2015] [Accepted: 12/22/2015] [Indexed: 01/05/2023] Open
Abstract
Millions of patients worldwide are admitted for acute heart failure (AHF) each year and physicians caring for these patients are confronted with the short-term challenges of reducing symptoms while preventing end organ dysfunction without causing additional harm, and the intermediate-term challenges of improving clinical outcomes such as hospital readmission and survival. There are limited data demonstrating the efficacy of any currently available therapies for AHF to meet these goals. After diuretics, vasodilators are the most common intravenous therapy for AHF, but neither nitrates, nitroprusside, nor nesiritide have robust evidence supporting their ability to provide meaningful effects on clinical outcomes, except perhaps early symptom improvement. Recently, a number of novel agents with vasodilating properties have been developed for the treatment of AHF. These agents include serelaxin, natriuretic peptides (ularitide, cenderitide), β-arrestin-biased angiotensin II type 1 receptor ligands (TRV120027), nitroxyl donors (CXL-1020, CXL-1427), soluble guanylate cyclase modulators (cinaciguat, vericiguat), short-acting calcium channel blockers (clevidipine), and potassium channel activators (nicorandil). These development programmes range from the stage of early dose-finding studies (e.g. TRV120027, CXL-1427) to large, multicentre mortality trials (e.g. serelaxin, ularitide). There is an urgent need for agents with vasodilating properties that will improve both in-hospital and post-discharge clinical outcomes, and these novel approaches may provide opportunities to address this need.
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Affiliation(s)
- Abhishek Singh
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.,School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Saïd Laribi
- INSERM, UMRS 942, Biomarkers and cardiac diseases, Paris, France.,Emergency Department, APHP, Saint Louis-Lariboisière Hospitals, Paris, France
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.,School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alexandre Mebazaa
- INSERM, UMRS 942, Biomarkers and cardiac diseases, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France.,Department of Anesthesiology and Critical Care, APHP, Saint Louis-Lariboisière Hospitals, Paris, France
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20
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Long B, Koyfman A, Chin EJ. Misconceptions in acute heart failure diagnosis and Management in the Emergency Department. Am J Emerg Med 2018; 36:1666-1673. [PMID: 29887195 DOI: 10.1016/j.ajem.2018.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Acute heart failure (AHF) accounts for a significant number of emergency department (ED) visits, and the disease may present along a spectrum with a variety of syndromes. OBJECTIVE This review evaluates several misconceptions concerning heart failure evaluation and management in the ED, followed by several pearls. DISCUSSION AHF is a heterogeneous syndrome with a variety of presentations. Physicians often rely on natriuretic peptides, but the evidence behind their use is controversial, and these should not be used in isolation. Chest radiograph is often considered the most reliable imaging test, but bedside ultrasound (US) provides a more sensitive and specific evaluation for AHF. Diuretics are a foundation of AHF management, but in pulmonary edema, these medications should only be provided after vasodilator administration, such as nitroglycerin. Nitroglycerin administered in high doses for pulmonary edema is safe and effective in reducing the need for intensive care unit admission. Though classically dopamine is the first vasopressor utilized in patients with hypotensive cardiogenic shock, norepinephrine is associated with improved outcomes and lower mortality. Disposition is complex in patients with AHF, and risk stratification tools in conjunction with other assessments allow physicians to discharge patients safely with follow up. CONCLUSION A variety of misconceptions surround the evaluation and management of heart failure including clinical assessment, natriuretic peptide use, chest radiograph and US use, nitroglycerin and diuretics, vasopressor choice, and disposition. This review evaluates these misconceptions while providing physicians with updates in evaluation and management of AHF.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas 75390, TX, United States
| | - Eric J Chin
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
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21
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Acute blood pressure elevation: Therapeutic approach. Pharmacol Res 2018; 130:180-190. [DOI: 10.1016/j.phrs.2018.02.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/21/2017] [Accepted: 02/21/2018] [Indexed: 12/25/2022]
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22
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Wang Y, Li X, Li Z, Zhang Y, Wang D. YiQiFuMai injection for chronic heart failure: Protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e9957. [PMID: 29465586 PMCID: PMC5842014 DOI: 10.1097/md.0000000000009957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Chronic heart AQ4 failure (CHF) is the final stage of various heart diseases. YiQiFuMai injection (YQFMI) has been widely applied in the treatment of CHF. However, to our knowledge, there has been no systematic review or meta-analysis of randomized controlled trails (RCTs) regarding the effectiveness of this treatment. Here, we provide a protocol to evaluate the efficacy and safety of YQFMI for CHF. METHODS To evaluate the clinical efficacy of YQFMI in treating CHF, 2 researcher members will independently search the RCTs in the following 8 Chinese and English databases, in which the data collection will be from the time when the respective databases were established to January 2018. The databases will include MEDLINE, EMBASE, Cochrane CENTRAL, CINAHL, the Chinese Biomedical Literature Database, the China National Knowledge Infrastructure, VIP Information and Wanfang Data. The therapeutic effects according to the mortality and the New York Heart Association (NYHA) function classification will be accepted as the primary outcomes. We will use RevMan V.5.3 software as well to compute the data synthesis carefully when a meta-analysis is allowed. RESULTS This study will provide a high-quality synthesis of current evidence of YQFMI for CHF from several aspects including mortality, NYHA function classification. CONCLUSION The conclusion of our systematic review will provide evidence to judge whether YQFMI is an effective intervention for CHF.PROSPERO registration number: PROSPERO CRD42017079696.
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Affiliation(s)
- Yuanping Wang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou
| | - Xiaohui Li
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou
| | - Ziqing Li
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou
| | - Yu Zhang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou
| | - Dawei Wang
- Shunde Hospital Affiliated of Guangzhou University of Chinese Medicine, Shunde, China
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23
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Collins SP, Levy PD, Fermann GJ, Givertz MM, Martindale JM, Pang PS, Storrow AB, Diercks DD, Michael Felker G, Fonarow GC, Lanfear DJ, Lenihan DJ, Lindenfeld JM, Frank Peacock W, Sawyer DM, Teerlink JR, Butler J. What's Next for Acute Heart Failure Research? Acad Emerg Med 2018; 25:85-93. [PMID: 28990334 DOI: 10.1111/acem.13331] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/29/2017] [Accepted: 10/01/2017] [Indexed: 12/11/2022]
Abstract
Each year over one million patients with acute heart failure (AHF) present to a United States emergency department (ED). The vast majority are hospitalized for further management. The length of stay and high postdischarge event rate in this cohort have changed little over the past decade. Therapeutic trials have failed to yield substantive improvement in postdischarge outcomes; subsequently, AHF care has changed little in the past 40 years. Prior research studies have been fragmented as either "inpatient" or "ED-based." Recognizing the challenges in identification and enrollment of ED patients with AHF, and the lack of robust evidence to guide management, an AHF clinical trials network was developed. This network has demonstrated, through organized collaboration between cardiology and emergency medicine, that many of the hurdles in AHF research can be overcome. The development of a network that supports the collaboration of acute care and HF researchers, combined with the availability of federally funded infrastructure, will facilitate more efficient conduct of both explanatory and pragmatic trials in AHF. Yet many important questions remain, and in this document our group of emergency medicine and cardiology investigators have identified four high-priority research areas.
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Affiliation(s)
- Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN
| | - Phillip D. Levy
- Department of Emergency Medicine Wayne State University Detroit MI
| | - Gregory J. Fermann
- Department of Emergency Medicine University of Cincinnati Medical Center Cincinnati OH
| | | | | | - Peter S. Pang
- Department of Emergency Medicine Indiana University School of Medicine & Indianapolis EMS Indianapolis IN
| | - Alan B. Storrow
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN
| | - Deborah D. Diercks
- Department of Emergency Medicine University of Texas Southwestern Medical Center Dallas TX
| | | | - Gregg C. Fonarow
- Division of Cardiology University of California Los Angeles Ronald Reagan Medical Center Los AngelesCA
| | | | - Daniel J. Lenihan
- Division of Cardiology Vanderbilt University Medical Center Nashville TN
| | | | - W. Frank Peacock
- Department of Emergency Medicine Baylor University Medical Center Houston TX
| | | | - John R. Teerlink
- Division of Cardiology University of California San Francisco and the San Francisco VA San Francisco CA
| | - Javed Butler
- Division of Cardiology Stony Brook University Medical Center Stony BrookNY
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24
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Mebazaa A, Motiejunaite J, Gayat E, Crespo-Leiro MG, Lund LH, Maggioni AP, Chioncel O, Akiyama E, Harjola VP, Seferovic P, Laroche C, Julve MS, Roig E, Ruschitzka F, Filippatos G. Long-term safety of intravenous cardiovascular agents in acute heart failure: results from the European Society of Cardiology Heart Failure Long-Term Registry. Eur J Heart Fail 2017; 20:332-341. [PMID: 28990358 DOI: 10.1002/ejhf.991] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/24/2017] [Accepted: 08/08/2017] [Indexed: 12/28/2022] Open
Abstract
AIMS The aim of this study was to assess long-term safety of intravenous cardiovascular agents-vasodilators, inotropes and/or vasopressors-in acute heart failure (AHF). METHODS AND RESULTS The European Society of Cardiology Heart Failure Long-Term (ESC-HF-LT) registry was a prospective, observational registry conducted in 21 countries. Patients with unscheduled hospitalizations for AHF (n = 6926) were included: 1304 (18.8%) patients received a combination of intravenous (i.v.) vasodilators and diuretics, 833 (12%) patients received i.v. inotropes and/or vasopressors. Primary endpoint was long-term all-cause mortality. Main secondary endpoints were in-hospital and post-discharge mortality. Adjusted hazard ratio (HR) showed no association between the use of i.v. vasodilator and diuretic and long-term mortality [HR 0.784, 95% confidence interval (CI) 0.596-1.032] nor in-hospital mortality (HR 1.049, 95% CI 0.592-1.857) in the matched cohort (n = 976 paired patients). By contrast, adjusted HR demonstrated a detrimental association between the use of i.v. inotrope and/or vasopressor and long-term all-cause mortality (HR 1.434, 95% CI 1.128-1.823), as well as in-hospital mortality (HR 1.873, 95% CI 1.151-3.048) in the matched cohort (n = 606 paired patients). No association was found between the use of i.v. inotropes and/or vasopressors and long-term mortality in patients discharged alive (HR 1.078, 95% CI 0.769-1.512). A detrimental association with inotropes and/or vasopressors was seen in all geographic regions and, among catecholamines, dopamine was associated with the highest risk of death (HR 1.628, 95% CI 1.031-2.572 vs. no inotropes). CONCLUSIONS Vasodilators did not demonstrate any association with long-term clinical outcomes, while inotropes and/or vasopressors were associated with increased risk of all-cause death, mostly related to excess of in-hospital mortality in AHF.
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Affiliation(s)
- Alexandre Mebazaa
- INSERM U942, BIOmarkers in CArdioNeuroVAScular diseases, Paris, France.,APHP, Department of Anesthesiology and Critical Care, Saint Louis Lariboisière Hospitals, Paris, France.,Université Paris Diderot, Paris, France
| | - Justina Motiejunaite
- INSERM U942, BIOmarkers in CArdioNeuroVAScular diseases, Paris, France.,APHP, Department of Anesthesiology and Critical Care, Saint Louis Lariboisière Hospitals, Paris, France.,Department of Cardiology, Lithuanian University of Health Sciences Hospital Kaunas Clinics, Kaunas, Lithuania
| | - Etienne Gayat
- INSERM U942, BIOmarkers in CArdioNeuroVAScular diseases, Paris, France.,APHP, Department of Anesthesiology and Critical Care, Saint Louis Lariboisière Hospitals, Paris, France.,Université Paris Diderot, Paris, France
| | - Maria G Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco-CIBERCV and Instituto Investigación Biomedica A Coruna (INIBIC), Complexo Hospitalario Universitario A Coruna (CHUAC), La Coruna, Spain
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | - Ovidiu Chioncel
- Institutul De Urgente Boli Cardiovasculare CC Iliescu, Universitatea de Medicina Carol Davila, Bucharest, Romania
| | - Eiichi Akiyama
- INSERM U942, BIOmarkers in CArdioNeuroVAScular diseases, Paris, France.,Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Veli-Pekka Harjola
- University of Helsinki, Emergency Medicine, Department of Emergency Care and Services, Helsinki University Hospital, Helsinki, Finland
| | - Petar Seferovic
- Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Cecile Laroche
- EURObservational Research Programme, European Society of Cardiology, Sophia-Antipolis, France
| | | | - Eulalia Roig
- Department of Cardiology, Heart Failure and Transplantation Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Frank Ruschitzka
- Department of Cardiology, Heart Failure Clinic and Transplantation, University Heart Centre Zurich, Zurich, Switzerland
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25
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Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, Giannetti N, Grzeslo A, Hamilton PG, Heckman GA, Howlett JG, Koshman SL, Lepage S, McKelvie RS, Moe GW, Rajda M, Swiggum E, Virani SA, Zieroth S, Al-Hesayen A, Cohen-Solal A, D'Astous M, De S, Estrella-Holder E, Fremes S, Green L, Haddad H, Harkness K, Hernandez AF, Kouz S, LeBlanc MH, Masoudi FA, Ross HJ, Roussin A, Sussex B. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017; 33:1342-1433. [PMID: 29111106 DOI: 10.1016/j.cjca.2017.08.022] [Citation(s) in RCA: 442] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 02/06/2023] Open
Abstract
Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.
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Affiliation(s)
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | - Michael Chan
- Edmonton Cardiology Consultants, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Adam Grzeslo
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Serge Lepage
- Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | | | - Miroslaw Rajda
- QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Sean A Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Sabe De
- London Health Sciences, Western University, London, Ontario, Canada
| | | | - Stephen Fremes
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Green
- University of Alberta, Edmonton, Alberta, Canada
| | - Haissam Haddad
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, Québec, Canada
| | | | | | | | - Andre Roussin
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bruce Sussex
- Memorial University, St John's, Newfoundland, Canada
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Abstract
Clinicians make frequent treatment decisions regarding acute blood pressure reduction for the critically ill. Key to the decision making process is a balance between reducing arterial wall stress and maintaining perfusion to vital organs. In this article, we review the physiological considerations underlying acute blood pressure management, including the concept of cerebral autoregulation and its adaptations to chronic hypertension. We then discuss available pharmacological interventions suited for reducing blood pressure acutely. We also discuss specific blood pressure targets in common critical illnesses and consider future directions in this therapeutic area.
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Pang PS, Collins SP. Acute Heart Failure in the Emergency Department: Just a One Night Stand? Acad Emerg Med 2017; 24:385-387. [PMID: 28008693 DOI: 10.1111/acem.13151] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Peter S. Pang
- Department of Emergency Medicine Indiana University School of Medicine & Indianapolis EMS Indianapolis IN
| | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN
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Yang W, Zhou YJ, Fu Y, Qin J, Qin S, Chen XM, Guo JC, Wang DZ, Zhan H, Li J, He JY, Hua Q. Efficacy and Safety of Intravenous Urapidil for Older Hypertensive Patients with Acute Heart Failure: A Multicenter Randomized Controlled Trial. Yonsei Med J 2017; 58:105-113. [PMID: 27873502 PMCID: PMC5122625 DOI: 10.3349/ymj.2017.58.1.105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Urapidil is putatively effective for patients with hypertension and acute heart failure, although randomized controlled trials thereon are lacking. We investigated the efficacy and safety of intravenous urapidil relative to that of nitroglycerin in older patients with hypertension and heart failure in a randomized controlled trial. MATERIALS AND METHODS Patients (>60 y) with hypertension and heart failure were randomly assigned to receive intravenous urapidil (n=89) or nitroglycerin (n=91) for 7 days. Hemodynamic parameters, cardiac function, and safety outcomes were compared. RESULTS Patients in the urapidil group had significantly lower mean systolic blood pressure (110.1±6.5 mm Hg) than those given nitroglycerin (126.4±8.1 mm Hg, p=0.022), without changes in heart rate. Urapidil was associated with improved cardiac function as reflected by lower N terminal-pro B type natriuretic peptide after 7 days (3311.4±546.1 ng/mL vs. 4879.1±325.7 ng/mL, p=0.027) and improved left ventricular ejection fraction (62.2±3.4% vs. 51.0±2.4%, p=0.032). Patients given urapidil had fewer associated adverse events, specifically headache (p=0.025) and tachycardia (p=0.004). The one-month rehospitalization and all-cause mortality rates were similar. CONCLUSION Intravenous administration of urapidil, compared with nitroglycerin, was associated with better control of blood pressure and preserved cardiac function, as well as fewer adverse events, for elderly patients with hypertension and acute heart failure.
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Affiliation(s)
- Wei Yang
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu Jie Zhou
- Department of Cardiology, An Zhen Hospital affiliated with Capital Medical University, Beijing, China
| | - Yan Fu
- Fu Yan Emergency Department, Tong Ren Hospital affiliated with Capital Medical University, Beijing, China
| | - Jian Qin
- Department of Cardiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shu Qin
- Department of Cardiology, First Hospital affiliated with Chongqing University, Chongqing, China
| | - Xiao Min Chen
- Department of Cardiology, Ningbo First Hospital, Ningbo, China
| | - Jin Cheng Guo
- Department of Cardiology, Luhe Hospital of Beijing Tongzhou District, Beijing, China
| | - De Zhao Wang
- Department of Cardiology, Mentougou District Hospital of Beijing City, Beijing, China
| | - Hong Zhan
- Emergency Department, First Hospital affiliated with Sun Yat-sen University, Guangzhou, China
| | - Jing Li
- Department of Cardiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jing Yu He
- Emergency Department, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qi Hua
- Department of Cardiology, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Ayaz SI, Sharkey CM, Kwiatkowski GM, Wilson SS, John RS, Tolomello R, Mahajan A, Millis S, Levy PD. Intravenous enalaprilat for treatment of acute hypertensive heart failure in the emergency department. Int J Emerg Med 2016; 9:28. [PMID: 28032307 PMCID: PMC5195922 DOI: 10.1186/s12245-016-0125-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 12/01/2016] [Indexed: 11/28/2022] Open
Abstract
Background Afterload reduction with bolus enalaprilat is used by some for management of acute hypertensive heart failure (HF) but existing data on the safety and effectiveness of this practice are limited. The purpose of this study was to evaluate the clinical effects of bolus enalaprilat when administered to patients with acute hypertensive heart failure. Findings We performed an IRB-approved retrospective cohort study of patients who presented to the emergency department of a large urban academic hospital. Patients were identified by pharmacy record and included if they received enalaprilat intravenous (IV) bolus in the setting of acute hypertensive HF. A total of 103 patients were included. Patients were hypertensive on presentation (systolic blood pressure [SBP] = 195.2 [SD ± 32.3] mmHg) with significantly elevated mean NT-proBNP levels (3797.8 [SD ± 6523.2] pg/ml). The mean dose of enalaprilat was 1.3 [SD ± 0.7] mg, with most patients (76.7%) receiving a single 1.25 mg bolus. By 3 h postenalaprilat, SBP had decreased substantially (−30.5 mmHg) with only 2 patients (1.9%) developing hypotension. Renal function was unaffected, with no significant change in serum creatinine by 72 h. In the 30 days post-admission, patients spent an average of 23 [SD ± 7.5] days alive and out of hospital. Conclusions In this retrospective cohort of acute hypertensive HF patients, bolus IV enalaprilat resulted in a substantial reduction in systolic BP without adverse effect.
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Affiliation(s)
- Syed Imran Ayaz
- Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St. Antoine, UHC-6G, Detroit, MI, 48201, USA.
| | - Craig M Sharkey
- Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St. Antoine, UHC-6G, Detroit, MI, 48201, USA
| | | | | | - Reba S John
- Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St. Antoine, UHC-6G, Detroit, MI, 48201, USA
| | - Rosa Tolomello
- Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St. Antoine, UHC-6G, Detroit, MI, 48201, USA
| | - Arushi Mahajan
- Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St. Antoine, UHC-6G, Detroit, MI, 48201, USA
| | - Scott Millis
- Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St. Antoine, UHC-6G, Detroit, MI, 48201, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St. Antoine, UHC-6G, Detroit, MI, 48201, USA.,Detroit Receiving Hospital, 4201 St. Antoine, Detroit, MI, 48201, USA.,Cardiovascular Research Institute, Wayne State University School of Medicine, 540 East Canfield, Detroit, MI, 48201, USA
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Tyler JM, Pang PS, Teerlink JR. Serelaxin in the Treatment of Acute Heart Failure. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016. [DOI: 10.1007/s40138-016-0114-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med 2016; 35:126-131. [PMID: 27825693 DOI: 10.1016/j.ajem.2016.10.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/11/2016] [Accepted: 10/13/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The purpose of this study was to compare health care resource utilization among patients who were given intravenous nitroglycerin for acute heart failure (AHF) in the emergency department (ED) by intermittent bolus, continuous infusion, or a combination of both. METHODS We retrospectively identified 395 patients that received nitroglycerin therapy in the ED for the treatment of AHF over a 5-year period. Patients that received intermittent bolus (n=124) were compared with continuous infusion therapy (n=182) and combination therapy of bolus and infusion (n=89). The primary outcomes were the frequency of intensive care unit (ICU) admission and hospital length of stay (LOS). RESULTS On unadjusted analysis, rates of ICU admission were significantly lower in the bolus vs infusion and combination groups (48.4% vs 68.7% vs 83%, respectively; P<.0001) and median LOS (interquartile range) was shorter (3.7 [2.5-6.2 days]) compared with infusion (4.7 [2.9-7.1 days]) and combination (5.0 [2.9-6.7 days]) groups; P=.02. On adjusted regression models, the strong association between bolus nitroglycerin and reduced ICU admission rate remained, and hospital LOS was 1.9 days shorter compared with infusion therapy alone. Use of intubation (bolus [8.9%] vs infusion [8.8%] vs combination [16.9%]; P=.096) and bilevel positive airway pressure (bolus [26.6%] vs infusion [20.3%] vs combination [29.2%]; P=.21) were similar as was the incidence of hypotension, myocardial injury, and worsening renal function. CONCLUSIONS In ED patients with AHF, intravenous nitroglycerin by intermittent bolus was associated with a lower ICU admission rate and a shorter hospital LOS compared with continuous infusion.
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Collins SP, Levy PD, Martindale JL, Dunlap ME, Storrow AB, Pang PS, Albert NM, Felker GM, Fermann GJ, Fonarow GC, Givertz MM, Hollander JE, Lanfear DJ, Lenihan DJ, Lindenfeld JM, Peacock WF, Sawyer DB, Teerlink JR, Butler J. Clinical and Research Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society of Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group. J Card Fail 2016; 22:618-27. [DOI: 10.1016/j.cardfail.2016.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 04/14/2016] [Accepted: 04/18/2016] [Indexed: 12/20/2022]
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Collins SP, Levy PD, Martindale JL, Dunlap ME, Storrow AB, Pang PS, Albert NM, Felker GM, Fermann GJ, Fonarow GC, Givertz MM, Hollander JE, Lanfear DE, Lenihan DJ, Lindenfeld JM, Peacock WF, Sawyer DB, Teerlink JR, Butler J. Clinical and Research Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society for Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group. Acad Emerg Med 2016; 23:922-31. [PMID: 27286136 DOI: 10.1111/acem.13025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 04/19/2016] [Accepted: 04/19/2016] [Indexed: 01/04/2023]
Abstract
Management approaches for patients in the emergency department (ED) who present with acute heart failure (AHF) have largely focused on intravenous diuretics. Yet, the primary pathophysiologic derangement underlying AHF in many patients is not solely volume overload. Patients with hypertensive AHF (H-AHF) represent a clinical phenotype with distinct pathophysiologic mechanisms that result in elevated ventricular filling pressures. To optimize treatment response and minimize adverse events in this subgroup, we propose that clinical management be tailored to a conceptual model of disease that is based on these mechanisms. This consensus statement reviews the relevant pathophysiology, clinical characteristics, approach to therapy, and considerations for clinical trials in ED patients with H-AHF.
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Affiliation(s)
- Sean P. Collins
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | - Phillip D. Levy
- Department of Emergency Medicine; Wayne State University; Detroit MI
| | | | - Mark E. Dunlap
- Department of Medicine; Case Western University; Cleveland OH
| | - Alan B. Storrow
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | - Peter S. Pang
- Department of Emergency Medicine; Indiana University; Indianapolis IN
| | | | | | - Gregory J. Fermann
- Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
| | - Gregg C. Fonarow
- Department of Medicine; University of California at Los Angeles; Los Angeles CA
| | | | - Judd E. Hollander
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | | | | | | | - W. Frank Peacock
- Department of Emergency Medicine; Baylor College of Medicine; Houston TX
| | | | - John R. Teerlink
- Department of Medicine; San Francisco VA Medical Center; San Francisco CA
| | - Javed Butler
- Department of Medicine; Stony Brook University; Stony Brook NY
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Lee H, Kim TH, Leem J. Acupuncture for heart failure: A systematic review of clinical studies. Int J Cardiol 2016; 222:321-331. [PMID: 27500758 DOI: 10.1016/j.ijcard.2016.07.195] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/28/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acupuncture has been used for treating heart failure mainly in combination with conventional treatments, but evidence for its effectiveness and safety has not been well established. Our aim was to review randomized controlled trials (RCTs) on acupuncture for heart failure and assess the clinical evidence. METHODS Electronic databases such as Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and certain Chinese & Korean databases were searched until October 2015. The main outcomes assessed were mortality, New York Heart Association (NYHA) function classifications, and acupuncture-related adverse events. The details of acupuncture intervention were also investigated. RESULTS Among 4107 publications, seven RCTs were included; most of them showed considerable methodological flaws. We could not conduct a meta-analysis because of the heterogeneity of the included studies. In one acute heart failure study, acupuncture shortened intensive care unit (ICU) stay by 2.2days (95% CI 1.26, 3.14) and reduced the risk ratio of re-admission to 0.53 (95% CI 0.28, 0.99). However, mortality was not affected. Hemodynamic parameters also showed improvement. Another study reported an improved left ventricular ejection fraction by 9.95% (95% CI 3.24, 16.66). In five chronic heart failure studies, acupuncture improved exercise capacity, quality of life, hemodynamic parameters, and time domain heart rate variability parameters. Acupuncture decreased NT-pro BNP levels by 292.20 (95% CI -567.36, -17.04). No adverse effects were reported. CONCLUSIONS The effectiveness of acupuncture as a therapy for heart failure is currently inconclusive. Further large and rigorous clinical trials are needed to establish its clinical utility.
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Affiliation(s)
- Hojung Lee
- Department of Clinical Korean Medicine, Graduate School, Kyung Hee University,23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea; Korean Medicine Clinical Trial Center, Kyung Hee University Korean Medicine Hospital,23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea.
| | - Tae-Hun Kim
- Department of Clinical Korean Medicine, Graduate School, Kyung Hee University,23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea; Korean Medicine Clinical Trial Center, Kyung Hee University Korean Medicine Hospital,23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea.
| | - Jungtae Leem
- Department of Clinical Korean Medicine, Graduate School, Kyung Hee University,23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea; Korean Medicine Clinical Trial Center, Kyung Hee University Korean Medicine Hospital,23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea.
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35
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Katz SD. Blood Vessels Behaving Badly: Targeting Hypertension in Acute Decompensated Heart Failure. J Card Fail 2016; 22:628-30. [PMID: 27327971 DOI: 10.1016/j.cardfail.2016.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 06/16/2016] [Accepted: 06/16/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Stuart D Katz
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York.
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Lemachatti N, Philippon AL, Bloom B, Hausfater P, Riou B, Ray P, Freund Y. Temporal trends in nitrate utilization for acute heart failure in elderly emergency patients: A single-centre observational study. Arch Cardiovasc Dis 2016; 109:449-56. [PMID: 27342805 DOI: 10.1016/j.acvd.2016.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/01/2015] [Accepted: 01/26/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND We previously conducted a pilot study that reported the safety of isosorbide dinitrate boluses for elderly emergency patients with acute heart failure syndrome. AIMS To assess the temporal trend in the rate of elderly patients treated with isosorbide dinitrate, and to evaluate subsequent outcome differences. METHODS This was a single-centre study. We compared patients aged>75 years who attended the emergency department with a primary diagnosis of acute pulmonary oedema in the years 2007 and 2014. The primary endpoint was the rate of patients who received isosorbide dinitrate boluses in the emergency department. Secondary endpoints included in-hospital mortality, need for intensive care and length of stay. RESULTS We analysed 368 charts, 232 from patients included in 2014 (63%) and 136 in 2007 (37%). The mean age was 85±6 years in both groups. There was a significant rise in the rate of patients treated with isosorbide dinitrate between 2007 and 2014: 97 patients (42%) in 2014 vs. 24 patients (18%) in 2007 (P<0.01). Comparing the two periods, we report similar in-hospital mortality rates (8% vs. 11%; P=0.5), rates of admission to the intensive care unit (13% vs. 17%; P=0.3) and lengths of stay (10 days in both groups). CONCLUSION We observed a significant rise in the rate of elderly patients treated with isosorbide dinitrate boluses for acute heart failure. However, we did not observe any significant improvement in outcomes.
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Affiliation(s)
- Najla Lemachatti
- Emergency Department, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Anne-Laure Philippon
- Emergency Department, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Paris Sorbonne Université, UPMC Université Paris 6, UMRS Inserm 1166, IHU ICAN, 75013 Paris, France
| | | | - Pierre Hausfater
- Emergency Department, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Paris Sorbonne Université, UPMC Université Paris 6, UMRS Inserm 1166, IHU ICAN, 75013 Paris, France
| | - Bruno Riou
- Emergency Department, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Paris Sorbonne Université, UPMC Université Paris 6, UMRS Inserm 1166, IHU ICAN, 75013 Paris, France
| | - Patrick Ray
- Paris Sorbonne Université, UPMC Université Paris 6, UMRS Inserm 1166, IHU ICAN, 75013 Paris, France; Emergency Department, Hôpital Tenon, AP-HP, 75020 Paris, France
| | - Yonathan Freund
- Emergency Department, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Paris Sorbonne Université, UPMC Université Paris 6, UMRS Inserm 1166, IHU ICAN, 75013 Paris, France.
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Organ protection possibilities in acute heart failure. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2016.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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38
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Martindale JL, Wakai A, Collins SP, Levy PD, Diercks D, Hiestand BC, Fermann GJ, deSouza I, Sinert R. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2016; 23:223-42. [PMID: 26910112 DOI: 10.1111/acem.12878] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/31/2015] [Accepted: 09/16/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging. OBJECTIVES The primary objective of this study was to perform a systematic review and meta-analysis of the operating characteristics of diagnostic elements available to the emergency physician for diagnosing AHF. Secondary objectives were to develop a test-treatment threshold model and to calculate interval likelihood ratios (LRs) for natriuretic peptides (NPs) by pooling patient-level results. METHODS PubMed, EMBASE, and selected bibliographies were searched from January 1965 to March 2015 using MeSH terms to address the ability of the following index tests to predict AHF as a cause of dyspnea in adult patients in the ED: history and physical examination, electrocardiogram, chest radiograph (CXR), B-type natriuretic peptide (BNP), N-terminal proB-type natriuretic peptide (NT-proBNP), lung ultrasound (US), bedside echocardiography, and bioimpedance. A diagnosis of AHF based on clinical data combined with objective test results served as the criterion standard diagnosis. Data were analyzed using Meta-DiSc software. Authors of all NP studies were contacted to obtain patient-level data. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was utilized to evaluate the quality and applicability of the studies included. RESULTS Based on the included studies, the prevalence of AHF ranged from 29% to 79%. Index tests with pooled positive LRs ≥ 4 were the auscultation of S3 on physical examination (4.0, 95% confidence interval [CI] = 2.7 to 5.9), pulmonary edema on both CXR (4.8, 95% CI = 3.6 to 6.4) and lung US (7.4, 95% CI = 4.2 to 12.8), and reduced ejection fraction observed on bedside echocardiogram (4.1, 95% CI = 2.4 to 7.2). Tests with low negative LRs were BNP < 100 pg/mL (0.11, 95% CI = 0.07 to 0.16), NT-proBNP < 300 pg/mL (0.09, 95% CI = 0.03 to 0.34), and B-line pattern on lung US LR (0.16, 95% CI = 0.05 to 0.51). Interval LRs of BNP concentrations at the low end of "positive" results as defined by a cutoff of 100 pg/mL were substantially lower (100 to 200 pg/mL; 0.29, 95% CI = 0.23 to 0.38) than those associated with higher BNP concentrations (1000 to 1500 pg/mL; 7.12, 95% CI = 4.53 to 11.18). The interval LR of NT-proBNP concentrations even at very high values (30,000 to 200,000 pg/mL) was 3.30 (95% CI = 2.05 to 5.31). CONCLUSIONS Bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis.
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Affiliation(s)
| | - Abel Wakai
- The Emergency Care Research Unit; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Sean P. Collins
- The Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | - Phillip D. Levy
- The Department of Emergency Medicine; Wayne State University School of Medicine; Detroit MI
| | - Deborah Diercks
- The Department of Emergency Medicine; University of Texas Southwestern; Dallas TX
| | - Brian C. Hiestand
- The Department of Emergency Medicine; Wake Forest University School of Medicine; Winston-Salem NC
| | - Gregory J. Fermann
- The Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
| | - Ian deSouza
- The Department of Emergency Medicine; SUNY Downstate Medical Center; New York NY
| | - Richard Sinert
- The Department of Emergency Medicine; SUNY Downstate Medical Center; New York NY
- The Emergency Care Research Unit; Royal College of Surgeons in Ireland; Dublin Ireland
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Montero-Pérez-Barquero M, Morales-Rull JL. Organ protection possibilities in acute heart failure. Rev Clin Esp 2016; 216:157-64. [PMID: 26896381 DOI: 10.1016/j.rce.2016.01.003] [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: 11/17/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
Abstract
Unlike chronic heart failure (HF), the treatment for acute HF has not changed over the last decade. The drugs employed have shown their ability to control symptoms but have not achieved organ protection or managed to reduce medium to long-term morbidity and mortality. Advances in our understanding of the pathophysiology of acute HF suggest that treatment should be directed not only towards correcting the haemodynamic disorders and achieving symptomatic relief but also towards preventing organ damage, thereby counteracting myocardial remodelling and cardiac and extracardiac disorders. Compounds that exert vasodilatory and anti-inflammatory action in the acute phase of HF and can stop cell death, thereby boosting repair mechanisms, could have an essential role in organ protection.
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Affiliation(s)
- M Montero-Pérez-Barquero
- Servicio de Medicina Interna, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Reina Sofía, Universidad de Córdoba, Córdoba, España.
| | - J L Morales-Rull
- Unidad de Insuficiencia Cardiaca, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Región Sanitaria de Lleida, Lleida, España
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40
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Comment on "is addition of vasodilators to loop diuretics of value in the care of hospitalized acute heart failure patients? Real-world evidence from a retrospective analysis of a large United States hospital database". J Card Fail 2015; 21:434-435. [PMID: 25891832 DOI: 10.1016/j.cardfail.2015.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Indexed: 11/20/2022]
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