1
|
Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GFM, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
Collapse
Affiliation(s)
- Meaghan Lunney
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Marinella Ruospo
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Patrizia Natale
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Robert R Quinn
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Paul E Ronksley
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical CenterDepartment of Medicine3459 Fifth AvenuePittsburghPAUSA15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of OtagoDepartment of Medicine, NephrologistChristchurchNew Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Pietro Ravani
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | | |
Collapse
|
3
|
Vardeny O, Cavallari LH, Claggett B, Desai AS, Anand I, Rossignol P, Zannad F, Pitt B, Solomon SD. Race Influences the Safety and Efficacy of Spironolactone in Severe Heart Failure. Circ Heart Fail 2013; 6:970-6. [DOI: 10.1161/circheartfailure.113.000530] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Orly Vardeny
- From the University of Wisconsin School of Pharmacy, Madison, WI (O.V.); University of Illinois at Chicago, IL (L.H.C.); Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., S.D.S.); University of Minnesota, Minneapolis, MN (I.A.); INSERM, Centre d’Investigations Cliniques-9501 and INSERM U961, Université de Lorraine, Nancy, France (P.R., F.Z.); and University of Michigan, Ann Arbor, MI (B.P.)
| | - Larisa H. Cavallari
- From the University of Wisconsin School of Pharmacy, Madison, WI (O.V.); University of Illinois at Chicago, IL (L.H.C.); Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., S.D.S.); University of Minnesota, Minneapolis, MN (I.A.); INSERM, Centre d’Investigations Cliniques-9501 and INSERM U961, Université de Lorraine, Nancy, France (P.R., F.Z.); and University of Michigan, Ann Arbor, MI (B.P.)
| | - Brian Claggett
- From the University of Wisconsin School of Pharmacy, Madison, WI (O.V.); University of Illinois at Chicago, IL (L.H.C.); Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., S.D.S.); University of Minnesota, Minneapolis, MN (I.A.); INSERM, Centre d’Investigations Cliniques-9501 and INSERM U961, Université de Lorraine, Nancy, France (P.R., F.Z.); and University of Michigan, Ann Arbor, MI (B.P.)
| | - Akshay S. Desai
- From the University of Wisconsin School of Pharmacy, Madison, WI (O.V.); University of Illinois at Chicago, IL (L.H.C.); Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., S.D.S.); University of Minnesota, Minneapolis, MN (I.A.); INSERM, Centre d’Investigations Cliniques-9501 and INSERM U961, Université de Lorraine, Nancy, France (P.R., F.Z.); and University of Michigan, Ann Arbor, MI (B.P.)
| | - Inder Anand
- From the University of Wisconsin School of Pharmacy, Madison, WI (O.V.); University of Illinois at Chicago, IL (L.H.C.); Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., S.D.S.); University of Minnesota, Minneapolis, MN (I.A.); INSERM, Centre d’Investigations Cliniques-9501 and INSERM U961, Université de Lorraine, Nancy, France (P.R., F.Z.); and University of Michigan, Ann Arbor, MI (B.P.)
| | - Patrick Rossignol
- From the University of Wisconsin School of Pharmacy, Madison, WI (O.V.); University of Illinois at Chicago, IL (L.H.C.); Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., S.D.S.); University of Minnesota, Minneapolis, MN (I.A.); INSERM, Centre d’Investigations Cliniques-9501 and INSERM U961, Université de Lorraine, Nancy, France (P.R., F.Z.); and University of Michigan, Ann Arbor, MI (B.P.)
| | - Faiez Zannad
- From the University of Wisconsin School of Pharmacy, Madison, WI (O.V.); University of Illinois at Chicago, IL (L.H.C.); Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., S.D.S.); University of Minnesota, Minneapolis, MN (I.A.); INSERM, Centre d’Investigations Cliniques-9501 and INSERM U961, Université de Lorraine, Nancy, France (P.R., F.Z.); and University of Michigan, Ann Arbor, MI (B.P.)
| | - Bertram Pitt
- From the University of Wisconsin School of Pharmacy, Madison, WI (O.V.); University of Illinois at Chicago, IL (L.H.C.); Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., S.D.S.); University of Minnesota, Minneapolis, MN (I.A.); INSERM, Centre d’Investigations Cliniques-9501 and INSERM U961, Université de Lorraine, Nancy, France (P.R., F.Z.); and University of Michigan, Ann Arbor, MI (B.P.)
| | - Scott D. Solomon
- From the University of Wisconsin School of Pharmacy, Madison, WI (O.V.); University of Illinois at Chicago, IL (L.H.C.); Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., S.D.S.); University of Minnesota, Minneapolis, MN (I.A.); INSERM, Centre d’Investigations Cliniques-9501 and INSERM U961, Université de Lorraine, Nancy, France (P.R., F.Z.); and University of Michigan, Ann Arbor, MI (B.P.)
| |
Collapse
|
5
|
Butler J, Ezekowitz JA, Collins SP, Givertz MM, Teerlink JR, Walsh MN, Albert NM, Westlake Canary CA, Carson PE, Colvin-Adams M, Fang JC, Hernandez AF, Hershberger RE, Katz SD, Rogers JG, Spertus JA, Stevenson WG, Sweitzer NK, Wilson Tang W, Stough WG, Starling RC. Update on Aldosterone Antagonists Use in Heart Failure With Reduced Left Ventricular Ejection Fraction Heart Failure Society of America Guidelines Committee. J Card Fail 2012; 18:265-81. [DOI: 10.1016/j.cardfail.2012.02.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 02/15/2012] [Indexed: 01/11/2023]
|
7
|
Norgard NB, Prescott GM. Future of personalized pharmacotherapy in chronic heart failure patients. Future Cardiol 2011; 7:357-79. [DOI: 10.2217/fca.11.19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
There is a significant amount of diversity among heart failure (HF) patients. Contemporary HF regimens often do not take into consideration many of the factors that might influence an individual’s response to treatment. Clinical recommendations based on trial data derived from mainly younger Caucasian male study populations have, in most cases, been applied equally to women and African–Americans. Subgroup analyses of randomized HF trials and results of retrospective cohort studies have been used for customizing HF regimens in women and African–Americans. Pharmacogenetics is an emerging strategy for personalizing HF therapy. Genetic biomarkers may play an important role in predicting a patient’s response to treatment and in predicting those at risk of toxicity. HF pharmacotherapy has improved over the last two decades; however, substantial work remains in order to personalize HF management and maximize the benefit of pharmacologic interventions, while limiting adverse events.
Collapse
Affiliation(s)
| | - Gina M Prescott
- University at Buffalo, School of Pharmacy & Pharmaceutical Sciences, New York State Center of Excellence in Bioinformatics & Life Sciences, B3–322, 701 Ellicott Street, Buffalo, NY 1420, USA
| |
Collapse
|
8
|
Ghali JK, Massie BM, Mann DL, Rich MW. Heart failure guidelines, performance measures, and the practice of medicine: mind the gap. J Am Coll Cardiol 2011; 56:2077-80. [PMID: 21144966 DOI: 10.1016/j.jacc.2010.07.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 07/15/2010] [Accepted: 07/27/2010] [Indexed: 10/18/2022]
Abstract
Guidelines have rather quickly assumed a central role in health care delivery in the U.S. They have become the foundation on which performance measures are built and, therefore, a major player in assessing the quality of care provided by individuals and institutions, the ramifications of which involve reputation, reimbursement, and litigation. We are concerned, however, that in our enthusiasm for collectively endorsing these guidelines, we are marginalizing the importance of physician judgment and inadvertently risking the conversion of guidelines into "cookbooks." We believe that this viewpoint, while unequivocally acknowledging the fundamental importance of guidelines, simultaneously provides a critically important perspective on the potential for misuse of both guidelines and performance measures. Further, we hope that publication of this viewpoint will help temper enthusiasm for overzealous conversion of guidelines into performance measures, thereby restoring the vital role of physician judgment and insight into patient management.
Collapse
Affiliation(s)
- Jalal K Ghali
- DMC Cardiovascular Institute, Detroit, Michigan 48201, USA.
| | | | | | | |
Collapse
|