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Zhou J, Jin X, Zhou J, Xu Y, Cui X, Fu M, Hu K, Ge J. Clinical outcomes by serum potassium levels for patients hospitalized for heart failure: Secondary analysis of data from the China National Heart Failure Registry. Clin Cardiol 2023; 46:1345-1352. [PMID: 37577821 PMCID: PMC10642319 DOI: 10.1002/clc.24114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Dyskalemia is a mortality risk factor in patients with heart failure (HF). HYPOTHESIS We described the prevalence of dyskalemia, and clinical outcomes by serum potassium (sK) levels, in Chinese patients hospitalized for HF. METHODS In this secondary analysis of the prospective China National Heart Failure Registry, adult patients hospitalized between January 1, 2013 and June 30, 2015 who had at least one baseline sK measurement were followed for up to 3 years after discharge. The use of renin-angiotensin-aldosterone system inhibitors at baseline and clinical outcomes during follow-up were compared among sK groups. RESULTS Among 6950 patients, 5529 (79.6%) had normokalemia (sK >3.5-5.0 mmol/L), 1113 (16.0%) had hypokalemia (sK 0-3.5 mmol/L), and 308 (4.4%) had hyperkalemia (sK >5.0 mmol/L). Baseline characteristics that were most common in patients with hyperkalemia than those with hypo- and normokalemia included older age, HF with reduced ejection fraction, New York Heart Association Class III/IV status, hypertension, and chronic kidney disease. Use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) differed across sK groups (p = .0001); reported in 64.1%, 63.4%, and 54.5% of patients with hypo-, normo-, and hyperkalemia, respectively. Overall, 26.6%, 28.6%, and 36.0% of patients with hypo-, normo-, and hyperkalemia had rehospitalization for worsened HF, or cardiovascular mortality; p = .0057 for between-group comparison. CONCLUSIONS Patients with hyperkalemia received ACEIs or ARBs for HF treatment at baseline less frequently than those with hypo- or normokalemia, and had worse prognoses. This warrants further investigation into effective hyperkalemia management in HF.
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Affiliation(s)
- Jingmin Zhou
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Xuejuan Jin
- Department of Epidemiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Jun Zhou
- Department of Epidemiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Yamei Xu
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Xiaotong Cui
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Michael Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra HospitalUniversity of GothenburgGothenburgSweden
| | - Kai Hu
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
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Kobayashi S, Sugama N, Nagano H, Takahashi M, Kushiyama A. Renally inappropriate medications in elderly outpatients and inpatients with an impaired renal function. Hosp Pract (1995) 2023; 51:76-81. [PMID: 36695817 DOI: 10.1080/21548331.2023.2173412] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIMS The purpose of this study was to investigate differences in the frequency of renally inappropriate medications (RIMs) in outpatient and inpatient among three institutions. METHODS We collected prescription and renal function data for patients over 65 years of age from the drug department system. We selected 50 kinds of the most frequently used medicines which require dose adjustment according to a patient's renal function. RESULTS Outpatient RIM was seen in 611 cases (6.17%), and inpatient prescription RIM was seen in 317 cases (5.29%), showing a significant difference between the groups (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.02-1.35). However, in a multivariate analysis, when the renal function was included, that difference between outpatients and inpatients became insignificant (OR 1.16, 95% CI 0.98-1.37). The distribution of prescription with or without RIM in outpatient and inpatient settings depended on the CKD stage. Outpatients with a better CKD stage (stage 1-3) had a higher rate of RIM than inpatients, while patients with a worse CKD stage (stage 4 or 5) had a higher rate of RIM than outpatients. CONCLUSION The rate of RIM in outpatients tends to be high, and attention should be paid to RIM in inpatients with a severe CKD stage.
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Affiliation(s)
- Shotaro Kobayashi
- Department of Pharmacy, Sonoda Daiichi Hospital, Tokyo, Japan.,Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose City, Japan
| | - Norio Sugama
- Department of Pharmacy, Sonoda Daiichi Hospital, Tokyo, Japan
| | - Hiroyuki Nagano
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose City, Japan.,Department of Pharmacy, Saitama Medical University Hospital, Saitama, Japan
| | - Masahiro Takahashi
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose City, Japan
| | - Akifumi Kushiyama
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose City, Japan
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Lindner G, Burdmann EA, Clase CM, Hemmelgarn BR, Herzog CA, Małyszko J, Nagahama M, Pecoits-Filho R, Rafique Z, Rossignol P, Singer AJ. Acute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference. Eur J Emerg Med 2020; 27:329-337. [PMID: 32852924 PMCID: PMC7448835 DOI: 10.1097/mej.0000000000000691] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/17/2020] [Indexed: 11/30/2022]
Abstract
Hyperkalemia is a common electrolyte disorder observed in the emergency department. It is often associated with underlying predisposing conditions, such as moderate or severe kidney disease, heart failure, diabetes mellitus, or significant tissue trauma. Additionally, medications, such as inhibitors of the renin-angiotensin-aldosterone system, potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, succinylcholine, and digitalis, are associated with hyperkalemia. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened a conference in 2018 to identify evidence and address controversies on potassium management in kidney disease. This review summarizes the deliberations and clinical guidance for the evaluation and management of acute hyperkalemia in this setting. The toxic effects of hyperkalemia on the cardiac conduction system are potentially lethal. The ECG is a mainstay in managing hyperkalemia. Membrane stabilization by calcium salts and potassium-shifting agents, such as insulin and salbutamol, is the cornerstone in the acute management of hyperkalemia. However, only dialysis, potassium-binding agents, and loop diuretics remove potassium from the body. Frequent reevaluation of potassium concentrations is recommended to assess treatment success and to monitor for recurrence of hyperkalemia.
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Affiliation(s)
- Gregor Lindner
- Department of Internal and Emergency Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Emmanuel A. Burdmann
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | | | - Brenda R. Hemmelgarn
- Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Charles A. Herzog
- Division of Cardiology, Department of Medicine, Hennepin Healthcare/University of Minnesota, Minneapolis, Minnesota, USA
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Poland
| | - Masahiko Nagahama
- Division of Nephrology, Department of Internal Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Roberto Pecoits-Filho
- Pontificia Universidade Catolica do Paraná, Curitiba, Brazil and Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Zubaid Rafique
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques-Plurithématique 14-33 and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Adam J. Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, New York, USA
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Hyperkalemia and management of renin-angiotensin-aldosterone system inhibitors in chronic heart failure with reduced ejection fraction: A systematic review. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.03.010] [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] Open
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Fonseca C, Brito D, Branco P, Frazão JM, Silva-Cardoso J, Bettencourt P. Hyperkalemia and management of renin-angiotensin-aldosterone system inhibitors in chronic heart failure with reduced ejection fraction: A systematic review. Rev Port Cardiol 2020; 39:517-541. [PMID: 32868174 DOI: 10.1016/j.repc.2020.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 01/17/2020] [Accepted: 03/23/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Renin-angiotensin-aldosterone system inhibitors (RAASi) are the cornerstone of treatment of heart failure with reduced ejection fraction (HFrEF). RAASi optimization in real-life care is challenged by hyperkalemia, a potentially fatal adverse event, which can necessitate downtitration or discontinuation of RAASi and negatively impact survival in HFrEF. The literature on this problem is sparse. We performed a systematic review of studies on HFrEF to investigate the prevalence, incidence, and risk factors of hyperkalemia, RAASi prescription rates, frequency of RAASi downtitration or discontinuation due to hyperkalemia, and the potential negative effect of the latter on prognosis. METHODS We conducted a MEDLINE (PubMed) search including observational and interventional studies published between January 1987 and May 2018. RESULTS A total of 30 observational and 18 interventional studies were included in the review. The incidence of hyperkalemia reported was between 0% and 63% in observational studies and was between 0% and 30% in clinical trials. Risk factors for hyperkalemia included RAASi prescription, older age, diabetes, and chronic kidney disease. In real-life studies, RAASi were downtitrated or discontinued in 3-22% of HFrEF patients; hyperkalemia was the reported cause in 5% of cases. No reports were found on the impact on prognosis of RAASi downtitration or discontinuation due to hyperkalemia. CONCLUSIONS Hyperkalemia and RAASi downtitration or discontinuation are frequent, particularly in real-life HFrEF studies. Further research is needed to clarify the role of RAASi downtitration or discontinuation due to hyperkalemia and to assess its long-term prognostic impact in HFrEF patients.
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Affiliation(s)
- Cândida Fonseca
- Heart Failure Clinic, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisboa, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal.
| | - Dulce Brito
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte (CHLN), Lisboa, Portugal; CCUL, Faculty of Medicine, Universidade de Lisboa, Lisboa, Portugal
| | - Patrícia Branco
- Nephrology Department, Santa Cruz Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), Carnaxide, Portugal
| | - João Miguel Frazão
- Institute for Research and Innovation in Health Sciences (i3S) and Institute for Biomedical Engineering (INEB), Universidade do Porto, Porto, Portugal; Nephrology Department, Centro Hospitalar Universitário de São João (CHUSJ) and Faculty of Medicine, Universidade do Porto, Porto, Portugal
| | - José Silva-Cardoso
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal; Cardiology Department, Centro Hospitalar Universitário de São João (CHUSJ), Porto, Portugal
| | - Paulo Bettencourt
- Internal Medicine Department, CUF Porto Hospital, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
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Palaka E, Grandy S, Darlington O, McEwan P, van Doornewaard A. Associations between serum potassium and adverse clinical outcomes: A systematic literature review. Int J Clin Pract 2020; 74:e13421. [PMID: 31532067 DOI: 10.1111/ijcp.13421] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/30/2019] [Accepted: 09/13/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the growing body of evidence characterising the association between serum potassium levels and adverse clinical outcomes, a contemporary summary of available evidence is currently lacking. The objective of this study, therefore, was to undertake a systematic literature review to identify all relevant evidence assessing risk factors associated with the incidence of hyperkalaemia (HK) and also quantifying the effect of serum potassium levels on risk of adverse clinical outcomes. METHODS PubMed (Medline and Medline In-Process), Embase and the Cochrane Library were searched for studies published between January 2002 and November 2018. Search inclusion criteria included studies describing either the incidence of HK events and any associated risk factors, or associations between HK or serum potassium concentration and adverse clinical outcomes including mortality, hospitalisation, major adverse cardiac events (MACE) and renin-angiotensin-aldosterone system inhibitors (RAASi) discontinuation in adult patients with chronic kidney disease (CKD), heart failure (HF), type 2 diabetes (T2DM) or hypertension. RESULTS The search identified 1,897 publications. From these, a total of 123 studies met the inclusion criteria and were included in the review. The most commonly identified risk factors associated with HK events were the presence of CKD or renal impairment, T2DM, HF, hypertension, RAASi use and mineralocorticoid receptor antagonist use. Potassium levels both above and below the normal range were consistently associated with adverse clinical outcomes, with relative and absolute risks of outcomes increasing with severity of hyper- or hypokalaemia. These associations were consistently reported across a broad range of patient population types and study types. CONCLUSION The current body of published evidence is compelling in its confirmation of the associations between serum potassium levels and adverse clinical outcomes. This review further highlights the importance of avoiding both hyper- and hypokalaemia, in order to reduce risk of mortality, hospitalisation, MACE and RAASi discontinuation or down-titration.
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Affiliation(s)
| | - Susan Grandy
- Global Pricing and Market Access, AstraZeneca, Gaithersburg, MD, USA
| | | | - Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
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Mavrakanas TA, Giannetti N, Sapir-Pichhadze R, Alam A. Mineralocorticoid Receptor Antagonists and Renal Outcomes in Heart Failure Patients with and without Chronic Kidney Disease. Cardiorenal Med 2019; 10:32-41. [PMID: 31665724 DOI: 10.1159/000503223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/05/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The effect of mineralocorticoid receptor antagonists (MRAs) on chronic kidney disease (CKD) progression in patients with heart failure (HF) and with or without preexisting CKD has not been adequately studied. METHODS We conducted a retrospective cohort study including consecutive adult patients followed at the HF clinic of a tertiary care center who had already been on an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB). Exposure to MRAs was assessed at 6 months from registration. Patients who were never exposed to an MRA were the control group. RESULTS A total of 314 patients who were prescribed an MRA were compared to 1,116 patients who never received an MRA. Among them, 121 and 408 patients, respectively, had CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2). MRAs had to be discontinued in 36/121 patients with CKD (29.8%) and 57/165 patients without CKD (34.5%) (p = 0.39). MRA treatment was associated with a higher risk for persistent creatinine doubling among patients without CKD (hazard ratio 4.07, 95% confidence interval 1.41-11.73). A numerically lower risk was identified among CKD patients (hazard ratio 0.33, 95% confidence interval 0.04-2.78) (p for interaction = 0.009). The primary safety outcome, a composite of any doubling of serum creatinine or any episode of serious hyperkalemia (K+ >6 mmol/L), occurred more commonly in MRA users compared with nonusers in the subgroup of patients without CKD, but not in CKD patients (p for interaction = 0.02). CONCLUSION MRA treatment in addition to an ACEI or an ARB could be safely prescribed in HF patients with CKD as it is not associated with persistent renal function decline, acute kidney injury, or serious hyperkalemia, compared with ACEI/ARB monotherapy.
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Affiliation(s)
- Thomas A Mavrakanas
- Divisions of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada, .,Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland,
| | - Nadia Giannetti
- Division of Cardiology, Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada
| | - Ruth Sapir-Pichhadze
- Divisions of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada
| | - Ahsan Alam
- Divisions of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada
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Verbrugge FH, Martens P, Ameloot K, Haemels V, Penders J, Dupont M, Tang WHW, Droogné W, Mullens W. Spironolactone to increase natriuresis in congestive heart failure with cardiorenal syndrome. Acta Cardiol 2019; 74:100-107. [PMID: 29587582 DOI: 10.1080/00015385.2018.1455947] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Signs and symptoms of volume overload are the most frequent reason for hospital admission in acute heart failure (AHF). Diuretics are mainstay treatment, but their optimal type and dose regimen remain unclear, especially in patients with cardiorenal syndrome. METHODS This prospective study aimed to include 80 AHF patients with volume overload and cardiorenal syndrome. Through a 2 × 2 factorial design, patients were randomised towards (1) combinational treatment with acetazolamide and low-dose loop diuretics versus high-dose loop diuretics; and (2) open-label oral spironolactone 25 mg OD given upfront versus at discharge. Here reported are the results of the spironolactone treatment arm after complete follow-up of 34/80 patients (since the study was stopped because of slow recruitment). The primary study end-point was incident hypokalaemia (<3.5 mmol/L) or hyperkalaemia (>5.5 mmol/L). RESULTS Serum potassium derangements were numerically less frequent in the upfront versus discharge spironolactone group, yet this result was underpowered due to incomplete study recruitment (hyperkalaemia: 6% vs. 11%; hypokalaemia: 13% vs. 28%, respectively; p-value = .270). Natriuresis after 24 h was higher in the upfront vs. discharge spironolactone group (314 ± 142 vs. 200 ± 91 mmol/L, respectively; p-value = .010). Relative change in plasma NT-proBNP level after 72 h was similar among both groups (-16 ± 29% vs. -5 ± 45%, respectively; p value = .393), with no difference in all-cause mortality (p-value = .682) or the combination of all-cause mortality and heart failure readmission (p-value = .799). DISCUSSION Spironolactone use upfront in AHF patients at high risk for cardiorenal syndrome is safe and increases natriuresis.
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Affiliation(s)
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Veerle Haemels
- Department of Cardiovascular Medicine, UZ Leuven, Leuven, Belgium
| | - Joris Penders
- Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - W. H. Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Walter Droogné
- Department of Cardiovascular Medicine, UZ Leuven, Leuven, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
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Abstract
Disturbances in the potassium homeostasis are common among patients with heart failure (HF) and negatively affect clinical outcome. Patients with HF have a higher prevalence of common risk factors related to hyperkalaemia, including diabetes mellitus, hypertension, and chronic kidney disease. Furthermore, the use of renin-angiotensin-aldosterone system (RAAS) inhibitors, is an important risk factor for developing hyperkalaemia. The association between hyperkalaemia and mortality is not unequivocal, depends on the study type (trial vs. real-world setting) and is often confounded. More importantly, hyperkalaemia is an important cause of discontinuation or failure to uptitrate to guideline recommended dosages of RAAS inhibitors, which in turn may negatively impact clinical outcomes. The goal of this review is to discuss the epidemiology, aetiology, and clinical consequences of potassium disturbances in HF.
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Affiliation(s)
- Jasper Tromp
- Department of Cardiology, AB31, University Medical Centre Groningen, University Medical Center Groningen, University of Groningen, Hanzeplein 1,Groningen, The Netherlands
- National Heart Centre Singapore, National Heart Research Institute, 5 Hospital Dr, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| | - Peter van der Meer
- Department of Cardiology, AB31, University Medical Centre Groningen, University Medical Center Groningen, University of Groningen, Hanzeplein 1,Groningen, The Netherlands
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Rashid M, Kwok CS, Gale CP, Doherty P, Olier I, Sperrin M, Kontopantelis E, Peat G, Mamas MA. Impact of co-morbid burden on mortality in patients with coronary heart disease, heart failure, and cerebrovascular accident: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 3:20-36. [PMID: 28927187 DOI: 10.1093/ehjqcco/qcw025] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 05/05/2016] [Indexed: 01/02/2023]
Abstract
Aims We sought to investigate the prognostic impact of co-morbid burden as defined by the Charlson Co-morbidity Index (CCI) in patients with a range of prevalent cardiovascular diseases. Methods and results We searched MEDLINE and EMBASE to identify studies that evaluated the impact of CCI on mortality in patients with cardiovascular disease. A random-effects meta-analysis was undertaken to evaluate the impact of CCI on mortality in patients with coronary heart disease (CHD), heart failure (HF), and cerebrovascular accident (CVA). A total of 11 studies of acute coronary syndrome (ACS), 2 stable coronary disease, 5 percutaneous coronary intervention (PCI), 13 HF, and 4 CVA met the inclusion criteria. An increase in CCI score per point was significantly associated with a greater risk of mortality in patients with ACS [pooled relative risk ratio (RR) 1.33; 95% CI 1.15-1.54], PCI (RR 1.21; 95% CI 1.12-1.31), stable coronary artery disease (RR 1.38; 95% CI 1.29-1.48), and HF (RR 1.21; 95% CI 1.13-1.29), but not CVA. A CCI score of >2 significantly increased the risk of mortality in ACS (RR 2.52; 95% CI 1.58-4.04), PCI (RR 3.36; 95% CI 2.14-5.29), HF (RR 1.76; 95% CI 1.65-1.87), and CVA (RR 3.80; 95% CI 1.20-12.01). Conclusion Increasing co-morbid burden as defined by CCI is associated with a significant increase in risk of mortality in patients with underlying CHD, HF, and CVA. CCI provides a simple way of predicting adverse outcomes in patients with cardiovascular disease and should be incorporated into decision-making processes when counselling patients.
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Affiliation(s)
- Muhammad Rashid
- Keele Cardiovascular Research Group, Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - Ivan Olier
- Keele Cardiovascular Research Group, Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK
| | - Matthew Sperrin
- Far Institute, Institute of Population Health, University of Manchester, Manchester, UK
| | | | - George Peat
- Institute for Primary Care and Health Sciences, University of Keele, Keele, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK.,Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, UK
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Greenberg B. Mineralocorticoid receptor antagonists in heart failure: they work better when patients use them. Eur J Heart Fail 2018; 20:1335-1337. [PMID: 29851224 DOI: 10.1002/ejhf.1222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Barry Greenberg
- Sulpizio Family Cardiovascular Center, University of California San Diego, La Jolla, CA, USA
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12
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Hirai T, Yamaga R, Fujita A, Itoh T. Low body mass index is a risk factor for hyperkalaemia associated with angiotensin converting enzyme inhibitors and angiotensin II receptor blockers treatments. J Clin Pharm Ther 2018; 43:829-835. [PMID: 29908131 DOI: 10.1111/jcpt.12720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/14/2018] [Indexed: 12/19/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) represent the cornerstones of hypertension and congestive heart failure treatment. Risk factors for hyperkalaemia associated with ACEI and ARB are chronic kidney disease and concomitant medications which increase serum potassium level. Body mass index (BMI) also affects pharmacokinetics of ACEI and ARB and potassium disposition. We evaluated the relationship between BMI and hyperkalaemia associated with ACEI and ARB treatments. METHODS Study design is a retrospective case-control analysis. Patients who had been prescribed ACEI or ARB between June 2015 and June 2017 at Tokyo Women's Medical University, Medical Center East, were included. Patient clinical background was collected from medical records. Hyperkalaemia was defined as serum potassium above 5.5 meq/L. The concomitant use of ACEI and ARB, aldosterone antagonists, direct renin inhibitor, sulfamethoxazole-trimethoprim and non-steroidal anti-inflammatory drugs (NSAIDs) was regarded as hyperkalaemia-inducing medications. The relationship between BMI and hyperkalaemia associated with ACEI and ARB treatments was assessed using multivariable logistic regression analysis. RESULTS AND DISCUSSION The study included 2987 patients aged 70.1 ± 12.9 years, 61.0% were men, and BMI was 23.8 ± 4.4 kg/m2 . The incidence of hyperkalaemia was 7.8%. Multivariable logistic regression analysis revealed that age >65 years, low BMI, diabetes, history of treatment for hyperkalaemia, serum sodium <135 meq/L, eGFR <30 mL/min/1.73m2 and the concomitant use of hyperkalaemia-inducing medications were independent risk factors for hyperkalaemia associated with ACEI and ARB. WHAT IS NEW AND CONCLUSION This study demonstrated that BMI provides useful information for the identification of potential risk for hyperkalaemia associated with ACEI and ARB treatments.
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Affiliation(s)
- T Hirai
- Department of Pharmacy, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - R Yamaga
- Department of Pharmacy, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - A Fujita
- Department of Pharmacy, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - T Itoh
- Department of Pharmacy, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
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Hernáez Á, Delgado J, Cinca J, Fernández-Avilés F, Marrugat J. Prevalence and incidence of hyperkalemia in the Spanish population with heart failure with reduced ejection fraction: A systematic review and populational relevance. Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2018.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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14
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC .,Duke Clinical Research Institute, Durham, NC
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Robert J Mentz
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC.,Duke Clinical Research Institute, Durham, NC
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15
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Novel concept to guide systolic heart failure medication by repeated biomarker testing-results from TIME-CHF in context of predictive, preventive, and personalized medicine. EPMA J 2018; 9:161-173. [PMID: 29896315 PMCID: PMC5972133 DOI: 10.1007/s13167-018-0137-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 04/30/2018] [Indexed: 12/12/2022]
Abstract
Background It is uncertain whether repeated measurements of a multi-target biomarker panel may help to personalize medical heart failure (HF) therapy to improve outcome in chronic HF. Methods This analysis included 499 patients from the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF), aged ≥ 60 years, LVEF ≤ 45%, and NYHA ≥ II, who had repeated clinical visits within 19 months follow-up. The interaction between repeated measurements of biomarkers and treatment effects of loop diuretics, spironolactone, β-blockers, and renin-angiotensin system (RAS) inhibitors on risk of HF hospitalization or death was investigated in a hypothesis-generating analysis. Generalized estimating equation (GEE) models were used to account for the correlation between recurrences of events in a patient. Results One hundred patients (20%) had just one event (HF hospitalization or death) and 87 (17.4%) had at least two events. Loop diuretic up-titration had a beneficial effect for patients with high interleukin-6 (IL6) or high high-sensitivity C-reactive protein (hsCRP) (interaction, P = 0.013 and P = 0.001), whereas the opposite was the case with low hsCRP (interaction, P = 0.013). Higher dosage of loop diuretics was associated with poor outcome in patients with high blood urea nitrogen (BUN) or prealbumin (interaction, P = 0.006 and P = 0.001), but not in those with low levels of these biomarkers. Spironolactone up-titration was associated with lower risk of HF hospitalization or death in patients with high cystatin C (CysC) (interaction, P = 0.021). β-Blockers up-titration might have a beneficial effect in patients with low soluble fms-like tyrosine kinase-1 (sFlt) (interaction, P = 0.021). No treatment biomarker interactions were found for RAS inhibition. Conclusion The data of this post hoc analysis suggest that decision-making using repeated biomarker measurements may be very promising in bringing treatment of heart failure to a new level in the context of predictive, preventive, and personalized medicine. Clearly, prospective testing is needed before this novel concept can be adopted. Clinical trial registration isrctn.org, identifier: ISRCTN43596477 Electronic supplementary material The online version of this article (10.1007/s13167-018-0137-7) contains supplementary material, which is available to authorized users.
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16
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Desai AS, Liu J, Pfeffer MA, Claggett B, Fleg J, Lewis EF, McKinlay S, O'Meara E, Shah SJ, Sweitzer NK, Solomon S, Pitt B. Incident Hyperkalemia, Hypokalemia, and Clinical Outcomes During Spironolactone Treatment of Heart Failure With Preserved Ejection Fraction: Analysis of the TOPCAT Trial. J Card Fail 2018; 24:313-320. [PMID: 29572190 DOI: 10.1016/j.cardfail.2018.03.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/20/2018] [Accepted: 03/09/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND In patients with heart failure and preserved ejection fraction (HF-PEF) randomized in the Americas as part of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, treatment with spironolactone enhanced the risk of hyperkalemia but reduced the risk of hypokalemia. We examined the clinical correlates and prognostic implications of incident hypo- and hyperkalemia during study follow-up. METHODS We defined the region-specific incidence of hypokalemia (potassium [K+] <3.5 mmol/l) and hyperkalemia (K+ ≥5.5 mmol/l) among both placebo- and spironolactone-assigned patients in TOPCAT. Factors associated with incident hypokalemia and hyperkalemia and the relationship between incident K+ abnormalities and the risk of subsequent mortality were analyzed in multivariable regression models restricted to the Americas. RESULTS In the Americas, assignment to spironolactone increased risk for hyperkalemia (hazard ratio 3.21, 95% confidence interval 2.46-4.20, P < .001) and reduced risk of hypokalemia (hazard ratio 0.43, 95% confidence interval 0.34-0.55, P < .001). Assignment to spironolactone, lower estimated glomerular filtration rate, higher baseline K+, diabetes, and lower hemoglobin were associated with incident hyperkalemia, whereas assignment to placebo, lower K+, younger age, lower estimated glomerular filtration rate, and use of diuretics at baseline were associated with hypokalemia. The combination of spironolactone and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker was associated with incremental risk for hyperkalemia and protection from hypokalemia. Independent of region, both hypokalemia and hyperkalemia, were associated with higher risk for cardiovascular and all-cause mortality in multivariable-adjusted Cox regression models. CONCLUSIONS Both hyperkalemia and hypokalemia are associated with heightened risk for mortality in HF-PEF. Use of spironolactone in this population requires careful laboratory surveillance of K+ and creatinine, particularly in high-risk groups.
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Affiliation(s)
- Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Jiankang Liu
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jerome Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Eldrin F Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sonja McKinlay
- New England Research Institutes, Inc., Watertown, Massachusetts
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Scott Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Bertram Pitt
- Cardiovascular Division, University of Michigan School of Medicine, Ann Arbor, Michigan
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17
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Hernáez Á, Delgado JF, Cinca J, Fernández-Avilés F, Marrugat J. Prevalence and incidence of hyperkalaemia in the Spanish population with heart failure with reduced ejection fraction: a systematic review and populational relevance. Rev Clin Esp 2018; 218:253-260. [PMID: 29496276 DOI: 10.1016/j.rce.2018.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/01/2017] [Accepted: 01/23/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Hyperkalaemia (K+ levels≥5.5mmol/L) is a severe ion imbalance that occurs in patients who have heart failure (HF) with reduced ejection fraction (HFrEF) and increases the risk of ventricular fibrillation. Given that there are no estimates on the number of patients with this complication, the aim of this study was to estimate the prevalence and incidence of hyperkalaemia in patients with HFrEF in Spain. MATERIAL AND METHODS Based on a systematic literature search and through a meta-analysis, we calculated an HFrEF prevalence of ≤40% in the European and U.S. POPULATION Based on another systematic literature search, we calculated the prevalence of hyperkalaemia in patients with HF and its annual incidence rate. Considering the previous values and the Spanish population pyramid in 2016, we estimated the number of individuals with HFrEF who currently have hyperkalaemia and those who develop it each year in Spain. RESULTS Approximately 17,100 (10,000 men and 7100 women) of the 508,000 patients with HFrEF in Spain have hyperkalaemia. Furthermore, approximately 14,900 patients with HFrEF (9500 men and 5400 women) develop hyperkalaemia each year. CONCLUSIONS Approximately 1 of every 30 patients with HFrEF has plasma potassium values >5.5 mmol/L.
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Affiliation(s)
- Á Hernáez
- Grupo de investigación en Riesgo Cardiovascular y Nutrición-REGICOR, Institut Hospital d'Investigacions Mèdiques IMIM, Barcelona, España; CIBER de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, España
| | - J F Delgado
- Fundación Investigación i+12, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España; CIBER de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, España
| | - J Cinca
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, España; Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España
| | - F Fernández-Avilés
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, España; Departamento de Cardiología, Instituto de Investigación Sanitaria Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J Marrugat
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, España; Grupo de investigación en Epidemiología y Genética Cardiovascular-REGICOR, Institut Hospital d'Investigacions Mèdiques IMIM, Barcelona, España.
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18
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Okada K, Yamaguchi Y, Kamada N, Abe K, Wagou M, Katoh S, Sasaki H, Okada M, Saheki N. [The relationship between death from renal insufficiency and diuretic therapy among older adults at two nursing homes catering atomic bomb survivors]. Nihon Ronen Igakkai Zasshi 2018; 55:640-649. [PMID: 30542030 DOI: 10.3143/geriatrics.55.640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
AIM In Geriatrics Gerontology International we previously reported the efficacy of reducing diuretics to prevent falls and fractures in older adults. We have since noticed another important problem, regarding the diuretic therapy for older adults with decreased muscle and water volumes. We performed a study on renal insufficiency and diuretic therapy in an attempt to confirm the need for case control study between standard diuretic therapy administered, according to guidelines and "NY-mode" diuretic therapy, which involves the administration of the mineral-corticoid receptor inhibitor spironolactone at 12.5 mg orally every other day. METHODS We reviewed the causes of death among 1,855 residents living at 2 atomic bomb survivors nursing homes, with a focus on the death certification and diuretic therapy status of 48 older adults who died due to renal insufficiency. We also evaluated the relationship between the estimated glomerular filtration rate of 407 residents using serum creatinine data and the level of independence in daily life of disabled older adults. RESULTS We found that deaths due to chronic renal insufficiency were concentrated within certain period in two nursing homes examined and in patients receiving standard diuretic therapy (continuous daily loop diuretics or combination of loop diuretics with mineral-corticoid receptor inhibitor). Older adults with a relatively low level of independence in daily life showed a relatively higher estimated glomerular filtration rate, depending on their muscle volume. CONCLUSION These results suggest the need for a case control study of standard diuretic therapy and "NY-mode" therapy among older adults with decreased muscle and water volumes to not only prevent falls and fall-related fractures but also protect the kidney from damage.
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Affiliation(s)
- Kosuke Okada
- Department of Internal Medicine, COOP Saeki Hospital
- Former Hiroshima Atomic Bomb Survivors Nursing Home, Kandayama Yasuragien
| | - Yumiko Yamaguchi
- Former Hiroshima Atomic Bomb Survivors Nursing Home, Kurakake Nozomien
| | - Nanao Kamada
- Department of Internal Medicine, Hongou Central Hospital
- Former Hiroshima Atomic Bomb Survivors Relief Foundation
| | - Kazuhiro Abe
- Hiroshima Atomic Bomb Survivors Nursing Home, Kandayama Yasuragien
| | - Masakuni Wagou
- Hiroshima Atomic Bomb Survivors Nursing Home, Kurakake Nozomien
| | - Shigeko Katoh
- Faculty of Nursing, Hiroshima Bunnka Gakuen University
| | - Hidemi Sasaki
- Faculty of Nursing, Hiroshima Bunnka Gakuen University
| | - Masahiro Okada
- Department of Food and Dietetics, Two-year College of Hiroshima Bunka Gakuen
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19
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Abstract
Electrolyte abnormalities are common in heart failure and can arise from a variety of etiologies. Neurohormonal activation from ventricular dysfunction, renal dysfunction, and heart failure medications can perturb electrolyte homeostasis which impact both heart failure-related morbidity and mortality. These include disturbances in serum sodium, chloride, acid-base, and potassium homeostasis. Pharmacological treatments differ for each electrolyte abnormality and vary from older, established treatments like the vaptans or acetazolamide, to experimental or theoretical treatments like hypertonic saline or urea, or to newer, novel agents like the potassium binders: patiromer and zirconium cyclosilicate. Pharmacologic approaches range from limiting electrolyte intake or directly repleting the electrolyte, to blocking or promoting their resorption, and to neurohormonal antagonism. Because of the prevalence and clinical impact of electrolyte abnormalities, understanding both the older and newer therapeutic options is and will continue to be necessity for the management of heart failure.
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Affiliation(s)
- Justin L Grodin
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, 44195, USA.
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20
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Abstract
Medications that affect the renin-angiotensin-aldosterone system (RAAS) form the mainstay of current heart failure (HF) therapy in patients with reduced ejection fraction. Concerns about the risk of hyperkalaemia have created a significant barrier to optimal RAAS inhibitor therapy in patients with HF, however, and many patients are discontinuing or receiving suboptimal doses of these lifesaving therapies. This has serious health and economic implications due to adverse renal and cardiovascular events. There is therefore an important unmet need for novel therapeutic options for the long-term management of patients with, and at risk for, hyperkalaemia. Two new potassium-binding agents, patiromer and ZS-9, have been shown to be effective and safe for the treatment of hyperkalaemia, as well as the maintenance of normokalaemia, without dose reduction or discontinuation of RAAS inhibitors. In addition, the fast onset of ZS-9 action suggests that it may be useful in the treatment of acute hyperkalaemia. These agents may allow for dose optimisation of RAAS inhibitors for the long-term maintenance and protection of the renal and cardiovascular system.
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Affiliation(s)
- Mitja Lainscak
- Faculty of Medicine, University of Ljubljana and Department of Internal Medicine, General Hospital Murska Sobota, Ljubljana, Slovenia
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21
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Kojima T, Mizukami K, Tomita N, Arai H, Ohrui T, Eto M, Takeya Y, Isaka Y, Rakugi H, Sudo N, Arai H, Aoki H, Horie S, Ishii S, Iwasaki K, Takayama S, Suzuki Y, Matsui T, Mizokami F, Furuta K, Toba K, Akishita M. Screening Tool for Older Persons' Appropriate Prescriptions for Japanese: Report of the Japan Geriatrics Society Working Group on "Guidelines for medical treatment and its safety in the elderly". Geriatr Gerontol Int 2017; 16:983-1001. [PMID: 27594406 DOI: 10.1111/ggi.12890] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/13/2016] [Accepted: 06/30/2016] [Indexed: 12/14/2022]
Abstract
AIM In 2005, the Japan Geriatrics Society published a list of potentially inappropriate medication that was an extract from the "Guidelines for medical treatment and its safety in the elderly 2005." The 2005 guidelines are due for a revision, and a new comprehensive list of potentially inappropriate medications is required. METHODS A total of 15 diseases, conditions and special areas related to their clinical care were selected. We originated clinical questions and keywords for these 15 areas, carried out a systematic review using these search criteria, and formulated guidelines applying the Grading of Recommendations Assessment, Development and Evaluation system advocated by Minds2014. If we did not find good evidence despite the drug being clinically important, we looked for evidence of efficacy and for disease-specific guidelines, and incorporated them into our guidelines. RESULTS We selected 2098 articles (140 articles per area), and extracted another 186 articles through a manual search. We further added guidelines based on disease entity and made two lists, one of "drugs to be prescribed with special caution" and the other of "drugs to consider starting," primarily considering individuals aged 75 years or older or those who are frail or in need of special care. CONCLUSIONS New lists of potentially inappropriate medications and potential prescribing omissions called "Screening Tool for Older Person's Appropriate Prescriptions for Japanese" were constructed. We anticipate that future studies will highlight more evidence regarding the safety of high-quality drugs, further improving the provision of appropriate medical care for the elderly. Geriatr Gerontol Int 2016: 16: 983-1001.
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Affiliation(s)
- Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Katsuyoshi Mizukami
- Graduate School of Comprehensive Human Sciences, Faculty of Health and Sports Sciences, University of Tsukuba, Tokyo, Japan
| | - Naoki Tomita
- Department of Geriatrics and Gerontology, Institute of Development, Aging and Cancer, Tohoku University, Miyagi, Japan
| | - Hiroyuki Arai
- Department of Geriatrics and Gerontology, Institute of Development, Aging and Cancer, Tohoku University, Miyagi, Japan
| | - Takashi Ohrui
- Department of Geriatrics and Gerontology, Institute of Development, Aging and Cancer, Tohoku University, Miyagi, Japan.,Division of Geriatric Pharmacotherapy, Institute of Development, Aging and Cancer, Tohoku University, Miyagi, Japan
| | - Masato Eto
- Department of Geriatric Medicine, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan.,General Education Center, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Yasushi Takeya
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Isaka
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Noriko Sudo
- Center for Health Check-up and Preventive Medicine, Kanto Central Hospital, Tokyo, Japan
| | - Hidenori Arai
- National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Hiroaki Aoki
- Department of Urology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shigeo Horie
- Department of Urology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shinya Ishii
- Department of Geriatric Medicine, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Koh Iwasaki
- Ishinomaki-Ogatsu Municipal Clinic, Miyagi, Japan
| | - Shin Takayama
- Department of Education and Support for Regional Medicine, Department of Kampo Medicine, Tohoku University Hospital, Miyagi, Japan
| | - Yusuke Suzuki
- Centre for Community Liaison and Patient Consultations, Nagoya University Hospital, Aichi, Japan
| | - Toshifumi Matsui
- Department of Geriatric Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Fumihiro Mizokami
- Department of Pharmacy, National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Katsunori Furuta
- Department of Pharmacy, National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Kenji Toba
- Department of Geriatrics and Gerontology, Institute of Development, Aging and Cancer, Tohoku University, Miyagi, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
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22
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Molina-Jijón E, Rodríguez-Muñoz R, González-Ramírez R, Namorado-Tónix C, Pedraza-Chaverri J, Reyes JL. Aldosterone signaling regulates the over-expression of claudin-4 and -8 at the distal nephron from type 1 diabetic rats. PLoS One 2017; 12:e0177362. [PMID: 28493961 PMCID: PMC5426686 DOI: 10.1371/journal.pone.0177362] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 04/17/2017] [Indexed: 12/19/2022] Open
Abstract
Hyperglycemia in diabetes alters tight junction (TJ) proteins in the kidney. We evaluated the participation of aldosterone (ALD), and the effect of spironolactone (SPL), a mineralocorticoid receptor antagonist, on the expressions of claudin-2, -4, -5 and -8, and occludin in glomeruli, proximal and distal tubules isolated from diabetic rats. Type 1 diabetes was induced in female Wistar rats by a single tail vein injection of streptozotocin (STZ), and SPL was administrated daily by gavage, from days 3–21. Twenty-one days after STZ injection the rats were sacrificed. In diabetic rats, the serum ALD levels were increased, and SPL-treatment did not have effect on these levels or in hyperglycemia, however, proteinuria decreased in SPL-treated diabetic rats. Glomerular damage, evaluated by nephrin and Wilm’s tumor 1 (WT1) protein expressions, and proximal tubular damage, evaluated by kidney injury molecule 1 (Kim-1) and heat shock protein 72 kDa (Hsp72) expressions, were ameliorated by SPL. Also, SPL prevented decrement in claudin-5 in glomeruli, and claudin-2 and occludin in proximal tubules by decreasing oxidative stress, evaluated by superoxide anion (O2●―) production, and oxidative stress markers. In distal tubules, SPL ameliorated increase in mRNA, protein expression, and phosphorylation in threonine residues of claudin-4 and -8, through a serum and glucocorticoid-induced kinase 1 (SGK1), and with-no-lysine kinase 4 (WNK4) signaling pathway. In conclusion, this is the first study that demonstrates that ALD modulates the expression of renal TJ proteins in diabetes, and that the blockade of its actions with SPL, may be a promising therapeutic strategy to prevent alterations of TJ proteins in diabetic nephropathy.
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MESH Headings
- Aldosterone/metabolism
- Animals
- Claudin-4/metabolism
- Claudins/metabolism
- Diabetes Mellitus, Experimental/blood
- Diabetes Mellitus, Experimental/complications
- Diabetes Mellitus, Experimental/metabolism
- Diabetes Mellitus, Experimental/pathology
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/metabolism
- Diabetes Mellitus, Type 1/pathology
- Female
- Hyperglycemia/blood
- Hyperglycemia/drug therapy
- Hyperglycemia/prevention & control
- Immediate-Early Proteins/metabolism
- Kidney Glomerulus/drug effects
- Kidney Glomerulus/pathology
- Kidney Tubules/drug effects
- Kidney Tubules/pathology
- Models, Biological
- Natriuresis/drug effects
- Nephrons/metabolism
- Oxidative Stress/drug effects
- Phosphorylation/drug effects
- Potassium/blood
- Protein Serine-Threonine Kinases/metabolism
- Proteinuria/blood
- Proteinuria/complications
- Proteinuria/drug therapy
- Proteinuria/prevention & control
- Rats, Wistar
- Signal Transduction/drug effects
- Spironolactone/pharmacology
- Spironolactone/therapeutic use
- Tight Junctions/drug effects
- Tight Junctions/metabolism
- Weight Loss/drug effects
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Affiliation(s)
- Eduardo Molina-Jijón
- Department of Physiology, Biophysics and Neuroscience, Center for Research and Advanced Studies of the National Polytechnic Institute (CINVESTAV-IPN), Mexico City, México
- Departamento de Biociencias e Ingeniería, Centro Interdisciplinario de Investigaciones y Estudios sobre el Medio Ambiente y Desarrollo del Instituto Politécnico Nacional (CIIEMAD-IPN), Mexico City, México
| | - Rafael Rodríguez-Muñoz
- Department of Physiology, Biophysics and Neuroscience, Center for Research and Advanced Studies of the National Polytechnic Institute (CINVESTAV-IPN), Mexico City, México
| | - Ricardo González-Ramírez
- Department of Molecular Biology and Histocompatibility, Dr. Manuel Gea González, General Hospital, Mexico City, México
| | - Carmen Namorado-Tónix
- Department of Physiology, Biophysics and Neuroscience, Center for Research and Advanced Studies of the National Polytechnic Institute (CINVESTAV-IPN), Mexico City, México
| | - José Pedraza-Chaverri
- Department of Biology, Faculty of Chemistry, National Autonomous University of Mexico (UNAM), Mexico City, México
| | - Jose L. Reyes
- Department of Physiology, Biophysics and Neuroscience, Center for Research and Advanced Studies of the National Polytechnic Institute (CINVESTAV-IPN), Mexico City, México
- * E-mail:
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23
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McLellan J, Heneghan CJ, Perera R, Clements AM, Glasziou PP, Kearley KE, Pidduck N, Roberts NW, Tyndel S, Wright FL, Bankhead C. B-type natriuretic peptide-guided treatment for heart failure. Cochrane Database Syst Rev 2016; 12:CD008966. [PMID: 28102899 PMCID: PMC5449577 DOI: 10.1002/14651858.cd008966.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Heart failure is a condition in which the heart does not pump enough blood to meet all the needs of the body. Symptoms of heart failure include breathlessness, fatigue and fluid retention. Outcomes for patients with heart failure are highly variable; however on average, these patients have a poor prognosis. Prognosis can be improved with early diagnosis and appropriate use of medical treatment, use of devices and transplantation. Patients with heart failure are high users of healthcare resources, not only due to drug and device treatments, but due to high costs of hospitalisation care. B-type natriuretic peptide levels are already used as biomarkers for diagnosis and prognosis of heart failure, but could offer to clinicians a possible tool to guide drug treatment. This could optimise drug management in heart failure patients whilst allaying concerns over potential side effects due to drug intolerance. OBJECTIVES To assess whether treatment guided by serial BNP or NT-proBNP (collectively referred to as NP) monitoring improves outcomes compared with treatment guided by clinical assessment alone. SEARCH METHODS Searches were conducted up to 15 March 2016 in the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (OVID), Embase (OVID), the Database of Abstracts of Reviews of Effects (DARE) and the NHS Economic Evaluation Database in the Cochrane Library. Searches were also conducted in the Science Citation Index Expanded, the Conference Proceedings Citation Index on Web of Science (Thomson Reuters), World Health Organization International Clinical Trials Registry and ClinicalTrials.gov. We applied no date or language restrictions. SELECTION CRITERIA We included randomised controlled trials of NP-guided treatment of heart failure versus treatment guided by clinical assessment alone with no restriction on follow-up. Adults treated for heart failure, in both in-hospital and out-of-hospital settings, and trials reporting a clinical outcome were included. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data and evaluated risk of bias. Risk ratios (RR) were calculated for dichotomous data, and pooled mean differences (MD) (with 95% confidence intervals (CI)) were calculated for continuous data. We contacted trial authors to obtain missing data. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and GRADE profiler (GRADEPRO) was used to import data from Review Manager to create a 'Summary of findings' table. MAIN RESULTS We included 18 randomised controlled trials with 3660 participants (range of mean age: 57 to 80 years) comparing NP-guided treatment with clinical assessment alone. The evidence for all-cause mortality using NP-guided treatment showed uncertainty (RR 0.87, 95% CI 0.76 to 1.01; patients = 3169; studies = 15; low quality of the evidence), and for heart failure mortality (RR 0.84, 95% CI 0.54 to 1.30; patients = 853; studies = 6; low quality of evidence).The evidence suggested heart failure admission was reduced by NP-guided treatment (38% versus 26%, RR 0.70, 95% CI 0.61 to 0.80; patients = 1928; studies = 10; low quality of evidence), but the evidence showed uncertainty for all-cause admission (57% versus 53%, RR 0.93, 95% CI 0.84 to 1.03; patients = 1142; studies = 6; low quality of evidence).Six studies reported on adverse events, however the results could not be pooled (patients = 1144; low quality of evidence). Only four studies provided cost of treatment results, three of these studies reported a lower cost for NP-guided treatment, whilst one reported a higher cost (results were not pooled; patients = 931, low quality of evidence). The evidence showed uncertainty for quality of life data (MD -0.03, 95% CI -1.18 to 1.13; patients = 1812; studies = 8; very low quality of evidence).We completed a 'Risk of bias' assessment for all studies. The impact of risk of bias from lack of blinding of outcome assessment and high attrition levels was examined by restricting analyses to only low 'Risk of bias' studies. AUTHORS' CONCLUSIONS In patients with heart failure low-quality evidence showed a reduction in heart failure admission with NP-guided treatment while low-quality evidence showed uncertainty in the effect of NP-guided treatment for all-cause mortality, heart failure mortality, and all-cause admission. Uncertainty in the effect was further shown by very low-quality evidence for patient's quality of life. The evidence for adverse events and cost of treatment was low quality and we were unable to pool results.
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Affiliation(s)
- Julie McLellan
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Carl J Heneghan
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Rafael Perera
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Alison M Clements
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Paul P Glasziou
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)University DriveGold CoastQueenslandAustralia4229
| | - Karen E Kearley
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Nicola Pidduck
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Sally Tyndel
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - F Lucy Wright
- University of OxfordCancer Epidemiology Unit, Nuffield Department of Population HealthRichard doll BldgOld Road Campus, Roosevelt DriverOxfordUKOX3 7LF
| | - Clare Bankhead
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
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Martín-Pérez M, Ruigómez A, Michel A, García Rodríguez LA. Impact of hyperkalaemia definition on incidence assessment: implications for epidemiological research based on a large cohort study in newly diagnosed heart failure patients in primary care. BMC FAMILY PRACTICE 2016; 17:51. [PMID: 27145981 PMCID: PMC4857380 DOI: 10.1186/s12875-016-0448-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 04/22/2016] [Indexed: 01/06/2023]
Abstract
Background Various definitions of hyperkalaemia have been used in clinical research, and data from routine clinical practice on its incidence are sparse. We aimed to establish the incidence of hyperkalaemia in patients with newly diagnosed heart failure in the UK general population using different definitions for the condition. Methods We conducted a large retrospective cohort study using data from The Health Improvement Network primary care database. Patients with newly diagnosed heart failure (N = 19,194) were identified and followed until the first occurrence of hyperkalaemia. Different serum potassium (K+) thresholds were evaluated as possible definitions for hyperkalaemia, and incidence rates (IRs) calculated using a final operational definition both overall and among patient sub-groups. Results IRs of hyperkalaemia ranged from 0.92–7.93 per 100 person-years according to the definition. Based on considerable differences in the serum K+ normal range used between practices, 2176 (11.3 %) individuals were identified with a record of hyperkalaemia using our operational definition of a proportional increase of ≥10 % above the upper bound of the normal range: IR 2.90 per 100 person-years (95 % CI 2.78–3.02) over a mean follow-up of 3.91 years. Incidence rates were higher in older patients, and in those with diabetes or renal impairment. Conclusions Hyperkalaemia is a common finding in heart failure patients in primary care, but its incidence can vary nearly ten-fold depending on its definition. Since assessment of hyperkalaemia risk is essential for therapeutic decision making in heart failure patients, this finding warrants consideration in future epidemiological studies.
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Affiliation(s)
- Mar Martín-Pérez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain
| | - Ana Ruigómez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain
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Sanders-van Wijk S, Masson S, Milani V, Rickenbacher P, Gorini M, Tavazzi LT, Tobler D, Rickli H, Latini R, Brunner-La Roccaenen HP. Interaction of Galectin-3 Concentrations with the Treatment Effects of β-Blockers and RAS Blockade in Patients with Systolic Heart Failure: A Derivation-Validation Study from TIME-CHF and GISSI-HF. Clin Chem 2016; 62:605-16. [PMID: 26936932 DOI: 10.1373/clinchem.2015.246850] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/29/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Galectin-3 predicts prognosis in heart failure (HF) and may help to select HF patients in need of intensified therapy. METHODS This retrospective post hoc analysis included 219 patients from the Trial of Intensified versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure (TIME-HF) and 631 patients from Gruppo Italiano per lo Studio della Sopravvivenza nell'Insufficienza Cardiaca (GISSI-HF) with HF who had reduced ejection fraction and available galectin-3 plasma concentrations. The interaction between galectin-3, β-blockers, renin-angiotensin system (RAS) blockade, and spironolactone on outcome was evaluated in TIME-CHF and validated in GISSI-HF. End points were all-cause mortality and the composite of mortality with HF hospitalization or any hospitalization. RESULTS High galectin-3 concentrations were associated with adverse outcome in both cohorts and remained significantly associated with death after multivariate adjustment [hazard ratio 2.42 (95% CI 1.17-5.01), P = 0.02, in TIME-CHF; 1.47 (1.02-2.10), P = 0.04, in GISSI-HF). In TIME-CHF, patients with low galectin-3 plasma concentrations had a better prognosis when β-blockers were up-titrated, whereas patients with high galectin-3 plasma concentrations did not (interaction P < 0.05 for mortality and death with or without hospitalization). Opposite trends were seen for RAS blockade but were not statistically significant. Patients with high galectin-3 plasma concentrations had neutral prognosis when receiving spironolactone, whereas patients with low galectin-3 plasma concentrations had worse prognosis when receiving spironolactone (interaction P < 0.10 for death with or without hospitalization). In the GISSI-HF validation cohort, these interactions were confirmed for β-blockers (P < 0.05 for all end points) and consistent for RAS blockade (P < 0.10 for death with or without hospitalization), but inconsistent for spironolactone. CONCLUSIONS Galectin-3 is a mediocre prognostic marker, and galectin-3 concentrations interact with the treatment effect of β-blockers and possibly RAS blockade in patients with systolic HF.
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Affiliation(s)
| | - Serge Masson
- Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | | | | | | | - Luigi T Tavazzi
- GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Daniel Tobler
- Cardiology, University Hospital Basel, Basel, Switzerland
| | - Hans Rickli
- Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Roberto Latini
- Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Hans-Peter Brunner-La Roccaenen
- Maastricht University Medical Center, Maastricht, the Netherlands; Cardiology, University Hospital Basel, Basel, Switzerland
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Okada K, Okada M, Kamada N, Yamaguchi Y, Kakehashi M, Sasaki H, Katoh S, Morita K. Reduction of diuretics and analysis of water and muscle volumes to prevent falls and fall-related fractures in older adults. Geriatr Gerontol Int 2016; 17:262-269. [PMID: 26840036 DOI: 10.1111/ggi.12719] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2015] [Indexed: 01/28/2023]
Affiliation(s)
- Kosuke Okada
- Hiroshima Atomic Bomb Survivors Nursing Home Kandayama Yasuragien; Hiroshima Japan
| | - Masahiro Okada
- Department of Food and Dietetics; Hiroshima Bunka Gakuen Two-Year College; Hiroshima Japan
| | - Nanao Kamada
- Hiroshima Atomic Bomb Survivors Relief Foundation; Hiroshima Japan
| | - Yumiko Yamaguchi
- Hiroshima Atomic Bomb Survivors Nursing Home Kurakake Nozomien; Hiroshima Japan
| | - Masayuki Kakehashi
- Graduate School of Biomedical and Health Sciences; Hiroshima University; Hiroshima Japan
| | - Hidemi Sasaki
- Faculty of Nursing; Hiroshima Bunka Gakuen University; Kure Japan
| | - Shigeko Katoh
- Faculty of Nursing; Hiroshima Bunka Gakuen University; Kure Japan
| | - Katsuya Morita
- Faculty of Nursing; Hiroshima Bunka Gakuen University; Kure Japan
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Brunner-La Rocca HP, Bektas S. Biomarker Guided Therapy in Chronic Heart Failure. Card Fail Rev 2015; 1:96-101. [PMID: 28785440 PMCID: PMC5490943 DOI: 10.15420/cfr.2015.1.2.96] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/21/2015] [Indexed: 11/04/2022] Open
Abstract
This review article addresses the question of whether biomarker-guided therapy is ready for clinical implementation in chronic heart failure. The most well-known biomarkers in heart failure are natriuretic peptides, namely B-type natriuretic peptide (BNP) and N-terminal pro-BNP. They are well-established in the diagnostic process of acute heart failure and prediction of disease prognosis. They may also be helpful in screening patients at risk of developing heart failure. Although studied by 11 small- to medium-scale trials resulting in several positive meta-analyses, it is less well-established whether natriuretic peptides are also helpful for guiding chronic heart failure therapy. This uncertainty is expressed by differences in European and American guideline recommendations. In addition to reviewing the evidence surrounding the use of natriuretic peptides to guide chronic heart failure therapy, this article gives an overview of the shortcomings of the trials, how the results may be interpreted and the future directions necessary to fill the current gaps in knowledge. Therapy guidance in chronic heart failure using other biomarkers has not been prospectively tested to date. Emerging biomarkers, such as galectin-3 and soluble ST2, might be useful in this regard, as suggested by several post-hoc analyses.
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Affiliation(s)
| | - Sema Bektas
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Improvement in left ventricular ejection fraction and reverse remodeling in elderly heart failure patients on intense NT-proBNP-guided therapy. Int J Cardiol 2015; 191:286-93. [DOI: 10.1016/j.ijcard.2015.04.282] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/26/2015] [Accepted: 04/30/2015] [Indexed: 11/20/2022]
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Abbas S, Ihle P, Harder S, Schubert I. Risk of hyperkalemia and combined use of spironolactone and long-term ACE inhibitor/angiotensin receptor blocker therapy in heart failure using real-life data: a population- and insurance-based cohort. Pharmacoepidemiol Drug Saf 2015; 24:406-13. [PMID: 25683504 DOI: 10.1002/pds.3748] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 11/24/2014] [Accepted: 12/08/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Clinical trials and few observational studies report increased hyperkalemia risks in heart failure patients receiving aldosterone blockers in addition to standard therapy. The aim of this study is to assess the hyperkalemia risk and combined use of spironolactone and long-term ACE (angiotensin-converting enzyme) inhibitor/angiotensin receptor blocker (ARB) therapy for heart failure in a real-life setting of a heterogeneous population. METHODS Using claims data of the statutory health insurance fund AOK, covering 30% of the German population, we performed a nested case-control study in a cohort of heart failure patients receiving continuous ACE/ARB therapy (n = 1,491,894). Hyperkalemia risk associated with concurrent use of spironolactone and ACE/ARB was calculated by conditional logistic regression in 1062 cases and 10,620 risk-set-sampling-matched controls. RESULTS Risk of hyperkalemia in heart failure patients was significantly associated with spironolactone use (odds ratio (OR) (95% confidence interval (CI)) = 13.59 (11.63-15.88) in all and 11.05 (8.67-14.08) in those with information on New York Heart Association (NYHA) stage of disease). In the NYHA subpopulation, higher risk estimates were observed in short-term as compared with long-term users (OR (95%CI) = 13.00 (9.82-17.21) and 9.12 (6.78-12.26), respectively). Moreover, the association was stronger in older (≥70 years of age) as compared with younger patients (<70 years of age) (OR (95%CI) = 12.32 (9.35-16.23) and 8.73 (5.05-15.08), respectively), although interaction was not significant (pinteraction = 0.07). CONCLUSIONS Hyperkalemia risk associated with combined use of spironolactone and ACE/ARB is much stronger in real-life practice than observed in clinical trials. Careful potassium level monitoring in concomitant users of spironolactone and ACE/ARB is necessary.
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Affiliation(s)
- Sascha Abbas
- PMV Research Group at the Department of Child and Adolescent Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
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Brunner-La Rocca HP, Knackstedt C, Eurlings L, Rolny V, Krause F, Pfisterer ME, Tobler D, Rickenbacher P, Maeder MT. Impact of worsening renal function related to medication in heart failure. Eur J Heart Fail 2014; 17:159-68. [PMID: 25808849 DOI: 10.1002/ejhf.210] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 10/29/2014] [Accepted: 11/05/2014] [Indexed: 12/22/2022] Open
Abstract
AIMS Renal failure is a major challenge in treating heart failure (HF) patients. HF medication may deteriorate renal function, but the impact thereof on outcome is unknown. We investigated the effects of HF medication on worsening renal function (WRF) and the relationship to outcome. METHODS AND RESULTS This post-hoc analysis of TIME-CHF (NT-proBNP-guided vs. symptom-guided management in chronic HF) included patients with LVEF ≤45% and ≥1 follow-up visit (n = 462). WRF III was defined as a rise in serum creatinine ≥0.5 mg/dL (i.e. 44.2 µmol/L) at any time during the first 6 months. Four classes of medication were considered: loop diuretics, beta-blockers, renin-angiotensin system (RAS)-blockers, and spironolactone. Functional principal component analysis of daily doses was used to comprehend medication over time. All-cause mortality after 18 months was the primary outcome. Interactions between WRF, medication, and outcome were tested. Patients with WRF III received on average higher loop diuretic doses (P = 0.0002) and more spironolactone (P = 0.02), whereas beta-blockers (P = 0.69) did not differ and lower doses of RAS-blockers were given (P = 0.09). There were significant interactions between WRF III, medicationn and outcome. Thus, WRF III was associated with poor prognosis if high loop diuretic doses were given (P = 0.001), but not with low doses (P = 0.29). The opposite was found for spironolactone (poor prognosis in the case of WRF III with no spironolactone, P <0.0001; but not with spironolactone, P = 0.31). Beta-blockers were protective in all patients (P <0.001), but most in those with WRF III (P <0.05 for interaction). RAS-blockade was associated with improved outcome (P = 0.006), irrespective of WRF III. CONCLUSION Based on this analysis, it may be hypothesized that high doses of loop diuretics might have detrimental effects, particularly in combination with significant WRF, whereas spironolactone and beta-blockers might be protective in patients with WRF.
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Affiliation(s)
- Hans-Peter Brunner-La Rocca
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands; Division of Cardiology, University Hospital Basel, Switzerland
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Abstract
Heart failure (HF) is a common problem in older adults. Individuals aged 65 years or older are at a higher risk for developing HF, especially diastolic HF or HF with preserved ejection fraction (HFpEF). HF can be seen in up to 20 % of adults aged 85 years or older. In contrast to middle-aged (40-64 years) HF patients, multiple cardiac, non-cardiac and geriatric syndrome co-morbidities are seen in elderly HF patients. Additionally, age-related changes in pharmacokinetics and pharmacodynamics influence medication therapy. Hence, the management of older patients with HF is challenging and treatment should be modified in the light of the above-mentioned conditions. This article discusses the current evidence for medication management in both systolic HF or HF with reduced ejection fraction (HFrEF) and HFpEF, noting, however, the limited data for HFpEF and HFrEF in those 80 years of age or older. The objective of this article is to discuss evidence-based and outcomes-driven pharmacologic management strategies for chronic HF in the older adults for whom functional and other patient-centered outcomes might be more than or as important as clinical outcomes. Optimal management would be expected to help to reduce illness burden, reduce mortality and hospitalizations, and improve function and quality of life.
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Khanagavi J, Gupta T, Aronow WS, Shah T, Garg J, Ahn C, Sule S, Peterson S. Hyperkalemia among hospitalized patients and association between duration of hyperkalemia and outcomes. Arch Med Sci 2014; 10:251-7. [PMID: 24904657 PMCID: PMC4042045 DOI: 10.5114/aoms.2014.42577] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 06/22/2013] [Accepted: 06/24/2013] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION The aim of the study was to investigate predictors of mortality in patients hospitalized with hyperkalemia. MATERIAL AND METHODS Data among hospitalized patients with hyperkalemia (serum potassium ≥ 5.1 mEq/l) were collected. Patients with end-stage renal disease on dialysis were excluded. RESULTS Of 15,608 hospitalizations, 451 (2.9%) episodes of hyperkalemia occurred in 408 patients. In patients with hyperkalemia, chronic kidney disease, hypertension, diabetes, coronary artery disease and heart failure were common comorbidities. Acute kidney injury (AKI) and metabolic acidosis were common metabolic abnormalities, and 359 patients (88%) were on at least one drug associated with hyperkalemia. Mean duration to resolution of hyperkalemia was 12 ±9.9 h. Nonsteroidal anti-inflammatory drugs (HR = 1.59), highest potassium level (HR = 0.61), tissue necrosis (HR = 0.61), metabolic acidosis (HR = 0.77), and AKI (HR = 0.77) were significant independent determinants of duration prior to hyperkalemia resolution. Tissue necrosis (OR = 4.55), potassium supplementation (OR = 5.46), metabolic acidosis (OR = 4.84), use of calcium gluconate for treatment of hyperkalemia (OR = 4.62), AKI (OR = 3.89), and prolonged duration of hyperkalemia (OR = 1.06) were significant independent predictors of in-hospital mortality. CONCLUSIONS Tissue necrosis, potassium supplementation, metabolic acidosis, calcium gluconate for treatment of hyperkalemia, AKI and prolonged duration of hyperkalemia are independent predictors of in-hospital mortality.
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Affiliation(s)
- Jagadish Khanagavi
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Tanush Gupta
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Wilbert S. Aronow
- Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Tushar Shah
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Jalaj Garg
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Chul Ahn
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sachin Sule
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Stephen Peterson
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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Phillips BM, Milner S, Zouwail S, Roberts G, Cowan M, Riley SG, Phillips AO. Severe hyperkalaemia: demographics and outcome. Clin Kidney J 2014; 7:127-33. [PMID: 25852860 PMCID: PMC4377767 DOI: 10.1093/ckj/sft158] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 12/05/2013] [Indexed: 11/17/2022] Open
Abstract
Background Few studies have evaluated the prevalence of severe hyperkalaemia in unselected patient populations. We identified all episodes of severe hyperkalaemia occurring in 1 year, and described patient demographics, clinical response and outcome. We also assessed junior doctor knowledge of its causes and significance. Materials and methods A retrospective interrogation of the database of the regional biochemical laboratory identified all episodes of severe hyperkalaemia (K≥ 6.5 mmol/L) occurring in 2011. The understanding of trainee doctors of the importance, causes and treatment of severe hyperkalaemia was assessed by structured questionnaire. Results Severe hyperkalaemia was recorded in 433 samples (365 patients) giving a prevalence of 0.11%. Thirty-six per cent of episodes occurred in patients under the care of a nephrologist, who were significantly younger than those not under the care of a nephrologist. In the nephrology cohort, 86% occurred in patients with chronic kidney disease (CKD), the majority of which had CKD Stage 5. In the non-nephrology cohort, only 65% occurred in the context of CKD, which was equally distributed between Stages 3 and 5 CKD. In both patient groups, roughly 50% of episodes occurred in association with acute kidney injury (AKI). Acute mortality (death within 48 h of documented severe hyperkalaemia) was higher in the non-nephrology compared with the nephrology cohort. Time to repeat serum potassium was influenced by the clinical setting with shorter time to repeat for acute care compared with ward settings. Assessment of trainee doctor's knowledge suggested significant deficiencies in relation to severe hyperkalaemia. Conclusions The prevalence of severe hyperkalaemia was low and occurred predominantly in the context of CKD and/or AKI. The majority of episodes occurred in patients not under the care of a nephrologist. Variability in time to repeat serum potassium levels suggested deficiencies in care, and assessment of trainee doctor’s knowledge suggests the need for further educational initiatives to highlight its importance.
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Affiliation(s)
- B M Phillips
- Insititute of Nephrology , Cardiff University School of Medicine , Cardiff , UK
| | - S Milner
- Insititute of Nephrology , Cardiff University School of Medicine , Cardiff , UK
| | - S Zouwail
- Department of Biochemistry and Immunology , Cardiff and Vale University Health Board, University Hospital of Wales , Cardiff , UK ; Department of Medical Biochemistry, School of Medicine , Alexandria University , Alexandria , Egypt
| | - G Roberts
- Department of Nephrology and Transplantation , Cardiff and Vale University Health Board, University Hospital of Wales , Cardiff , UK
| | - M Cowan
- Insititute of Nephrology , Cardiff University School of Medicine , Cardiff , UK
| | - S G Riley
- Insititute of Nephrology , Cardiff University School of Medicine , Cardiff , UK
| | - A O Phillips
- Insititute of Nephrology , Cardiff University School of Medicine , Cardiff , UK
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Park IW, Sheen SS, Yoon D, Lee SH, Shin GT, Kim H, Park RW. Onset time of hyperkalaemia after angiotensin receptor blocker initiation: when should we start serum potassium monitoring? J Clin Pharm Ther 2013; 39:61-8. [PMID: 24262001 DOI: 10.1111/jcpt.12109] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 10/14/2013] [Indexed: 12/19/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Angiotensin receptor blockers (ARBs) frequently induce hyperkalaemia in high-risk patients. Early detection of hyperkalaemia can reduce the subsequent harmful effects. This study was performed to examine the onset time of hyperkalaemia after ARB therapy. METHODS We carried out a retrospective analysis to determine the onset time of hyperkalaemia (serum potassium >5·5 mm) among hospitalized patients newly starting ARB therapy between 2004 and 2012, in a tertiary teaching hospital. Predefined possible risk factors and concomitant medications were evaluated. RESULTS AND DISCUSSION During the 97-month study period, a total of 4267 hospitalized patients started ARBs as new drugs and 225 patients showed hyperkalaemia. A significantly increased risk of hyperkalaemia was detected among patients with a high baseline potassium [odds ratio (OR) 6·0] and those who took non-potassium-sparing diuretics (OR 2·2) or potassium supplements (OR 1·6). A high glomerular filtration rate (GFR) was associated with a lower risk of hyperkalaemia (OR 0·992). Fifty-two percentage of hyperkalaemic events occurred within the first week after initiation of ARB therapy. The highest frequency of hyperkalaemia occurred on the first day after initiation of ARBs. Hyperkalaemia occurred earlier in patients with a high baseline serum potassium level, reduced GFR, diabetes and in those without heart failure. WHAT IS NEW AND CONCLUSION Hyperkalaemia occurs most frequently at the beginning of ARB therapy in hospitalized patients. Monitoring of serum potassium and estimated GFR after initiation of ARBs should be started within a few days or not later than 1 week, especially in patients with risk factors.
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Affiliation(s)
- I-W Park
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
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Eschmann E, Beeler PE, Kaplan V, Schneemann M, Zünd G, Blaser J. Patient- and physician-related risk factors for hyperkalaemia in potassium-increasing drug-drug interactions. Eur J Clin Pharmacol 2013; 70:215-23. [PMID: 24150532 DOI: 10.1007/s00228-013-1597-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 09/30/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE Hyperkalaemia due to potassium-increasing drug-drug interactions (DDIs) is a clinically important adverse drug event. The purpose of this study was to identify patient- and physician-related risk factors for the development of hyperkalaemia. METHODS The risk for adult patients hospitalised in the University Hospital Zurich between 1 December 2009 and 31 December 2011 of developing hyperkalaemia was correlated with patient characteristics, number, type and duration of potassium-increasing DDIs and frequency of serum potassium monitoring. RESULTS The 76,467 patients included in this study were prescribed 8,413 potentially severe potassium-increasing DDIs. Patient-related characteristics associated with the development of hyperkalaemia were pulmonary allograft [relative risk (RR) 5.1; p < 0.0001), impaired renal function (RR 2.7; p < 0.0001), diabetes mellitus (RR 1.6; p = 0.002) and female gender (RR 1.5; p = 0.007). Risk factors associated with medication were number of concurrently administered potassium-increasing drugs (RR 3.3 per additional drug; p < 0.0001) and longer duration of the DDI (RR 4.9 for duration ≥6 days; p < 0.0001). Physician-related factors associated with the development of hyperkalaemia were undetermined or elevated serum potassium level before treatment initiation (RR 2.2; p < 0.001) and infrequent monitoring of serum potassium during a DDI (interval >48 h: RR 1.6; p < 0.01). CONCLUSION Strategies for reducing the risk of hyperkalaemia during potassium-increasing DDIs should consider both patient- and physician-related risk factors.
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Affiliation(s)
- Emmanuel Eschmann
- Research Centre for Medical Informatics, Directorate of Research and Education, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland,
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Safety and Efficacy of Eplerenone in Patients at High Risk for Hyperkalemia and/or Worsening Renal Function. J Am Coll Cardiol 2013; 62:1585-93. [DOI: 10.1016/j.jacc.2013.04.086] [Citation(s) in RCA: 176] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 04/13/2013] [Accepted: 04/15/2013] [Indexed: 11/20/2022]
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Jolobe OMP. Evolving strategies for the use of spironolactone in cardiovascular disease. Eur J Intern Med 2013; 24:303-9. [PMID: 23245930 DOI: 10.1016/j.ejim.2012.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 11/11/2012] [Accepted: 11/12/2012] [Indexed: 11/29/2022]
Abstract
The evolution of strategies for the use of spironolactone and its analogue, eplerenone, has, over the years, encompassed favourable modification of the natural history of symptomatic heart failure in subjects with subnormal left ventricular ejection fraction (LVEF), and mitigation of the risk of new-onset atrial fibrillation in mildly symptomatic systolic heart failure. Given the fact that these benefits might be attributable, at least in part, to mitigation of severity of diastolic dysfunction when the latter co-exists with subnormal LVEF, what needs to be explored is the possibility of similar benefits from the use of these agents in patients such as those with hypertension, and aortic valve stenosis, in whom left ventricular dysfunction is of the predominantly diastolic subtype.
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Affiliation(s)
- Oscar M P Jolobe
- Manchester Medical Society, Room 4.54 Simon Building, Brunswick Street, Manchester M13 9PL, United Kingdom.
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Sanders-van Wijk S, Muzzarelli S, Neuhaus M, Kiencke S, Maeder M, Estlinbaum W, Tobler D, Mayer K, Erne P, Pfisterer ME, Brunner-La Rocca HP. Safety and tolerability of intensified, N-terminal pro brain natriuretic peptide-guided compared with standard medical therapy in elderly patients with congestive heart failure: results from TIME-CHF. Eur J Heart Fail 2013; 15:910-8. [PMID: 23666681 DOI: 10.1093/eurjhf/hft079] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS NT-proBNP-guided therapy results in intensification of medical heart failure (HF) therapy and is suggested to improve outcome. However, it is feared that an intensified, NT-proBNP-guided therapy carries a risk of adverse effects. Therefore, the safety and tolerability of NT-proBNP-guided therapy in the Trial of Intensified vs standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF) was assessed. METHODS AND RESULTS A total of 495 chronic HF patients, aged ≥60, with an LVEF ≤45%, NYHA class ≥II, randomized to NT-proBNP-guided or symptom-guided therapy and ≥1 month follow-up were included in the present safety analysis. All adverse events (AEs) were recorded during the 18-month trial period. A total of 5212 AEs were noted, 433 of them serious. NT-proBNP-guided therapy led to a higher up-titration of HF medication and was well tolerated, with a dropout rate (12% vs. 11%, P = 1.0) and AE profile [number of AEs/patient-year 4.7 (2.8-9.4) vs. 5.4 (2.7-11.4), P = 0.69; number of severe AEs/patient-year 0.7 (0-2.7) vs. 1.3 (0-3.9), P = 0.21] similar to that of symptom-guided therapy, although most subjects in both treatment groups (96% vs. 95%, P = 0.55) experienced at least one AE. Age and number of co-morbidities were associated with AEs and interacted with the safety profile of NT-proBNP-guided therapy: positive effects were more frequent in younger and less co-morbid patients whereas potential negative effects-although small and related to non-severe AEs only-were only seen in the older and more co-morbid patients. CONCLUSIONS NT-proBNP-guided therapy is safe in elderly and highly co-morbid HF patients. Trial registration ISRCTN43596477.
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Abstract
The United States population, particularly among older age groups, continues to expand. Because the incidence of heart failure increases with age, largely due to the development of heart failure risk factors such as hypertension and coronary artery disease, the epidemic of heart failure is likely to grow further in the coming decades. This article will review the epidemiology of heart failure among older adults, the influence of an aging population on heart failure prevalence and phenotype, the complications in management for a larger and older heart failure population, and the potential implications of these changes for health care costs and delivery. Ultimately, these challenges demand research into optimal therapeutic strategies for older heart failure patients, including improved prevention and treatment of the major causes of heart failure, an increasing role forpalliative care, and innovations in patient-centered health care delivery.
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Affiliation(s)
- Rebecca Vigen
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO 80045, USA.
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Circulating aldosterone and mortality in female nursing home residents. Exp Gerontol 2013; 48:313-8. [DOI: 10.1016/j.exger.2013.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Revised: 12/11/2012] [Accepted: 01/07/2013] [Indexed: 11/19/2022]
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Abstract
Hyperkalaemia is well recognized as a medical emergency. However, with the publication of trials showing benefit with renin-aldosterone axis suppression in heart failure, the epidemiology of patients presenting with hyperkalaemia has changed. The reported incidence of rate of serious hyperkalaemia (>6.0 mEq/l of potassium) ranges from 6 to 12% in patients on spironolactone with congestive cardiac failure (CCF). A rational choice of therapy based on present evidence is different from the traditionally used algorithm, given our understanding of the physiology relevant to this patient group. This article discusses the changing face of hyperkalaemia and the present evidence and discusses options in treatment of hyperkalaemia.
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Affiliation(s)
- A Chapagain
- Department of Renal Medicine and Transplantation, St Bartholomew's and the Royal London Hospital, London E1 1BB, UK.
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