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Scatularo CE, Battioni L, Guazzone A, Esperón G, Corsico L, Grancelli HO. Basal natriuresis as a predictor of diuretic resistance and clinical evolution in acute heart failure. Curr Probl Cardiol 2024; 49:102674. [PMID: 38795800 DOI: 10.1016/j.cpcardiol.2024.102674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Some clinical guidelines recommend serial measurement of natriuresis to detect diuretic resistance (DR) in acute heart failure (AHF) patients, but it adds complexity to the management. OBJECTIVES To correlate a single measurement of basal natriuresis (BN) on admission with the development of DR and clinical evolution in AHF hospitalized patients. METHODS Prospective and multicenter study included AHF hospitalized patients, without shock or creatinine >2.5mg%. Patients received 40mg of intravenous furosemide on admission, then BN was measured, and diuretic treatment was guided by protocol. BN was considered low if <70 meq/L. DR was defined as the need of furosemide >240mg/day, tubular blockade (TB), hypertonic saline solution (HSS) or renal replacement therapy (RRT). In-hospital cardiovascular (CV) mortality, CV mortality and AHF readmissions at 60-day post-discharge were evaluated. RESULTS 157 patients were included. BN was low in 22%. DR was development in 19% (12.7% furosemide >240mg/day, 8% TB, 4% RRT). Low NB was associated with DR (44% vs 12%; p 0.0001), persistence of congestion (26.5% vs 11.4%; p 0.05), furosemide >240 mg/day (29% vs 8%; p 0.003), higher cumulative furosemide dose at 72 hours (220 vs 160mg; p 0.0001), TB (20.6 vs 4.9%; p 0.008), RRT (11.8 vs 1.6%; p 0.02), worsening of AHF (27% vs 9%; p 0.01), inotropes use (21% vs 7%; p 0.48), respiratory assistance (12% vs 2%; p 0.02) and a higher in-hospital CV mortality (12% vs 4%; p 0.1). No association was demonstrated with post-discharge endpoints. CONCLUSIONS In AHF patients, low BN was associated with DR, persistent congestion, need for aggressive decongestion strategies, and worse in-hospital evolution.
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Affiliation(s)
- Cristhian E Scatularo
- Department of Cardiology, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina.
| | - Luciano Battioni
- Council of heart failure and pulmonary hypertension, Argentine Society of Cardiology, Argentina
| | - Analía Guazzone
- Department of Cardiology, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
| | - Guillermina Esperón
- Department of Cardiology, Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | - Luciana Corsico
- Department of Cardiology, Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | - Hugo O Grancelli
- Department of Cardiology, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
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Tuttle ML, Fang JC, Sarnak MJ, McCallum W. Epidemiology and Management of Patients With Kidney Disease and Heart Failure With Preserved Ejection Fraction. Semin Nephrol 2024; 44:151516. [PMID: 38704338 PMCID: PMC11283973 DOI: 10.1016/j.semnephrol.2024.151516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) comprises approximately one-half of all diagnoses of heart failure. There is significant overlap of this clinical syndrome with chronic kidney disease (CKD), with many shared comorbid conditions. The presence of CKD in patients with HFpEF is one of the most powerful risk factors for adverse clinical outcomes, including death and heart failure hospitalization. The pathophysiology linking HFpEF and CKD remains unclear, but it is postulated to consist of numerous bidirectional pathways, including endothelial dysfunction, inflammation, obesity, insulin resistance, and impaired sodium handling. The diagnosis of HFpEF requires certain criteria to be satisfied, including signs and symptoms consistent with volume overload caused by structural or functional cardiac abnormalities and evidence of increased cardiac filling pressures. There are numerous overlapping metabolic clinical syndromes in patients with HFpEF and CKD that can serve as targets for intervention. With an increasing number of therapies available for HFpEF and CKD as well as for obesity and diabetes, improved recognition and diagnosis are paramount for appropriate management and improved clinical outcomes in patients with both HFpEF and CKD.
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Affiliation(s)
| | - James C Fang
- Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, MA.
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Mullens W, Dauw J, Gustafsson F, Mebazaa A, Steffel J, Witte KK, Delgado V, Linde C, Vernooy K, Anker SD, Chioncel O, Milicic D, Hasenfuß G, Ponikowski P, von Bardeleben RS, Koehler F, Ruschitzka F, Damman K, Schwammenthal E, Testani JM, Zannad F, Böhm M, Cowie MR, Dickstein K, Jaarsma T, Filippatos G, Volterrani M, Thum T, Adamopoulos S, Cohen-Solal A, Moura B, Rakisheva A, Ristic A, Bayes-Genis A, Van Linthout S, Tocchetti CG, Savarese G, Skouri H, Adamo M, Amir O, Yilmaz MB, Simpson M, Tokmakova M, González A, Piepoli M, Seferovic P, Metra M, Coats AJS, Rosano GMC. Integration of implantable device therapy in patients with heart failure. A clinical consensus statement from the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2024; 26:483-501. [PMID: 38269474 DOI: 10.1002/ejhf.3150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 10/27/2023] [Accepted: 01/15/2024] [Indexed: 01/26/2024] Open
Abstract
Implantable devices form an integral part of the management of patients with heart failure (HF) and provide adjunctive therapies in addition to cornerstone drug treatment. Although the number of these devices is growing, only few are supported by robust evidence. Current devices aim to improve haemodynamics, improve reverse remodelling, or provide electrical therapy. A number of these devices have guideline recommendations and some have been shown to improve outcomes such as cardiac resynchronization therapy, implantable cardioverter-defibrillators and long-term mechanical support. For others, more evidence is still needed before large-scale implementation can be strongly advised. Of note, devices and drugs can work synergistically in HF as improved disease control with devices can allow for further optimization of drug therapy. Therefore, some devices might already be considered early in the disease trajectory of HF patients, while others might only be reserved for advanced HF. As such, device therapy should be integrated into HF care programmes. Unfortunately, implementation of devices, including those with the greatest evidence, in clinical care pathways is still suboptimal. This clinical consensus document of the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC) describes the physiological rationale behind device-provided therapy and also device-guided management, offers an overview of current implantable device options recommended by the guidelines and proposes a new integrated model of device therapy as a part of HF care.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
- UHasselt, Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Jeroen Dauw
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
- UHasselt, Doctoral School for Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Finn Gustafsson
- The Heart Center, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Alexandre Mebazaa
- Université de Paris, UMR Inserm - MASCOT; APHP Saint Louis Lariboisière University Hospitals, Department of Anesthesia-Burn-Critical Care, Paris, France
| | - Jan Steffel
- Hirslanden Heart Clinic and University of Zurich, Zurich, Switzerland
| | - Klaus K Witte
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Hospital University Germans Trias i Pujol, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | - Cecilia Linde
- Karolinska Institutet, Department of Medicine, Karolinska University Hospital, Heart Vascular and Neurology Theme, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Davor Milicic
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Gerd Hasenfuß
- University Medical Center Göttingen (UMG), Department of Cardiology and Pneumology, German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | | | - Friedrich Koehler
- Medical Department, Division of Cardiology and Angiology, Centre for Cardiovascular Telemedicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Ruschitzka
- Clinic of Cardiology, University Heart Centre, University Hospital, Zurich, Switzerland
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Ehud Schwammenthal
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, and Tel Aviv University, Ramat Aviv, Israel
| | - Jeffrey M Testani
- Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Michael Böhm
- Universitatsklinikum des Saarlandes, Klinik fur Innere Medizin III, Saarland University, Kardiologie, Angiologie und Internistische Intensivmedizin, Homburg, Germany
| | - Martin R Cowie
- Royal Brompton Hospital, Guy's & St Thomas' NHS Foundation Trust, and School of Cardiovascular Medicine and Sciences, Faculty of Lifesciences & Medicine, King's College London, London, UK
| | - Kenneth Dickstein
- University of Bergen, Bergen, Norway; and Stavanger University Hospital, Stavanger, Norway
| | - Tiny Jaarsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia; Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | | | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany and Fraunhofer institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Stamatis Adamopoulos
- Heart Failure and Transplant Unit, Onassis Cardiac Surgery Centre, Athens, Greece
| | - Alain Cohen-Solal
- Department of Cardiology, University Hospital Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Brenda Moura
- Armed Forces Hospital, Porto, and Faculty of Medicine of Porto, Porto, Portugal
| | - Amina Rakisheva
- Cardiology Department, Scientific Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | - Arsen Ristic
- Universi Faculty of Medicine, University of Belgrade, and Serbian Academy of Arts and Sciences, Belgrade, Serbia
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Badalona, Spain
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charité - Universitätmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
| | - Carlo Gabriele Tocchetti
- Cardio-Oncology Unit, Department of Translational Medical Sciences (DISMET); Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center for Clinical and Translational Research (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA); Federico II University, Naples, Italy
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Hadi Skouri
- Division of Cardiology, Internal Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Offer Amir
- Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | | | | | - Arantxa González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra, and IdiSNA, Navarra Institute for Health Research, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Massimo Piepoli
- Clinical Cardiac Unit, Policlinico San Donato, University of Milan, Milan, Italy
| | - Petar Seferovic
- Universi Faculty of Medicine, University of Belgrade, and Serbian Academy of Arts and Sciences, Belgrade, Serbia
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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D'Amato A, Prosperi S, Severino P, Myftari V, Labbro Francia A, Cestiè C, Pierucci N, Marek-Iannucci S, Mariani MV, Germanò R, Fanisio F, Lavalle C, Maestrini V, Badagliacca R, Mancone M, Fedele F, Vizza CD. Current Approaches to Worsening Heart Failure: Pathophysiological and Molecular Insights. Int J Mol Sci 2024; 25:1574. [PMID: 38338853 PMCID: PMC10855688 DOI: 10.3390/ijms25031574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Worsening heart failure (WHF) is a severe and dynamic condition characterized by significant clinical and hemodynamic deterioration. It is characterized by worsening HF signs, symptoms and biomarkers, despite the achievement of an optimized medical therapy. It remains a significant challenge in cardiology, as it evolves into advanced and end-stage HF. The hyperactivation of the neurohormonal, adrenergic and renin-angiotensin-aldosterone system are well known pathophysiological pathways involved in HF. Several drugs have been developed to inhibit the latter, resulting in an improvement in life expectancy. Nevertheless, patients are exposed to a residual risk of adverse events, and the exploration of new molecular pathways and therapeutic targets is required. This review explores the current landscape of WHF, highlighting the complexities and factors contributing to this critical condition. Most recent medical advances have introduced cutting-edge pharmacological agents, such as guanylate cyclase stimulators and myosin activators. Regarding device-based therapies, invasive pulmonary pressure measurement and cardiac contractility modulation have emerged as promising tools to increase the quality of life and reduce hospitalizations due to HF exacerbations. Recent innovations in terms of WHF management emphasize the need for a multifaceted and patient-centric approach to address the complex HF syndrome.
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Affiliation(s)
- Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Vincenzo Myftari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Aurora Labbro Francia
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Claudia Cestiè
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Nicola Pierucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Stefanie Marek-Iannucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Rosanna Germanò
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
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5
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Inamoto M, Kohyama N, Suzuki H, Ebato M, Kogo M. Predictors of a Good Diuretic Response and Administration Methods for Carperitide in Patients With Acute Heart Failure. Clin Ther 2024; 46:12-19. [PMID: 37945501 DOI: 10.1016/j.clinthera.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE In Japan, carperitide has been recommended for the treatment of pulmonary congestion in patients with acute heart failure. Identifying useful indicators to support the decision to administer carperitide and the optimal timing of administration may lead to better improvement of pulmonary congestion. Therefore, we investigated the factors associated with good diuretic response to carperitide in patients with acute heart failure and the optimal timing of carperitide administration. METHODS This retrospective cohort study investigated 293 hospitalized patients who were diagnosed with acute heart failure and treated with carperitide at the Department of Cardiology, Showa University Fujigaoka Hospital. The primary endpoint was the diuretic response to carperitide. Patients with urine output ≥100 mL/h were defined as the good diuretic response group, and those with a urine output <100 mL/h during the first 6 hours of carperitide administration were defined as the poor diuretic response group. Multivariate analysis was used to examine the predictors of good diuretic response. The relationship between the time from intravenous furosemide to carperitide administration and urine output was also investigated. FINDINGS The patients' median age was 77 (range: 28-99) years, and 75.5% had New York Heart Association stage IV acute heart failure. The median urine output within 6 hours of carperitide administration was 104.5 (range: 6.6-1571.3) mL/h, and 118 patients (53.6%) showed a good diuretic response. Significant predictors of good diuretic response were age < 75 years [odds ratio (OR) 4.186; 95% confidence interval (CI), 2.129-8.230; P < 0.001], no prior use of loop diuretics (OR 2.155; 95% CI, 1.104-4.207; P = 0.024), blood urea nitrogen <20 mg/dL (OR 2.637; 95% CI, 1.340-5.190; P = 0.005), and white blood cell count <8.6 × 109/L (OR 3.162; 95% CI, 1.628-6.140; P = 0.001). The median urine output in the group with <2 hours between intravenous furosemide and carperitide administration was significantly higher than that in the group with an interval >6 hours [127.3; interquartile range (IQR), 77.6-216.2 mL/h vs. 66.2; IQR. 51.8-114.8 mL/h; P = 0.012). IMPLICATIONS The 4 predictors (age, no prior use of loop diuretics, blood urea nitrogen, and white blood cell count) of good diuretic response are useful indicators to support decision-making for carperitide administration. Additionally, the administration of carperitide within 2 hours of intravenous furosemide may lead to the improvement of pulmonary congestion.
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Affiliation(s)
- Mayumi Inamoto
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, Showa University School of Pharmacy, Tokyo, Japan; Department of Pharmacy, Showa University Fujigaoka Hospital, Kanagawa, Japan.
| | - Noriko Kohyama
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, Showa University School of Pharmacy, Tokyo, Japan
| | - Hiroshi Suzuki
- Department of Cardiovascular Medicine, Showa University Fujigaoka Hospital, Kanagawa, Japan
| | - Mio Ebato
- Department of Cardiovascular Medicine, Showa University Fujigaoka Hospital, Kanagawa, Japan
| | - Mari Kogo
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, Showa University School of Pharmacy, Tokyo, Japan
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Fernandez Hazim C, Duarte G, Urena AP, Jain S, Mishra R, Vittorio TJ, Rodriguez-Guerra M. Diuretic resistance and the role of albumin in congestive heart failure. Drugs Context 2023; 12:2023-6-5. [PMID: 38188263 PMCID: PMC10768781 DOI: 10.7573/dic.2023-6-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Diuresis with loop diuretics is the mainstay treatment for volume optimization in patients with congestive heart failure, in which perfusion and volume expansion play a crucial role. There are robust guidelines with extensive evidence for the management of heart failure; however, clear guidance is needed for patients who do not respond to standard diuretic treatment. Diuretic resistance (DR) can be defined as an insufficient quantity of natriuresis with proper diuretic therapy. A combination of diuretic regimens is used to overcome DR and, more recently, SGLT2 inhibitors have been shown to improve diuresis. Despite DR being relatively common, it is challenging to treat and there remains a notable lack of substantial data guiding its management. Moreover, DR has been linked with poor prognosis. This review aims to expose the multiple approaches for treatment of patients with DR and the importance of intravascular volume expansion in the response to therapy.
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Affiliation(s)
| | | | - Ana P Urena
- Medicina Cardiovascular Asociada, Santo Domingo, Dominican Republic
| | - Swati Jain
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rishabh Mishra
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy J Vittorio
- BronxCare Health System, Icahn School of Medicine at Mt. Sinai, Bronx, NY, USA
| | - Miguel Rodriguez-Guerra
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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7
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McCallum W, Sarnak MJ. Cardiorenal Syndrome in the Hospital. Clin J Am Soc Nephrol 2023; 18:933-945. [PMID: 36787124 PMCID: PMC10356127 DOI: 10.2215/cjn.0000000000000064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/22/2022] [Indexed: 01/22/2023]
Abstract
The cardiorenal syndrome refers to a group of complex, bidirectional pathophysiological pathways involving dysfunction in both the heart and kidney. Upward of 60% of patients admitted for acute decompensated heart failure have CKD, as defined by an eGFR of <60 ml/min per 1.73 m 2 . CKD, in turn, is one of the strongest risk factors for mortality and cardiovascular events in acute decompensated heart failure. Although not well understood, the mechanisms in the cardiorenal syndrome include venous congestion, arterial underfilling, neurohormonal activation, inflammation, and endothelial dysfunction. Arterial underfilling may lead to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, leading to sodium reabsorption and vasoconstriction. Venous congestion likely also mediates and perpetuates these maladaptive pathways. To rule out intrinsic kidney disease that is distinct from the cardiorenal syndrome, one should obtain a careful history, review longitudinal eGFR trends, assess albuminuria and proteinuria, and review the urine sediment and kidney imaging. The hallmark of the cardiorenal syndrome is intense sodium avidity and diuretic resistance, often requiring a combination of diuretics with varying pharmacological targets, and monitoring of urinary response to guide escalations in therapy. Invasive means of decongestion may be required including ultrafiltration or KRT such as peritoneal dialysis, which is often better tolerated from a hemodynamic perspective than intermittent hemodialysis. Strategies for increasing forward perfusion in states of low cardiac output and cardiogenic shock may include afterload reduction and inotropes and, in the most severe cases, mechanical circulatory support devices, many of which have kidney-specific considerations.
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Affiliation(s)
- Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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8
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Urbani A, Pensotti F, Provera A, Galassi A, Guazzi M, Castini D. Extracorporeal veno-venous ultrafiltration in congestive heart failure: What’s the state of the art? A mini-review. World J Cardiol 2023; 15:205-216. [PMID: 37274372 PMCID: PMC10237006 DOI: 10.4330/wjc.v15.i5.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/19/2023] [Accepted: 04/24/2023] [Indexed: 05/19/2023] Open
Abstract
Hospitalizations for heart failure exceed 1 million per year in both the United States and Europe and more than 90% are due to symptoms and signs of fluid overload. Rates of rehospitalizations or emergency department visit at 60 days are remarkable regardless of whether loop diuretics were administered at low vs high doses or by bolus injection vs continuous infusion. Ultrafiltration (UF) has been considered a promising alternative to stepped diuretic therapy and it consists in the mechanical, adjustable removal of iso-tonic plasma water across a semipermeable membrane with the application of hydrostatic pressure gradient generated by a pump. Fluid removal with ultrafiltration presents several advantages such as elimination of higher amount of sodium with less neurohormonal activation. However, the conflicting results from UF studies highlight that patient selection and fluid removal targets are not completely understood. The best way to assess fluid status and therefore establish the fluid removal target is also still a matter of debate. Herein, we provide an up-to-date systematic review about the role of ultrafiltration among patients with fluid overload and its gaps in daily practice.
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Affiliation(s)
- Andrea Urbani
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Filippo Pensotti
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Andrea Provera
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Andrea Galassi
- Nephrology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Marco Guazzi
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Diego Castini
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
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Gelman R, Hurvitz N, Nesserat R, Kolben Y, Nachman D, Jamil K, Agus S, Asleh R, Amir O, Berg M, Ilan Y. A second-generation artificial intelligence-based therapeutic regimen improves diuretic resistance in heart failure: Results of a feasibility open-labeled clinical trial. Biomed Pharmacother 2023; 161:114334. [PMID: 36905809 DOI: 10.1016/j.biopha.2023.114334] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 03/11/2023] Open
Abstract
INTRODUCTION Diuretics are a mainstay therapy for congestive heart failure (CHF); however, over one-third of patients develop diuretic resistance. Second-generation artificial intelligence (AI) systems introduce variability into treatment regimens to overcome the compensatory mechanisms underlying the loss of effectiveness of diuretics. This open-labeled, proof-of-concept clinical trial sought to investigate the ability to improve diuretic resistance by implementing algorithm-controlled therapeutic regimens. METHODS Ten CHF patients with diuretic resistance were enrolled in an open-labeled trial where the Altus Care™ app managed diuretics' dosage and administration times. The app provides a personalized therapeutic regimen creating variability in dosages and administration times within pre-defined ranges. Response to therapy was measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) score, 6-minute walk test (SMW), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, and renal function. RESULTS The second-generation, AI-based, personalized regimen alleviated diuretic resistance. All evaluable patients demonstrated clinical improvement within ten weeks of intervention. A dose reduction (based on a three-week average before and last three weeks of intervention) was achieved in 7/10 patients (70 %, p = 0.042). The KCCQ score improved in 9/10 (90 %, p = 0.002), the SMW improved in 9/9 (100 %, p = 0.006), NT-proBNP was decreased in 7/10 (70 %, p = 0.02), and serum creatinine was decreased in 6/10 (60 %, p = 0.05). The intervention was associated with reduced number of emergency room visits and the number of CHF-associated hospitalizations. SUMMARY The results support that the randomization of diuretic regimens guided by a second-generation personalized AI algorithm improves the response to diuretic therapy. Prospective controlled studies are needed to confirm these findings.
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Affiliation(s)
- Ram Gelman
- Departments of Medicine, Hadassah Medical Center, and Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Noa Hurvitz
- Departments of Medicine, Hadassah Medical Center, and Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Rima Nesserat
- Departments of Medicine, Hadassah Medical Center, and Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Yotam Kolben
- Departments of Medicine, Hadassah Medical Center, and Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Dean Nachman
- Departments of Cardiology, Hadassah Medical Center, and Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Khurram Jamil
- Oberon Sciences and Area 9 Innovation, Stanford University, Palo Alto, CA, USA
| | - Samuel Agus
- Oberon Sciences and Area 9 Innovation, Stanford University, Palo Alto, CA, USA
| | - Rabea Asleh
- Departments of Cardiology, Hadassah Medical Center, and Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Offer Amir
- Departments of Cardiology, Hadassah Medical Center, and Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Marc Berg
- Oberon Sciences and Area 9 Innovation, Stanford University, Palo Alto, CA, USA
| | - Yaron Ilan
- Departments of Medicine, Hadassah Medical Center, and Faculty of Medicine, Hebrew University, Jerusalem, Israel.
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Şorodoc V, Asaftei A, Puha G, Ceasovschih A, Lionte C, Sîrbu O, Bologa C, Haliga RE, Constantin M, Coman AE, Petriș OR, Stoica A, Şorodoc L. Management of Hyponatremia in Heart Failure: Practical Considerations. J Pers Med 2023; 13:jpm13010140. [PMID: 36675801 PMCID: PMC9865833 DOI: 10.3390/jpm13010140] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 01/12/2023] Open
Abstract
Hyponatremia is commonly encountered in the setting of heart failure, especially in decompensated, fluid-overloaded patients. The pathophysiology of hyponatremia in patients with heart failure is complex, including numerous mechanisms: increased activity of the sympathetic nervous system and the renin-angiotensin-aldosterone system, high levels of arginine vasopressin and diuretic use. Symptoms are usually mild but hyponatremic encephalopathy can occur if there is an acute decrease in serum sodium levels. It is crucial to differentiate between dilutional hyponatremia, where free water excretion should be promoted, and depletional hyponatremia, where administration of saline is needed. An inappropriate correction of hyponatremia may lead to osmotic demyelination syndrome which can cause severe neurological symptoms. Treatment options for hyponatremia in heart failure, such as water restriction or the use of hypertonic saline with loop diuretics, have limited efficacy. The aim of this review is to summarize the principal mechanisms involved in the occurrence of hyponatremia, to present the main guidelines for the treatment of hyponatremia, and to collect and analyze data from studies which target new treatment options, such as vaptans.
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Affiliation(s)
- Victoriţa Şorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Andreea Asaftei
- 2nd Rheumatology Department, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
- Correspondence: (A.A.); (A.C.); (C.L.)
| | - Gabriela Puha
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Alexandr Ceasovschih
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
- Correspondence: (A.A.); (A.C.); (C.L.)
| | - Cătălina Lionte
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (A.A.); (A.C.); (C.L.)
| | - Oana Sîrbu
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cristina Bologa
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Raluca Ecaterina Haliga
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihai Constantin
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Adorata Elena Coman
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Ovidiu Rusalim Petriș
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Alexandra Stoica
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Laurenţiu Şorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
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11
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Liu Y, Zhang Y, Chen H, Zhao J, Ma Q, Yang G, Wang X, Wu Z, Hou J, Cheng Q, Ao Q. Efficacy of tolvaptan on the short and mid-term prognosis in elderly patients with acute heart failure coexisting with oliguria: A retrospective cohort study. Front Cardiovasc Med 2023; 9:1075631. [PMID: 36698930 PMCID: PMC9868427 DOI: 10.3389/fcvm.2022.1075631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/05/2022] [Indexed: 01/11/2023] Open
Abstract
Background In patients with acute heart failure (AHF) coexisting with oliguria, high doses of loop diuretics are often ineffective in increasing urine output and may adversely affect the patient's prognosis, especially in elderly patients. We investigated the efficacy of adding tolvaptan (TLV) on improving the prognosis in elderly patients with AHF coexisting with oliguria. Methods All data for this retrospective cohort study were extracted from the electronic medical record system of the Second Medical Center of Chinese PLA General Hospital from January 2018 to December 2020. Patients diagnosed with AHF coexisting with oliguria were enrolled in this study and were divided into TLV and non-TLV groups based on the use of TLV. The primary outcome was all-cause mortality at 7 and 90-day. The secondary outcomes were the remission of AHF within 7 and 30 days or continued progression of AHF, and new-onset chronic kidney disease (CKD) after 90 days. Cox proportional hazards regression was used to assess the relationships between all-cause mortality and diuretic regimens, demographics, laboratory parameters, comorbidities, and medications. Results A total of 308 patients met the study criteria for the final statistical analysis, and they had a median age of 91 years (88, 95). The results showed that the addition of TLV was associated with a decreased risk of the 7 and 90-day all-cause mortality in patients with AHF with oliguria [adjusted HR, 95% CI: 0.60 (0.37, 0.98), p = 0.042; 0.56 (0.41, 0.75), p < 0.001, respectively]. Adding TLV significantly increased urine output and decreased N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in 7 days, and alleviated the progression of AHF within 30 days. There were no statistically significant differences between the patients with or without TLV in terms of the occurrence of hypernatremia, the development of hepatic impairment within 30 days, and new-onset CKD after 90 days. Conclusions This study demonstrated that the addition of TLV was clinically effective in increasing urine output, and had favorable effects on alleviating AHF progression and may reduce the risk of all-cause mortality at 7 and 90-day in elderly patients with AHF with oliguria, and TLV had a good safety profile. Trial registration http://www.chictr.org.cn/showprojen.aspx?proj=148046, identifier: ChiCTR2200055518.
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12
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Meariman JK, Sutphen JC, Gao J, Kapusta DR. Nalfurafine, a G-Protein-Biased KOR (Kappa Opioid Receptor) Agonist, Enhances the Diuretic Response and Limits Electrolyte Losses to Standard-of-Care Diuretics. Hypertension 2022; 79:379-390. [PMID: 34852633 PMCID: PMC8755620 DOI: 10.1161/hypertensionaha.121.18503] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Nalfurafine is a G-protein-biased KOR (kappa opioid receptor) agonist that produces analgesia and lacks central nervous system adverse effects. Here, we examined the cardiovascular and renal responses to intravenous and oral nalfurafine alone and in combination with furosemide, hydrochlorothiazide, or amiloride. We hypothesized that nalfurafine, given its distinct mechanism of vasopressin inhibition, would increase urine output to these diuretics and limit electrolyte loss. Following catheterization, conscious Sprague-Dawley rats received an isotonic saline infusion and were then administered an intravenous bolus of nalfurafine, a diuretic, or a combination. Mean arterial pressure, heart rate, and urine output were recorded for 90 minutes. In another study, rats were placed in metabolic cages and administered drug in an oral volume load. Hourly urine samples were then collected for 5 hours. Intravenous and oral nalfurafine produced a marked diuresis, antinatriuresis, antikaliuresis, and a decrease in mean arterial pressure. Compared with diuretic treatment alone, intravenous coadministration with nalfurafine significantly increased urine output to furosemide and hydrochlorothiazide and decreased sodium and potassium excretion. Notably, mean arterial pressure was reduced with nalfurafine/diuretic combination therapy compared to diuretics alone. Similarly, oral coadministration of nalfurafine significantly increased urine output to hydrochlorothiazide and decreased sodium and potassium excretion, whereas combination with furosemide only limited the amount of sodium excreted. Further, both intravenous and oral coadministration of nalfurafine enhanced the diuresis to amiloride and decreased sodium excretion. Together, these findings demonstrate that nalfurafine enhances the diuresis to standard-of-care diuretics without causing an excessive loss of electrolytes, offering a new approach to treat several cardiovascular conditions.
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Affiliation(s)
- Jacob K Meariman
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, 1901 Perdido St, New Orleans, LA 70112
| | - Jane C Sutphen
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, 1901 Perdido St, New Orleans, LA 70112
| | - Juan Gao
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, 1901 Perdido St, New Orleans, LA 70112
| | - Daniel R Kapusta
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, 1901 Perdido St, New Orleans, LA 70112,Cardiovascular Center of Excellence, Louisiana State University Health Sciences Center, 1901 Perdido St, New Orleans, LA 70112
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13
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Blázquez‐Bermejo Z, Farré N, Caravaca Perez P, Llagostera M, Morán‐Fernández L, Fort A, de Juan Bagudá J, García‐Cosio MD, Ruiz‐Bustillo S, Delgado JF. Dose of furosemide before admission predicts diuretic efficiency and long-term prognosis in acute heart failure. ESC Heart Fail 2022; 9:656-666. [PMID: 34766460 PMCID: PMC8788037 DOI: 10.1002/ehf2.13696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/21/2021] [Accepted: 10/29/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS The outpatient diuretic dose is a marker of diuretic resistance and prognosis in chronic heart failure (HF). Still, the impact of the preadmission dose on diuretic efficiency (DE) and prognosis in acute HF is not fully known. METHODS AND RESULTS We conducted an observational and prospective study. All patients admitted for acute HF treated with intravenous diuretic and at least one criterion of congestion on admission were evaluated. Decongestion [physical examination, hemoconcentration, N-terminal pro-brain natriuretic peptide (NT-proBNP) change, and lung ultrasound], DE (weight loss and urine output per unit of 40 mg furosemide), and urinary sodium were monitored on the fifth day of admission. DE was dichotomized into high-low based on the median value. A multivariate Cox regression analysis was conducted to find predictors of HF readmission or mortality. A total of 105 patients were included between July 2017 and July 2019. Mean age was 74.5 ± 12.0 years, 64.8% were male, 33.3% had de novo HF, and mean left ventricular ejection fraction was 46 ± 17%. Median follow-up was 26 [15-35] months. Low DE based on weight loss was associated with a higher previous dose of furosemide (odds ratio [OR] 1.01 [1.00-1.02]), thiazide treatment before admission (OR 9.37 [2.19-40.14]), and lower diastolic blood pressure (OR 0.95 [0.91-0.98]) in the multivariate regression model. Only previous dose of furosemide (OR 1.01 [1.00-1.02]) and haemoglobin at admission (OR 0.76 [0.58-0.99]) were associated with low DE based on urine output in the multivariate analysis. The correlation between the previous dose of furosemide and DE based on weight loss was poor (r = -0.12; P = 0.209) and with DE based on urine output was weak to moderate (r = -0.33; P < 0.001). Low DE based on weight loss and urine output was associated with lesser decongestion measured by NT-proBNP (P = 0.011; P = 0.007), hemoconcentration (P = 0.006; P = 0.044), and lung ultrasound (P = 0.034; P = 0.029), but not by physical examination (P = 0.506; P = 0.560). Survival and event-free survival in acute decompensated HF (ADHF) were lower than in de novo HF; a preadmission dose of furosemide > 80 mg in ADHF identified patients with particularly poor prognosis (log-rank < 0.001). In ADHF, the preadmission dose of furosemide (hazard ratio [HR] 1.34 [1.08-1.67] per 40 mg) and NT-proBNP at admission (HR 1.03 [1.01-1.06] per 1000 pg/mL) were independently associated with mortality or HF readmission in the multivariate Cox regression analysis. CONCLUSIONS The outpatient dose of furosemide before acute HF admission predicts DE and must be taken into account when deciding on the initial diuretic dose. In ADHF, the outpatient dose of furosemide can predict long-term prognosis better than DE during hospitalization.
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Affiliation(s)
- Zorba Blázquez‐Bermejo
- Cardiology DepartmentHospital del MarBarcelonaSpain
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
| | - Nuria Farré
- Cardiology DepartmentHospital del MarBarcelonaSpain
- Biomedical Research Group on Heart Disease (GREC)Hospital del Mar Medical Research Group (IMIM)BarcelonaSpain
- Department of MedicineUniversidad Autónoma de BarcelonaBarcelonaSpain
| | - Pedro Caravaca Perez
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
- CIBER de Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | | | - Laura Morán‐Fernández
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
- CIBER de Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | - Aleix Fort
- Cardiology DepartmentHospital del MarBarcelonaSpain
| | - Javier de Juan Bagudá
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
- CIBER de Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | - María Dolores García‐Cosio
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
- CIBER de Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | - Sonia Ruiz‐Bustillo
- Cardiology DepartmentHospital del MarBarcelonaSpain
- Biomedical Research Group on Heart Disease (GREC)Hospital del Mar Medical Research Group (IMIM)BarcelonaSpain
- Department of MedicineUniversitat Pompeu FabraBarcelonaSpain
| | - Juan F. Delgado
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
- CIBER de Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
- Faculty of MedicineUniversidad Complutense de MadridMadridSpain
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14
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Minh NG, Hoang HN, Maeda D, Matsue Y. Tolvaptan Add-on Therapy to Overcome Loop Diuretic Resistance in Acute Heart Failure With Renal Dysfunction (DR-AHF): Design and Rationale. Front Cardiovasc Med 2022; 8:783181. [PMID: 35155599 PMCID: PMC8829876 DOI: 10.3389/fcvm.2021.783181] [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: 09/25/2021] [Accepted: 12/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background Diuretic Resistance in Acute Heart Failure (DR-AHF) was designed to demonstrate the effectiveness of the early tolvaptan (a vasopressin-2 receptor antagonist) add-on therapy in patients with AHF with renal dysfunction and to provide clinical evidence of loop diuretic resistance. Methods and Results This single-centered, open-labeled, randomized, and controlled trial enrolled 128 patients hospitalized with AHF, as participants. These patients with a wet-warm phenotype, whose estimated glomerular filtration rates are of ≥15 ml/min/1.73 m2 and ≤ 60 ml/min/1.73 m2, with a cumulative urine output of <300 ml 2 h after the first dose of intravenous furosemide, will be randomly assigned 1:1 to receive standard care with an uptitrating intravenous furosemide alone, or a combination therapy with 15 mg of tolvaptan administered once daily for 2 days. The standard furosemide treatment will follow the latest position statements of the Heart Failure Association. The primary endpoint is the cumulative urine output at 48 h. The key secondary endpoints include the improvement of fractional excretion of sodium at 6 h, the total dose of furosemide, and the incidence of worsening renal function (WRF) at 48 h. Conclusions Although the combination of diuretic treatment has recently gained more attention due to its physiologically synergistic action, its advantages may be outweighed by the substantial risk of electrolyte disturbances and severe WRF. Further, there is no consensus on the time point for early starting of add-on therapy and for the preferred diuretic combination. Trial registration NCT04331132.
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Affiliation(s)
- Nhat Giang Minh
- Department of Cardiology, Nhan Dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam
- *Correspondence: Nhat Giang Minh
| | - Hai Nguyen Hoang
- Department of Cardiology, Nhan Dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam
| | - Daichi Maeda
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yuya Matsue
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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15
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Cox ZL, Rao VS, Ivey-Miranda JB, Moreno-Villagomez J, Mahoney D, Ponikowski P, Biegus J, Turner JM, Maulion C, Bellumkonda L, Asher JL, Parise H, Wilson PF, Ellison DH, Wilcox CS, Testani JM. Compensatory post-diuretic renal sodium reabsorption is not a dominant mechanism of diuretic resistance in acute heart failure. Eur Heart J 2021; 42:4468-4477. [PMID: 34529781 DOI: 10.1093/eurheartj/ehab620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/02/2021] [Accepted: 08/27/2021] [Indexed: 01/12/2023] Open
Abstract
AIMS In healthy volunteers, the kidney deploys compensatory post-diuretic sodium reabsorption (CPDSR) following loop diuretic-induced natriuresis, minimizing sodium excretion and producing a neutral sodium balance. CPDSR is extrapolated to non-euvolemic populations as a diuretic resistance mechanism; however, its importance in acute decompensated heart failure (ADHF) is unknown. METHODS AND RESULTS Patients with ADHF in the Mechanisms of Diuretic Resistance cohort receiving intravenous loop diuretics (462 administrations in 285 patients) underwent supervised urine collections entailing an immediate pre-diuretic spot urine sample, then 6-h (diuretic-induced natriuresis period) and 18-h (post-diuretic period) urine collections. The average spot urine sodium concentration immediately prior to diuretic administration [median 15 h (13-17) after last diuretic] was 64 ± 33 mmol/L with only 4% of patients having low (<20 mmol/L) urine sodium consistent with CPDSR. Paradoxically, greater 6-h diuretic-induced natriuresis was associated with larger 18-h post-diuretic spontaneous natriuresis (r = 0.7, P < 0.001). Higher pre-diuretic urine sodium to creatinine ratio (r = 0.37, P < 0.001) was the strongest predictor of post-diuretic spontaneous natriuresis. In a subgroup of patients (n = 43) randomized to protocol-driven intensified diuretic therapies, the mean diuretic-induced natriuresis increased three-fold. In contrast to the substantial decrease in spontaneous natriuresis predicted by CPDSR, no change in post-diuretic spontaneous natriuresis was observed (P = 0.47). CONCLUSION On a population level, CPDSR was not an important driver of diuretic resistance in hypervolemic ADHF. Contrary to CPDSR, a greater diuretic-induced natriuresis predicted a larger post-diuretic spontaneous natriuresis. Basal sodium avidity, rather than diuretic-induced CPDSR, appears to be the predominant determinate of both diuretic-induced and post-diuretic natriuresis in hypervolemic ADHF.
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, 1 University Park Drive, Nashville, TN 37204, USA.,Department of Pharmacy, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA.,Hospital de Cardiologia, Instituto Mexicano del Seguro Social, 330 Cuauhtemoc Avenue. Cuauhtemoc, Mexico City 06720, Mexico
| | - Julieta Moreno-Villagomez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA.,Universidad Nacional Autónoma de México, Avenida Insurgentes Sur, Mexico City 3000, Mexico
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Rektorat, wybrzeże Ludwika Pasteura 1, Wroclaw 50-367, Poland
| | - Jan Biegus
- Clinical Military Hospital, Weigla 5, Wroclaw 50-981, Poland
| | - Jeffrey M Turner
- Department of Medicine, Division of Nephrology, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Lavanya Bellumkonda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Jennifer L Asher
- Department of Comparative Medicine, Yale University School of Medicine, 310 Cedar Street, New Haven, CT 06520, USA
| | - Helen Parise
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Perry F Wilson
- Clinical and Translational Research Accelerator, Yale University School of Medicine, 60 Temple Street, New Haven, CT 06520, USA
| | - David H Ellison
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University and the Veterans Affairs Portland Health Care System, 3181 S.W. Sam Jackson Park Road Portland, OR 97239, USA
| | - Christopher S Wilcox
- Division of Nephrology and Hypertension and Hypertension Center, Georgetown University, 3800 Reservoir Road, N.W., Washington, DC 20007, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
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16
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Cox ZL, Sarrell BA, Cella MK, Tucker B, Arroyo JP, Umanath K, Tidwell W, Guide A, Testani JM, Lewis JB, Dwyer JP. Multinephron Segment Diuretic Therapy to Overcome Diuretic Resistance in Acute Heart Failure: A Single-Center Experience. J Card Fail 2021; 28:21-31. [PMID: 34403831 DOI: 10.1016/j.cardfail.2021.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The concept of multinephron segment diuretic therapy (MSDT) has been recommended in severe diuretic resistance with only expert opinion and case-level evidence. The purpose of this study was to investigate the safety and efficacy of MSDT, combining 4 diuretic classes, in acute heart failure (AHF) complicated by diuretic resistance. METHODS AND RESULTS A retrospective analysis was conducted in patients hospitalized with AHF at a single medical center who received MSDT, including concomitant carbonic anhydrase inhibitor, loop, thiazide, and mineralocorticoid receptor antagonist diuretics. Subjects served as their own controls with efficacy evaluated as urine output and weight change before and after MSDT. Serum chemistries, renal replacement therapies, and in-hospital mortality were evaluated for safety. Patients with severe diuretic resistance before MSDT were analyzed as a subcohort. A total of 167 patients with AHF and diuretic resistance received MSDT. MSDT was associated with increased median 24-hour urine output in the first day of therapy compared with the previous day (2.16 L [0.95-4.14 L] to 3.08 L [1.74-4.86 L], P = .003) in the total cohort and in the Severe diuretic resistance cohort (0.91 L [0.43-1.43 L] to 2.08 L [1.13-3.96 L], P < .001). The median cumulative weight loss at day 7 or discharge was -7.4 kg (-15.3 to -3.4 kg) (P = .02). Neither serum sodium, chloride, potassium, bicarbonate, or creatinine changed significantly relative to baseline (P > .05 for all). CONCLUSIONS In an AHF cohort with diuretic resistance, MSDT was associated with increased diuresis without changes in serum chemistries or kidney function. Prospective studies of MSDT in AHF and diuretic resistance are warranted.
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Bonnie Ann Sarrell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary Katherine Cella
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
| | - Brent Tucker
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
| | - Juan P Arroyo
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kausik Umanath
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan; Division of Nephrology and Hypertension, Wayne State University, Detroit, Michigan
| | - William Tidwell
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Guide
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey M Testani
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Julia B Lewis
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamie P Dwyer
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
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Mareev VY, Garganeeva AA, Ageev FT, Arutunov GP, Begrambekova YL, Belenkov YN, Vasyuk YA, Galyavich AS, Gilarevsky SR, Glezer MG, Drapkina OM, Duplyakov DV, Kobalava ZD, Koziolova NA, Kuzheleva EA, Mareev YV, Ovchinnikov AG, Orlova YA, Perepech NB, Sitnikova MY, Skvortsov AA, Skibitskiy VV, Chesnikova AI. [The use of diuretics in chronic heart failure. Position paper of the Russian Heart Failure Society]. ACTA ACUST UNITED AC 2021; 60:13-47. [PMID: 33522467 DOI: 10.18087/cardio.2020.12.n1427] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 11/18/2022]
Abstract
The document focuses on key issues of diuretic therapy in CHF from the standpoint of current views on the pathogenesis of edema syndrome, its diagnosis, and characteristics of using diuretics in various clinical situations.
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Affiliation(s)
- V Yu Mareev
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | - A A Garganeeva
- "Research Institute for Cardiology", Siberian State Medical University, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - F T Ageev
- Scientific Medical Research Center of Cardiology, Russia
| | - G P Arutunov
- Russian National Research Medical University named after Pirogov, Moscow
| | - Yu L Begrambekova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | - Yu N Belenkov
- Sechenov Moscow State Medical University, Moscow, Russia
| | - Yu A Vasyuk
- Moscow State Medical and Dental University named after Evdokimov, Moscow, Russia
| | | | - S R Gilarevsky
- Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - M G Glezer
- Sechenov Moscow State Medical University, Moscow, Russia
| | - O M Drapkina
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia
| | - D V Duplyakov
- Samara Regional Clinical Cardiological Dispensary, Russia
| | - Zh D Kobalava
- Russian State University of Peoples' Friendship, Moscow, Russia
| | - N A Koziolova
- Federal State Budgetary Institution of Healthcare of Higher Education "Perm State Medical University named after Academician E.A. Wagner ", Russia
| | - E A Kuzheleva
- "Research Institute for Cardiology", Siberian State Medical University, Tomsk National Research Medical Center, Russian Academy of Sciences, Russia
| | - Yu V Mareev
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia Robertson Centre for Biostatistics, Glasgow, Great Britain
| | | | - Ya A Orlova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | | | - M Yu Sitnikova
- Almazov National Medical Research Center, St. Petersburg, Russia
| | - A A Skvortsov
- Scientific Medical Research Center of Cardiology, Russia
| | - V V Skibitskiy
- Kuban State Medical University" of the Ministry of Health of the Russian Federation, Russia
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18
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Levosimendan Plus Dobutamine in Acute Decompensated Heart Failure Refractory to Dobutamine. J Clin Med 2020; 9:jcm9113605. [PMID: 33182314 PMCID: PMC7695257 DOI: 10.3390/jcm9113605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/28/2020] [Accepted: 11/02/2020] [Indexed: 01/20/2023] Open
Abstract
Randomized studies showed that Dobutamine and Levosimendan have similar impact on outcome but their combination has never been assessed in acute decompensated heart failure (ADHF) with low cardiac output. This is a retrospective, single-center study that included 89 patients (61 ± 15 years) admitted for ADHF requiring inotropic support. The first group consisted of patients treated with dobutamine alone (n = 42). In the second group, levosimendan was administered on top of dobutamine, when the superior vena cava oxygen saturation (ScVO2) remained <60% after 3 days of dobutamine treatment (n = 47). The primary outcome was the occurrence of major cardiovascular events (MACE) at 6 months, defined as all cause death, heart transplantation or need for mechanical circulatory support. Baseline clinical characteristics were similar in both groups. At day-3, the ScVO2 target (>60%) was reached in 36% and 32% of patients in the dobutamine and dobutamine-levosimendan group, respectively. After adding levosimendan, 72% of the dobutamine-levosimendan-group reached the ScVO2 target value at dobutamine weaning. At six months, 42 (47%) patients experienced MACE (n = 29 for death). MACE was less frequent in the dobutamine-levosimendan (32%) than in the dobutamine-group (64%, p = 0.003). Independent variables associated with outcome were admission systolic blood pressure and dobutamine-levosimendan strategy (OR = 0.44 (0.23–0.84), p = 0.01). In conclusion, levosimendan added to dobutamine may improve the outcome of ADHF refractory to dobutamine alone.
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Loughran KA, Larouche-Lebel É, Huh T, Testani JM, Rao VS, Oyama MA. Prediction and measurement of diuretic responsiveness after oral administration of furosemide to healthy dogs and dogs with congestive heart failure. J Vet Intern Med 2020; 34:2253-2264. [PMID: 33125814 PMCID: PMC7694836 DOI: 10.1111/jvim.15952] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 10/13/2020] [Accepted: 10/19/2020] [Indexed: 02/06/2023] Open
Abstract
Background In human patients, cumulative urine volume (uVol) and urine sodium (uNa) can be predicted using spot urine samples and these quantitative measures help detect low diuretic responsiveness (LDR). Hypothesis/objectives Formulas using spot urine samples predict cumulative uVol and uNa output after oral administration of furosemide to dogs. Animals Eight healthy dogs, 6 dogs with congestive heart failure (CHF). Methods Prospective interventional study. Spot urine samples at 180 and 270 minutes after furosemide (3 mg/kg PO) were used to predict cumulative uVol and uNa output over 7 hours. Differentiation of dogs fulfilling predefined criteria for LDR was examined using receiver operating characteristic (ROC) curves. Results Predicted uNa output at 180 minutes (rs = 0.763, [95% confidence interval [CI], 0.375‐0.923], P = .002) and 270 minutes (r = 0.816, [95% CI, 0.503‐0.940], P < .001) was highly correlated to 7‐hour uNa output. Predicted uVol at 180 minutes (r = 0.598, [95% CI, 0.098‐0.857], P = .02) and 270 minutes (r = 0.791, [95% CI, 0.450‐0.931], P < .001) was moderately correlated to 7‐hour uVol. Predicted uNa using 180‐minute (area under the curve [AUC], 0.933 [95% CI, 0.804‐1.000]) and 270‐minute (AUC, 0.911 [95% CI, 0.756‐1.000]) samples identified dogs with LDR (n = 5) with high accuracy. Conclusions and Clinical Importance Urinary Na excretion and uVol are complementary but distinct aspects of diuretic responsiveness in dogs. Quantification of diuretic responsiveness in the clinical setting opens new diagnostic, treatment, and monitoring strategies.
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Affiliation(s)
- Kerry A Loughran
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Éva Larouche-Lebel
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Terry Huh
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey M Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Veena S Rao
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mark A Oyama
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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20
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Espriella RDL, Bayés-Genis A, Revuelta-LóPEZ E, Miñana G, Santas E, Llàcer P, García-Blas S, Fernández-Cisnal A, Bonanad C, Ventura S, Sánchez R, Bodí V, Cordero A, Fácila L, Mollar A, Sanchis J, Núñez J. Soluble ST2 and Diuretic Efficiency in Acute Heart Failure and Concomitant Renal Dysfunction. J Card Fail 2020; 27:427-434. [PMID: 33038531 DOI: 10.1016/j.cardfail.2020.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/27/2020] [Accepted: 10/02/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Identifying patients at risk of poor diuretic response in acute heart failure (AHF) is critical to make prompt adjustments in therapy. The objective of this study was to investigate whether the circulating levels of soluble ST2 predict the cumulative diuretic efficiency (DE) at 24 and 72 hours in patients with AHF and concomitant renal dysfunction. METHODS AND RESULTS This is a post hoc analysis of the IMPROVE-HF trial, in which we enrolled 160 patients with AHF and renal dysfunction (estimated glomerular filtrate rate of <60 mL/min/1.73 m2). DE was calculated as the net fluid output produced per 40 mg of furosemide equivalents. The association between sST2 and DE was evaluated by using multivariate linear regression analysis. The median cumulative DE at 24 and 72 hour was 747 mL (interquartile range 490-1167 mL) and 1844 mL (interquartile range 1142-2625 mL), respectively. The median sST2 and mean estimated glomerular filtrate rate were 72 ng/mL (interquartile range 47-117 ng/mL), and 34.0 ± 8.5 mL/min/1.73 m2, respectively. In a multivariable setting, higher sST2 were significant and nonlinearly related to lower DE both at 24 and 72 hours (P = .002 and P = .019, respectively). CONCLUSIONS In patients with AHF and renal dysfunction at presentation, circulating levels of sST2 were independently and negatively associated with a poor diuretic response, both at 24 and 72 hours.
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Affiliation(s)
- Rafael De La Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Antoni Bayés-Genis
- CIBER Cardiovascular, Madrid, Spain; Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona. Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Elena Revuelta-LóPEZ
- Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona. Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Pau Llàcer
- Internal Medicine Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Sergio García-Blas
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Agustín Fernández-Cisnal
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Silvia Ventura
- Internal Medicine Department, Hospital de La Plana, Villa-Real, Castellón, Spain
| | - Ruth Sánchez
- Internal Medicine Department, Hospital Virgen de Los Lirios, Alcoy, Spain
| | - Vicent Bodí
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Alberto Cordero
- Cardiology Department, Hospital Universitario San Juan de Alicante, Alicante, Spain
| | - Lorenzo Fácila
- Cardiology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | - Anna Mollar
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain.
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21
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Wilcox CS, Testani JM, Pitt B. Pathophysiology of Diuretic Resistance and Its Implications for the Management of Chronic Heart Failure. Hypertension 2020; 76:1045-1054. [PMID: 32829662 PMCID: PMC10683075 DOI: 10.1161/hypertensionaha.120.15205] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diuretic resistance implies a failure to increase fluid and sodium (Na+) output sufficiently to relieve volume overload, edema, or congestion, despite escalating doses of a loop diuretic to a ceiling level (80 mg of furosemide once or twice daily or greater in those with reduced glomerular filtration rate or heart failure). It is a major cause of recurrent hospitalizations in patients with chronic heart failure and predicts death but is difficult to diagnose unequivocally. Pharmacokinetic mechanisms include the low and variable bioavailability of furosemide and the short duration of all loop diuretics that provides time for the kidneys to restore diuretic-induced Na+ losses between doses. Pathophysiological mechanisms of diuretic resistance include an inappropriately high daily salt intake that exceeds the acute diuretic-induced salt loss, hyponatremia or hypokalemic, hypochloremic metabolic alkalosis, and reflex activation of the renal nerves. Nephron mechanisms include tubular tolerance that can develop even during the time that the renal tubules are exposed to a single dose of diuretic, or enhanced reabsorption in the proximal tubule that limits delivery to the loop, or an adaptive increase in reabsorption in the downstream distal tubule and collecting ducts that offsets ongoing blockade of Na+ reabsorption in the loop of Henle. These provide rationales for novel strategies including the concurrent use of diuretics that block these nephron segments and even sequential nephron blockade with multiple diuretics and aquaretics combined in severely diuretic-resistant patients with heart failure.
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Affiliation(s)
- Christopher Stuart Wilcox
- From the Division of Nephrology and Hypertension and Hypertension Center, Georgetown University, Washington DC (C.S.W.)
| | | | - Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor, MI (B.P.)
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22
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Broscious R, Kukin A, Noel ZR, Devabhakthuni S, Seung H, Ramani GV, Reed BN. Comparing Diuresis Patterns in Hospitalized Patients With Heart Failure With Reduced Versus Preserved Ejection Fraction: A Retrospective Analysis. J Cardiovasc Pharmacol Ther 2020; 26:165-172. [PMID: 32975450 DOI: 10.1177/1074248420960930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Congestion predominates in exacerbations of heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF), but evidence suggests that excess volume may be distributed differently in these 2 subgroups. METHODS AND RESULTS In this retrospective study, diuretic efficiency (DE, or net urine output per 40-mg of intravenous furosemide equivalent) during the first 72 hours was compared between patients hospitalized with HFrEF (n = 121) versus HFpEF (n = 120). Multivariate analysis was used to compare the 2 groups based on expected baseline differences (e.g., demographics, heart failure etiology, concomitant therapy). During the first 72 hours, mean daily diuretic doses were higher in patients with HFpEF versus HFrEF (172.0 vs. 159.9 mg, respectively, P = 0.026) but urine output was not significantly different (2603.3 mL vs. 2667.5 mL, respectively, adjusted P = 0.100). Similarly, mean cumulative DE did not differ (-673.5 vs. -637.8 mL/40-mg in the HFrEF and HFpEF groups, respectively, adjusted P = 0.884). An exploratory analysis of propensity-matched cohorts yielded similar findings. Correlations between the components of DE varied considerably and only became weak to moderately correlated toward the end of the observation period. CONCLUSIONS Although cumulative DE did not differ between patients with HFrEF and HFpEF, variable correlations in the components of DE suggest there may be differences in diuretic response that warrant future analysis.
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Affiliation(s)
- Rachael Broscious
- Department of Pharmacy, 5631West Virginia University Medicine, Morgantown, WV, USA
| | - Alina Kukin
- Department of Pharmacy Practice and Science, 15513University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Zachary R Noel
- Department of Pharmacy Practice and Science, 15513University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Sandeep Devabhakthuni
- Department of Pharmacy Practice and Science, 15513University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Hyunuk Seung
- Department of Pharmacy Practice and Science, 15513University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Gautam V Ramani
- Department of Medicine, 15513University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brent N Reed
- Department of Pharmacy Practice and Science, 15513University of Maryland School of Pharmacy, Baltimore, MD, USA
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Morris AA, Nayak A, Ko YA, D'Souza M, Felker GM, Redfield MM, Tang WHW, Testani JM, Butler J. Racial Differences in Diuretic Efficiency, Plasma Renin, and Rehospitalization in Subjects With Acute Heart Failure. Circ Heart Fail 2020; 13:e006827. [PMID: 32635768 DOI: 10.1161/circheartfailure.119.006827] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Black patients have higher rates of hospitalization for acute heart failure than other race/ethnic groups. We sought to determine whether diuretic efficiency is associated with racial differences in risk for rehospitalization after acute heart failure. METHODS A post hoc analysis was performed on 721 subjects (age, 68±13 years; 22% black) enrolled in 3 acute heart failure clinical trials: ROSE-AHF (Renal Optimization Strategies Evaluation in Acute Heart Failure), DOSE-AHF (Diuretic Optimization Strategy Evaluation in Acute Decompensated Heart Failure), and CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure). Repeated-measures ANOVA was used to test for a race×time effect on measures of decongestion. Diuretic efficiency was calculated as net fluid balance per total furosemide equivalents. In a subset of subjects, Cox regression was used to examine the association between race and rehospitalization according to plasma renin activity (PRA). RESULTS Compared with nonblack patients, black patients were younger and more likely to have nonischemic heart failure. During the first 72 to 96 hours, there was greater fluid loss (P=0.001), decrease in NT-proBNP (N-terminal pro-B-type natriuretic peptide; P=0.002), and lower levels of PRA (P<0.0001) in black patients. Diuretic efficiency was higher in black than in nonblack patients (403 [interquartile range, 221-795] versus 325 [interquartile range, 154-698]; P=0.014). However, adjustment for baseline PRA attenuated the association between black race and diuretic efficiency. Over a median follow-up of 68 (interquartile range, 56-177) days, there was an increased risk of all-cause and heart failure-specific rehospitalization in nonblack patients with increasing levels of PRA, while the risk of rehospitalization was relatively constant across levels of PRA in black patients. CONCLUSIONS Higher diuretic efficiency in black patients with acute heart failure may be related to racial differences in activity of the renin-angiotensin-aldosterone system.
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Affiliation(s)
- Alanna A Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.A.M., A.N., M.D.)
| | - Aditi Nayak
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.A.M., A.N., M.D.)
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, GA (Y.-A.K.)
| | - Melroy D'Souza
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.A.M., A.N., M.D.)
| | | | | | | | - Jeffrey M Testani
- Division of Cardiology, Yale University School of Medicine, New Haven, CT (J.M.T.)
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson (J.B.)
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Rosenblum H, Kapur NK, Abraham WT, Udelson J, Itkin M, Uriel N, Voors AA, Burkhoff D. Conceptual Considerations for Device-Based Therapy in Acute Decompensated Heart Failure. Circ Heart Fail 2020; 13:e006731. [DOI: 10.1161/circheartfailure.119.006731] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acute decompensated heart failure remains the most common cause of hospitalization in older adults, and studies of pharmacological therapies have yielded limited progress in improving outcomes for these patients. This has prompted the development of novel device–based interventions, classified mechanistically based on the way in which they intend to improve central hemodynamics, increase renal perfusion, remove salt and water from the body, and result in clinically meaningful degrees of decongestion. In this review, we provide an overview of the pathophysiology of acute decompensated heart failure, current management strategies, and failed pharmacological therapies. We provide an in depth description of seven investigational device classes designed to target one or more of the pathophysiologic derangements in acute decompensated heart failure, denoted by the acronym DRI
2
P
2
S. Dilators decrease central pressures by increasing venous capacitance through splanchnic nerve modulation. Removers remove excess fluid through peritoneal dialysis, aquaphoresis, or hemodialysis. Inotropes directly modulate the cardiac nerve plexus to enhance ventricular contractility. Interstitial devices enhance volume removal through lymphatic duct decompression. Pushers are novel descending aorta rotary pumps that directly increase renal artery pressure. Pullers reduce central venous pressures or renal venous pressures to increase renal perfusion. Selective intrarenal artery catheters facilitate direct delivery of short acting vasodilator therapy. We also discuss challenges posed in clinical trial design for these novel device–based strategies including optimal patient selection and appropriate end points to establish efficacy.
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Affiliation(s)
- Hannah Rosenblum
- Division of Cardiology, New York Presbyterian Hospital, New York, NY (H.R., N.U.)
| | - Navin K. Kapur
- Cardiology, Tufts Medical Center, Boston, MA (N.K.K., J.U.)
| | - William T. Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH (W.T.A.)
| | - James Udelson
- Cardiology, Tufts Medical Center, Boston, MA (N.K.K., J.U.)
| | - Maxim Itkin
- Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadephia, PA (M.I.)
| | - Nir Uriel
- Division of Cardiology, New York Presbyterian Hospital, New York, NY (H.R., N.U.)
| | - Adriaan A. Voors
- Department of Cardiology, University of Groningen, Groningen, the Netherlands (A.A.V.)
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Cox ZL, Hung R, Lenihan DJ, Testani JM. Diuretic Strategies for Loop Diuretic Resistance in Acute Heart Failure: The 3T Trial. JACC-HEART FAILURE 2019; 8:157-168. [PMID: 31838029 DOI: 10.1016/j.jchf.2019.09.012] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This study compared combination diuretic strategies in acute heart failure (AHF) complicated by diuretic resistance (DR). BACKGROUND Combination diuretic regimens to overcome loop DR are commonly used but with limited evidence. METHODS This study was a randomized, double-blinded trial in 60 patients hospitalized with AHF and intravenous (IV) loop DR. Patients were randomized to oral metolazone, IV chlorothiazide, or tolvaptan therapy. All patients received concomitant high-dose IV infusions of furosemide. The primary outcome was 48-h weight loss. RESULTS The cohort exhibited DR prior to enrollment, producing 1,188 ± 476 ml of urine in 12 h during high-dose loop diuretic therapy (IV furosemide: 612 ± 439 mg/day). All 3 interventions significantly improved diuretic efficacy (p < 0.001). Compared to metolazone (4.6 ± 2.7 kg), neither IV chlorothiazide (5.8 ± 2.7 kg; 1.2 kg [95% confidence interval (CI)]: -2.9 to 0.6; p = 0.292) nor tolvaptan (4.1 ± 3.3 kg; 0.5 kg [95% CI: -1.5 to 2.4; p = 0.456) resulted in more weight loss at 48 h. Median (interquartile range [IQR]) cumulative urine output increased significantly and did not differ among those receiving metolazone (7.78 [IQR: 6.59 to 10.10] l) and chlorothiazide (8.77 [IQR: 7.37 to 10.86] l; p = 0.245) or tolvaptan (9.70 [IQR: 6.36 to 13.81] l; p = 0.160). Serum sodium decreased less with tolvaptan than with metolazone (+4 ± 5 vs. -1 ± 3 mEq/l; p = 0.001), but 48-h spot urine sodium was lower with tolvaptan (58 ± 25 mmol/l) than with metolazone (104 ± 16 mmol/l; p = 0.002) and with chlorothiazide (117 ± 14 mmol/l; p < 0.001). CONCLUSIONS In this moderately sized DR trial, weight loss was excellent with the addition of metolazone, IV chlorothiazide, or tolvaptan to loop diuretics, without a detectable between-group difference. (Comparison of Oral or Intravenous Thiazides vs. tolvaptan in Diuretic Resistant Decompensated Heart Failure [3T]; NCT02606253).
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville Tennessee; Department of Pharmacy, Vanderbilt University Medical Center, Nashville Tennessee.
| | - Rebecca Hung
- Division of Cardiology, Vanderbilt University Medical Center, Nashville Tennessee
| | - Daniel J Lenihan
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey M Testani
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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Manguba AS, Vela Parada X, Coca SG, Lala A. Synthesizing Markers of Kidney Injury in Acute Decompensated Heart Failure: Should We Even Keep Looking? Curr Heart Fail Rep 2019; 16:257-273. [DOI: 10.1007/s11897-019-00448-9] [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] [Indexed: 12/17/2022]
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Hollenberg SM, Warner Stevenson L, Ahmad T, Amin VJ, Bozkurt B, Butler J, Davis LL, Drazner MH, Kirkpatrick JN, Peterson PN, Reed BN, Roy CL, Storrow AB. 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2019; 74:1966-2011. [PMID: 31526538 DOI: 10.1016/j.jacc.2019.08.001] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Price JF, Younan S, Cabrera AG, Denfield SW, Tunuguntla H, Choudhry S, Dreyer WJ, Akcan-Arikan A. Diuretic Responsiveness and Its Prognostic Significance in Children With Heart Failure. J Card Fail 2019; 25:941-947. [PMID: 30986498 DOI: 10.1016/j.cardfail.2019.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/27/2019] [Accepted: 03/30/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Loop diuretics are considered first-line therapy for congestion in children with heart failure, although some patients remain volume overloaded during treatment. We sought to characterize loop diuretic responsiveness (DR) in children hospitalized with acute decompensated failure and to determine whether a decreased response was associated with worse outcomes. METHODS AND RESULTS DR was calculated for 108 consecutive children ˂21 years of age who were hospitalized with acute decompensated heart failure. DR was defined as net fluid (mL) output per 1 mg of furosemide equivalents during the first 72 hours of treatment with a loop diuretic. The primary outcome was the composite end point of inpatient death or use of mechanical circulatory support. The median DR was 6.0 mL/mg (interquartile range -2.4 to 15.7 mL/mg). Thirty-two percent of patients remained in a positive fluid balance after 72 hours of treatment with a loop diuretic. Death or use of mechanical circulatory support occurred in 29 patients (27%). Low DR was associated with the composite end point, even after adjusting for net urine output and loop diuretic dose indexed to weight (odds ratio 5.3; P = .003). Patients with low DR also experienced longer length of hospital stay than patients with greater DR (median 33 days vs 11 days; P = .002). CONCLUSION In children hospitalized with acute decompensated heart failure, early diminished loop DR during decongestion therapy is common and portends a poor prognosis.
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Affiliation(s)
- Jack F Price
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
| | - Samuel Younan
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Antonio G Cabrera
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Susan W Denfield
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Hari Tunuguntla
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Swati Choudhry
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - William J Dreyer
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Sections of Nephrology and Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Abstract
PURPOSE OF REVIEW Diuretic resistance (DR) occurs along a spectrum of relative severity and contributes to worsening of acute heart failure (AHF) during an inpatient stay. This review gives an overview of mechanisms of DR with a focus on loop diuretics and summarizes the current literature regarding the prognostic value of diuretic efficiency and predictors of natriuretic response in AHF. RECENT FINDINGS The pharmacokinetics of diuretics are impaired in chronic heart failure, but little is known about mechanisms of DR in AHF. Almost all diuresis after administration of a loop diuretic dose occurs in the first few hours after administration and within-dose DR can develop. Recent studies suggest that DR at the level of the nephron may be more important than defects in diuretic delivery to the tubule. Because loop diuretics induce natriuresis, urine sodium (UNa) concentration may serve as a functional, physiological, and direct measure for diuretic responsiveness to a given loop diuretic dose. Identifying and targeting individuals with DR for more aggressive, tailored therapy represents an important opportunity to improve outcomes. A better understanding of the mechanistic underpinnings of DR in AHF is needed to identify additional biomarkers and guide future trials and therapies.
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Affiliation(s)
- Richa Gupta
- Department of Cardiovascular Medicine, Vanderbilt University Medical Center, 1121 Medical Center Dr., Nashville, TN, 37212, USA
| | - Jeffrey Testani
- Department of Cardiovascular Medicine, Yale Medical Center, PO Box 208017, New Haven, CT, 06520, USA
| | - Sean Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, 1313 21st Ave. S, 703 Oxford House, Nashville, TN, 37232, USA.
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Gottlieb S. The Risks of Big Databases: Why Do Married People Drown in Kentucky? J Card Fail 2018; 24:451-452. [DOI: 10.1016/j.cardfail.2018.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 06/22/2018] [Accepted: 06/22/2018] [Indexed: 11/28/2022]
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Efficient, Efficacious, Effective: Still a Long Way to Go for Diuretic Treatment of Acute Decompensated Heart Failure. J Card Fail 2018; 24:439-441. [DOI: 10.1016/j.cardfail.2018.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 06/14/2018] [Accepted: 06/14/2018] [Indexed: 11/22/2022]
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