From CONSENSUS to CHARM—how do ACEI and ARB produce clinical benefits in CHF?

A retrospective study on the short-term effect of high-dose spironolactone (80 mg/d) on chronic congestive heart failure

To explore the short-term effect of high-dose spironolactone (80 mg/d) on chronic congestive heart failure (CHF).The general clinical data of 211 patients with CHF from February 2016 to August 2019 were collected and analyzed. Patients were divided into Low-dose group (taking 40 mg/d spironolactone) and High-dose group (taking 80 mg/d spironolactone) according to the patient's previous dose of spironolactone. The changes of B-type brain natriuretic peptide (BNP), NT-pro BNP (N terminal pro B type natriuretic peptide), echocardiography, 6-minute walking test (6MWT), and comprehensive cardiac function assessment data were collected for analysis.Compared with before treatment, the blood potassium of the two groups increased significantly (P < .05), but the blood potassium did not exceed the normal range. Compared with before treatment, BNP, NT-pro BNP, LVEDD, LVEDV and NYHA grading were significantly decreased (P < .05), LVEF and 6-MWT were significantly increased (P < .05). Compared with the Low-dose group, the high-dose group BNP (117.49 ± 50.32 vs 195.76 ± 64.62, P < .05), NT-pro BNP (312.47 ± 86.28 vs 578.47 ± 76.73, P < .05), LVEDD (45.57 ± 5.69 vs 51.96 ± 5.41, P <.05), LVEDV (141.63 ± 51.14 vs 189.85 ± 62.49, P < .05) and NYHA grading (1.29 ± 0.41 vs 1.57 ± 0.49, P < .05) were significantly reduced, but, 6-MWT (386.57 ± 69.72 vs 341.73 ± 78.62, P < .05), LVEF (41.62 ± 2.76 vs 36.02 ± 2.18, P < .05) and total effective rate (92.68% vs 81.39%, P < .05) increased significantly.Compared with 40 mg spironolactone, 80 mg spironolactone can rapidly reduce BNP and NT-pro BNP concentration, enhance exercise tolerance, improve clinical signs and cardiac function classification, and has better efficacy.

The Effect of Renin-Angiotensin-Aldosterone System Blockade Medications on Contrast-Induced Nephropathy in Patients Undergoing Coronary Angiography: A Meta-Analysis

BACKGROUND

Contrast-induced nephropathy (CIN) is the main complication of contrast media administration (CM) in patients undergoing coronary angiography (CAG) and percutaneous coronary intervention (PCI). There are inconsistent results in the literature regarding the effect of renin-angiotensin-aldosterone system (RAAS) blockers (angiotensin-converting enzyme inhibitors [ACEIs] and angiotensin receptor blockers [ARBs]) on CIN. We evaluated the association between the administration of ACEI/ARBs and CIN, as well as the effect of ACEI/ARBs on post-procedural changes in renal function index, in patients undergoing CAG.

METHODS

We searched Pubmed, EMBASE, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for relevant studies. The primary search generated 893 potentially relevant articles. A total of 879 studies were excluded because they did not meet the selection criteria. Finally, 14 studies were eligible for inclusion. There were 7,288 patients that received ACEI/ARBs and 8,159 patients that received placebo or naive to ACEI/ARBs in the study. A random or a fixed effect model was used to calculate the pooled odd ratios (ORs).

RESULTS

The risk of CIN was significantly increased in the ACEI/ARBs group compared to the control group (OR= 1.50, 95%CI: 1.03-2.18, P =0.03). The magnitude of association was significantly reinforced in the observational studies (OR=1.84, 95%CI 1.19-2.85, P=0.006) but not in the randomized controlled trials (OR=0.88, 95%CI 0.41-1.90 P=0.74). The summary adjusted OR of 4 observational studies was 1.56 (95%CI 1.25-1.94, P<0.0001) and was weaker than the unadjusted OR.

CONCLUSIONS

Although there is some evidence to suggest that the administration of RAAS blockers was associated with the increased risk of CIN in patients undergoing CAG, the robustness of our study remains weak. The results are based on small observational studies and need further validation.

Ameliorative effect of Captopril and Valsartan on an animal model of diabetic cardiomyopathy

The objective of this study was to clarify the relationship between angiotensin II and the pathogenesis of diabetic cardiomyopathy by observing the effects of related drugs on diabetic cardiomyopathy in rats. Captopril and Valsartan, an automatic biochemical analyzer, and radioimmunoassay technology were used to an experimental rat model of diabetic cardiomyopathy to dynamically measure the levels of creatine kinase-MB, lactate dehydrogenase-1 in the serum, and angiotensin I and II in the plasma, and to observe changes in the myocardial ultrastructure. The content of angiotensin I and II was increased and the renin-angiotensin system was in a hyperfunctional state in experimental rats with myocardial damage. Angiotensin-converting enzyme inhibitors and angiotensin II receptor 1 antagonists improved the myocardial structure and cardiac function. It is concluded that hyperfunction of the renin-angiotensin system is involved in the pathogenesis of diabetic cardiomyopathy, with an increase in angiotensin being a key factor. Preventing the increase in angiotensin II or the action of angiotensin II on its receptor can prevent the occurrence and development of diabetic cardiomyopathy.

The heart in renovascular disease—An association demanding further investigation

A close relationship exists between cardiovascular and renal disease; they often occur concomitantly, and abnormalities in either system are pathophysiologically important in both causing disease and determining clinical outcome in the other. Whilst the main focus of the article relates to the adverse association between atherosclerotic renovascular disease (ARVD) and the cardiovascular system, it is important to briefly review relevant epidemiology.

Effects of ramipril on renal function during progressive overpacing-induced heart failure in dogs

OBJECTIVE

To investigate the effects of preventive angiotensin converting enzyme inhibitor treatment with ramipril in dogs with progressively severe experimentally induced heart failure.

ANIMALS

20 dogs.

PROCEDURES

Dogs were randomly allocated to receive no treatment (control) or ramipril (0.125 mg/kg, PO, daily) for 7 weeks. Physical examination, repetitive catheterization of the right side of the heart, and echocardiography were performed before the study (day 0) and weekly for 7 weeks. Renal plasma flow (RPF) as determined by para-aminohippuric acid clearance and glomerular filtration rate (GFR) as determined by creatinine and iohexol clearances were measured on day 0 and at weeks 4 and 7.

RESULTS

Overpacing induced a progressive increase in right atrial pressure (RAP) and pulmonary artery pressure, occluded (PAPO), with a decrease in systemic arterial pressure. There were progressive alterations of echocardiographic indices of diastolic and systolic ventricular function. The RPF and GFR decreased before cardiac output decreased, and filtration fraction increased. The logarithm of the urinary sodium-to-potassium concentration ratio (log(10)[Na(+)/K(+)]) decreased. Significant effects of ramipril included a delay in clinical signs of heart failure, a late decrease in RAP and PAPO, and increases in the sodium excretion fraction and log(10)(Na(+)/K(+)). There was a satisfactory agreement between the creatinine and iohexol clearance measurements.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that, in this rapid-evolving, dilated cardiomyopathy, activation of the renin-angiotensin system contributes to the pathophysiology of heart failure late in the disease and essentially by an activation of renal salt and water retention.

Neurohormones and heart failure: the importance of aldosterone

Heart failure is a major cause of cardiovascular morbidity and mortality and its incidence is on the increase. The pathophysiology of heart failure is multi-factorial but recent studies suggest that aldosterone plays an important and independent role in its progression. Emerging evidence now suggests that aldosterone exerts renal-independent effects. It binds to its mineralocorticoid receptor to produce direct effects on the myocardium and vasculature, leading to damaging processes such as hypertrophy, necrosis, fibrosis and endothelial dysfunction, factors known to contribute to the pathophysiology of heart failure. Mineralocorticoid receptor antagonists have thus emerged as a new paradigm for the treatment of heart failure. The benefits of these agents on both morbidity and mortality when used in patients with chronic symptomatic heart failure have been demonstrated by recent trials.

The Prevalence of Potential Drug-Drug Interactions in Patients with Heart Failure at Hospital Discharge

BACKGROUND/OBJECTIVE

Pharmacotherapy for heart failure is complex and, due to polypharmacy, is associated with a large risk of potential drug-drug interactions (DDIs). The objective of the present study was to assess the prevalence of potential DDIs in the medication of hospitalised heart failure patients and to evaluate their clinical relevance.

STUDY DESIGN/METHODS

The medication of 400 patients was retrospectively analysed for potential DDIs at hospital admission and discharge using a computerised drug interaction program. Main inclusion criteria were the diagnosis of heart failure and a minimum of two drug prescriptions at discharge.

RESULTS

In the study population of 400 heart failure patients (median age 79 years, 55.5% men), the median number of drugs per patient was lower at admission than at discharge (6 [interquartile range {IQR} 4-9] vs 8 [IQR 6-10]; p < 0.001). At hospital admission, a total of 863 potential DDIs were detected in 272 patients (68.0%; 95% CI 63.4, 72.6). At discharge, 1171 potential DDIs were detected in 355 patients (88.8%; 95% CI 85.7, 91.8). This corresponds with a significant increase in the median number of potential DDIs per patient from admission to discharge (1.5 [IQR 0-3] vs 3 [IQR 1-4]; p < 0.001). Of the 1171 potential DDIs at discharge, 432 (36.9%) were prevalent at admission and 739 (63.1%) resulted from a medication change during the hospital stay. Of these 739 new potential DDIs, the severity of the potential adverse effect was rated as 'major' in 190 (25.7%) patients, 'moderate' in 482 (65.2%) and 'minor' in 67 (9.1%). The 190 potential DDIs with major severity were recorded in a total of 145 patients (36.3%; 95% CI 31.5, 41.0%). Hyperkalaemia was the most prevalent potential adverse effect of major severity (n = 93) and the combination of an ACE inhibitor with a potassium-sparing diuretic was recorded in 64 (16.0%) patients.

CONCLUSIONS

The study shows that hospitalisation of patients with heart failure results in an increase in the number of drugs prescribed per patient and, thereby, also in the number of potentially interacting drug combinations per patient. Although electronic drug interaction programs are a valuable tool to check for potential DDIs, the clinical relevance of most potential DDIs can only be judged by assessment of the individual patient.

Angiotensin II induces apoptosisin vivoin skeletal, as well as cardiac, muscle of the rat

Our previous work has established that angiotensin II is cardiotoxic. Here we sought to investigate whether skeletal muscle is similarly susceptible to damage. Male Wistar rats were either given a single subcutaneous injection of angiotensin II (range 1 microg kg-1 to 10 mg kg-1) or only the vehicle and killed 7 h later, or implanted with preconditioned osmotic pumps dispensing 1 mg kg-1 day-1 angiotensin II and killed 9 or 18 h later. Apoptotic (caspase 3 positive) myocytes were counted on cryosections of the heart, soleus, tibialis anterior and diaphragm muscle. Single injections of 100 microg kg-1 to 10 mg kg-1 angiotensin II induced significant (P<0.05) myocyte apoptosis (per 10(4) viable myocytes) in the heart and this was heterogeneously distributed, peaking (5.7+/-0.6; P<0.05) at a point 6 mm from the apex, i.e. approximately three-quarters of the way towards the base. The slow-twitch soleus muscle was also damaged significantly (peak=2.6+/-0.4; P<0.05), while only the administration of 1 mg kg-1 induced significant (P<0.05) apoptosis in the fast-twitch tibialis anterior muscle (peak=1.2+/-0.3). Infusion of 1 mg kg-1 day-1 angiotensin II induced more myocyte apoptosis than a single bolus administration of the same dose, and in general there was a higher incidence of apoptosis in muscles harvested after 18 than after 9 h. Infusion of 1 mg kg-1 day-1 angiotensin II over 18 h induced significant (P<0.05) myocyte apoptosis in the heart (3.3+/-0.4), soleus (3.9+/-1), tibialis anterior (5.9+/-0.4) and diaphragm (19.8+/-5.6) muscle. Depending on the muscle type, angiotensin II induces myocyte apoptosis in skeletal muscle to a similar or greater extent as in cardiac muscle, supporting the hypothesis that angiotensin II is generally toxic to all striated muscles.

ACE inhibitors in heart failure: what more do we need to know?

ACE inhibitors have significantly decreased cardiovascular mortality, myocardial infarction (MI), and hospitalizations for heart failure (HF) in patients with asymptomatic or symptomatic left ventricular (LV) systolic dysfunction. Furthermore, the extended 12-year study of the SOLVD (Studies Of Left Ventricular Dysfunction) Prevention and Treatment trials (X-SOLVD) demonstrated a significant benefit with a reduction of cumulative all-cause death compared with placebo (50.9% vs 56.4%) [hazard ratio (HR) 0.86; 95% CI 0.79, 0.93; p < 0.001]. The survival benefits and significant reductions in cardiovascular morbidity related to treatment with ACE inhibitors are likely achieved by titrating the dose of ACE inhibitors to the target dose achieved in clinical trials. Although the ATLAS (Assessment of Treatment with Lisinopril And Survival) study, which randomly allocated HF patients to low- or high-dose lisinopril, showed no significant difference between groups for the primary outcome of all-cause mortality (HR 0.92; 95% CI 0.82, 1.03), the predetermined secondary combined outcome of all-cause mortality and HF hospitalization was reduced by 15% for the patients receiving high-dose lisinopril compared with low-dose (p < 0.001) with a 24% reduction in HF hospitalization (p = 0.002). Despite the use of ACE inhibitors, blockade of the renin angiotensin aldosterone system (RAAS) remains incomplete, with evidence of continued production of angiotensin II by non-ACE-dependent pathways. The safety and potential benefits of angiotensin receptor antagonists (angiotensin receptor blockers [ARBs]) in patients with impaired systolic function have been assessed in moderate to large clinical trials. In patients with impaired LV systolic function and HF, combination therapy with ARBs with recommended HF therapy including ACE inhibitors in patients who remain symptomatic may be considered for its morbidity benefit. Based on the CHARM (Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity)-Added data, candesartan cilexetil in addition to standard HF therapy results in a further reduction of cardiovascular mortality. Close monitoring of renal function and serum potassium levels is needed in this setting. The VALIANT (VALsartan In Acute myocardial iNfarction Trial) results suggest that valsartan is as effective as captopril in patients following an acute MI with HF and/or LV systolic dysfunction and may be used as an alternative treatment in ACE inhibitor-intolerant patients. There was no survival benefit with valsartan-captopril combination compared with captopril alone in this trial. Despite these results, ACE inhibitors remain the first-choice therapeutic agent in post-MI patients, and ARBs can be used in patients with clear intolerance. Although the use of ACE inhibitors may be appealing in patients with HF and preserved LV systolic function, there is currently no evidence from large clinical trials to support this.

Fiftieth anniversary of aldosterone: from discovery to cardiovascular therapy

Half a century after the elucidation of its molecular structure, aldosterone is generating the greatest interest, not in the fields of endocrinology or renal medicine but in cardiology-where aldosterone over-activation is now perceived as detrimental in heart failure (HF) and ischaemic heart disease. Clinically, excess aldosterone is associated with higher morbidity and mortality after myocardial infarction (MI) and HF. The Randomised Aldactone Evaluation Study (RALES) study in severe chronic heart failure and the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival (EPHESUS) study in post-MI heart failure have shown that use of non-selective and selective aldosterone receptor antagonists, respectively, improves prognosis. The pathophysiological mechanisms underpinning these damaging aldosterone-mediated cardiovascular effects are still being elucidated, but prime candidates include cardiomyocyte necrosis and apoptosis, and myocardial fibrosis resulting in adverse cardiac remodelling, coronary vasculopathy, tachyarrhythmia and positive feedback activation of the renin-angiotensin-aldosterone system. Practical points for consideration when instigating therapy include preferential use of aldosterone receptor antagonists to maintain electrolyte balance whenever loop or thiazide diuretics are used (vulnerable HF patients require higher ranges of potassium and magnesium to minimise propensity for tachyarrthythmia), for renoprotection and for counteracting aldosterone breakthrough despite adequate ACE inhibition; use of the minimum doses of loop diuretics required to lessen activation of the renin-angiotensin-aldosterone system in HF; use of selective aldosterone receptor antagonists to avoid gynaecomastia/mastalgia and impotence; and prophylactic use of aldosterone receptor antagonists to improve prognosis.