1
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Miñana G, de la Espriella R, Palau P, Amiguet M, Seller J, García Pinilla JM, Núñez E, Górriz JL, Valle A, Sanchis J, Bayés-Genís A, Núñez J. Early glomerular filtration rate decline is associated with hemoglobin rise following dapagliflozin initiation in heart failure with reduced ejection fraction. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:783-792. [PMID: 36958534 DOI: 10.1016/j.rec.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/08/2023] [Indexed: 03/25/2023]
Abstract
INTRODUCTION AND OBJECTIVES Sodium-glucose cotransporter-2 inhibitors (SGLT2i) induce short-term changes in renal function and hemoglobin. Their pathophysiology is incompletely understood. We aimed to evaluate the relationship between 1- and 3-month estimated glomerular filtration rate (eGFR) and hemoglobin changes following initiation of dapagliflozin in patients with stable heart failure with reduced ejection fraction (HFrEF). METHODS This is a post hoc analysis of a randomized clinical trial that evaluated the effect of dapagliflozin on 1- and 3-month peak oxygen consumption in outpatients with stable HFrEF (DAPA-VO2 trial, NCT04197635). We used linear mixed regression analysis to assess the relationship between eGFR and hemoglobin changes across treatment arms. RESULTS A total of 87 patients were evaluated in this substudy. The mean age was 67.0± 10.5 years, and 21 (24.1%) were women. The mean baseline eGFR and hemoglobin were 66.9±20.7mL/min/1.73m2 and 14.3±1.7g/dL, respectively. Compared with placebo, eGFR did not significantly change at either time points in the dapagliflozin group, but hemoglobin significantly increased at 1 and 3 months. At 1 month, the hemoglobin increase was related to decreases in eGFR only in the dapagliflozin arm (P <.001). At 3 months, there was no significant association in either treatment arms (P=.123). Changes in eGFR were not associated with changes in peak oxygen consumption, quality of life, or natriuretic peptides. CONCLUSIONS In patients with stable HFrEF, 1-month changes in eGFR induced by dapagliflozin are inversely related to changes in hemoglobin. This association was no longer significant at 3 months.
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Affiliation(s)
- Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España
| | - Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España
| | - Patricia Palau
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España
| | - Martina Amiguet
- Departamento de Medicina, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Universitat Jaume I, Castellón, España
| | - Julia Seller
- Servicio de Cardiología, Hospital de Denia, Alicante, España
| | - José Manuel García Pinilla
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España; Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, IBIMA, Málaga, España
| | - Eduardo Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España.
| | - José Luis Górriz
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España
| | - Alfonso Valle
- Servicio de Cardiología, Hospital de Denia, Alicante, España
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España
| | - Antoni Bayés-Genís
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España; Servicio de Cardiología, Hospital Germans Trias i Pujol, Universitat de Barcelona, Badalona, Barcelona, España
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España
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2
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Kenneally LF, Lorenzo M, Romero-González G, Cobo M, Núñez G, Górriz JL, Barrios AG, Fudim M, de la Espriella R, Núñez J. Kidney function changes in acute heart failure: a practical approach to interpretation and management. Clin Kidney J 2023; 16:1587-1599. [PMID: 37779845 PMCID: PMC10539207 DOI: 10.1093/ckj/sfad031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Indexed: 10/03/2023] Open
Abstract
Worsening kidney function (WKF) is common in patients with acute heart failure (AHF) syndromes. Although WKF has traditionally been associated with worse outcomes on a population level, serum creatinine concentrations vary greatly during episodes of worsening heart failure, with substantial individual heterogeneity in terms of their clinical meaning. Consequently, interpreting such changes within the appropriate clinical context is essential to unravel the pathophysiology of kidney function changes and appropriately interpret their clinical meaning. This article aims to provide a critical overview of WKF in AHF, aiming to provide physicians with some tips and tricks to appropriately interpret kidney function changes in the context of AHF.
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Affiliation(s)
- Laura Fuertes Kenneally
- Cardiology Department, General Hospital of Alicante, Dr Balmis. Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL). Alicante, Spain
| | - Miguel Lorenzo
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Gregorio Romero-González
- Nephrology Department, University Hospital Germans Trias I Pujol, Badalona, Spain, International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
| | - Marta Cobo
- CIBER Cardiovascular
- Cardiology Department, Hospital Universitario Puerta de Hierro Majadahonda (IDIPHISA), Madrid, Spain
| | - Gonzalo Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Jose Luis Górriz
- Nephrology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, Valencia, Spain
| | - Ana Garcia Barrios
- Cardiology Department, General Hospital of Alicante, Dr Balmis. Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL). Alicante, Spain
| | - Marat Fudim
- Cardiology Department, Duke University Medical Center. Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
- CIBER Cardiovascular
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3
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Lucas BP, Misra S, Donnelly WT, Daubenspeck JA, Leiter J. Relative Blood Volume Profiles Hours After Loop Diuretic Administration: A Systematic Review and Meta-analysis. CJC Open 2023; 5:641-649. [PMID: 37720179 PMCID: PMC10502431 DOI: 10.1016/j.cjco.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/11/2023] [Indexed: 09/19/2023] Open
Abstract
Background Plasma refill rates can be estimated by combining measurements of urine output with relative blood volume profiles. Change in plasma refill rates could guide decongestive loop diuretic therapy in acute heart failure. The objective of the study was to assess average relative blood volume profiles generated from 2 or 3 follow-up measurements obtained hours after loop diuretic administration in subjects with vs without baseline congestion. Methods A systematic review was conducted of articles written in English, French, Spanish, and German, using MEDLINE (1964 to 2019), Cochrane Reviews (1996 to 2019), and Embase (1974 to 2019). Search terms included the following: diuretics, hemoconcentration, plasma volume, and blood volume. We included studies of adults given a loop diuretic with at least one baseline and one follow-up measurement. A single author extracted subject- or group-level blood volume measurements, aggregated them when needed, and converted them to relative changes. Results Across all 16 studies that met the prespecified inclusion criteria, relative blood volume maximally decreased 9.2% (6.6% to 12.0%) and returned to baseline after 3 or more hours. Compared to subjects without congestion, those with congestion experienced smaller decreases in relative blood volume across all follow-up periods (P = 0.001) and returned to baseline within the final follow-up period. Conclusions Single doses of loop diuretics produce measurable changes in relative blood volume that follow distinct profiles for subjects with vs without congestion. Measured alongside urine output, these profiles may be used to estimate plasma refill rates-potential patient-specific targets for decongestive therapy across serial diuretic doses.
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Affiliation(s)
- Brian P. Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- The Dartmouth Institute of Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Shantum Misra
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - William T. Donnelly
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | | | - J.C. Leiter
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
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4
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Pathophysiology-Based Management of Acute Heart Failure. Clin Pract 2023; 13:206-218. [PMID: 36826161 PMCID: PMC9955619 DOI: 10.3390/clinpract13010019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/22/2023] [Accepted: 01/29/2023] [Indexed: 02/01/2023] Open
Abstract
Even though acute heart failure (AHF) is one of the most common admission diagnoses globally, its pathogenesis is poorly understood, and there are few effective treatments available. Despite an heterogenous onset, congestion is the leading contributor to hospitalization, making it a crucial therapeutic target. Complete decongestion, nevertheless, may be hard to achieve, especially in patients with reduced end organ perfusion. In order to promote a personalised pathophysiological-based therapy for patients with AHF, we will address in this review the pathophysiological principles that underlie the clinical symptoms of AHF as well as examine how to assess them in clinical practice, suggesting that gaining a deeper understanding of pathophysiology might result in significant improvements in HF therapy.
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5
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Odajima S, Fujimoto W, Kuroda K, Yamashita S, Imanishi J, Iwasaki M, Todoroki T, Okuda M, Hayashi T, Konishi A, Shinohara M, Toh R, Hirata K, Tanaka H. Association of congestion with worsening renal function in acute decompensated heart failure according to age. ESC Heart Fail 2022; 9:4250-4261. [PMID: 36113882 PMCID: PMC9773715 DOI: 10.1002/ehf2.14157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/05/2022] [Accepted: 09/08/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS Acute decompensated heart failure (ADHF) is a frequent cause of hospitalization for patients with heart disease, and ADHF patients are at high risk of heart failure (HF) re-hospitalization. Residual congestion at discharge is also a strong predictor of poor outcomes and re-hospitalization for ADHF patients. However, the impact of residual congestion at discharge on worsening renal function (WRF) in both high-aged and older patients remains uncertain because previous studies of WRF in ADHF patients were conducted for older patients. We therefore designed and conducted a retrospective, population-based study using the Kobe University Heart Failure Registry in Awaji Medical Center (KUNIUMI) Registry to investigate the association of residual congestion at discharge with WRF in ADHF patients according to age. METHODS AND RESULTS We studied 966 hospitalized ADHF patients with a mean age of 80.2 ± 11.4 years from among 1971 listed in the KUNIUMI Registry. WRF was defined as an increase of ≥0.3 mg/dL in the serum creatinine level during the hospital stay compared with the value on admission. The primary endpoint was defined as cardiovascular death or HF re-hospitalization after discharge over a mean follow-up period of 2.0 ± 0.1 years. The primary endpoint was recorded for 369 patients (38.2%). As expected, patients with both WRF and residual congestion at discharge had significantly less favourable outcomes compared with those without one of them, and patients without either of these two characteristics had the most favourable outcomes, whereas those with residual congestion and with WRF had the least favourable outcomes. Moreover, WRF was significantly associated with worse outcomes for high-aged patients ≥80 years old, but not for those <80 years old if decongested. Multivariable Cox regression analysis showed that both residual congestion at discharge and WRF were the independent predictors of outcomes for high-aged patients, but residual congestion at discharge, not WRF, was the independent predictor of outcomes for older patients. CONCLUSIONS Association of residual congestion at discharge with WRF for hospitalized ADHF patients can differ according to age. Our findings showed the importance of WRF and residual congestion at discharge for high-aged ADHF patients and of aggressive diuresis to alleviate congestion for older ADHF patients for better management of such patients in a rapidly ageing society.
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Affiliation(s)
- Susumu Odajima
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Wataru Fujimoto
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan,Department of CardiologyHyogo Prefectural Awaji Medical CenterSumotoJapan
| | - Koji Kuroda
- Department of CardiologyHyogo Prefectural Awaji Medical CenterSumotoJapan
| | - Soichiro Yamashita
- Department of CardiologyHyogo Prefectural Awaji Medical CenterSumotoJapan
| | - Junichi Imanishi
- Department of CardiologyHyogo Prefectural Awaji Medical CenterSumotoJapan
| | - Masamichi Iwasaki
- Department of CardiologyHyogo Prefectural Awaji Medical CenterSumotoJapan
| | - Takafumi Todoroki
- Department of CardiologyHyogo Prefectural Awaji Medical CenterSumotoJapan
| | - Masanori Okuda
- Department of CardiologyHyogo Prefectural Awaji Medical CenterSumotoJapan
| | - Takatoshi Hayashi
- Department of CardiologyHyogo Prefectural Awaji Medical CenterSumotoJapan
| | - Akihide Konishi
- Clinical & Translational Research CenterKobe University HospitalKobeJapan
| | - Masakazu Shinohara
- Division of EpidemiologyKobe University Graduate School of MedicineKobeJapan
| | - Ryuji Toh
- Division of Evidence‐based Laboratory MedicineKobe University Graduate School of MedicineKobeJapan
| | - Ken‐ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan,Division of Evidence‐based Laboratory MedicineKobe University Graduate School of MedicineKobeJapan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
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6
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Aronson D. The interstitial compartment as a therapeutic target in heart failure. Front Cardiovasc Med 2022; 9:933384. [PMID: 36061549 PMCID: PMC9428749 DOI: 10.3389/fcvm.2022.933384] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/15/2022] [Indexed: 12/23/2022] Open
Abstract
Congestion is the single most important contributor to heart failure (HF) decompensation. Most of the excess volume in patients with HF resides in the interstitial compartment. Inadequate decongestion implies persistent interstitial congestion and is associated with worse outcomes. Therefore, effective interstitial decongestion represents an unmet need to improve quality of life and reduce clinical events. The key processes that underlie incomplete interstitial decongestion are often ignored. In this review, we provide a summary of the pathophysiology of the interstitial compartment in HF and the factors governing the movement of fluids between the interstitial and vascular compartments. Disruption of the extracellular matrix compaction occurs with edema, such that the interstitium becomes highly compliant, and large changes in volume marginally increase interstitial pressure and allow progressive capillary filtration into the interstitium. Augmentation of lymph flow is required to prevent interstitial edema, and the lymphatic system can increase fluid removal by at least 10-fold. In HF, lymphatic remodeling can become insufficient or maladaptive such that the capacity of the lymphatic system to remove fluid from the interstitium is exceeded. Increased central venous pressure at the site of the thoracic duct outlet also impairs lymphatic drainage. Owing to the kinetics of extracellular fluid, microvascular absorption tends to be transient (as determined by the revised Starling equation). Therefore, effective interstitial decongestion with adequate transcapillary plasma refill requires a substantial reduction in plasma volume and capillary pressure that are prolonged and sustained, which is not always achieved in clinical practice. The critical importance of the interstitium in the congestive state underscores the need to directly decongest the interstitial compartment without relying on the lowering of intracapillary pressure with diuretics. This unmet need may be addressed by novel device therapies in the near future.
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7
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(Application of hemoconcentration and plasma volume estimation indicators in the evaluation of the degree of congestion in a patient with heart failure). COR ET VASA 2022. [DOI: 10.33678/cor.2021.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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8
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Swolinsky JS, Tuvshinbat E, Leistner DM, Edelmann F, Knebel F, Nerger NP, Lemke C, Roehle R, Haase M, Costanzo MR, Rauch G, Mitrovic V, Gasanin E, Meier D, McCullough PA, Eckardt KU, Molitoris BA, Schmidt-Ott KM. Discordance between estimated and measured changes in plasma volume among patients with acute heart failure. ESC Heart Fail 2021; 9:66-76. [PMID: 34881523 PMCID: PMC8788058 DOI: 10.1002/ehf2.13739] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/04/2021] [Accepted: 11/11/2021] [Indexed: 11/08/2022] Open
Abstract
Aims In acute heart failure (AHF), changes of venous haemoglobin (Hb) concentrations, haematocrit (Hct), and estimated plasma volume (ePV) have been proposed as surrogates of decongestion. These estimates are based on the theoretical assumptions that changes of Hb concentrations and Hct are driven by the intravascular volume status and that the intravascular Hb pool remains stable. The objective of this study was to assess the relationship of changes of measured plasma volume (mPV) with changes of Hb, Hct, and ePV in AHF. Methods and results We studied 36 AHF patients, who received two sequential assessments of mPV, measured red cell volume (mRCV) and measured total blood volume (mTBV) (48 h apart), during the course of diuretic therapy using a novel visible fluorescent injectate (VFI) technique based on the indicator dilution principle. Changes of ePV were calculated based on the Kaplan–Hakim or Strauss formula. AHF patients receiving diuretics (median intravenous furosemide equivalent 160 mg/48 h) displayed a wide range of changes of mPV (−25.4% to +37.0%). Changes in mPV were not significantly correlated with changes of Hb concentration [Pearson's r (r) = −0.241, P = 0.157], Hct (r = −0.307, P = 0.069), ePVKaplan–Hakim (r = 0.228, P = 0.182), or ePVStrauss (r = 0.237, P = 0.163). In contrast to theoretical assumptions, changes of mTBV were poorly correlated with changes of Hb concentrations and some patients displayed unanticipated variability of mRCV, suggesting an unstable intravascular red cell pool. Conclusions Changes of Hb or Hct were not reflective of directly measured changes of intravascular volume status in AHF patients. Basing clinical assessment of decongestion on changes of Hb or Hct may misguide clinical decision‐making on an individual patient level.
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Affiliation(s)
- Jutta S Swolinsky
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
| | - Enkhtuvshin Tuvshinbat
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
| | - David M Leistner
- Department of Internal Medicine and Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Frank Edelmann
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Fabian Knebel
- Department of Cardiology and Angiology, Campus Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Niklas P Nerger
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
| | - Caroline Lemke
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
| | - Robert Roehle
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Clinical Study Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael Haase
- Medical Faculty, Otto von-Guericke-University Magdeburg, Magdeburg, Germany.,Diaverum Renal Care Center, Potsdam, Germany
| | | | - Geraldine Rauch
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | | | | | | | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
| | - Bruce A Molitoris
- FAST BioMedical, Indianapolis, IN, USA.,Indiana University, Indianapolis, IN, USA
| | - Kai M Schmidt-Ott
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
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9
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Inpatient Diuretic Management of Acute Heart Failure: A Practical Review. Am J Cardiovasc Drugs 2021; 21:595-608. [PMID: 33709346 DOI: 10.1007/s40256-020-00463-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 02/08/2023]
Abstract
The inpatient treatment of acute heart failure (AHF) is aimed at achieving euvolemia, relieving symptoms, and reducing rehospitalization. Adequate treatment of AHF is rooted in understanding the pharmacokinetics and pharmacodynamics of select diuretic agents used to achieve decongestion. While loop diuretics remain the primary treatment of AHF, the dosing strategies of loop diuretics and the use of adjunct diuretic classes to augment clinical response can be complex. This review examines the latest strategies for diuretic management in patients with AHF, including dosing and monitoring strategies, interaction of diuretics with other medication classes, use adjunctive therapies, and assessing endpoints for diuretic. The goal of the review is to guide the reader through commonly encountered clinical scenarios and pitfalls in the diuretic management of patients with AHF.
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10
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Abstract
Heart failure (HF) is one of the major causes of morbidity and mortality in the world. According to a 2019 American Heart Association report, about 6.2 million American adults had HF between 2013 and 2016, being responsible for almost 1 million admissions. As the population ages, the prevalence of HF is anticipated to increase, with 8 million Americans projected to have HF by 2030, posing a significant public health and financial burden. Acute decompensated HF (ADHF) is a syndrome characterized by volume overload and inadequate cardiac output associated with symptoms including some combination of exertional shortness of breath, orthopnea, paroxysmal nocturnal dyspnea (PND), fatigue, tissue congestion (e.g., peripheral edema) and decreased mentation. The pathology is characterized by hemodynamic abnormalities that result in autonomic imbalance with an increase in sympathetic activity, withdrawal of vagal activity and neurohormonal activation (NA) resulting in increased plasma volume in the setting of decreased sodium excretion, increased water retention and in turn an elevation of filling pressures. These neurohormonal changes are adaptive mechanisms which in the short term are associated with increased contractility of the left ventricular (LV) and improvement in cardiac output. But chronically, the failing heart is unable to overcome the excessive pressure and volume leading to worsening HF. The primary symptomatic management of ADHF includes intravenous (IV) diuresis to help with decongestion and return to euvolemic status. Even though diuretics have not been shown to provide any mortality benefit, they have been clinically proven to be of significant benefit in the acute decompensated phase, as well as in chronic management of HF. Loop diuretics remain the mainstay of therapy for symptomatic management of HF with use of thiazide diuretics for synergistic effect in the setting of diuretic resistance. Poor diuretic efficacy has been linked with higher mortality and increased rehospitalizations.
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Affiliation(s)
- Sarabjeet S Suri
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Salpy V Pamboukian
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
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11
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Kobayashi M, Girerd N, Duarte K, Chouihed T, Chikamori T, Pitt B, Zannad F, Rossignol P. Estimated plasma volume status in heart failure: clinical implications and future directions. Clin Res Cardiol 2021; 110:1159-1172. [PMID: 33409701 DOI: 10.1007/s00392-020-01794-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/10/2020] [Indexed: 01/02/2023]
Abstract
Congestion is one of the main predictors of poor outcome in patients with heart failure (HF). Assessing and monitoring congestion is essential for optimizing HF therapy. Among the various available methods, serial measurements of estimated plasma volume (ePVS) using routine blood count and/or body weight (e.g., the Strauss, Duarte, Hakim formulas) may be useful in HF management. Further prospective study is warranted to determine whether ePVS can help optimize decongestion therapy (loop diuretics, mineralocorticoid receptor antagonists, SGLT2i) in various HF settings. This narrative review summarizes the recent evidence supporting the association of ePVS with clinical congestion and outcome(s) and discusses future directions for monitoring ePVS in HF.
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Affiliation(s)
- Masatake Kobayashi
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France
| | - Nicolas Girerd
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France
| | - Kevin Duarte
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France
| | - Tahar Chouihed
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France
| | | | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France
| | - Patrick Rossignol
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France.
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12
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Almufleh A, Desai AS, Fay R, Ferreira JP, Buckley LF, Mehra MR, Rossignol P, Zannad F. Correlation of laboratory haemoconcentration measures with filling pressures obtained via pulmonary arterial pressure sensors in ambulatory heart failure patients. Eur J Heart Fail 2020; 22:1907-1911. [PMID: 32353199 DOI: 10.1002/ejhf.1848] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 12/28/2022] Open
Abstract
AIMS Laboratory measures of haemoconcentration correlate with invasive haemodynamics and clinical outcomes in hospitalized heart failure (HF) patients. We aimed to determine the association between haemoconcentration and haemodynamic measures in ambulatory HF patients with implantable pulmonary arterial pressure (PAP) sensors. METHODS AND RESULTS We reviewed ambulatory HF patients (n = 23) managed at the Brigham and Women's Hospital with implantable PAP sensors (CardioMEMS™, Abbott, Atlanta, GA, USA) who had sufficient data for serial haemodynamic-haemoconcentration correlation. The primary measures of interest were the absolute changes in haemoglobin and diastolic PAP at follow-up compared to baseline values (obtained at implantation). In 23 patients (median age 64 years, 57% with HF with preserved ejection fraction), 518 paired laboratory-haemodynamic measurements were evaluated. At a median follow-up of 27 (interquartile range 13-42) months, 17 (74%) patients had at least one hospitalization (59 total hospitalizations including 30 HF hospitalizations). For the population as a whole, diastolic PAP was negatively correlated with haemoglobin level (r = -0.09, P = 0.053). This negative correlation was more apparent when changes in haemoglobin and diastolic PAP were evaluated at the time of HF hospitalization compared to baseline values (r = -0.40, P = 0.029). The mean rise in diastolic PAP of 3.6 mmHg at HF hospitalization corresponded to a numerical decline of 0.6 g/dL in haemoglobin (P = 0.20). CONCLUSION Change in haemoglobin was correlated with change in diastolic PAP in ambulatory HF patients, especially at the time of HF hospitalization. These findings support the potential for investigation into the role of ambulatory monitoring of haemoglobin as an inexpensive, non-invasive tool to guide de-congestion strategies and potentially prevent HF hospitalizations.
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Affiliation(s)
- Aws Almufleh
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Renaud Fay
- Université de Lorraine, Inserm Clinical Investigation Center 1433, CHRU Nancy, Inserm U1116, FCRIN INI-CRCT, Nancy, France
| | - Joao Pedro Ferreira
- Université de Lorraine, Inserm Clinical Investigation Center 1433, CHRU Nancy, Inserm U1116, FCRIN INI-CRCT, Nancy, France
| | - Leo F Buckley
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Mandeep R Mehra
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Patrick Rossignol
- Université de Lorraine, Inserm Clinical Investigation Center 1433, CHRU Nancy, Inserm U1116, FCRIN INI-CRCT, Nancy, France
| | - Faiez Zannad
- Université de Lorraine, Inserm Clinical Investigation Center 1433, CHRU Nancy, Inserm U1116, FCRIN INI-CRCT, Nancy, France
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13
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Jobs A, Vonthein R, König IR, Schäfer J, Nauck M, Haag S, Fichera CF, Stiermaier T, Ledwoch J, Schneider A, Valentova M, von Haehling S, Störk S, Westermann D, Lenz T, Arnold N, Edelmann F, Seppelt P, Felix S, Lutz M, Hedwig F, Borggrefe M, Scherer C, Desch S, Thiele H. Inferior vena cava ultrasound in acute decompensated heart failure: design rationale of the CAVA-ADHF-DZHK10 trial. ESC Heart Fail 2020; 7:973-983. [PMID: 31991063 PMCID: PMC7261559 DOI: 10.1002/ehf2.12598] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/04/2019] [Accepted: 11/27/2019] [Indexed: 12/20/2022] Open
Abstract
Aims Treating patients with acute decompensated heart failure (ADHF) presenting with volume overload is a common task. However, optimal guidance of decongesting therapy and treatment targets are not well defined. The inferior vena cava (IVC) diameter and its collapsibility can be used to estimate right atrial pressure, which is a measure of right‐sided haemodynamic congestion. The CAVA‐ADHF‐DZHK10 trial is designed to test the hypothesis that ultrasound assessment of the IVC in addition to clinical assessment improves decongestion as compared with clinical assessment alone. Methods and results CAVA‐ADHF‐DZHK10 is a randomized, controlled, patient‐blinded, multicentre, parallel‐group trial randomly assigning 388 patients with ADHF to either decongesting therapy guided by ultrasound assessment of the IVC in addition to clinical assessment or clinical assessment alone. IVC ultrasound will be performed daily between baseline and hospital discharge in all patients. However, ultrasound results will only be reported to treating physicians in the intervention group. Treatment target is relief of congestion‐related signs and symptoms in both groups with the additional goal to reduce the IVC diameter ≤21 mm and increase IVC collapsibility >50% in the intervention group. The primary endpoint is change in N‐terminal pro‐brain natriuretic peptide from baseline to hospital discharge. Secondary endpoints evaluate feasibility, efficacy of decongestion on other scales, and the impact of the intervention on clinical endpoints. Conclusions CAVA‐ADHF‐DZHK10 will investigate whether IVC ultrasound supplementing clinical assessment improves decongestion in patients admitted for ADHF.
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Affiliation(s)
- Alexander Jobs
- Department of Cardiology/Angiology/Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany.,DZHK (German Centre for Cardiovascular Research).,Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| | - Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Universität zu Lübeck, Lübeck, Germany
| | - Inke R König
- Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Universität zu Lübeck, Lübeck, Germany
| | - Jane Schäfer
- Zentrum für Klinische Studien, Universität Lübeck, Lübeck, Germany
| | - Matthias Nauck
- DZHK (German Centre for Cardiovascular Research).,Institut für Klinische Chemie und Laboratoriumsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Svenja Haag
- Department of Cardiology/Angiology/Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany.,DZHK (German Centre for Cardiovascular Research)
| | - Carlo Federico Fichera
- Department of Cardiology/Angiology/Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany.,DZHK (German Centre for Cardiovascular Research)
| | - Thomas Stiermaier
- Department of Cardiology/Angiology/Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany.,DZHK (German Centre for Cardiovascular Research)
| | - Jakob Ledwoch
- DZHK (German Centre for Cardiovascular Research).,Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alisa Schneider
- DZHK (German Centre for Cardiovascular Research).,Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Miroslava Valentova
- DZHK (German Centre for Cardiovascular Research).,Department of Cardiology and Pneumology, University Medical Centre Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Stephan von Haehling
- DZHK (German Centre for Cardiovascular Research).,Department of Cardiology and Pneumology, University Medical Centre Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany
| | - Dirk Westermann
- DZHK (German Centre for Cardiovascular Research).,Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Tobias Lenz
- DZHK (German Centre for Cardiovascular Research).,Deutsches Herzzentrum München, Munich, Germany
| | - Natalie Arnold
- DZHK (German Centre for Cardiovascular Research).,Kardiologie I, University Medical Center Mainz, Mainz, Germany
| | - Frank Edelmann
- DZHK (German Centre for Cardiovascular Research).,Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Philipp Seppelt
- DZHK (German Centre for Cardiovascular Research).,Medizinische Klinik III/Kardiologie, Angiologie, Nephrologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Stephan Felix
- DZHK (German Centre for Cardiovascular Research).,Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Lutz
- DZHK (German Centre for Cardiovascular Research).,Department of Cardiology and Angiology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Felix Hedwig
- DZHK (German Centre for Cardiovascular Research).,Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Martin Borggrefe
- DZHK (German Centre for Cardiovascular Research).,First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), Mannheim, Germany
| | - Clemens Scherer
- DZHK (German Centre for Cardiovascular Research).,Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Steffen Desch
- DZHK (German Centre for Cardiovascular Research).,Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
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14
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Sujino Y, Nakano S, Tanno J, Shiraishi Y, Goda A, Mizuno A, Nagatomo Y, Kohno T, Muramatsu T, Nishimura S, Kohsaka S, Yoshikawa T. Clinical implications of the blood urea nitrogen/creatinine ratio in heart failure and their association with haemoconcentration. ESC Heart Fail 2019; 6:1274-1282. [PMID: 31814319 PMCID: PMC6989280 DOI: 10.1002/ehf2.12531] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/02/2019] [Accepted: 09/06/2019] [Indexed: 11/16/2022] Open
Abstract
Aims The blood urea nitrogen (BUN)/creatinine ratio is a strong prognostic indicator in patients with acute decompensated heart failure (ADHF). However, the clinical impact of a high BUN/creatinine ratio at discharge with respect to renal dysfunction, neurohormonal hyperactivity, and different responsiveness to decongestion therapy remains unclear. Herein, we examined (i) the predictive value of a high BUN/creatinine ratio at discharge and (ii) its haemoconcentration‐dependent effects, in patients with ADHF. Methods and results The West Tokyo Heart Failure registry was a multicentre, prospective cohort registry‐based study that enrolled patients hospitalized with a diagnosis of ADHF. The endpoint was post‐discharge all‐cause death. Based on the degree of haemoconcentration, patients (n = 2090) were divided into four subcategories. In multivariate proportional hazard analyses, a higher BUN/creatinine ratio was independently associated with higher all‐cause mortality in the total population and in the extreme haemodilution (ΔHaemoglobin ≤ −0.9 g/dL) and haemoconcentration (0.8 g/dL ≤ ΔHaemoglobin) subcategories, but not in the modest haemodilution/haemoconcentration subcategories. Conclusions A higher BUN/creatinine ratio at discharge was independently associated with higher post‐discharge all‐cause mortality in patients with ADHF. The predictive value of a high BUN/creatinine ratio at discharge was haemoconcentration dependent and may be an unfavourable predictor in patients showing excessive haemoconcentration and haemodilution, but not in those showing modest haemoconcentration/haemodilution.
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Affiliation(s)
- Yasumori Sujino
- Department of Cardiology, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Jun Tanno
- Department of Cardiology, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ayumi Goda
- Division of Cardiology, Kyorin University School of Medicine, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Saitama, Japan
| | - Takashi Kohno
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.,Division of Cardiology, Kyorin University School of Medicine, Tokyo, Japan
| | - Toshihiro Muramatsu
- Department of Cardiology, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Shigeyuki Nishimura
- Department of Cardiology, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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15
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Blumer V, Greene SJ, Sun JL, Bart BA, Ambrosy AP, Butler J, DeVore AD, Fudim M, Hernandez AF, McNulty SE, Felker GM, Mentz RJ. Haemoconcentration during treatment of acute heart failure with cardiorenal syndrome: from the CARRESS-HF trial. Eur J Heart Fail 2019; 21:1472-1476. [PMID: 31452311 DOI: 10.1002/ejhf.1592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/21/2019] [Accepted: 07/23/2019] [Indexed: 11/09/2022] Open
Affiliation(s)
- Vanessa Blumer
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Durham, NC, USA
| | - Bradley A Bart
- Division of Cardiology, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Andrew P Ambrosy
- Division of Cardiology, The Permanente Medical Group, San Francisco, CA, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Adam D DeVore
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Adrian F Hernandez
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | | | - G Michael Felker
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Robert J Mentz
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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16
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Abstract
The treatment of cardiorenal syndrome is as complex as the various mechanisms underlying its pathophysiology. Randomized controlled data typically focus on the treatment of heart failure with cardiac specific endpoints and a lack of worsening renal function used as a surrogate for efficacy. When heart failure is considered the inciting event, the acute state is managed with vasodilators, inotropic support, and decongestion; whereas neurohormonal axis inhibition is more commonly applied to chronic state. A recent shift in thought process regarding the interplay of cardiac and renal dysfunction suggests that renal congestion may be the primary driver of worsening renal function.
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Affiliation(s)
- Jack Rubinstein
- University of Cincinnati, Medical Science Building, 231 Albert Sabin Way, MLC 0542, Cincinnati, OH 45267, USA.
| | - Darek Sanford
- University of Cincinnati, Medical Science Building, 231 Albert Sabin Way, MLC 0542, Cincinnati, OH 45267, USA
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17
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Escobar Cervantes C. Hemoconcentration and acute heart failure, an emerging predictive factor or already established? Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2018.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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18
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Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, Testani JM, Tang WHW, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic PM, Ruschitzka F, Coats AJ. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019; 21:137-155. [PMID: 30600580 DOI: 10.1002/ejhf.1369] [Citation(s) in RCA: 559] [Impact Index Per Article: 111.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/14/2018] [Accepted: 10/27/2018] [Indexed: 12/11/2022] Open
Abstract
The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of diuretic therapy. The appropriate use of diuretics however remains challenging, especially when worsening renal function, diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic diuretic strategies, based upon diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Alexandre Mebazaa
- University of Paris Diderot, Hôpitaux Universitaires Saint Louis Lariboisière, APHP, U 942 Inserm, F-CRIN INI-CRCT, Paris, France
| | | | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | | | | | | | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d'Investigations Clinique 1433 and Inserm U1116; CHRU Nancy; F-CRIN INI-CRCT, Nancy, France
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, Athens, Greece.,University of Cyprus, Nicosia, Cyprus
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19
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Hemoconcentración e insuficiencia cardiaca aguda, ¿un factor predictor emergente o ya consolidado? Rev Clin Esp 2019; 219:32-33. [DOI: 10.1016/j.rce.2018.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 11/15/2022]
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20
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Fudim M, Loungani R, Doerfler SM, Coles A, Greene SJ, Cooper LB, Fiuzat M, O'Connor CM, Rogers JG, Mentz RJ. Worsening renal function during decongestion among patients hospitalized for heart failure: Findings from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. Am Heart J 2018; 204:163-173. [PMID: 30121018 DOI: 10.1016/j.ahj.2018.07.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/25/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Worsening renal function (WRF) can occur throughout a hospitalization for acute heart failure (HF). However, decongestion can be measured in different ways and the prognostic implications of WRF in the setting of different measures of decongestion are unclear. METHODS Patients (N = 433) from the ESCAPE were classified by measures of decongestion during hospitalization: hemodynamic (right atrial pressure ≤8 mmHg and/or wedge pressure ≤15 mmHg at discharge), clinical (≤1 sign of congestion at discharge), hemoconcentration (any increase in hemoglobin) and estimated plasma volume using the Hakim formula (5% reduction in plasma volume). WRF was defined as creatinine increase ≥0.3 mg/dl during hospitalization. The association between WRF and 180-day all-cause death was assessed. RESULTS Successful decongestion was observed in 124 (60%) patients by hemodynamics, 204 (49%) by clinical exam, 173 (47%) by hemoconcentration, and 165 (45%) by plasma volume. There was no agreement between the hemodynamic assessment and other decongestion measures in up to 43% of cases. Persistent congestion with concomitant WRF at discharge was associated with worse outcomes compared to patients without congestion and WRF. Among patients decongested at discharge, in-hospital WRF was not significantly associated with 180-day all-cause death, when using hemodynamic, clinical or estimated plasma volume as measures of decongestion (P > .05 for all markers). CONCLUSIONS In patients hospitalized for HF, although there was disagreement across common measures of decongestion, in-hospital WRF was not associated with increased hazard of all-cause mortality among patients successfully decongested at discharge.
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21
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Mullens W, Verbrugge FH, Nijst P, Martens P, Tartaglia K, Theunissen E, Bruckers L, Droogne W, Troisfontaines P, Damman K, Lassus J, Mebazaa A, Filippatos G, Ruschitzka F, Dupont M. Rationale and design of the ADVOR (Acetazolamide in Decompensated Heart Failure with Volume Overload) trial. Eur J Heart Fail 2018; 20:1591-1600. [DOI: 10.1002/ejhf.1307] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/11/2018] [Accepted: 08/02/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost-Limburg; Genk Belgium
- Hasselt University, Diepenbeek/Hasselt; Belgium
| | | | | | | | | | | | | | | | | | - Kevin Damman
- University Medical Center Groningen; Groningen The Netherlands
| | - Johan Lassus
- Helsinki University Central Hospital; Helsinki Finland
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22
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Simonavičius J, Knackstedt C, Brunner-La Rocca HP. Loop diuretics in chronic heart failure: how to manage congestion? Heart Fail Rev 2018; 24:17-30. [DOI: 10.1007/s10741-018-9735-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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23
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Putting creatinine and hemoconcentration in their place as prognostic predictors in the conundrum of acute heart failure. Rev Port Cardiol 2018; 37:603-605. [DOI: 10.1016/j.repc.2018.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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24
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Putting creatinine and hemoconcentration in their place as prognostic predictors in the conundrum of acute heart failure. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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25
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Fujita T, Inomata T, Yazaki M, Iida Y, Kaida T, Ikeda Y, Nabeta T, Ishii S, Maekawa E, Yanagisawa T, Koitabashi T, Takeuchi I, Ako J. Hemodilution after Initial Treatment in Patients with Acute Decompensated Heart Failure. Int Heart J 2018; 59:573-579. [DOI: 10.1536/ihj.17-307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Teppei Fujita
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital
| | - Mayu Yazaki
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Yuichiro Iida
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Toyoji Kaida
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Yuki Ikeda
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Takeru Nabeta
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Shunsuke Ishii
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Emi Maekawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Toshimi Koitabashi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Ichiro Takeuchi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
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26
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What's new in cardiorenal syndrome? Intensive Care Med 2018; 44:908-910. [PMID: 29700563 DOI: 10.1007/s00134-018-5190-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/18/2018] [Indexed: 12/11/2022]
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27
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Abstract
PURPOSE OF REVIEW This review aims to summarize the renal effects of sodium-glucose transporter-2 (SGLT-2) inhibitors and their potential implications in heart failure pathophysiology. RECENT FINDINGS In patients with diabetes and established atherosclerosis, the SGLT-2 inhibitor empagliflozin versus placebo significantly reduced the rate of heart failure admissions with 35%. Moreover, empagliflozin slowed kidney disease progression and reduced the need for renal replacement therapy. SGLT-2 inhibitors inhibit proximal tubular sodium and chloride reabsorption, leading to increased nephron flux throughout the distal renal tubules, most notably at the level of the macula densa. Afferent arteriolar vasoconstriction is promoted through tubulo-glomerular feedback and reduces glomerular capillary hydrostatic pressure, relieving podocyte stress and explaining renal preservation. Further, plasma volume is contracted and natriuresis promoted without inducing neurohumoral activation. Finally, SGLT-2 inhibitors may improve endothelial function and energy metabolism efficiency. Together, these promising features place them as a potential novel treatment for heart failure.
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Affiliation(s)
- Frederik H Verbrugge
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
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Girerd N, Seronde MF, Coiro S, Chouihed T, Bilbault P, Braun F, Kenizou D, Maillier B, Nazeyrollas P, Roul G, Fillieux L, Abraham WT, Januzzi J, Sebbag L, Zannad F, Mebazaa A, Rossignol P. Integrative Assessment of Congestion in Heart Failure Throughout the Patient Journey. JACC-HEART FAILURE 2017; 6:273-285. [PMID: 29226815 DOI: 10.1016/j.jchf.2017.09.023] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 09/15/2017] [Accepted: 09/26/2017] [Indexed: 12/26/2022]
Abstract
Congestion is one of the main predictors of poor patient outcome in patients with heart failure. However, congestion is difficult to assess, especially when symptoms are mild. Although numerous clinical scores, imaging tools, and biological tests are available to assist physicians in ascertaining and quantifying congestion, not all are appropriate for use in all stages of patient management. In recent years, multidisciplinary management in the community has become increasingly important to prevent heart failure hospitalizations. Electronic alert systems and communication platforms are emerging that could be used to facilitate patient home monitoring that identifies congestion from heart failure decompensation at an earlier stage. This paper describes the role of congestion detection methods at key stages of patient care: pre-admission, admission to the emergency department, in-hospital management, and lastly, discharge and continued monitoring in the community. The multidisciplinary working group, which consisted of cardiologists, emergency physicians, and a nephrologist with both clinical and research backgrounds, reviewed the current literature regarding the various scores, tools, and tests to detect and quantify congestion. This paper describes the role of each tool at key stages of patient care and discusses the advantages of telemedicine as a means of providing true integrated patient care.
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Affiliation(s)
- Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques 1433, Université de Lorraine, CHU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Marie-France Seronde
- Service de cardiologie CHU de Besançon, EA 3920, Unité INSERM 942 CHU Lariboisière, Paris, France
| | - Stefano Coiro
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - Tahar Chouihed
- INSERM, Centre d'Investigations Cliniques 1433, Université de Lorraine, CHU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France; Emergency Department, CHU de Nancy, France
| | - Pascal Bilbault
- Emergency Department, Hôpitaux Universitaires de Strasbourg, Strasbourg, France and EA 7293 Stress vasculaire, Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - François Braun
- Structures de Médecine d'Urgence, Centre Hospitalier Régional, Hôpital de Mercy, Metz, France
| | - David Kenizou
- Service de cardiologie, Hôpital Emile Muller, Mulhouse, France
| | - Bruno Maillier
- Service de cardiologie, Centre hospitalier de Troyes, Anatole, France
| | - Pierre Nazeyrollas
- Centre de Recherche et d'Investigation Clinique, Service de Cardiologie, CHU de Reims, Reims, France
| | - Gérard Roul
- Pôle d'activité médico-chirurgicale cardiovasculaire Nouvel Hôpital Civil, Strasbourg, France and Unité d'insuffisance cardiaque, Centre de compétence des cardiomyopathies
| | | | - William T Abraham
- Davis Heart and Lung Research Institute, Ohio State University, Columbus, Ohio
| | - James Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Laurent Sebbag
- Hospices Civils de Lyon, Hôpital Louis Pradel, Pôle Médico-Chirurgical de Transplantation Cardiaque Adulte, Bron, France
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques 1433, Université de Lorraine, CHU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Alexandre Mebazaa
- Department of Anesthesiology, Critical Care and Burn Unit, St. Louis Hospital, University Paris, UMR-S942, INSERM and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network Nancy, GREAT Network, Paris, France
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques 1433, Université de Lorraine, CHU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France.
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Cheema B, Ambrosy AP, Kaplan RM, Senni M, Fonarow GC, Chioncel O, Butler J, Gheorghiade M. Lessons learned in acute heart failure. Eur J Heart Fail 2017; 20:630-641. [PMID: 29082676 DOI: 10.1002/ejhf.1042] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 09/18/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022] Open
Abstract
Acute heart failure (HF) is a global pandemic with more than one million admissions to hospital annually in the US and millions more worldwide. Post-discharge mortality and readmission rates remain unchanged and unacceptably high. Although recent drug development programmes have failed to deliver novel therapies capable of reducing cardiovascular morbidity and mortality in patients hospitalized for worsening chronic HF, hospitalized HF registries and clinical trial databases have generated a wealth of information improving our collective understanding of the HF syndrome. This review will summarize key insights from clinical trials in acute HF and hospitalized HF registries over the last several decades, focusing on improving the management of patients with HF and reduced ejection fraction.
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Affiliation(s)
- Baljash Cheema
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Andrew P Ambrosy
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Rachel M Kaplan
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Michele Senni
- Cardiovascular Department, Papa Giovannni XXIII Hospital, Bergamo, Italy
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USA
| | - Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases 'Prof. C.C. Iliescu', Cardiology 1, UMF Carol Davila, Bucharest, Romania
| | | | - Mihai Gheorghiade
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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Kajimoto K, Minami Y, Otsubo S, Sato N. Association of admission and discharge anemia status with outcomes in patients hospitalized for acute decompensated heart failure: Differences between patients with preserved and reduced ejection fraction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 8:606-614. [DOI: 10.1177/2048872617730039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: In acute decompensated heart failure patients with a preserved or reduced ejection fraction, the association of admission and discharge anemia status with outcomes remains unclear. Methods and results: Of the 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 4433 patients (2017 with a preserved and 2416 with a reduced ejection fraction) were examined to investigate associations among the anemia status at admission and discharge (no anemia, developed anemia, resolved anemia, or persistent anemia), a preserved or reduced ejection fraction and the primary endpoint (all-cause death and readmission for heart failure). In the preserved ejection fraction group, adjusted analysis showed that either developed or persistent anemia was associated with a significantly higher risk of the primary endpoint relative to no anemia (hazard ratio: 1.53; 95% confidence interval (CI): 1.11–2.11; p=0.009 and hazard ratio: 1.60; 95% CI: 1.26–2.04; p<0.001, respectively), but there was no association between resolved anemia and the primary endpoint (hazard ratio: 0.98; 95% CI: 0.67–1.45; p=0.937). In the reduced ejection fraction group, either developed or resolved anemia was associated with a tendency toward higher risk of the primary endpoint relative to no anemia (hazard ratio: 1.29; 95% CI: 0.95–1.62; p=0.089, and hazard ratio: 1.31; 95% CI: 0.96–1.77; p=0.085, respectively), while persistent anemia was associated with a significantly higher risk of the primary endpoint relative to no anemia (hazard ratio: 1.36; 95% CI: 1.12–1.65; p=0.002). Conclusions: In acute decompensated heart failure patients, the association of admission and discharge anemia status with outcomes differs markedly between patients with a preserved or reduced ejection fraction.
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Affiliation(s)
| | - Yuichiro Minami
- Department of Cardiology, Tokyo Women’s Medical University, Japan
| | - Shigeru Otsubo
- Department of Blood Purification, Tohto Sangenjaya Clinic, Japan
| | - Naoki Sato
- Department of Internal Medicine, Cardiology, and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital, Japan
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31
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Ahmad T, Testani JM. Haemoconcentration as a treatment goal in heart failure: ready for prime time? Eur J Heart Fail 2017; 19:237-240. [PMID: 28157266 DOI: 10.1002/ejhf.715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 11/03/2016] [Accepted: 11/04/2016] [Indexed: 12/28/2022] Open
Affiliation(s)
- Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jeffrey M Testani
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
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Scheen A. Reappraisal of the diuretic effect of empagliflozin in the EMPA-REG OUTCOME trial: Comparison with classic diuretics. DIABETES & METABOLISM 2016; 42:224-33. [DOI: 10.1016/j.diabet.2016.05.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/11/2016] [Indexed: 12/23/2022]
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33
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Murad K, Dunlap ME. Measuring Congestion in Acute Heart Failure: The “Holy Grail” Still Awaits. J Card Fail 2016; 22:689-91. [DOI: 10.1016/j.cardfail.2016.06.424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 10/21/2022]
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34
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Oh J, Kang SM, Kim IC, Han S, Yoo BS, Choi DJ, Kim JJ, Jeon ES, Cho MC, Oh BH, Chae SC, Lee MM, Ryu KH. The beneficial prognostic value of hemoconcentration is negatively affected by hyponatremia in acute decompensated heart failure: Data from the Korean Heart Failure (KorHF) Registry. J Cardiol 2016; 69:790-796. [PMID: 27590414 DOI: 10.1016/j.jjcc.2016.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/01/2016] [Accepted: 08/06/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hemoconcentration (HC) is associated with reduced mortality, whereas hyponatremia (HN) has been associated with an increased risk of adverse outcomes in patients with acute decompensated heart failure (ADHF). We sought to determine if the presence of HN influences the beneficial prognostic value of HC in ADHF patients. METHODS We analyzed 2046 ADHF patients from the Korean Heart Failure Registry. We defined HC as an increased hemoglobin level from admission to discharge, and HN as sodium <135mmol/L at admission. Our primary composite endpoint was all-cause mortality and/or HF re-hospitalization. RESULTS Overall, HC occurred in 889 (43.5%) patients and HN was observed in 418 patients (20.4%). HC offered higher 2-year event-free survival in patients without HN (73.2% vs. 63.1% for no-HC, log-rank p<0.001), but not in patients with HN (54.2% vs. 58.7% for no-HC, log-rank p=0.879, p for interaction=0.003). In a multiple Cox proportional hazard analysis, HC without HN conferred a significant event-free survival benefit (hazard ratio: 0.703, 95% confidence interval 0.542-0.912, p=0.008) over no-HC with HN. CONCLUSIONS Only HC occurring in ADHF without HN was associated with improved clinical outcomes. These results provide further support for the importance of HN as a challenging therapeutic target in ADHF patients.
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Affiliation(s)
- Jaewon Oh
- Division of Cardiology, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Seoul, Republic of Korea
| | - Seok-Min Kang
- Division of Cardiology, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Seoul, Republic of Korea.
| | - In-Cheol Kim
- Division of Cardiology, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Seoul, Republic of Korea
| | - Seongwoo Han
- Division of Cardiology, Hallym University Medical Center, Hwaseong, Republic of Korea
| | - Byung-Su Yoo
- Division of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Dong-Ju Choi
- Division of Cardiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae-Joong Kim
- Division of Cardiology, Ulsan University Asan Medical Center, Seoul, Republic of Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Sungkyunkwan University Samsung Medical Center, Seoul, Republic of Korea
| | - Myeong-Chan Cho
- Division of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Byung-Hee Oh
- Division of Cardiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Shung Chull Chae
- Division of Cardiology, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Myung-Mook Lee
- Division of Cardiology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Kyu-Hyung Ryu
- Division of Cardiology, Hallym University Medical Center, Hwaseong, Republic of Korea
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Ferreira JP, Girerd N, Arrigo M, Medeiros PB, Ricardo MB, Almeida T, Rola A, Tolpannen H, Laribi S, Gayat E, Mebazaa A, Mueller C, Zannad F, Rossignol P, Aragão I. Enlarging Red Blood Cell Distribution Width During Hospitalization Identifies a Very High-Risk Subset of Acutely Decompensated Heart Failure Patients and Adds Valuable Prognostic Information on Top of Hemoconcentration. Medicine (Baltimore) 2016; 95:e3307. [PMID: 27057905 PMCID: PMC4998821 DOI: 10.1097/md.0000000000003307] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Red blood cell distribution width (RDW) may serve as an integrative marker of pathological processes that portend worse prognosis in heart failure (HF). The prognostic value of RDW variation (ΔRDW) during hospitalization for acute heart failure (AHF) has yet to be studied.We retrospectively analyzed 2 independent cohorts: Centro Hospitalar do Porto (derivation cohort) and Lariboisière hospital (validation cohort). In the derivation cohort a total of 170 patients (age 76.2 ± 10.3 years) were included and in the validation cohort 332 patients were included (age 76.4 ± 12.2 years). In the derivation cohort the primary composite outcome of HF admission and/or cardiovascular death occurred in 78 (45.9%) patients during the 180-day follow-up period.Discharge RDW and ΔRDW were both increased when hemoglobin levels were lower; peripheral edema was also associated with increased discharge RDW (all P < 0.05). Discharge RDW value was significantly associated with adverse events: RDW > 15% at discharge was associated with a 2-fold increase in event rate, HR = 1.95 (1.05-3.62), P = 0.04, while a ΔRDW >0 also had a strong association with outcome, HR = 2.47 (1.35-4.51), P = 0.003. The addition of both discharge RDW > 15% and ΔRDW > 0 to hemoconcentration was associated with a significant improvement in the net reclassification index, NRI = 18.3 (4.3-43.7), P = 0.012. Overlapping results were found in the validation cohort.As validated in 2 independent AHF cohorts, an in-hospital RDW enlargement and an elevated RDW at discharge are associated with increased rates of mid-term events. RDW variables improve the risk stratification of these patients on top of well-established prognostic markers.
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Affiliation(s)
- João Pedro Ferreira
- From the INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERMU1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France (JPF, NG, FZ, PR); Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal (JPF); INSERM UMR-S 942, APHP Lariboisière University Hospital, F-CRIN INI-CRCT, Paris, France (MA, AR, HT, SL, EG, AM); Internal Medicine Department, Centro Hospitalar do Porto, Porto, Portugal (PBM, MBR, TA); Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospital, Assistance Publique - Hôpitaux de Paris; Université Paris Diderot, Paris, France (EG, AM); Cardiovascular Research Institute Basel (CRIB), University Hospital, Basel, Switzerland (CM); and Department of Cardiology, University Hospital, Basel, Switzerland; Intensive Care Unit, Centro Hospitalar do Porto, Porto, Portugal (IA)
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Greene SJ, Fonarow GC, Vaduganathan M, Khan SS, Butler J, Gheorghiade M. The vulnerable phase after hospitalization for heart failure. Nat Rev Cardiol 2015; 12:220-9. [DOI: 10.1038/nrcardio.2015.14] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
The administration of loop diuretics to achieve decongestion is the cornerstone of therapy for acute heart failure. Unfortunately, impaired response to diuretics is common in these patients and associated with adverse outcomes. Diuretic resistance is thought to result from a complex interplay between cardiac and renal dysfunction, and specific renal adaptation and escape mechanisms, such as neurohormonal activation and the braking phenomenon. However, our understanding of diuretic response in patients with acute heart failure is still limited and a uniform definition is lacking. Three objective methods to evaluate diuretic response have been introduced, which all suggest that diuretic response should be determined based on the effect of diuretic dose administered. Several strategies have been proposed to overcome diuretic resistance, including combination therapy and ultrafiltration, but prospective studies in patients who are truly unresponsive to diuretics are lacking. An enhanced understanding of diuretic response should ultimately lead to an improved, individualized approach to treating patients with acute heart failure.
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Vaduganathan M, Gheorghiade M. Roadmap to inpatient heart failure management. J Cardiol 2014; 65:26-31. [PMID: 25238886 DOI: 10.1016/j.jjcc.2014.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 08/25/2014] [Indexed: 12/26/2022]
Abstract
Heart failure (HF) accounts for over 1 million primary hospitalizations in the USA each year and carries a tremendous burden on costs and patient outcomes. The clinical syndrome of HF is not a single disease, but represents the complex interplay between various cardiac and non-cardiac processes, each of which need to be individually addressed. This review provides an updated, contemporary roadmap for inpatient worsening chronic HF management with a focus on identifying and addressing initiating mechanisms, amplifying factors, and cardiac structural abnormalities. Inpatient risk stratification should guide patient education, team structuring, disposition, and post-discharge monitoring.
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Affiliation(s)
- Muthiah Vaduganathan
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
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