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Folkerts K, Millier A, Smela B, Olewinska E, Schmedt N, Mernagh P, Kovesdy CP. Real-world evidence for steroidal mineralocorticoid receptor antagonists in patients with chronic kidney disease. J Nephrol 2022; 36:1135-1167. [DOI: 10.1007/s40620-022-01492-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022]
Abstract
Abstract
Background
Mineralocorticoid receptor antagonists (MRAs) were shown to delay chronic kidney disease (CKD) progression in patients with hypertension and/or heart failure (HF) and proteinuria.
Objective
We conducted a systematic literature review on real-world evidence to identify the literature gaps related to the efficacy and safety outcomes of MRAs administered to CKD patients.
Results
A total of 751 records were identified of which, 23 studies (26 publications) were analyzed. Studies included heterogeneous populations, including the overall CKD, CKD and diabetes, CKD and HF, and CKD and a history of cardiovascular disease. Most of the studies were small and non-rigorous, resulting in a notable lack of evidence in these populations. In the overall CKD population, steroidal MRAs resulted in a significant or sustained eGFR reduction but no efficacy in delaying progression to end-stage kidney disease. No cardiovascular protection was found. Results for all-cause mortality and hospitalization for HF were inconsistent; however, the longest follow-up studies indicate similar or lower incidence for spironolactone non-users. Most results consistently reported a higher incidence of hyperkalemia among patients on steroidal MRAs in all CKD stages, and side effects led to high discontinuation rates in the real-world setting.
Conclusions
Despite the limited availability of evidence on the effectiveness and safety of steroidal MRAs in CKD patients and subgroups with diabetes, HF or history of cardiovascular disease, MRAs were shown to have a limited effect on renal and cardiovascular outcomes. Gaps in the evidence regarding the efficacy and safety of MRAs are particularly relevant in diabetic CKD patients; therefore, further research is warranted.
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Lorente-Ros M, Aguilar-Gallardo JS, Shah A, Narasimhan B, Aronow WS. An overview of mineralocorticoid receptor antagonists as a treatment option for patients with heart failure: the current state-of-the-art and future outlook. Expert Opin Pharmacother 2022; 23:1737-1751. [PMID: 36262014 DOI: 10.1080/14656566.2022.2138744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in patients with heart failure. These benefits of MRAs vary in different heart failure populations based on left ventricular ejection fraction and associated comorbidities. AREAS COVERED We define the pharmacologic properties of MRAs and the pathophysiological rationale for their utility in heart failure. We outline the current literature on the use of MRAs in different heart failure populations, including reduced and preserved ejection fraction (HFrEF/ HFpEF), and acute heart failure decompensation. Finally, we describe the limitations of currently available data and propose future directions of study. EXPERT OPINION While there is strong evidence supporting the use of MRAs in HFrEF, evidence in patients with HFpEF or acute heart failure is less definitive. Comorbidities such as obesity or atrial fibrillation could be clinical modifiers of the response to MRAs and potentially alter the risk/benefit ratio in these subpopulations. Emerging evidence for new non-steroidal MRAs reveal promising preliminary results that, if confirmed in large randomized clinical trials, could favor a change in clinical practice.
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Affiliation(s)
- Marta Lorente-Ros
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Jose S Aguilar-Gallardo
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Aayush Shah
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Bharat Narasimhan
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Wilbert S Aronow
- Department of Cardiology, New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY 10901, USA
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3
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Barry AR. Managing Heart Failure With Reduced Ejection Fraction in Patients With Chronic Kidney Disease: A Case-Based Approach and Contemporary Review. CJC Open 2022; 4:802-809. [PMID: 36148258 PMCID: PMC9486859 DOI: 10.1016/j.cjco.2022.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/21/2022] [Indexed: 11/23/2022] Open
Abstract
Patients with heart failure with reduced ejection fraction (HFrEF) often have concurrent chronic kidney disease (CKD), which can make initiating and titrating the 4 standard pharmacologic therapies a challenge. Drug dosing is often based on a calculation of the patient’s creatine clearance or estimated glomerular filtration rate (eGFR), but it should also incorporate the trend in their renal function over time and the risk of toxicity of the drug. The presence of CKD in a patient should not preclude the use of a renin-angiotensin system inhibitor, although patients should be monitored frequently for worsening renal function and hyperkalemia. Sacubitril/valsartan is not recommended in patients with an eGFR < 30 mL/min per 1.73 m2. Of the 3 ß-blockers recommended in the management of HFrEF, only bisoprolol may accumulate in patients with renal impairment; however, patients should still be titrated to the target dose (10 mg daily) or the maximally tolerated dose, depending on their clinical response. The sodium-glucose cotransporter 2 inhibitors are effective at reducing adverse cardiovascular and renal outcomes in patients with HFrEF and CKD (eGFR ≥ 25 mL/min per 1.73 m2 with dapagliflozin or ≥ 20 mL/min per 1.73 m2 with empagliflozin), although declining kidney function is a risk, due to the osmotic diuretic effect. Finally, mineralocorticoid receptor antagonist therapy should be considered in all patients with HFrEF and an eGFR ≥ 30 mL/min per 1.73 m2. The starting dose should be low (eg, 6.25-12.5 mg daily or 12.5 mg every other day) and can be uptitrated based on the patient’s renal function and serum potassium.
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Chow C, Mentz RJ, Greene SJ. Update on the Impact of Comorbidities on the Efficacy and Safety of Heart Failure Medications. Curr Heart Fail Rep 2021; 18:132-143. [PMID: 33835396 DOI: 10.1007/s11897-021-00512-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Multiple newer medications benefit patients with heart failure with reduced ejection fraction (HFrEF). While these therapies benefit the broad population with HFrEF, the efficacy and safety of these therapies have been less well characterized in patients with significant comorbidities. RECENT FINDINGS Common comorbidities of high interest in heart failure (HF) include diabetes mellitus, chronic kidney disease (CKD), atrial fibrillation, and obesity, and each has potential implications for clinical management. As the burden of comorbidities increases in HF populations, risk-benefit assessments of HF therapies in the context of different comorbidities are increasingly relevant for clinical practice. This review summarizes data regarding the core HFrEF therapies in the context of comorbidities, with specific attention to sodium-glucose cotransporter 2 inhibitors, sacubitril/valsartan, mineralocorticoid receptor antagonists (MRAs), and beta-blockers. In general, studies support consistent treatment effects with regard to clinical outcome benefits in the presence of comorbidities. Likewise, safety profiles are relatively consistent irrespective of comorbidities, with the exception of heightened risk of hyperkalemia with MRA therapy in patients with severe CKD. In conclusion, while HF management is complex in the context of multiple comorbidities, the totality of evidence strongly supports guideline-directed medical therapies as foundational for improving outcomes in these high-risk patients.
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Affiliation(s)
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, 200 Morris Street, Durham, NC, 27701, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, 200 Morris Street, Durham, NC, 27701, USA.
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Cosimato C, Agoritsas T, Mavrakanas TA. Mineralocorticoid receptor antagonists in patients with chronic kidney disease. Pharmacol Ther 2020; 219:107701. [PMID: 33027644 DOI: 10.1016/j.pharmthera.2020.107701] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/17/2020] [Indexed: 11/24/2022]
Abstract
Mineralocorticoid receptor antagonists (MRA) can reduce cardiovascular morbidity and mortality in patients with heart failure and ischemic heart disease. In addition, these agents have been used in patients with diabetic nephropathy to control proteinuria and slow down chronic kidney disease (CKD) progression. Current guidelines recommend against the use of MRAs in patients with advanced CKD. However, there is growing interest on their use in this population that has unmet needs (high cardiovascular morbidity and mortality) and unique challenges (risk of acute kidney injury or hyperkalemia). This narrative review discusses the emerging role of MRAs for the management of cardiovascular disease and/or the prevention of CKD progression, highlighting results from randomized controlled trials and presenting real-world data from available registries. Results from recent trials in patients on maintenance dialysis are also discussed.
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Affiliation(s)
- Cosimo Cosimato
- Division of General Internal Medicine, Department of Medicine, University Hospitals of Geneva & Faculty of Medicine, Geneva, Switzerland
| | - Thomas Agoritsas
- Division of General Internal Medicine, Department of Medicine, University Hospitals of Geneva & Faculty of Medicine, Geneva, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Thomas A Mavrakanas
- Division of General Internal Medicine, Department of Medicine, University Hospitals of Geneva & Faculty of Medicine, Geneva, Switzerland; Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada.
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Duran JM, Gad S, Brann A, Greenberg B. Mineralocorticoid receptor antagonist use following heart failure hospitalization. ESC Heart Fail 2020; 7:482-492. [PMID: 32035000 PMCID: PMC7160481 DOI: 10.1002/ehf2.12635] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 01/15/2020] [Accepted: 01/17/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS Patients hospitalized for heart failure (HF) are at increased risk for events post-discharge. Mineralocorticoid receptor antagonists (MRAs) improve the clinical course of patients with HF with reduced ejection fraction. We assessed MRA use in high-risk patients following an HF hospitalization to determine rate of MRA prescription, likelihood of drug continuation post-discharge, reasons for discontinuation, and association between MRA maintenance and outcomes. METHODS AND RESULTS Patients admitted to our hospital system between 2011 and 2013 were identified retrospectively through automated search of electronic medical records for appropriate ICD 9 and 10 codes. Patients with left ventricular ejection fraction <40%, New York Heart Association class III-IV symptoms, >1 year of follow-up and no contraindication to MRA use were included. Of 271 patients meeting inclusion criteria, 105 (38.7%) were prescribed an MRA on discharge from index admission. Over a median follow-up of 3.12 ± 0.09 years, 70 (66.7%) continued MRA therapy, while 35 (33.3%) discontinued MRA therapy. Hyperkalemia, which occurred in 43 of the 105 patients (40.1%), was the most frequent cause of MRA discontinuation. Patients who maintained MRA therapy had significantly less all-cause, cardiovascular, and HF hospitalizations and significantly better survival compared with those who discontinued drug. CONCLUSIONS A minority of HF with reduced ejection fraction patients who were eligible for an MRA received them following HF hospitalization and nearly a third of them discontinued drug. Patients who discontinued an MRA were more likely to be hospitalized or die during follow-up. These findings indicate a need for better strategies to increase MRA prescription and maintain therapy following a hospitalization for HF.
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Affiliation(s)
- Jason M. Duran
- Department of CardiologyUniversity of California San DiegoLa JollaCAUSA
| | - Shady Gad
- Department of CardiologyUniversity of California San DiegoLa JollaCAUSA
| | - Alison Brann
- Department of CardiologyUniversity of California San DiegoLa JollaCAUSA
| | - Barry Greenberg
- Department of CardiologyUniversity of California San DiegoLa JollaCAUSA
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Khan MS, Khan MS, Moustafa A, Anderson AS, Mehta R, Khan SS. Efficacy and Safety of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure and Chronic Kidney Disease. Am J Cardiol 2020; 125:643-650. [PMID: 31843235 DOI: 10.1016/j.amjcard.2019.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/09/2019] [Accepted: 11/13/2019] [Indexed: 12/21/2022]
Abstract
Mineralocorticoid receptor antagonists (MRA) improve clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF) and reduce risk of heart failure (HF) hospitalization in patients with heart failure with preserved ejection fraction (HFpEF). However, the benefit and risks of MRA use are not clear in HF patients and chronic kidney disease (CKD) with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. We conducted a systematic review evaluating the efficacy and safety of MRA in patients with HF and CKD. PubMed, Embase, and Cochrane Central databases were searched for relevant studies on patients with HF and reduced renal function (defined as eGFR <60 mL/min/1.73 m2). Seven studies with 5,522 patients were included. We found 3 studies in patients with HFrEF, 1 study with HFpEF, and 2 in acute HF and 1 with mixed patient population of HF. Post hoc analyses from randomized controlled trials demonstrated reduction of risk in the primary end point (adverse cardiovascular outcomes and/or all-cause mortality and/or HF hospitalization) with MRA use in the CKD subgroup (eGFR 30 to 60 mL/min/1.73 m2) despite a greater risk of hyperkalemia and higher rates of drug discontinuation. In 3 observational studies, propensity score matching was performed to compare patients treated with and without MRA and did not identify benefits, but conclusions from these studies were limited due to residual confounding and concern for bias. In conclusion, benefits of MRA use in HF appear to be consistent in patients with reduced renal function (eGFR 30 to 60 mL/min/1.73 m).
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8
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Lam PH, Dooley DJ, Arundel C, Morgan CJ, Fonarow GC, Bhatt DL, Allman RM, Ahmed A. One- to 10-Day Versus 11- to 30-Day All-Cause Readmission and Mortality in Older Patients With Heart Failure. Am J Cardiol 2019; 123:1840-1844. [PMID: 30928031 PMCID: PMC10463564 DOI: 10.1016/j.amjcard.2019.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/19/2019] [Accepted: 03/04/2019] [Indexed: 11/21/2022]
Abstract
Heart failure (HF) is the leading cause for 30-day all-cause readmission in older Medicare beneficiaries and 30-day all-cause readmission is associated with a higher risk of mortality. In the current analysis, we examined if that association varied by timing of 30-day all-cause readmission. Of the 8,049 Medicare beneficiaries hospitalized for HF, 1,688 had 30-day all-cause readmissions, of whom 1,519 were alive at 30 days. Of these, 626 (41%) had early (first 10 days) 30-day readmission. Propensity scores for early 30-day readmission, estimated for all 1,519 patients, were used to assemble a matched cohort of 596 pairs of patients with early versus late (11 to 30 days) all-cause readmission balanced on 34 baseline characteristics. Two-year all-cause mortality occurred in 51% and 57% of matched patients with early versus late 30-day all-cause readmissions, respectively (hazard ratio [HR] associated with late 30-day readmission, 1.22; 95% confidence interval [CI], 1.04 to 1.42; p = 0.014). This association was not observed in the subset of 436 patients whose 30-day all-cause readmission was due to HF (HR, 1.01; 95% CI, 0.79 to 1.28; p = 0.963), but was observed in the subset of 756 patients whose 30-day all-cause readmission was not due to HF (HR, 1.37; 95% CI, 1.12 to 1.67; p = 0.002; p for interaction, 0.057). In conclusion, in a high-risk subset of older hospitalized HF patients readmitted within 30 days, readmission during 11 to 30 (vs 1 to 10) days was associated with a higher risk of death and this association appeared to be more pronounced in those readmitted for non-HF-related reasons.
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Affiliation(s)
- Phillip H Lam
- Veterans Affairs Medical Center, Washington, District of Columbia; Brigham and Women's Hospital Heart & Vascular Center, Boston, Massachusetts
| | - Daniel J Dooley
- Veterans Affairs Medical Center, Washington, District of Columbia; Georgetown University, Washington, District of Columbia; MedStar Washington Hospital Center, Washington, District of Columbia
| | - Cherinne Arundel
- Veterans Affairs Medical Center, Washington, District of Columbia; George Washington University, Washington, District of Columbia
| | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | - Ali Ahmed
- Veterans Affairs Medical Center, Washington, District of Columbia; George Washington University, Washington, District of Columbia; University of Alabama at Birmingham, Birmingham, Alabama.
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9
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Hein AM, Scialla JJ, Edmonston D, Cooper LB, DeVore AD, Mentz RJ. Medical Management of Heart Failure With Reduced Ejection Fraction in Patients With Advanced Renal Disease. JACC. HEART FAILURE 2019; 7:371-382. [PMID: 31047016 PMCID: PMC6501813 DOI: 10.1016/j.jchf.2019.02.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 02/20/2019] [Indexed: 02/06/2023]
Abstract
Large randomized clinical trials (RCT) supporting guidelines for the management of heart failure with reduced ejection fraction (HFrEF) have typically excluded patients with advanced chronic kidney disease (CKD). Patients with concomitant advanced CKD and HFrEF experience poor cardiovascular outcomes and mortality relative to either disease in isolation and have been shown to consistently receive lower rates of HFrEF guideline-directed medical therapy (GDMT). This review evaluated recent evidence for the use of GDMT in patients with HFrEF and advanced CKD approaching dialysis from RCTs and observational cohorts. The authors also discuss the limitations and challenges inherent in the evidence for GDMT in this population, and offer guidance to clinicians for proper clinical use and future research directions.
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Affiliation(s)
- Aaron M Hein
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel Edmonston
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Lauren B Cooper
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Adam D DeVore
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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10
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Potential target-organ protection of mineralocorticoid receptor antagonist in acute kidney disease. J Hypertens 2019; 37:125-134. [PMID: 30063639 DOI: 10.1097/hjh.0000000000001876] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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11
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Spironolactone and Outcomes in Older Patients with Heart Failure and Reduced Ejection Fraction. Am J Med 2019; 132:71-80.e1. [PMID: 30240686 PMCID: PMC6511886 DOI: 10.1016/j.amjmed.2018.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 08/31/2018] [Accepted: 09/04/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The efficacy of mineralocorticoid receptor antagonists or aldosterone antagonists in heart failure with reduced ejection fraction (HFrEF) is well known. Less is known about their effectiveness in real-world older patients with HFrEF. METHODS Of the 8206 patients with heart failure and ejection fraction ≤35% without prior spironolactone use in the Medicare-linked OPTIMIZE-HF registry, 6986 were eligible for spironolactone therapy based on serum creatinine criteria (men ≤2.5 mg/dL, women ≤2.0 mg/dL) and 865 received a discharge prescription for spironolactone. Using propensity scores for spironolactone use, we assembled a matched cohort of 1724 (862 pairs) patients receiving and not receiving spironolactone, balanced on 58 baseline characteristics (Creatinine Cohort: mean age, 75 years, 42% women, 17% African American). We repeated the above process to assemble a secondary matched cohort of 1638 (819 pairs) patients with estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2 (eGFR Cohort: mean age, 75 years, 42% women, 17% African American). RESULTS In the matched Creatinine Cohort, spironolactone-associated hazard ratios (95% confidence intervals) for all-cause mortality, heart failure readmission, and combined endpoint of heart failure readmission or all-cause mortality were 0.92 (0.81-1.03), 0.87 (0.77-0.99), and 0.87 (0.79-0.97), respectively. Respective hazard ratios (95% confidence intervals) in the matched eGFR Cohort were 0.87 (0.77-0.98), 0.92 (0.80-1.05), and 0.91 (0.82-1.02). CONCLUSIONS These findings provide evidence of consistent, albeit modest, clinical effectiveness of spironolactone in older patients with HFrEF regardless of renal eligibility criteria used. Additional strategies are needed to improve the effectiveness of aldosterone antagonists in clinical practice.
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12
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Patterson SJ, Reaves AB, Tolley EA, Ulrich D, Hilty C, Clarke CJ, Self TH. Underutilization of Aldosterone Antagonists in Heart Failure. Hosp Pharm 2017; 52:698-703. [PMID: 29276242 DOI: 10.1177/0018578717724886] [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] [Indexed: 11/17/2022]
Abstract
Background: Treatment with an aldosterone antagonist (AA) has been shown in multiple trials to reduce heart failure (HF)-related morbidity, mortality, and hospital readmission. American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) treatment guidelines recommend the use of an AA in all HF patients with an ejection fraction ≤35% and no known contraindication. Several studies have documented underuse of AA. Objectives: To determine the proportion of patients who received AA therapy consistent with the ACCF/AHA guidelines. Secondary objectives included determining the proportion of patients who received an AA inconsistent with guidelines and 30- and 90-day readmission rates. Methods: A retrospective chart review was conducted of patients admitted to an inner city academic medical center with a diagnosis of HF between August 16, 2011, and June 5, 2013. Results: A total of 346 HF admissions (87.6% African American) were evaluated. Use of an AA at discharge was consistent with guidelines in 31% of patients. A total of 121 patients (35%) were discharged on an AA. Among the remaining 225 patients who were not discharged on an AA, 170 (75.6%) had no contraindication to therapy. Sixty-one patients were readmitted within 30 days, and a total of 108 patients were readmitted within 90 days. There were no significant differences in readmission rates between patients who were discharged on AA therapy and those who were not. Conclusion: AAs are still underutilized in the treatment of HF.
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Affiliation(s)
| | - Anne B Reaves
- Methodist University Hospital, USA.,The University of Tennessee Health Science Center, Memphis, USA
| | | | | | | | - Catherine J Clarke
- Methodist University Hospital, USA.,The University of Tennessee Health Science Center, Memphis, USA
| | - Timothy H Self
- The University of Tennessee Health Science Center, Memphis, USA
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13
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Morath B, Mayer T, Send AFJ, Hoppe-Tichy T, Haefeli WE, Seidling HM. Risk factors of adverse health outcomes after hospital discharge modifiable by clinical pharmacist interventions: a review with a systematic approach. Br J Clin Pharmacol 2017; 83:2163-2178. [PMID: 28452063 DOI: 10.1111/bcp.13318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 12/19/2022] Open
Abstract
The present review assessed the evidence on risk factors for the occurrence of adverse health outcomes after discharge (i.e. unplanned readmission or adverse drug event after discharge) that are potentially modifiable by clinical pharmacist interventions. The findings were compared with patient characteristics reported in guidelines that supposedly indicate a high risk of drug-related problems. First, guidelines and risk assessment tools were searched for patient characteristics indicating a high risk of drug-related problems. Second, a systematic PubMed search was conducted to identify risk factors significantly associated with adverse health outcomes after discharge that are potentially modifiable by a clinical pharmacist intervention. After the PubMed search, 37 studies were included, reporting 16 risk factors. Only seven of 34 patient characteristics mentioned in pertinent guidelines corresponded to one of these risk factors. Diabetes mellitus (n = 11), chronic obstructive lung disease (n = 9), obesity (n = 7), smoking (n = 5) and polypharmacy (n = 5) were the risk factors reported most frequently in the studies. Additionally, single studies also found associations of adverse health outcomes with different drug classes {e.g. warfarin [hazard ratio 1.50; odds ratio (OR) 3.52], furosemide [OR 2.25] or high beta-blocker starting doses [OR 3.10]}. Although several modifiable risk factors were found, many patient characteristics supposedly indicating a high risk of drug-related problems were not part of the assessed risk factors in the context of an increased risk of adverse health outcomes after discharge. Therefore, an obligatory set of modifiable patient characteristics should be created and implemented in future studies investigating the risk for adverse health outcomes after discharge.
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Affiliation(s)
- Benedict Morath
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Hospital Pharmacy, Heidelberg University, Im Neuenheimer Feld 670, 69120, Heidelberg, Germany
| | - Tanja Mayer
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Alexander Francesco Josef Send
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Torsten Hoppe-Tichy
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Hospital Pharmacy, Heidelberg University, Im Neuenheimer Feld 670, 69120, Heidelberg, Germany
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Hanna Marita Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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14
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Tseng WC, Liu JS, Hung SC, Kuo KL, Chen YH, Tarng DC, Hsu CC. Effect of spironolactone on the risks of mortality and hospitalization for heart failure in pre-dialysis advanced chronic kidney disease: A nationwide population-based study. Int J Cardiol 2017; 238:72-78. [PMID: 28363684 DOI: 10.1016/j.ijcard.2017.03.080] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 01/05/2017] [Accepted: 03/16/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Spironolactone has been shown to reduce cardiovascular death in patients with mild-to-moderate chronic kidney disease (CKD), but its risks and benefits in advanced CKD remain unsettled. We aimed to assess whether spironolactone reduces cardiovascular mortality and morbidity in pre-dialysis stage 5 CKD patients. METHODS Using Taiwan's National Health Insurance Research Database from January 2000 to June 2009, we enrolled 27,213 pre-dialysis stage 5 CKD adult patients, in whom 1363 patients were treated with spironolactone (user) and 25,850 were not (nonuser). Outcomes were all-cause mortality, hospitalization for heart failure (HHF) and major adverse cardiac event (MACE, the composite of acute myocardial infarction and ischemic stroke). Patients were followed up till December 31, 2009. RESULTS Over 85,758 person-years of follow-up, spironolactone users had higher incidence for all-cause mortality (24.7/100 person-years vs. 10.6/100 person-years), infection-related death (4.4/100 person-years vs. 1.7/100 person-years) and HHF (4.0/100 person-years vs. 1.4/100 person-years). Multivariable Cox hazards model showed that spironolactone users were associated with higher risks of all-cause mortality (adjusted hazard ratio [aHR] 1.35, 95% confidence interval [CI] 1.24-1.46), infection-related death (aHR 1.42, CI 1.16-1.73) and HHF (aHR 1.35, CI 1.08-1.67) as compared to nonusers. The risks for cardiovascular mortality, MACE and hyperkalemia-associated hospitalization were similar between two groups. After matching users and nonusers (1:3 ratio) by propensity scores, the results were consistent in matched cohort and across subgroups. CONCLUSIONS Spironolactone may be associated with higher risks for all-cause and infection-related mortality and HHF in pre-dialysis stage 5 CKD patients. Spironolactone should be used with caution in advanced CKD patients.
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Affiliation(s)
- Wei-Cheng Tseng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jia-Sin Liu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Szu-Chun Hung
- Division of Nephrology, Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Taipei, Taiwan
| | - Ko-Lin Kuo
- Division of Nephrology, Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Taipei, Taiwan
| | - Yu-Hsin Chen
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan; Department and Institute of Physiology, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Chih-Cheng Hsu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan; Department of Health Services Administration, China Medical University, Taichung, Taiwan.
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Lack of evidence of lower 30-day all-cause readmission in Medicare beneficiaries with heart failure and reduced ejection fraction discharged on spironolactone. Int J Cardiol 2016; 227:462-466. [PMID: 27866868 DOI: 10.1016/j.ijcard.2016.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/28/2016] [Accepted: 11/02/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Therapy with evidence-based heart failure (HF) medications has been shown to be associated with lower risk of 30-day all-cause readmission in patients with HF and reduced ejection fraction (HFrEF). METHODS We examined the association of aldosterone antagonist use with 30-day all-cause readmission in this population. Of the 2443 Medicare beneficiaries with HF and left ventricular EF ≤35% discharged home from 106 Alabama hospitals during 1998-2001, 2060 were eligible for spironolactone therapy (serum creatinine ≤2.5 for men and ≤2mg/dl for women, and serum potassium <5mEq/L). After excluding 186 patients already receiving spironolactone on admission, the inception cohort consisted of 1874 patients eligible for a new discharge prescription for spironolactone, of which 329 received one. Using propensity scores for initiation of spironolactone therapy, we assembled a matched cohort of 324 pairs of patients receiving and not receiving spironolactone balanced on 34 baseline characteristics (mean age 72years, 42% women, 33% African American). RESULTS Thirty-day all-cause readmission occurred in 17% and 19% of matched patients receiving and not receiving spironolactone, respectively (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.64-1.32; p=0.650). Spironolactone had no association with 30-day all-cause mortality (HR, 0.84; 95% CI, 0.38-1.88; p=0.678) or HF readmission (HR, 0.74; 95% CI, 0.41 1.31; p=0.301). These associations remained unchanged during 12months of post-discharge follow-up. CONCLUSION A discharge prescription for spironolactone had no association with 30-day all-cause readmission among older, hospitalized Medicare beneficiaries with HFrEF eligible for spironolactone therapy.
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Lu R, Zhang Y, Zhu X, Fan Z, Zhu S, Cui M, Zhang Y, Tang F. Effects of mineralocorticoid receptor antagonists on left ventricular mass in chronic kidney disease patients: a systematic review and meta-analysis. Int Urol Nephrol 2016; 48:1499-509. [PMID: 27193436 DOI: 10.1007/s11255-016-1319-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 05/09/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRAs) are used widely in treatment of heart failure, but their effects on cardiovascular complications and mortality of chronic kidney disease (CKD) are not well known. Thus, we aim to assess such therapeutic effects of MRAs on CKD. METHODS Electronic literature published in any language until Dec 31, 2015, was systematically searched on PubMed, Embase, and Cochrane Central Register of Controlled Trials. Primary outcome was left ventricular mass (LVM) or LVM index (LVMI), and secondary outcome was all-cause mortality and major adverse cardiovascular events (MACEs). Results of continuous outcomes were pooled using mean difference (MD) and standard mean difference (SMD). Risk ratios (RRs) with 95 % confidence intervals (CIs) were pooled using a random- or fixed-effects model. RESULTS Totally 12 studies (6 randomized controlled trials with 1003 participants) involving 4935 patients were included. MRA treatment versus non-MRA treatment resulted in a significant change of 0.93 SMD (standard mean difference) in LVM (LVMI), a significant reduction of 22 % in all-cause mortality, a significant reduction of incidence of MACEs (RR 0.65, P = 0.001), significantly higher prevalence rates of hyperkalemia (>5.5 mmol/L), but no significant change in prevalence rates of severe hyperkalemia (>6.0 mmol/L). CONCLUSION MRA benefits CKD patients in terms of LVMI, all-cause mortality, and MACEs with no incidence of severe hyperkalemia. Nevertheless, the real effects of MRAs on cardiovascular events and mortality as well as their safety in CKD patients should be identified by further studies with prospective and large-sample clinical trials.
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Affiliation(s)
- RenJie Lu
- Department of Pharmacy, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Yan Zhang
- Department of Internal Medicine, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Xishan Zhu
- Department of Urinary Surgery, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Zhengda Fan
- Department of Pharmacy, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Shanmei Zhu
- Department of Pharmacy, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Manman Cui
- Department of Infectious Diseases, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Yanping Zhang
- Department of Infectious Diseases, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Fenglei Tang
- Department of Pharmacy, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China.
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Pitt B, Rossignol P. The safety of mineralocorticoid receptor antagonists (MRAs) in patients with heart failure. Expert Opin Drug Saf 2016; 15:659-65. [PMID: 26958701 DOI: 10.1517/14740338.2016.1163335] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Mineralocorticoid receptor antagonists (MRAs) have been accorded a class 1 indication for patients with chronic heart failure and a reduced left ventricular ejection fraction (HFREF) in both European and American guidelines. Uptake, however, has been less than optimal largely due to concerns about their safety, in particular the risk of hyperkalemia and renal dysfunction. AREAS COVERED This review presents the current state of affairs regarding the safety of MRAs in heart failure with reduced ejection fraction. EXPERT OPINION Careful patient selection and adherence to guideline-recommended inclusion and exclusion criteria, dosing, and serial monitoring of serum potassium and renal function, along with patient education regarding the potassium content of common foods, should minimize these risks and allow increased use of MRAs. Additionally, this may also result in a further reduction in cardiovascular mortality and hospitalizations for heart failure. The development of new non-steroidal MRAs, and especially new potassium binding molecules that are well tolerated and effective, hold the promise for increased safety and, therefore, increased and more prolonged use of MRAs in patients with heart failure, especially those with chronic kidney disease, diabetes mellitus, and the elderly.
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Affiliation(s)
- Bertram Pitt
- a School of Medicine , University of Michigan , Ann Arbor , MI , USA
| | - Patrick Rossignol
- b Inserm, Centre d'Investigations Cliniques- Plurithématique 14-33, Inserm U1116, CHU Nancy , Université de Lorraine, Association Lorraine de Traitement de l'Insuffisance Rénale, and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) , Nancy , France
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Inampudi C, Deedwania P, Fonarow GC, Sanders PW, Aronow WS, Ahmed A. Reply: To PMID 24846806. Am J Cardiol 2015; 115:156. [PMID: 25454018 DOI: 10.1016/j.amjcard.2014.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 10/14/2014] [Indexed: 11/18/2022]
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Eschalier R, Girerd N, Rossignol P. Do not analyze too quickly a result: how spironolactone is always point at! Am J Cardiol 2015; 115:155-6. [PMID: 25454017 DOI: 10.1016/j.amjcard.2014.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 10/14/2014] [Indexed: 11/15/2022]
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