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Fu EL, Wexler DJ, Cromer SJ, Bykov K, Paik JM, Patorno E. SGLT-2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors and risk of hyperkalemia among people with type 2 diabetes in clinical practice: population based cohort study. BMJ 2024; 385:e078483. [PMID: 38925801 PMCID: PMC11200155 DOI: 10.1136/bmj-2023-078483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES To evaluate the comparative effectiveness of sodium-glucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and dipeptidyl peptidase-4 (DPP-4) inhibitors in preventing hyperkalemia in people with type 2 diabetes in routine clinical practice. DESIGN Population based cohort study with active-comparator, new user design. SETTING Claims data from Medicare and two large commercial insurance databases in the United States from April 2013 to April 2022. PARTICIPANTS 1:1 propensity score matched adults with type 2 diabetes newly starting SGLT-2 inhibitors versus DPP-4 inhibitors (n=778 908), GLP-1 receptor agonists versus DPP-4 inhibitors (n=729 820), and SGLT-2 inhibitors versus GLP-1 receptor agonists (n=873 460). MAIN OUTCOME MEASURES Hyperkalemia diagnosis in the inpatient or outpatient setting. Secondary outcomes were hyperkalemia defined as serum potassium levels ≥5.5 mmol/L and hyperkalemia diagnosis in the inpatient or emergency department setting. RESULTS Starting SGLT-2 inhibitor treatment was associated with a lower rate of hyperkalemia than DPP-4 inhibitor treatment (hazard ratio 0.75, 95% confidence interval (CI) 0.73 to 0.78) and a slight reduction in rate compared with GLP-1 receptor agonists (0.92, 0.89 to 0.95). Use of GLP-1 receptor agonists was associated with a lower rate of hyperkalemia than DPP-4 inhibitors (0.79, 0.77 to 0.82). The three year absolute risk was 2.4% (95% CI 2.1% to 2.7%) lower for SGLT-2 inhibitors than DPP-4 inhibitors (4.6% v 7.0%), 1.8% (1.4% to 2.1%) lower for GLP-1 receptor agonists than DPP-4 inhibitors (5.7% v 7.5%), and 1.2% (0.9% to 1.5%) lower for SGLT-2 inhibitors than GLP-1 receptor agonists (4.7% v 6.0%). Findings were consistent for the secondary outcomes and among subgroups defined by age, sex, race, medical conditions, other drug use, and hemoglobin A1c levels on the relative scale. Benefits for SGLT-2 inhibitors and GLP-1 receptor agonists on the absolute scale were largest for those with heart failure, chronic kidney disease, or those using mineralocorticoid receptor antagonists. Compared with DPP-4 inhibitors, the lower rate of hyperkalemia was consistently observed across individual agents in the SGLT-2 inhibitor (canagliflozin, dapagliflozin, empagliflozin) and GLP-1 receptor agonist (dulaglutide, exenatide, liraglutide, semaglutide) classes. CONCLUSIONS In people with type 2 diabetes, SGLT-2 inhibitors and GLP-1 receptor agonists were associated with a lower risk of hyperkalemia than DPP-4 inhibitors in the overall population and across relevant subgroups. The consistency of associations among individual agents in the SGLT-2 inhibitor and GLP-1 receptor agonist classes suggests a class effect. These ancillary benefits of SGLT-2 inhibitors and GLP-1 receptor agonists further support their use in people with type 2 diabetes, especially in those at risk of hyperkalemia.
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Affiliation(s)
- Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Deborah J Wexler
- Diabetes Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sara J Cromer
- Diabetes Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Ahdoot RS, Hsiung JT, Agiro A, Brahmbhatt YG, Cooper K, Fawaz S, Westfall L, Norris KC, Kalantar-Zadeh K, Streja E. Hyperkalemia Recurrence and Its Association With Race and Ethnicity in United States Veterans: A Retrospective Cohort Study. Cureus 2024; 16:e59003. [PMID: 38800332 PMCID: PMC11127698 DOI: 10.7759/cureus.59003] [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] [Accepted: 04/22/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Information on whether race and ethnicity are associated with a greater risk of recurrent hyperkalemia is limited. The aim of this study was to examine the association between race or ethnicity and recurrent hyperkalemia in a population of US veterans. METHODS This retrospective study used the US Veterans Affairs database to identify adults (aged ≥18 years) with at least one serum potassium measurement during the study period who ever experienced hyperkalemia (serum potassium > 5.0 mmol/L). The proportion of patients with hyperkalemia recurrence (≥1 subsequent event) within one year was determined for different race and ethnicity groups. The association between patient race and ethnicity and the risk of hyperkalemia recurrence within one year after the index hyperkalemia event was analyzed using competing risk regression. RESULTS Among a total of 1,493,539 veterans with incident hyperkalemia (median age (interquartile range): 61.0 years (54.0, 71.0)), recurrence within one year occurred in 19.1% of Black, 16.0% of Native Hawaiian/other Pacific Islander, 15.1% of White, 14.9% of American Indian/Alaska Native, and 13.1% of Asian patient groups. Recurrent hyperkalemia occurred in 18.1% of Hispanic and 15.6% of non-Hispanic patient groups. In a fully-adjusted regression model, recurrent hyperkalemia risk was significantly higher in Black versus White patient groups (subhazard ratio (sHR), 1.17; 95% confidence interval (CI), 1.16-1.19; p< 0.0001) and in Hispanic versus non-Hispanic patient groups (sHR, 1.30; 95% CI, 1.28-1.33; p< 0.0001). DISCUSSION/CONCLUSION Among US veterans with incident hyperkalemia, the risk of recurrent hyperkalemia was higher in Black and Hispanic patient groups. This information may be useful for health system screenings to risk stratify patient groups and both guide the frequency of serum potassium monitoring and better understand the root causes of group differences.
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Affiliation(s)
- Rebecca S Ahdoot
- Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, USA
| | - Jui-Ting Hsiung
- Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, USA
- Department of Research, Tibor Rubin VA Medical Center, Long Beach, USA
| | - Abiy Agiro
- Department of Medical Affairs, AstraZeneca, Wilmington, USA
| | | | - Kerry Cooper
- Department of Medical Affairs, AstraZeneca, Wilmington, USA
| | - Souhiela Fawaz
- Department of Medical Affairs, AstraZeneca, Wilmington, USA
| | - Laura Westfall
- Department of Medical Affairs, AstraZeneca, Wilmington, USA
| | - Keith C Norris
- Department of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Kamyar Kalantar-Zadeh
- Department of Research, Tibor Rubin VA Medical Center, Long Beach, USA
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, USA
| | - Elani Streja
- Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, USA
- Department of Research, Tibor Rubin VA Medical Center, Long Beach, USA
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Fu EL, Mastrorilli J, Bykov K, Wexler DJ, Cervone A, Lin KJ, Patorno E, Paik JM. A population-based cohort defined risk of hyperkalemia after initiating SGLT-2 inhibitors, GLP1 receptor agonists or DPP-4 inhibitors to patients with chronic kidney disease and type 2 diabetes. Kidney Int 2024; 105:618-628. [PMID: 38101515 PMCID: PMC10922914 DOI: 10.1016/j.kint.2023.11.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 11/02/2023] [Accepted: 11/10/2023] [Indexed: 12/17/2023]
Abstract
Hyperkalemia is a common adverse event in patients with chronic kidney disease (CKD) and type 2 diabetes and limits the use of guideline-recommended therapies such as renin-angiotensin system inhibitors. Here, we evaluated the comparative effects of sodium-glucose cotransporter-2 inhibitors (SGLT-2i), glucagon-like peptide-1 receptor agonists (GLP-1RA) and dipeptidyl peptidase-4 inhibitors (DPP-4i) on the risk of hyperkalemia. We conducted a population-based active-comparator, new-user cohort study using claims data from Medicare and two large United States commercial insurance databases (April 2013-April 2022). People with CKD stages 3-4 and type 2 diabetes who newly initiated SGLT-2i vs. DPP-4i (141671 patients), GLP-1RA vs. DPP-4i (159545 patients) and SGLT-2i vs. GLP-1RA (93033 patients) were included. The primary outcome was hyperkalemia diagnosed in inpatient or outpatient settings. Secondary outcomes included hyperkalemia diagnosed in inpatient or emergency department setting, and serum potassium levels of 5.5 mmol/L or more. Pooled hazard ratios and rate differences were estimated after propensity score matching to adjust for over 140 potential confounders. Initiation of SGLT-2i was associated with a lower risk of hyperkalemia compared with DPP-4i (hazard ratio 0.74; 95% confidence interval 0.68-0.80) and contrasted to GLP-1RA (0.92; 0.86-0.99). Compared with DPP-4i, GLP-1RA were also associated with a lower risk of hyperkalemia (0.80; 0.75-0.86). Corresponding absolute rate differences/1000 person-years were -24.8 (95% confidence interval -31.8 to -17.7), -5.0 (-10.9 to 0.8), and -17.7 (-23.4 to -12.1), respectively. Similar findings were observed for the secondary outcomes, among subgroups, and across single agents within the SGLT-2i and GLP-1RA classes. Thus, SGLT-2i and GLP-1RA are associated with a lower risk of hyperkalemia than DPP-4i in patients with CKD and type 2 diabetes, further supporting the use of these drugs in this population.
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Affiliation(s)
- Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julianna Mastrorilli
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah J Wexler
- Diabetes Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts, USA.
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Neuenschwander JF, Silverstein AR, Teigland CL, Kumar S, Zeng EY, Agiro AT, Pottorf WJ, Peacock WF. The Increased Clinical and Economic Burden of Hyperkalemia in Medicare Patients Admitted to Long-Term Care Settings. Adv Ther 2023; 40:1204-1223. [PMID: 36652174 PMCID: PMC9988794 DOI: 10.1007/s12325-022-02420-x] [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: 10/21/2022] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Older patients are at increased risk for hyperkalemia (HK). This study describes the prevalence, recurrence, and clinical and economic burden of HK in Medicare patients admitted to a long-term care (LTC) setting. METHODS Retrospective cohort study using 100% Medicare Fee-for-Service (FFS) claims identified patients aged ≥ 65 years with index admission between 2017 and 2019 to a LTC setting (skilled nursing, home health, inpatient rehabilitation, or long-term acute care). Beneficiaries were required to have 12 months continuous medical and pharmacy coverage prior to index LTC admission and ≥ 30 days after LTC discharge (follow-up). Patient characteristics, healthcare resource utilization, and costs were assessed. HK was defined as ICD-10 diagnosis code E87.5 in any claim position or Medicare Part D fill for oral potassium binder. RESULTS Of 4,562,231 patients with a LTC stay, the prevalence of HK was 14.7% over the full study period (pre-index, index stay, and follow-up). Excluding those with HK only during the follow-up period resulted in 4,081,103 patients. Of these, 290,567 (7.1%) had HK and 3,790,536 (92.9%) did not have HK during or within 14 days prior to index LTC stay. The HK recurrence rate during index stay and follow-up was 48.3%. Unmatched HK versus non-HK patients were more often male (43.0% vs. 35.4%), Black (13.5% vs. 8.0%), dual eligible for Medicaid (34.2% vs. 25.0%), with higher mean Charlson Comorbidity Index scores (6.2 vs. 3.9) (all p < 0.0001). After propensity matching, HK patients were 2.2 times more likely to be hospitalized, with higher mortality (30.8% vs. 21.5%) and higher total healthcare costs during both index stay (US$26,520 vs. $18,021; p < 0.0011) and follow-up ($57,948 vs. $41,744 (p < 0.0011) versus matched non-HK patients. CONCLUSION Prevalence and recurrence of HK was high among LTC patients, and HK was associated with significantly greater clinical and economic burden during and post-LTC.
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Affiliation(s)
| | | | | | | | - Edric Y Zeng
- Avalere Health, 1201 New York Ave NW, Washington, DC, 20005, USA
| | - Abiy T Agiro
- AstraZeneca, 1800 Concord Pike, Wilmington, DE, 19803, USA
| | | | - W Frank Peacock
- Henry J.N. Taub Department of Emergency Medicine, Ben Taub Hospital, 1504 Taub Loop, Houston, TX, 77030, USA
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Cherney DZI, Bell A, Girard L, McFarlane P, Moist L, Nessim SJ, Soroka S, Stafford S, Steele A, Tangri N, Weinstein J. Management of Type 2 Diabetic Kidney Disease in 2022: A Narrative Review for Specialists and Primary Care. Can J Kidney Health Dis 2023; 10:20543581221150556. [PMID: 36726361 PMCID: PMC9884958 DOI: 10.1177/20543581221150556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/03/2022] [Indexed: 01/26/2023] Open
Abstract
Purpose of review Kidney disease is present in almost half of Canadian patients with type 2 diabetes (T2D), and it is also the most common first cardiorenal manifestation of T2D. Despite clear guidelines for testing, opportunities are being missed to identify kidney diseases, and many Canadians are therefore not receiving the best available treatments. This has become even more important given recent clinical trials demonstrating improvements in both kidney and cardiovascular (CV) endpoints with sodium-glucose cotransporter 2 (SGLT2) inhibitors and a nonsteroidal mineralocorticoid receptor antagonist, finerenone. The goal of this document is to provide a narrative review of the current evidence for the treatment of diabetic kidney disease (DKD) that supports this new standard of care and to provide practice points. Sources of information An expert panel of Canadian clinicians was assembled, including 9 nephrologists, an endocrinologist, and a primary care practitioner. The information the authors used for this review consisted of published clinical trials and guidelines, selected by the authors based on their assessment of their relevance to the questions being answered. Methods Panelists met virtually to discuss potential questions to be answered in the review and agreed on 10 key questions. Two panel members volunteered as co-leads to write the summaries and practice points for each of the identified questions. Summaries and practice points were distributed to the entire author list by email. Through 2 rounds of online voting, a second virtual meeting, and subsequent email correspondence, the authors reached consensus on the contents of the review, including all the practice points. Key findings It is critical that DKD be identified as early as possible in the course of the disease to optimally prevent disease progression and associated complications. Patients with diabetes should be routinely screened for DKD with assessments of both urinary albumin and kidney function. Treatment decisions should be individualized based on the risks and benefits, patients' needs and preferences, medication access and cost, and the degree of glucose lowering needed. Patients with DKD should be treated to achieve targets for A1C and blood pressure. Renin-angiotensin-aldosterone system blockade and treatment with SGLT2 inhibitors are also key components of the standard of care to reduce the risk of kidney and CV events for these patients. Finerenone should also be considered to further reduce the risk of CV events and chronic kidney disease progression. Education of patients with diabetes prescribed SGLT2 inhibitors and/or finerenone is an important component of treatment. Limitations No formal guideline process was used. The practice points are not graded and are not intended to be viewed as having the weight of a clinical practice guideline or formal consensus statement. However, most practice points are well aligned with current clinical practice guidelines.
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Affiliation(s)
- David Z. I. Cherney
- Division of Nephrology, Department of
Medicine, Toronto General Hospital, University of Toronto, ON, Canada
- Temerty Faculty of Medicine, University
of Toronto, ON, Canada
| | - Alan Bell
- Department of Family & Community
Medicine, University of Toronto, ON, Canada
| | - Louis Girard
- Division of Nephrology, Department of
Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Philip McFarlane
- Division of Nephrology, Department of
Medicine, Toronto General Hospital, University of Toronto, ON, Canada
| | - Louise Moist
- Division of Nephrology, Department of
Medicine, Schulich School of Medicine & Dentistry, Western University, London,
ON, Canada
| | - Sharon J. Nessim
- Division of Nephrology, Jewish General
Hospital, McGill University, Montreal, QC, Canada
| | - Steven Soroka
- QEII Health Sciences Centre, Nova
Scotia Health, Halifax, Canada
| | - Sara Stafford
- Fraser Health Division of
Endocrinology, University of British Columbia, Surrey, Canada
| | | | - Navdeep Tangri
- Departments of Medicine and Community
Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Jordan Weinstein
- Division of Nephrology, St. Michael’s
Hospital, University of Toronto, ON, Canada
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Toto F, Salvioni E, Magrì D, Sciomer S, Piepoli M, Badagliacca R, Galotta A, Baracchini N, Paolillo S, Corrà U, Raimondo R, Lagioia R, Filardi PP, Iorio A, Senni M, Correale M, Cicoira M, Perna E, Metra M, Guazzi M, Limongelli G, Sinagra G, Parati G, Cattadori G, Bandera F, Bussotti M, Mapelli M, Cipriani M, Bonomi A, Cunha G, Re F, Vignati C, Garascia A, Lombardi C, Scardovi AB, Passantino A, Emdin M, Passino C, Santolamazza C, Girola D, Zaffalon D, Vizza D, De Martino F, Agostoni P. Does moderate hyperkalemia influence survival in HF? Insights from the MECKI score data base. Int J Cardiol 2023; 371:273-277. [PMID: 36115445 DOI: 10.1016/j.ijcard.2022.09.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The prognostic role of moderate hyperkalemia in reduced ejection fraction (HFrEF) patients is still controversial. Despite this, it affects the use of renin-angiotensin-aldosterone system inhibitors (RAASi) with therapy down-titration or discontinuation. OBJECTIVES Aim of the study was to assess the prognostic impact of moderate hyperkalemia in chronic HFrEF optimally treated patients. METHODS AND RESULTS We retrospectively analyzed MECKI (Metabolic Exercise test data combined with Cardiac and Kidney Indexes) database, with median follow-up of 4.2 [IQR 1.9-7.5] years. Data on K+ levels were available in 7087 cases. Patients with K+ plasma level ≥ 5.6 mEq/L and < 4 mEq/L were excluded. Remaining patients were categorized into normal >4 and < 5 mEq/L (n = 4826, 68%) and moderately high ≥5.0 and ≤ 5.5 mEq/L (n = 496, 7%) K+. Then patients were matched by propensity score in 484 couplets of patients. MECKI score value was 7% [IQR 3.1-14.1%] and 7.3% [IQR 3.4-15%] (p = 0.678) in patients with normal and moderately high K+ values while cardiovascular mortality events at two years follow-up were 41 (4.2%) and 33 (3.4%) (p = 0.333) in each group respectively. CONCLUSIONS Moderate hyperkalemia does not influence patients' outcome in a large cohort of ambulatory HFrEF patients.
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Affiliation(s)
- Federica Toto
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Rome, Italy
| | | | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, "Sapienza" Università degli Studi di Roma, Roma, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, "Sapienza", Rome University, Rome, Italy
| | | | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Rome, Italy
| | | | - Nikita Baracchini
- Cardiovascular Department, "Azienda Sanitaria Universitaria Giuliano-Isontina", Trieste, Italy
| | | | - Ugo Corrà
- Cardiology Department, Istituti Clinici Scientifici Maugeri, IRCCS, Veruno Institute, Veruno, Italy
| | - Rosa Raimondo
- Divisione di Cardiologia Riabilitativa, Istituti Clinici Scientifici Maugeri, Tradate, Italy
| | - Rocco Lagioia
- UOC Cardiologia di Riabilitativa, Mater Dei Hospital, Bari, Italy
| | - Pasquale Perrone Filardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples and Mediterranea CardioCentro, Naples, Italy
| | - Annamaria Iorio
- Department of Cardiology, Heart Failure and Heart Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Michele Senni
- Department of Cardiology, Heart Failure and Heart Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | | | | | - Enrico Perna
- Dipartimento Cardiologico "A. De Gasperis", Ospedale Cà Granda- A.O. Niguarda, Milano, Italy
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialities, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Guazzi
- Ospedale San Paolo, Università degli studi di Milano, Italy
| | - Giuseppe Limongelli
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Napoli
| | - Gianfranco Sinagra
- Cardiovascular Department, "Azienda Sanitaria Universitaria Giuliano-Isontina", Trieste, Italy
| | - Gianfranco Parati
- Istituto Auxologico Italiano, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Gaia Cattadori
- Unità Operativa Cardiologia Riabilitativa, IRCCS Multimedica, Milano, Italy
| | - Francesco Bandera
- Department of Biomedical Sciences for Health, University of Milano, Milan, Italy; Cardiology University Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Maurizio Bussotti
- Cardiac Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Scientific Institute of Milan, Milan, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of clinical sciences and community health, Cardiovascular section, University of Milan, Milan, Italy
| | - Manlio Cipriani
- ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Gonçalo Cunha
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Cardiology department, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Federica Re
- Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo-Forlanini Hospital, Roma, Italy
| | | | - Andrea Garascia
- Dipartimento Cardiologico "A. De Gasperis", Ospedale Cà Granda- A.O. Niguarda, Milano, Italy
| | - Carlo Lombardi
- Cardiology, Department of Medical and Surgical Specialities, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Andrea Passantino
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, Institute of Bari, Bari, Italy
| | - Michele Emdin
- Institute of Life Science, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy
| | - Claudio Passino
- Institute of Life Science, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Caterina Santolamazza
- Dipartimento Cardiologico "A. De Gasperis", Ospedale Cà Granda- A.O. Niguarda, Milano, Italy
| | - Davide Girola
- Clinica Hildebrand Centro di riabilitazione Brissago, Switzerland
| | - Denise Zaffalon
- Cardiovascular Department, "Azienda Sanitaria Universitaria Giuliano-Isontina", Trieste, Italy
| | - Dario Vizza
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Rome, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of clinical sciences and community health, Cardiovascular section, University of Milan, Milan, Italy,.
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YILMAZ ÖZTEKİN GM, GENÇ A, ŞAHİN A, ÇAĞIRCI G, ARSLAN Ş. Frequency and predictors of hyperkalemia in the heart failure outpatient clinic. ACTA MEDICA ALANYA 2022. [DOI: 10.30565/medalanya.1172354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objectives: Hyperkalemia is a common and life-threatening condition affecting heart failure (HF) patients. This study aims to show the frequency of hyperkalemia and related factors in the HF outpatient clinic in real world data.
Methods: 1146 patients monitored in the HF outpatient clinic with left ventricular ejection fraction ≤ 40% and potassium level ≥ 3.5 mmol/L were included in the study.
Results: The median potassium value of the patients was 4.6 [IQR, 4.3-5] mmol/L. It was evaluated in three groups as 3.5-5 mmol/L (normokalaemia), 5.1-5.5 mmol/L (mild hyperkalemia), and ≥ 5.5 mmol/L (moderate to severe hyperkalemia) according to baseline potassium levels. 14.5% of patients had mild hyperkalemia and 7.1% had moderate to severe hyperkalemia. Patients with a potassium value of > 5 mmol/L made up 21.6%. The estimated glomerular filtration rate (eGFR) (OR: 0.968, 95% CI: 0.959-0.977, p
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Affiliation(s)
| | - Ahmet GENÇ
- University of Health Sciences, Antalya Training and Research Hospital
| | | | - Göksel ÇAĞIRCI
- University of Health Sciences, Antalya Training and Research Hospital
| | - Şakir ARSLAN
- University of Health Sciences, Antalya Training and Research Hospital
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8
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Scicchitano P, Iacoviello M, Massari F, De Palo M, Caldarola P, Mannarini A, Passantino A, Ciccone MM, Magnesa M. Optimizing Therapies in Heart Failure: The Role of Potassium Binders. Biomedicines 2022; 10:biomedicines10071721. [PMID: 35885026 PMCID: PMC9313061 DOI: 10.3390/biomedicines10071721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 11/21/2022] Open
Abstract
Heart failure (HF) is a worrisome cardiac pandemic with a negative prognostic impact on the overall survival of individuals. International guidelines recommend up-titration of standardized therapies in order to reduce symptoms, hospitalization rates, and cardiac death. Hyperkalemia (HK) has been identified in 3–18% of HF patients from randomized controlled trials and over 25% of HF patients in the “real world” setting. Pharmacological treatments and/or cardio-renal syndrome, as well as chronic kidney disease may be responsible for HK in HF patients. These conditions can prevent the upgrade of pharmacological treatments, thus, negatively impacting on the overall prognosis of patients. Potassium binders may be the best option in patients with HK in order to reduce serum concentrations of K+ and to promote correct upgrades of therapies. In addition to the well-established use of sodium polystyrene sulfonate (SPS), two novel drugs have been recently introduced: sodium zirconium cyclosilicate (SZC) and patiromer. SZC and patiromer are gaining a central role for the treatment of chronic HK. SZC has been shown to reduce K+ levels within 48 h, with guaranteed maintenance of normokalemia for up to12 months. Patiromer has resulted in a statistically significant decrease in serum potassium for up to 52 weeks. Therefore, long-term results seemed to positively promote the implementation of these compounds in clinical practice due to their low rate side effects. The aim of this narrative review is to delineate the impact of new potassium binders in the treatment of patients with HF by providing a critical reappraisal for daily application of novel therapies for hyperkalemia in the HF setting.
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Affiliation(s)
- Pietro Scicchitano
- Cardiology Section, Hospital “F. Perinei” Altamura (BA), 70022 Altamura, Italy;
- Correspondence: ; Tel.: +39-0803108286
| | - Massimo Iacoviello
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (M.I.); (M.M.)
| | - Francesco Massari
- Cardiology Section, Hospital “F. Perinei” Altamura (BA), 70022 Altamura, Italy;
| | - Micaela De Palo
- Cardiac Surgery Unit, Azienda Ospedaliero-Universitaria Policlinico Bari, 70124 Bari, Italy;
| | | | - Antonia Mannarini
- Division of University Cardiology, Cardiothoracic Department, Policlinic University Hospital, 70124 Bari, Italy;
| | - Andrea Passantino
- Division of Cardiology and Cardiac Rehabilitation, Scientific Clinical Institutes Maugeri, IRCCS Institute of Bari, 70124 Bari, Italy;
| | - Marco Matteo Ciccone
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy;
| | - Michele Magnesa
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (M.I.); (M.M.)
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9
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Weinstein J, Girard LP, Lepage S, McKelvie RS, Tennankore K. Prevention and management of hyperkalemia in patients treated with renin-angiotensin-aldosterone system inhibitors. CMAJ 2021; 193:E1836-E1841. [PMID: 34872955 PMCID: PMC8648362 DOI: 10.1503/cmaj.210831] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jordan Weinstein
- Division of Nephrology (Weinstein), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Glomerulonephritis Clinic (Girard), University of Calgary, Calgary, Alta.; Sherbrooke University (Lepage), Sherbrooke, Que.; Division of Cardiology (McKelvie), St. Joseph's Health Care; Canada and Western University (McKelvie), London, Ont.; Nova Scotia Health Authority (Tennankore), Dalhousie University, Halifax, NS
| | - Louis-Philippe Girard
- Division of Nephrology (Weinstein), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Glomerulonephritis Clinic (Girard), University of Calgary, Calgary, Alta.; Sherbrooke University (Lepage), Sherbrooke, Que.; Division of Cardiology (McKelvie), St. Joseph's Health Care; Canada and Western University (McKelvie), London, Ont.; Nova Scotia Health Authority (Tennankore), Dalhousie University, Halifax, NS
| | - Serge Lepage
- Division of Nephrology (Weinstein), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Glomerulonephritis Clinic (Girard), University of Calgary, Calgary, Alta.; Sherbrooke University (Lepage), Sherbrooke, Que.; Division of Cardiology (McKelvie), St. Joseph's Health Care; Canada and Western University (McKelvie), London, Ont.; Nova Scotia Health Authority (Tennankore), Dalhousie University, Halifax, NS
| | - Robert S McKelvie
- Division of Nephrology (Weinstein), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Glomerulonephritis Clinic (Girard), University of Calgary, Calgary, Alta.; Sherbrooke University (Lepage), Sherbrooke, Que.; Division of Cardiology (McKelvie), St. Joseph's Health Care; Canada and Western University (McKelvie), London, Ont.; Nova Scotia Health Authority (Tennankore), Dalhousie University, Halifax, NS
| | - Karthik Tennankore
- Division of Nephrology (Weinstein), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Glomerulonephritis Clinic (Girard), University of Calgary, Calgary, Alta.; Sherbrooke University (Lepage), Sherbrooke, Que.; Division of Cardiology (McKelvie), St. Joseph's Health Care; Canada and Western University (McKelvie), London, Ont.; Nova Scotia Health Authority (Tennankore), Dalhousie University, Halifax, NS
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10
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Byrne C, Pareek M, Vaduganathan M, Biering-Sørensen T, Krogager ML, Kragholm KH, Steensig K, Mortensen MB, Mishra SR, McCullough MJ, Desai NR, Torp-Pedersen C, Olsen MH, Bhatt DL. Serum Potassium and Mortality in High-Risk Patients: SPRINT. Hypertension 2021; 78:1586-1594. [PMID: 34601970 DOI: 10.1161/hypertensionaha.121.17736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Christina Byrne
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark (C.B.)
| | - Manan Pareek
- Brigham and Women's Hospital, Heart & Vascular Center (M.P., M.V., T.B.-S., D.L.B.), Harvard Medical School, Boston, MA.,Department of Cardiology, Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT (M.P., N.R.D.).,Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Hillerød, Denmark (M.P., C.T.-P.)
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital, Heart & Vascular Center (M.P., M.V., T.B.-S., D.L.B.), Harvard Medical School, Boston, MA
| | - Tor Biering-Sørensen
- Brigham and Women's Hospital, Heart & Vascular Center (M.P., M.V., T.B.-S., D.L.B.), Harvard Medical School, Boston, MA.,Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark (T.B.-S.).,Institute of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (T.B.-S.)
| | - Maria Lukács Krogager
- Department of Cardiology, Aalborg University Hospital, Denmark (M.L.K., K.H.K., K.S., C.T.-P.)
| | - Kristian Hay Kragholm
- Department of Cardiology, Aalborg University Hospital, Denmark (M.L.K., K.H.K., K.S., C.T.-P.)
| | - Kamilla Steensig
- Department of Cardiology, Aalborg University Hospital, Denmark (M.L.K., K.H.K., K.S., C.T.-P.)
| | | | - Shiva Raj Mishra
- World Heart Federation, Salim Yusuf Emerging Leaders Program, Geneva, Switzerland (S.R.M.)
| | - Megan J McCullough
- Massachusetts General Hospital Corrigan Minehan Heart Center (M.J.M.S), Harvard Medical School, Boston, MA
| | - Nihar R Desai
- Department of Cardiology, Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT (M.P., N.R.D.)
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Hillerød, Denmark (M.P., C.T.-P.).,Department of Cardiology, Aalborg University Hospital, Denmark (M.L.K., K.H.K., K.S., C.T.-P.)
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital, Denmark (M.H.O.).,Department of Regional Health Research, University of Southern Denmark (M.H.O.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Heart & Vascular Center (M.P., M.V., T.B.-S., D.L.B.), Harvard Medical School, Boston, MA
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11
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Neuen BL, Oshima M, Perkovic V, Agarwal R, Arnott C, Bakris G, Cannon CP, Charytan DM, Edwards R, Górriz JL, Jardine MJ, Levin A, Neal B, De Nicola L, Pollock C, Rosenthal N, Wheeler DC, Mahaffey KW, Heerspink HJL. Effects of canagliflozin on serum potassium in people with diabetes and chronic kidney disease: the CREDENCE trial. Eur Heart J 2021; 42:4891-4901. [PMID: 34423370 DOI: 10.1093/eurheartj/ehab497] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/20/2021] [Accepted: 07/15/2021] [Indexed: 01/23/2023] Open
Abstract
AIMS Hyperkalaemia is a common complication of type 2 diabetes mellitus (T2DM) and limits the optimal use of agents that block the renin-angiotensin-aldosterone system, particularly in patients with chronic kidney disease (CKD). In patients with CKD, sodium‒glucose cotransporter 2 (SGLT2) inhibitors provide cardiorenal protection, but whether they affect the risk of hyperkalaemia remains uncertain. METHODS AND RESULTS The CREDENCE trial randomized 4401 participants with T2DM and CKD to the SGLT2 inhibitor canagliflozin or matching placebo. In this post hoc analysis using an intention-to-treat approach, we assessed the effect of canagliflozin on a composite outcome of time to either investigator-reported hyperkalaemia or the initiation of potassium binders. We also analysed effects on central laboratory-determined hyper- and hypokalaemia (serum potassium ≥6.0 and <3.5 mmol/L, respectively) and change in serum potassium. At baseline, the mean serum potassium in canagliflozin and placebo arms was 4.5 mmol/L; 4395 (99.9%) participants were receiving renin-angiotensin system blockade. The incidence of investigator-reported hyperkalaemia or initiation of potassium binders was lower with canagliflozin than with placebo [occurring in 32.7 vs. 41.9 participants per 1000 patient-years; hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.64-0.95, P = 0.014]. Canagliflozin similarly reduced the incidence of laboratory-determined hyperkalaemia (HR 0.77, 95% CI 0.61-0.98, P = 0.031), with no effect on the risk of hypokalaemia (HR 0.92, 95% CI 0.71-1.20, P = 0.53). The mean serum potassium over time with canagliflozin was similar to that of placebo. CONCLUSION Among patients treated with renin-angiotensin-aldosterone system inhibitors, SGLT2 inhibition with canagliflozin may reduce the risk of hyperkalaemia in people with T2DM and CKD without increasing the risk of hypokalaemia.
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Affiliation(s)
- Brendon L Neuen
- Renal and Metabolic Division, The George Institute for Global Health, UNSW Sydney, Sydney, NSW 2042, Australia
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Ishikawa 920-1192, Japan
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
| | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center, Indianapolis, IN 46202, USA
| | - Clare Arnott
- Renal and Metabolic Division, The George Institute for Global Health, UNSW Sydney, Sydney, NSW 2042, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW 2050, Australia
| | - George Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL 60637, USA
| | | | - David M Charytan
- Nephrology Division, New York University Langone Medical Center, New York University School of Medicine, New York, NY 10016, USA
| | - Robert Edwards
- Janssen Research & Development, LLC, Raritan, NJ 08869, USA
| | - Jose L Górriz
- Department of Nephrology, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Meg J Jardine
- Concord Repatriation General Hospital, Sydney, NSW 2139, Australia.,NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW 2050, Australia
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, BC V6Z 1Y6, Canada
| | - Bruce Neal
- Renal and Metabolic Division, The George Institute for Global Health, UNSW Sydney, Sydney, NSW 2042, Australia.,The Charles Perkins Centre, University of Sydney, Sydney, NSW 2050, Australia
| | - Luca De Nicola
- Department of Advanced Medical and Surgical Sciences, Nephrology and Dialysis Unit, University Vanvitelli, Naples, Italy
| | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Royal North Shore Hospital, St Leonards, NSW 2064, Australia
| | | | - David C Wheeler
- Department of Renal Medicine, UCL Medical School, London WC1E 6DE, UK
| | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 AD Groningen, the Netherlands
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12
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Daniels MS, Park BI, McKay DL. Adverse Effects of Medications on Micronutrient Status: From Evidence to Guidelines. Annu Rev Nutr 2021; 41:411-431. [PMID: 34111363 DOI: 10.1146/annurev-nutr-120420-023854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recent dietary reference intake workshops focusing on nutrient requirements in chronic disease populations have called attention to the potential adverse effects of chronic medication use on micronutrient status. Although this topic is mostly ill defined in the literature, several noteworthy drug-nutrient interactions (DNIs) are of clinical and public health significance. The purpose of this narrative review is to showcase classic examples of DNIs and their impact on micronutrient status, including those related to antidiabetic, anticoagulant, antihypertensive, antirheumatic, and gastric acid-suppressing medications. Purported DNIs related to other drug families, while relevant and worthy of discussion, are not included. Unlike previous publications, this review is primarily focused on DNIs that have sufficient evidence supporting their inclusion in US Food and Drug Administration labeling materials and/or professional guidelines. While the evidence is compelling, more high-quality research is needed to establish clear and quantitative relationships between chronic medication use and micronutrient status. Expected final online publication date for the Annual Review of Nutrition, Volume 41 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Michael S Daniels
- Jean Mayer USDA Human Nutrition Research Center on Aging, Boston, Massachusetts 02111, USA; , .,Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts 02111, USA;
| | - Brian I Park
- Jean Mayer USDA Human Nutrition Research Center on Aging, Boston, Massachusetts 02111, USA; , .,Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts 02111, USA;
| | - Diane L McKay
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts 02111, USA;
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13
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Abstract
Hyperkalaemia has become an increasingly prevalent finding in patients with heart failure (HF), especially with renin–angiotensin–aldosterone system (RAAS) inhibitors and angiotensin–neprilysin inhibitors being the cornerstone of medical therapy. Patients living with HF often have other comorbidities, such as diabetes and chronic kidney disease, which predispose to hyperkalaemia. Until now, we have not had any reliable or tolerable therapies for the treatment of hyperkalaemia to facilitate implementation or achievement of target doses of RAAS inhibition. Patiromer sorbitex calcium and sodium zirconium cyclosilicate are two novel potassium-binding resins that have shown promise in the management of patients predisposed to developing recurrent hyperkalaemia, and their use may allow for further optimisation of guideline directed medical therapy.
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Affiliation(s)
- Umar Ismail
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba Winnipeg, Manitoba, Canada
| | - Kiran Sidhu
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba Winnipeg, Manitoba, Canada
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba Winnipeg, Manitoba, Canada
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14
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Watson K, Kukin A, Wasik AK, Shulenberger CE. Nonsteroidal Mineralocorticoid Receptor Antagonists: Exploring Role in Cardiovascular Disease. J Cardiovasc Pharmacol 2021; 77:685-698. [PMID: 34057158 DOI: 10.1097/fjc.0000000000000990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 01/28/2021] [Indexed: 12/20/2022]
Abstract
ABSTRACT Aldosterone, a mineralocorticoid hormone, plays a role in the pathophysiology of many cardiovascular disease states. Mineralocorticoid receptor antagonists (MRAs) have been shown to improve clinical outcomes in select patient populations. However, use of available steroidal receptor antagonists, eplerenone and spironolactone, is often limited by the risk or development of hyperkalemia. Nonsteroidal MRAs have been designed to overcome this limitation. The nonsteroidal MRAs have been studied in patients with heart failure with reduced ejection fraction, hypertension, and to lower the risk of cardiac and renal outcomes in those with type 2 diabetes and renal disease. In this review, the pharmacology of the MRAs is compared, the data evaluating the use of nonsteroidal MRAs are examined, and the place of this new generation of therapy is discussed. At this time, it seems that there could be a future role for nonsteroidal MRAs to reduce the risk of renal outcomes in high-risk individuals.
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Affiliation(s)
- Kristin Watson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
- ATRIUM Cardiology Collaborative, Baltimore, MD
| | - Alina Kukin
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Allie K Wasik
- Department of Pharmacy, Northwestern Memorial Hospital Bluhm Cardiovascular Institute, Chicago, IL; and
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15
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Davis J, Israni R, Mu F, Cook EE, Szerlip H, Uwaifo G, Fonseca V, Betts KA. Inpatient management and post-discharge outcomes of hyperkalemia. Hosp Pract (1995) 2021; 49:273-279. [PMID: 34038312 PMCID: PMC9102837 DOI: 10.1080/21548331.2021.1925554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
OBJECTIVES Patients with hyperkalemia are commonly treated in the inpatient setting; however, real-world evidence is limited. The purpose of this study was to describe the inpatient management and post-discharge outcomes among patients with hyperkalemia. METHODS Electronic medical record data (2012-2018) were used to analyze US adult patients with an inpatient stay with hyperkalemia (≥1 potassium value >5.0mEq/L). Patient characteristics, treatments, and monitoring six months prior to and during the inpatient stay, and hyperkalemia recurrence and inpatient readmissions post-discharge were summarized and compared among patients with mild (>5.0-5.5mEq/L), moderate (>5.5-6.0), and severe (>6.0) hyperkalemia. RESULTS Of the 21,793 patients, 69.2% had mild, 19.0% had moderate, and 11.8% had severe hyperkalemia during inpatient care. The most common inpatient treatments were temporizing agents (mild: 28.9%; moderate: 46.0%; severe: 73.0%), diuretics (32.7%; 37.1%; 34.6%), and sodium-polystyrene sulfonate (11.7%; 27.8%; 45.3%). Almost no patients (0.1%) received a potassium binder at discharge. Most patients (86.8%) had their potassium levels return to ≤5.0mEq/L during the inpatient stay. Death during the inpatient stay occurred in 12.3% of mild, 15.5% of moderate, and 19.5% of severe hyperkalemic patients. Within 30 days of discharge, hyperkalemia recurred in 13.3%, 15.4%, and 18.4% of patients with mild, moderate, and severe hyperkalemia, respectively. Additionally, 19.7%, 21.5%, and 19.6% of patients were readmitted to inpatient care within 30 days post-discharge. CONCLUSION Among patients with hyperkalemia in the inpatient setting, treatment and normalization of serum potassium levels were common. However, death, readmission, and hyperkalemia recurrence were also fairly common across all cohorts. Future studies examining measures to reduce inpatient death, readmission, and hyperkalemia recurrence among patients with hyperkalemia in inpatient care are warranted.
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Affiliation(s)
| | | | - Fan Mu
- Analysis Group, Inc, Boston, Massachusetts, USA
| | - Erin E Cook
- Analysis Group, Inc, Boston, Massachusetts, USA
| | | | | | - Vivian Fonseca
- Tulane University Medical Center, Tulane University School of Medicine, New Orleans, Louisiana, USA
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16
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Kobayashi M, Voors AA, Ouwerkerk W, Duarte K, Girerd N, Rossignol P, Metra M, Lang CC, Ng LL, Filippatos G, Dickstein K, van Veldhuisen DJ, Zannad F, Ferreira JP. Perceived risk profile and treatment optimization in heart failure: an analysis from BIOlogy Study to TAilored Treatment in chronic heart failure. Clin Cardiol 2021; 44:780-788. [PMID: 33960439 PMCID: PMC8207977 DOI: 10.1002/clc.23576] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/07/2021] [Accepted: 02/08/2021] [Indexed: 12/21/2022] Open
Abstract
Background Achieving target doses of angiotensin‐converting‐enzyme inhibitor/angiotensin‐receptor blockers (ACEi/ARB) and beta‐blockers in heart failure with reduced ejection fraction (HFrEF) is often underperformed. In BIOlogy Study to TAilored Treatment in chronic heart failure (BIOSTAT‐CHF) study, many patients were not up‐titrated for which no clear reason was reported. Therefore, we hypothesized that perceived‐risk profile might influence treatment optimization. Methods We studied 2100 patients with HFrEF (LVEF≤40%) to compare the clinical characteristics and adverse events associated with treatment up‐titration (after a 3‐month titration protocol) between; a) patients not reaching target doses for unclear reason; b) patients not reaching target doses due to symptoms and/or side effects; c) patients reaching target doses. Results For ACEi/ARB, (a), (b) and (c) was observed in 51.3%, 25.9% and 22.7% of patients, respectively. For beta‐blockers, (a), (b) and (c) was observed in 67.5%, 20.2% and 12.3% of patients, respectively. By multinomial logistic regression analysis for ACEi/ARB, patients in group (a) and (b) had lower blood pressure and poorer renal function, and patients in group (a) were older and had lower ejection fraction. For beta‐blockers, patients in group (a) and (b) had more severe congestion and lower heart rate. At 9 months, adverse events (i.e., hypotension, bradycardia, renal impairment, and hyperkalemia) occurred similarly among the three groups. Conclusions Patients in whom clinicians did not give a reason why up‐titration was missed were older and had more co‐morbidities. Patients in whom up‐titration was achieved did not have excess adverse events. However, from these observational findings, the pattern of subsequent adverse events among patients in whom up‐titration was missed cannot be determined.
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Affiliation(s)
- Masatake Kobayashi
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Hospital Drive, Singapore.,Department of Dermatology, Amsterdam UMC, Amsterdam Infection & Immunity Institute, University of Amsterdam, Amsterdam, Netherlands
| | - Kevin Duarte
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Patrick Rossignol
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Marco Metra
- Cardiology. University and Civil hospitals of Brescia, Brescia, Italy
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | | | - Kenneth Dickstein
- Department of Internal Medicine, University of Bergen, Bergen, Norway.,Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
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17
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Hyperkalemia Management in Older Adults With Diabetic Kidney Disease Receiving Renin-Angiotensin-Aldosterone System Inhibitors: A Post Hoc Analysis of the AMETHYST-DN Clinical Trial. Kidney Med 2021; 3:360-367.e1. [PMID: 34136782 PMCID: PMC8178474 DOI: 10.1016/j.xkme.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Rationale & Objective Older people are more likely to have reduced kidney function and multiple comorbid conditions predisposing them to hyperkalemia. This post hoc subgroup analysis aimed to evaluate the effectiveness of patiromer, a sodium-free nonabsorbed polymer, in lowering serum potassium levels in older patients receiving a renin-angiotensin-aldosterone system inhibitor with chronic kidney disease (CKD), type 2 diabetes mellitus (T2DM), and hypertension. Study Design Post hoc subgroup analysis of the randomized open-label AMETHYST-DN clinical trial. Setting & Participants Multicenter clinical trial. Individuals 75 years and older with CKD, T2DM, hypertension, and hyperkalemia at baseline (N = 60; mean age, 77 years; 30 men [50%]; mean estimated glomerular filtration rate, 41.6 ± 14.3 mL/min/1.73 m2). Intervention Patients with hyperkalemia were randomly assigned to receive patiromer at doses ranging from 4.2 to 16.8 g twice daily. Outcomes We evaluated changesin serum potassium levels from baseline to week 4 and time points through 52 weeks. Long-term safety and tolerability were assessed through the end of 52 weeks and included frequency of adverse events, clinical laboratory measurements, and vital signs. Results Of 306 AMETHYST-DN participants, 60 were 75 years or older. All 60 patients had CKD and T2DM; 37% had heart failure. At screening, patients had an estimated glomerular filtration rate of 42 mL/min/1.73 m2, median urinary albumin-creatinine ratio of 127 mg/g, and baseline mean serum potassium level of 5.19 mEq/L. Mean serum potassium level was reduced at each time point from the first postbaseline visit (day 3) through week 52. Limitations This small subgroup analysis was not prespecified and therefore randomization was lost; thus, it should be considered hypothesis generating. Conclusions Among older patients with hyperkalemia and diabetic kidney disease, treatment with patiromer resulted in significant reductions in serum potassium levels after 4 weeks and lasted through 52 weeks. Patiromer was effective in lowering serum potassium levels and was well tolerated in older patients. Funding Vifor Pharma, Inc. Trial Registration NCT01371747.
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Muhlestein JB, Kammerer J, Bair TL, Knowlton KU, Le VT, Anderson JL, Lappé DL, May HT. Frequency and clinical impact of hyperkalaemia within a large, modern, real-world heart failure population. ESC Heart Fail 2020; 8:691-696. [PMID: 33331114 PMCID: PMC7835576 DOI: 10.1002/ehf2.13164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 11/07/2022] Open
Abstract
AIMS This analysis qualitatively describes the impact of hyperkalaemia (HK) and renin-angiotensin-aldosterone system inhibitor (RAASi) use on clinical outcomes in patients with heart failure (HF). METHODS AND RESULTS Patients were included if they were ≥18 years old; had a serum potassium result between 1 January 2003 and 3 December 2018; had ≥2 separate, non-urgent care or emergency department encounters; and had an HF diagnosis. Criteria were met by 52 253 patients; 48 333 had sufficient follow-up for analysis. Patients were stratified by the presence/absence of HK (serum potassium >5.0 mmol/L) (n = 31 619 and n = 20 634, respectively) and by baseline left ventricular ejection fraction (LVEF) ≤40% or >40%. Compared with patients without HK (no-HK), those with HK had significantly higher rates of baseline cardiovascular risk factors, prior diagnoses, and greater RAASi use in both baseline and follow-up periods. Assessed outcomes included RAASi use, rate of 3 year major adverse cardiovascular events (MACE), and individual component rates. Between baseline and follow-up analyses, the proportion of patients on RAASi decreased by 5% in patients with HK but increased by 20% in no-HK patients. Overall, MACE and death were consistently highest in the presence of HK without RAASi treatment (63% and 62%, respectively) and lowest in no-HK but on RAASi (25% and 21%, respectively). After complete multivariable adjustment, these trends were consistent regardless of baseline LVEF. CONCLUSIONS In this large, real-world HF population, HK was common and linked to baseline clinical risk factors, declining use of RAASi treatment, and an increase in future MACE, regardless of baseline LVEF. Both HK and reduced RAASi use were independent predictors of future MACE.
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Affiliation(s)
- Joseph B. Muhlestein
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
- Department of CardiologyUniversity of UtahSalt Lake CityUTUSA
| | - Jennifer Kammerer
- Managed Care Health OutcomesRelypsa, Inc., a Vifor Pharma Group CompanyRedwood CityCAUSA
| | - Tami L. Bair
- BioinformaticsIntermountain Medical Center Heart InstituteSalt Lake CityUTUSA
| | - Kirk U. Knowlton
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
- Department of CardiologyUniversity of UtahSalt Lake CityUTUSA
| | - Viet T. Le
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
| | - Jeffrey L. Anderson
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
- Department of CardiologyUniversity of UtahSalt Lake CityUTUSA
| | - Donald L. Lappé
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
| | - Heidi T. May
- EpidemiologyIntermountain Medical Center Heart InstituteSalt Lake CityUTUSA
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Volterrani M, Perrone V, Sangiorgi D, Giacomini E, Iellamo F, Degli Esposti L. Effects of hyperkalaemia and non-adherence to renin-angiotensin-aldosterone system inhibitor therapy in patients with heart failure in Italy: a propensity-matched study. Eur J Heart Fail 2020; 22:2049-2055. [PMID: 33459467 PMCID: PMC7756371 DOI: 10.1002/ejhf.2024] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/17/2020] [Accepted: 10/09/2020] [Indexed: 12/28/2022] Open
Abstract
Aims The aims of this study were to evaluate if the risk of cardiovascular events and all‐cause mortality was higher in the presence of hyperkalaemia (HK) in patients with heart failure (HF) treated with renin–angiotensin–aldosterone system inhibitors (RAASi), and to investigate in this cohort the increased risk of cardiovascular events and all‐cause mortality among HK patients with non‐optimal adherence to RAASi therapy. Methods and results In this retrospective cohort study based on administrative databases of five Italian Local Health Units, all adult patients with a HF diagnosis between January 2010 and December 2017 were included only if they were prescribed RAASi therapy during the first 3 months after the index date, that corresponded to the date of first HF diagnosis during the inclusion period. Patients were considered to have HK if serum potassium level was ≥5.5 mmol/L. A propensity score matching was applied before evaluation of hazard ratios. Patients with HK were 37% (P < 0.001) and 70% (P < 0.001), respectively, more at risk of cardiovascular events and of dying for all‐cause mortality compared to non‐HK patients. Among the HK group, patients non‐adherent to RAASi therapy had a 39% (P = 0.105) higher risk of cardiovascular events and a twofold increased risk (P < 0.001) of all‐cause death. Conclusion Findings from this real‐world study showed that in a cohort of HF patients under RAASi therapy, subjects with HK had an enhanced risk of cardiovascular events or death compared to patients without HK. Moreover, in HK patients, sub‐optimal adherence to RAASi therapy was associated with an increased risk of all‐cause mortality.
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Affiliation(s)
| | | | - Diego Sangiorgi
- CliCon Srl Health, Economics & Outcomes Research, Ravenna, Italy
| | - Elisa Giacomini
- CliCon Srl Health, Economics & Outcomes Research, Ravenna, Italy
| | - Ferdinando Iellamo
- Department of Clinical Science and Translational Medicine, Tor Vergata University, Rome, Italy
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Beldhuis IE, Myhre PL, Claggett B, Damman K, Fang JC, Lewis EF, O'Meara E, Pitt B, Shah SJ, Voors AA, Pfeffer MA, Solomon SD, Desai AS. Efficacy and Safety of Spironolactone in Patients With HFpEF and Chronic Kidney Disease. JACC-HEART FAILURE 2020; 7:25-32. [PMID: 30606484 DOI: 10.1016/j.jchf.2018.10.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/16/2018] [Accepted: 10/23/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study investigated the association between baseline renal function and the net benefit of spironolactone in patients with heart failure (HF) with a preserved ejection fraction (HFpEF). BACKGROUND Guidelines recommend consideration of spironolactone to reduce HF hospitalization in HFpEF. However, spironolactone may increase risk for hyperkalemia and worsening renal function, particularly in patients with chronic kidney disease. METHODS This investigation analyzed data from patients enrolled in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial) Americas study (N = 1,767) to examine the association between the baseline estimated glomerular filtration rate (eGFR) and the primary composite outcome of cardiovascular death, HF hospitalization, or aborted cardiac arrest, as well as safety outcomes, including hyperkalemia, worsening renal function, and permanent drug discontinuation for adverse events (AEs). Variations in the efficacy and safety of spironolactone according to eGFR were examined in Cox models using interaction terms. RESULTS The incidence of both the primary outcome and drug-related AEs increased with declining eGFR. Compared with placebo, across all eGFR categories, spironolactone was associated with lower relative risk for the primary efficacy outcome and for hypokalemia, but higher relative risk for hyperkalemia, worsening renal function, and drug discontinuation. During 4-year follow-up, the absolute risk for AEs that prompted drug discontinuation was amplified in the lower eGFR categories, which suggested heightened risk for drug intolerance with declining renal function. CONCLUSIONS Although consistent efficacy of spironolactone was observed across the range of eGFR, the risk of AEs was amplified in the lower eGFR categories. These data supported use of spironolactone to treat HFpEF patients with advanced chronic kidney disease only when close laboratory surveillance is possible.
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Affiliation(s)
- Iris E Beldhuis
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Peder L Myhre
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kevin Damman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Eldrin F Lewis
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eileen O'Meara
- Department of Medicine, Montreal Heart Institute, Montreal, Montreal, Canada
| | - Bertram Pitt
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marc A Pfeffer
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Akshay S Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
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Wang AYM. Optimally managing hyperkalemia in patients with cardiorenal syndrome. Nephrol Dial Transplant 2020; 34:iii36-iii44. [PMID: 31800079 DOI: 10.1093/ndt/gfz225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Indexed: 12/27/2022] Open
Abstract
Renin-angiotensin-aldosterone system inhibitors (RAASi) are now a standard treatment in most patients with cardiovascular disease, especially in those with heart failure (HF). The European Society of Cardiology and the American College of Cardiology/American Heart Association gave a Class IA recommendation for the use of RAASi in the treatment of Classes II-IV symptomatic HF with reduced ejection fraction (HFREF), based on their strong clinical benefits of lowering all-cause mortality and HF hospitalizations in these subjects. However, RAASi therapy or adding mineralocorticoid receptor antagonists in subjects receiving background angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may be associated with an increased risk of hyperkalemia (HK), especially in those with reduced kidney function. As a result, a significant proportion of these subjects either have RAASi dose reduced or more often discontinued when they develop HK. Discontinuation of RAASi in patients hospitalized with HFREF was associated with higher postdischarge mortality and rehospitalization rates, while optimal dosing of RAASi significantly reduced median hospital stays, outpatient visits and related costs. Thus, effective treatment is required to lower potassium level and maintain normokalemia in subjects with HF and reduced kidney disease who develop or are at risk of HK, thus enabling them to continue their RAASi therapy and maximize benefits from RAASi. In this review, we provide an up-to-date review of the prevalence and significance of HK in patients with cardiorenal syndrome, as well as their optimal management of HK with recent novel therapies.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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Rangaswami J, Bhalla V, Blair JEA, Chang TI, Costa S, Lentine KL, Lerma EV, Mezue K, Molitch M, Mullens W, Ronco C, Tang WHW, McCullough PA. Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies: A Scientific Statement From the American Heart Association. Circulation 2020; 139:e840-e878. [PMID: 30852913 DOI: 10.1161/cir.0000000000000664] [Citation(s) in RCA: 577] [Impact Index Per Article: 144.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cardiorenal syndrome encompasses a spectrum of disorders involving both the heart and kidneys in which acute or chronic dysfunction in 1 organ may induce acute or chronic dysfunction in the other organ. It represents the confluence of heart-kidney interactions across several interfaces. These include the hemodynamic cross-talk between the failing heart and the response of the kidneys and vice versa, as well as alterations in neurohormonal markers and inflammatory molecular signatures characteristic of its clinical phenotypes. The mission of this scientific statement is to describe the epidemiology and pathogenesis of cardiorenal syndrome in the context of the continuously evolving nature of its clinicopathological description over the past decade. It also describes diagnostic and therapeutic strategies applicable to cardiorenal syndrome, summarizes cardiac-kidney interactions in special populations such as patients with diabetes mellitus and kidney transplant recipients, and emphasizes the role of palliative care in patients with cardiorenal syndrome. Finally, it outlines the need for a cardiorenal education track that will guide future cardiorenal trials and integrate the clinical and research needs of this important field in the future.
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Beusekamp JC, Tromp J, Cleland JG, Givertz MM, Metra M, O’Connor CM, Teerlink JR, Ponikowski P, Ouwerkerk W, van Veldhuisen DJ, Voors AA, van der Meer P. Hyperkalemia and Treatment With RAAS Inhibitors During Acute Heart Failure Hospitalizations and Their Association With Mortality. JACC-HEART FAILURE 2019; 7:970-979. [DOI: 10.1016/j.jchf.2019.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 12/28/2022]
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Dyskalemia, its patterns, and prognosis among patients with incident heart failure: A nationwide study of US veterans. PLoS One 2019; 14:e0219899. [PMID: 31393910 PMCID: PMC6687136 DOI: 10.1371/journal.pone.0219899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 07/04/2019] [Indexed: 12/01/2022] Open
Abstract
Background Although hypokalemia has been viewed as a significant concern among patients with heart failure (HF), recent advances in HF management tend to increase the risk of hyperkalemia. Objective To characterize contemporary data regarding correlates and prognostic values of dyskalemia in patients with HF. Design, setting, and participants In cross-sectional and longitudinal analyses, we studied 142,087 patients with newly diagnosed HF in US nationwide Veterans Administration database from 2005 through 2013. Exposures Demographic characteristics, laboratory variables, comorbidities, and medication use for the analysis of correlates of dyskalemia as well as potassium level in the analysis of mortality. Main Outcomes and Measures Dyskalemia and mortality. Results Hypokalemia (<3.5 mmol/L) at baseline was observed in 3.0% of the population, whereas hyperkalemia (≥5.5 mmol/L) was seen in 0.9%. An additional 20.4% and 5.7% had mild hypokalemia (3.5–3.9 mmol/L) and mild hyperkalemia (5.0–5.4 mmol/L). Key correlates were black race, higher blood pressure, and use of potassium-wasting diuretics for hypokalemia, and lower kidney function for hyperkalemia. Baseline potassium levels showed a U-shaped association with mortality, with the lowest risk between 4.0–4.5 mmol/L. With respect to potassium levels over a year after HF diagnosis, persistent (>50% of measurements), intermittent (>1 occurrence but ≤50%), and transient (1 occurrence) hypo- and hyperkalemia were also related to increased mortality in a graded fashion regardless of the aforementioned thresholds for dyskalemia. These dyskalemic patterns were also related to other clinical actions and demands such as emergency room visit. Conclusions Potassium levels below 4 mmol/L and above 5 mmol/L at and after HF diagnosis were associated with poor prognosis and the clinical actions. HF patients (particularly with risk factors for dyskalemia like black race and kidney dysfunction) may require special attention for both hypo- and hyperkalemia.
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Dunlay SM, Givertz MM, Aguilar D, Allen LA, Chan M, Desai AS, Deswal A, Dickson VV, Kosiborod MN, Lekavich CL, McCoy RG, Mentz RJ, Piña IL. Type 2 Diabetes Mellitus and Heart Failure: A Scientific Statement From the American Heart Association and the Heart Failure Society of America: This statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update. Circulation 2019; 140:e294-e324. [PMID: 31167558 DOI: 10.1161/cir.0000000000000691] [Citation(s) in RCA: 323] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
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Dunlay SM, Givertz MM, Aguilar D, Allen LA, Chan M, Desai AS, Deswal A, Dickson VV, Kosiborod MN, Lekavich CL, McCoy RG, Mentz RJ, PiÑa IL. Type 2 Diabetes Mellitus and Heart Failure, A Scientific Statement From the American Heart Association and Heart Failure Society of America. J Card Fail 2019; 25:584-619. [PMID: 31174952 DOI: 10.1016/j.cardfail.2019.05.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
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Basnet S, Dhital R, Tharu B, Ghimire S, Poudel DR, Donato A. Influence of abnormal potassium levels on mortality among hospitalized heart failure patients in the US: data from National Inpatient Sample. J Community Hosp Intern Med Perspect 2019; 9:103-107. [PMID: 31044040 PMCID: PMC6484484 DOI: 10.1080/20009666.2019.1593778] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/07/2019] [Indexed: 12/28/2022] Open
Abstract
Background: Abnormalities in serum potassium levels have been associated with variable mortality risk among hospitalized patients with heart failure (HF). We aim to use a large database study to further characterize risk of mortality, demographic factors, and associated comorbidities among heart failure inpatients. Methods: Our sample population was from the US National Inpatient Sample database from the year 2009–2011. The inclusion criteria used to identify patients was those with a diagnosis of heart failure as per ICD-9 classification. Other demographic factors considered in data collection included income, and cardiac risk factors. Taking these factors into consideration, a univariate association of potassium level and mortality was performed, as well as multivariable logistic regression controlling for demographic factors and associated conditions. Results: Of the 2,660,609 patients who were discharged with a diagnosis of heart failure during this time period, patients with hypokalemia during hospitalization had increased mortality risk (OR: 1.96, 95% CI: 1.91–2.01) when compared with those with hyperkalemia who had decreased inpatient mortality risk OR: 0.94,95% CI: 0.91–0.96) versus those not coded for potassium abnormalities. This finding was significant even regardless of the etiology of the hypokalemia while the hyperkalemic patients were noted to have no difference or a decreased risk in all subtypes and groups. Conclusion: Unlike heart failure patients with hyperkalemia, those with hypokalemia are at an increased inpatient mortality risk. Whether our mortality findings translate to longer-term outpatient settings where significantly less monitoring is possible is a matter for further study.
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Affiliation(s)
- Sijan Basnet
- Department of Internal Medicine, Reading Hospital and Medical Center, West Reading, PA, USA
| | - Rashmi Dhital
- Department of Internal Medicine, Reading Hospital and Medical Center, West Reading, PA, USA
| | - Biswaraj Tharu
- Department of Internal Medicine, Trumbull Regional Medical Center, Warren, OH, USA
| | - Sushil Ghimire
- Department of Internal Medicine, Reading Hospital and Medical Center, West Reading, PA, USA
| | - Dilli Ram Poudel
- Department of Internal Medicine, Reading Hospital and Medical Center, West Reading, PA, USA
| | - Anthony Donato
- Department of Internal Medicine, Reading Hospital and Medical Center, West Reading, PA, USA
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Belmar Vega L, Galabia ER, Bada da Silva J, Bentanachs González M, Fernández Fresnedo G, Piñera Haces C, Palomar Fontanet R, Ruiz San Millán JC, de Francisco ÁLM. Epidemiology of hyperkalemia in chronic kidney disease. Nefrologia 2019; 39:277-286. [PMID: 30898450 DOI: 10.1016/j.nefro.2018.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 11/19/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Hyperkalaemia is a significant electrolyte imbalance in chronic kidney disease (CKD). Renin-angiotensin-aldosterone system inhibitors (RAASi) have beneficial cardio-renal properties, although they can often cause hyperkalaemia. OBJECTIVE To examine the prevalence of hyperkalaemia in CKD, identify factors associated with its appearance and the relationship between hyperkalaemia and mortality. PATIENTS AND METHODS Retrospective observational study on patients with CKD in the period 1971-2017. The population was categorised into 3groups: Group 1, patients with CKD without renal replacement therapy; Group 2, patients on haemodialysis; and Group 3, patients on continuous ambulatory peritoneal dialysis. RESULTS A total of 2,629 patients were evaluated. The prevalence observed in the different groups was: 9.6%, 16.4% and 10.6%, respectively. Risk factors related to the appearance of hyperkalaemia in the CKD group were glomerular filtration rate (GFR) (P<.001), plasma creatinine (P<.001), plasma sodium (P<.001), haemoglobin (P=.028), diastolic blood pressure (P=.012), intake of ACE inhibitors and/or angiotensin ii receptor blockers (P=.008), treatment with metformin (P<.001) and diabetes (P=.045). Treatment with RAASi significantly increased hyperkalaemia as GFR decreased, as well as in patients with diabetes or heart failure. CONCLUSIONS Hyperkalaemia is a frequent metabolic alteration in CKD patients that increases in the presence of drugs with beneficial cardio-renal properties (RAASi), which means that patients often lose the benefit associated with these drugs. New, recently-appearing non-absorbable compounds, which bind to potassium in the gastrointestinal tract, enhancing faecal excretion and thus maintaining the cardio-renal benefit of the RAASi, could be relevant in the progress of patients with CKD.
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Affiliation(s)
- Lara Belmar Vega
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España.
| | - Emilio Rodrigo Galabia
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Jairo Bada da Silva
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | | | - Gema Fernández Fresnedo
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Celestino Piñera Haces
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Rosa Palomar Fontanet
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
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Abstract
Disturbances in the potassium homeostasis are common among patients with heart failure (HF) and negatively affect clinical outcome. Patients with HF have a higher prevalence of common risk factors related to hyperkalaemia, including diabetes mellitus, hypertension, and chronic kidney disease. Furthermore, the use of renin-angiotensin-aldosterone system (RAAS) inhibitors, is an important risk factor for developing hyperkalaemia. The association between hyperkalaemia and mortality is not unequivocal, depends on the study type (trial vs. real-world setting) and is often confounded. More importantly, hyperkalaemia is an important cause of discontinuation or failure to uptitrate to guideline recommended dosages of RAAS inhibitors, which in turn may negatively impact clinical outcomes. The goal of this review is to discuss the epidemiology, aetiology, and clinical consequences of potassium disturbances in HF.
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Affiliation(s)
- Jasper Tromp
- Department of Cardiology, AB31, University Medical Centre Groningen, University Medical Center Groningen, University of Groningen, Hanzeplein 1,Groningen, The Netherlands
- National Heart Centre Singapore, National Heart Research Institute, 5 Hospital Dr, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| | - Peter van der Meer
- Department of Cardiology, AB31, University Medical Centre Groningen, University Medical Center Groningen, University of Groningen, Hanzeplein 1,Groningen, The Netherlands
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Linde C, Qin L, Bakhai A, Furuland H, Evans M, Ayoubkhani D, Palaka E, Bennett H, McEwan P. Serum potassium and clinical outcomes in heart failure patients: results of risk calculations in 21 334 patients in the UK. ESC Heart Fail 2019; 6:280-290. [PMID: 30629342 PMCID: PMC6437434 DOI: 10.1002/ehf2.12402] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 12/04/2018] [Indexed: 11/08/2022] Open
Abstract
Aims At present, the clinical burden of hypokalaemia and hyperkalaemia among European heart failure patients, and relationships between serum potassium and adverse clinical outcomes in this population, is not well characterized. The aim of this study was to investigate associations between mortality, major adverse cardiac events, and renin–angiotensin–aldosterone system inhibitor (RAASi) discontinuation across serum potassium levels, in a UK cohort of incident heart failure patients. Methods and results This was a retrospective observational cohort study of newly diagnosed heart failure patients listed in the Clinical Practice Research Datalink, with a first record of heart failure (index date) between 2006 and 2015. Hypokalaemia and hyperkalaemia episodes were defined as the number of serum potassium measurements exceeding each threshold (<3.5, ≥5.0, ≥5.5, and ≥6.0 mmol/L), without such a measurement in the preceding 7 days. Risk equations developed using Poisson generalized estimating equations were utilized to estimate adjusted incident rate ratios (IRRs) relating serum potassium and clinical outcomes (death, major adverse cardiac event, and RAASi discontinuation). Among 21,334 eligible heart failure patients, 1969 (9.2%), 7648 (35.9%), 2725 (12.8%), and 763 (3.6%) experienced episodes of serum potassium <3.5, ≥5.0, ≥5.5, and ≥6.0 mmol/L, respectively. The adjusted IRRs for mortality exhibited a U‐shaped association pattern with serum potassium. Relative to the reference category (4.5 to <5.0 mmol/L), adjusted IRRs for mortality were estimated as 1.98 (95% confidence interval: 1.69–2.33), 1.23 (1.12–1.36), 1.35 (1.14–1.60), and 3.02 (2.28–4.02), for patients with serum potassium <3.5, ≥5.0 to <5.5, ≥5.5 to <6.0, and ≥6.0 mmol/L, respectively. The adjusted IRRs for major adverse cardiac events demonstrated a non‐statistically significant relationship with serum potassium. Discontinuation of RAASi therapy exhibited a J‐shaped trend in association with serum potassium. Compared with the reference category (4.5 to <5.0 mmol/L), adjusted IRRs were estimated as 1.07 (0.89–1.28) in patients with serum potassium <3.5 mmol/L, increasing to 1.32 (1.14–1.53) and 2.19 (1.63–2.95) among those with serum potassium ≥5.5 to <6.0 and ≥6.0 mmol/L, respectively. Conclusions In UK patients with new onset heart failure, both hypokalaemia and hyperkalaemia were associated with increased mortality risk, and hyperkalaemia was associated with increased likelihood of RAASi discontinuation. Our results demonstrate the potential importance of serum potassium monitoring for heart failure outcomes and management.
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Affiliation(s)
- Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Lei Qin
- Global Health Economics, AstraZeneca, Gaithersburg, MD, USA
| | - Ameet Bakhai
- Department of Cardiology, Royal Free Hospital, London, UK
| | - Hans Furuland
- Department of Nephrology, Uppsala University Hospital, Uppsala, Sweden
| | - Marc Evans
- Diabetes Resource Centre, Llandough Hospital, Cardiff, UK
| | | | | | | | - Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK.,School of Human and Health Sciences, Swansea University, Swansea, UK
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Potential target-organ protection of mineralocorticoid receptor antagonist in acute kidney disease. J Hypertens 2019; 37:125-134. [PMID: 30063639 DOI: 10.1097/hjh.0000000000001876] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Yılmaz İ. Angiotensin-Converting Enzyme Inhibitors Induce Cough. Turk Thorac J 2019; 20:36-42. [PMID: 30664425 DOI: 10.5152/turkthoracj.2018.18014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 09/18/2018] [Indexed: 01/13/2023]
Abstract
Angiotensin-converting enzyme inhibitors (ACE-I) are widely used in diseases, such as hypertension, congestive heart failure, and myocardial infarction. Although these drugs are well tolerated, one out of five patients discontinues ACE-I due to drug side effects, mainly chronic cough. However, the pathogenesis of ACE-I-induced cough remains controversial and requires further study. In this review, the mechanisms that are suggested in ACE-I-induced cough pathophysiology will be discussed in detail in light of the current literature.
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Affiliation(s)
- İnsu Yılmaz
- Department of Chest Diseases, Division of Immunology and Allergy, Erciyes University School of Medicine, Kayseri, Turkey
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Incidence, Predictors, and Outcome Associations of Dyskalemia in Heart Failure With Preserved, Mid-Range, and Reduced Ejection Fraction. JACC-HEART FAILURE 2019; 7:65-76. [DOI: 10.1016/j.jchf.2018.10.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/04/2018] [Indexed: 12/13/2022]
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Connelly KA, Gilbert RE, Liu P. Treatment of Diabetes in People With Heart Failure. Can J Diabetes 2018; 42 Suppl 1:S196-S200. [PMID: 29650096 DOI: 10.1016/j.jcjd.2017.10.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 10/17/2022]
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Abegaz TM, Birru EM, Mekonnen GB. Potentially inappropriate prescribing in Ethiopian geriatric patients hospitalized with cardiovascular disorders using START/STOPP criteria. PLoS One 2018; 13:e0195949. [PMID: 29723249 PMCID: PMC5933717 DOI: 10.1371/journal.pone.0195949] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 04/03/2018] [Indexed: 12/18/2022] Open
Abstract
Background There was a paucity of data on the magnitude of potentially inappropriate prescriptions (PIPs) among Ethiopian elderly cardiovascular patients. Objective The aim of this study was to assess PIPs and associated factors in the elderly population with cardiovascular disorders using the START/STOPP screening criteria. Methods A hospital-based cross-sectional study was conducted at medical wards of a teaching hospital in Ethiopia from 1 December 2016–30 May 2017. Included patients were hospitalized elderly patients aged 65 years or older with cardiovascular disorders; their medications were evaluated using the START/STOPP screening criteria from admission to discharge. Multivariable logistic regression was applied to identify factors associated with inappropriate medications. One Way Analysis Of Variance (ANOVA) was carried out to test significant differences on the number of PIPs per individual diagnosis. Results Two hundred thirty-nine patients were included in the analysis. More-than a third of the patients were diagnosed with heart failure, 88 (36.82%). A total of 221 PIPs were identified in 147 patients, resulting in PIP prevalence of 61.5% in the elderly population. Of the total number of PIPs, occurrence of one, two and three PIPs accounted for 83 (56.4%), 52(35.4%), and 12(8.2%) respectively. One way ANOVA test showed significant differences on the mean number of PIPs per individual diagnosis (f = 5.718, p<0.001). Angiotensin Converting Enzyme Inhibitors (ACEIs) were the most common inappropriately prescribed medications, 32(14.5%). Hospital stay, AOR: 1.086 (1.016–1.160), number of medications at discharge, AOR: 1.924 (1.217–3.041) and the presence of co-morbidities, AOR: 3.127 (1.706–5.733) increased the likelihood of PIP. Conclusion Approximately, two-thirds of elderly cardiovascular patients encountered potentially inappropriate prescriptions. ACEIs were the most commonly mis-prescribed medications. Longer hospital stay, presence of comorbidities and prescription of large number of medications at discharge have been correlated with the occurrence of inappropriate medication. It is essential to evaluate patients’ medications during hospital stay using the STOPP and START tool to reduce PIPs.
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Affiliation(s)
- Tadesse Melaku Abegaz
- Department of clinical pharmacy, school of pharmacy, college of medicine and health sciences, university of Gondar, Gondar, Ethiopia
- * E-mail:
| | - Eshetie Melese Birru
- Department of pharmacology, school of pharmacy, college of medicine and health sciences, university of Gondar, Gondar, Ethiopia
| | - Gashaw Binega Mekonnen
- Department of clinical pharmacy, school of pharmacy, college of medicine and health sciences, university of Gondar, Gondar, Ethiopia
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Rosano GMC, Tamargo J, Kjeldsen KP, Lainscak M, Agewall S, Anker SD, Ceconi C, Coats AJS, Drexel H, Filippatos G, Kaski JC, Lund L, Niessner A, Ponikowski P, Savarese G, Schmidt TA, Seferovic P, Wassmann S, Walther T, Lewis BS. Expert consensus document on the management of hyperkalaemia in patients with cardiovascular disease treated with renin angiotensin aldosterone system inhibitors: coordinated by the Working Group on Cardiovascular Pharmacotherapy of the European Society of Cardiology. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2018; 4:180-188. [DOI: 10.1093/ehjcvp/pvy015] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/26/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Giuseppe M C Rosano
- Department of Medical Sciences, IRCCS San Raffaele, via di val cannuta, Roma, Italy
- Cardiology Clinical Academic Group, St George’s Hospitals NHS Trust University of London, Cranmer Terrace, London, UK
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine. University Complutense, CIBERCV, Madrid, Spain
| | - Keld P Kjeldsen
- Department of Medicine, Copenhagen University Hospital (Holbæk Hospital), Holbæk, Denmark
- Institute for Clinical Medicine, Copenhagen University, Blegdamsvej 3B, Copenhagen N, Denmark
- Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej, Aalborg East, Denmark
| | - Mitja Lainscak
- Faculty of Medicine, University of Ljubljana, General Hospital Murska Sobota, Slovenia
- Department of Internal Medicine, General Hospital Murska Sobota, Slovenia
| | - Stefan Agewall
- Oslo University Hospital, Oslo universitetssykehus HF, Postboks 4950 Nydalen, Oslo, Ullevål, Norway
- Institute of Clinical Sciences, University of Oslo, Oslo universitetssykehus HF, Postboks 4950 Nydalen, Oslo, Norway
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité Universitätsmedizin Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Charité Universitätsmedizin Berlin, Germany
- Partner Site Berlin, Charité Universitätsmedizin Berlin, Germany
- Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Göttingen, Germany
| | - Claudio Ceconi
- University Hospital of Ferrara, U.O. Cardiologia Via Savonarola, 9, Ferrara FE, Italy
| | - Andrew J S Coats
- Department of Medical Sciences, IRCCS San Raffaele, via di val cannuta, Roma, Italy
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria
- Department of Internal Medicine, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
- University of the Principality of Liechtenstein, Triesen, Liechtenstein
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, 75 Mikras Asias str., Goudi, Athens, Greece
| | - Juan Carlos Kaski
- Department of Medical Sciences, IRCCS San Raffaele, via di val cannuta, Roma, Italy
| | - Lars Lund
- Karolinska Institutet, and Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Alexander Niessner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Centre for Heart Diseases, Military Hospital, Wroclaw, Poland
| | - Gianluigi Savarese
- Karolinska Institutet, and Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Thomas A Schmidt
- Department of Emergency Medicine, Holbaek Hospital, University of Copenhagen, Holbæk, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Petar Seferovic
- Department of Cardiology, University of Belgrade, Studentski trg 1, Belgrade, Serbia
| | - Sven Wassmann
- Cardiology Pasing, Munich, Germany
- University of the Saarland, Homburg/Saar, Germany
| | - Thomas Walther
- Department of Pharmacology and Therapeutics, School of Medicine and School of Pharmacy, University College Cork, Cork, Ireland
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Greifswald, Germany
| | - Basil S Lewis
- Lady Davis Carmel Medical Center, Mikhal St 7, Haifa, Israel
- Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, 1 Efron St. Bat Galim, Haifa, Israel
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Davidson JP, King AJ, Kumaraswamy P, Caldwell JS, Korner P, Blanks RC, Jacobs JW. Evaluation of the Pharmacodynamic Effects of the Potassium Binder RDX7675 in Mice. J Cardiovasc Pharmacol Ther 2018; 23:244-253. [PMID: 29130735 PMCID: PMC5987854 DOI: 10.1177/1074248417741685] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 10/09/2017] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Hyperkalemia is a common complication in patients with heart failure or chronic kidney disease, particularly those who are taking inhibitors of the renin-angiotensin-aldosterone system. RDX7675, the calcium salt of a reengineered polystyrene sulfonate-based resin, is a potassium binder that is being investigated as a novel treatment for hyperkalemia. This study evaluated the pharmacodynamic effects of RDX7675 in mice, compared to 2 current treatments, sodium polystyrene sulfonate (SPS) and patiromer. METHODS Seven groups of 8 male CD-1 mice were given either standard chow (controls) or standard chow containing 4.0% or 6.6% active moiety of RDX7675, patiromer, or SPS for 72 hours. Stool and urine were collected over the final 24 hours of treatment for ion excretion analyses. RESULTS RDX7675 increased stool potassium (mean 24-hour excretion: 4.0%, 9.19 mg; 6.6%, 18.11 mg; both P < .0001) compared with controls (4.47 mg) and decreased urinary potassium (mean 24-hour excretion: 4.0%, 12.05 mg, P < .001; 6.6%, 6.68 mg, P < .0001; vs controls, 20.38 mg). The potassium-binding capacity of RDX7675 (stool potassium/gram of resin: 4.0%, 1.14 mEq/g; 6.6%, 1.32 mEq/g) was greater (all P < .0001) than for patiromer (4.0%, 0.63 mEq/g; 6.6%, 0.48 mEq/g) or SPS (4.0%, 0.73 mEq/g; 6.6% 0.55 mEq/g). RDX7675 and patiromer decreased urinary sodium (mean 24-hour excretion: 0.07-1.38 mg; all P < .001) compared to controls (5.01 mg). In contrast, SPS increased urinary sodium excretion (4.0%, 13.31 mg; 6.6%, 17.60 mg; both P < .0001) compared to controls. CONCLUSIONS RDX7675 reduced intestinal potassium absorption and had a greater potassium-binding capacity than patiromer or SPS in mice. The calcium-based resins RDX7675 and patiromer reduced intestinal sodium absorption, unlike sodium-based SPS. These results support further studies in humans to confirm the potential of RDX7675 for the treatment of patients with hyperkalemia.
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Desai AS, Liu J, Pfeffer MA, Claggett B, Fleg J, Lewis EF, McKinlay S, O'Meara E, Shah SJ, Sweitzer NK, Solomon S, Pitt B. Incident Hyperkalemia, Hypokalemia, and Clinical Outcomes During Spironolactone Treatment of Heart Failure With Preserved Ejection Fraction: Analysis of the TOPCAT Trial. J Card Fail 2018; 24:313-320. [PMID: 29572190 DOI: 10.1016/j.cardfail.2018.03.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/20/2018] [Accepted: 03/09/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND In patients with heart failure and preserved ejection fraction (HF-PEF) randomized in the Americas as part of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, treatment with spironolactone enhanced the risk of hyperkalemia but reduced the risk of hypokalemia. We examined the clinical correlates and prognostic implications of incident hypo- and hyperkalemia during study follow-up. METHODS We defined the region-specific incidence of hypokalemia (potassium [K+] <3.5 mmol/l) and hyperkalemia (K+ ≥5.5 mmol/l) among both placebo- and spironolactone-assigned patients in TOPCAT. Factors associated with incident hypokalemia and hyperkalemia and the relationship between incident K+ abnormalities and the risk of subsequent mortality were analyzed in multivariable regression models restricted to the Americas. RESULTS In the Americas, assignment to spironolactone increased risk for hyperkalemia (hazard ratio 3.21, 95% confidence interval 2.46-4.20, P < .001) and reduced risk of hypokalemia (hazard ratio 0.43, 95% confidence interval 0.34-0.55, P < .001). Assignment to spironolactone, lower estimated glomerular filtration rate, higher baseline K+, diabetes, and lower hemoglobin were associated with incident hyperkalemia, whereas assignment to placebo, lower K+, younger age, lower estimated glomerular filtration rate, and use of diuretics at baseline were associated with hypokalemia. The combination of spironolactone and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker was associated with incremental risk for hyperkalemia and protection from hypokalemia. Independent of region, both hypokalemia and hyperkalemia, were associated with higher risk for cardiovascular and all-cause mortality in multivariable-adjusted Cox regression models. CONCLUSIONS Both hyperkalemia and hypokalemia are associated with heightened risk for mortality in HF-PEF. Use of spironolactone in this population requires careful laboratory surveillance of K+ and creatinine, particularly in high-risk groups.
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Affiliation(s)
- Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Jiankang Liu
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jerome Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Eldrin F Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sonja McKinlay
- New England Research Institutes, Inc., Watertown, Massachusetts
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Scott Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Bertram Pitt
- Cardiovascular Division, University of Michigan School of Medicine, Ann Arbor, Michigan
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Seferović PM, Petrie MC, Filippatos GS, Anker SD, Rosano G, Bauersachs J, Paulus WJ, Komajda M, Cosentino F, de Boer RA, Farmakis D, Doehner W, Lambrinou E, Lopatin Y, Piepoli MF, Theodorakis MJ, Wiggers H, Lekakis J, Mebazaa A, Mamas MA, Tschöpe C, Hoes AW, Seferović JP, Logue J, McDonagh T, Riley JP, Milinković I, Polovina M, van Veldhuisen DJ, Lainscak M, Maggioni AP, Ruschitzka F, McMurray JJV. Type 2 diabetes mellitus and heart failure: a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018. [PMID: 29520964 DOI: 10.1002/ejhf.1170] [Citation(s) in RCA: 395] [Impact Index Per Article: 65.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The coexistence of type 2 diabetes mellitus (T2DM) and heart failure (HF), either with reduced (HFrEF) or preserved ejection fraction (HFpEF), is frequent (30-40% of patients) and associated with a higher risk of HF hospitalization, all-cause and cardiovascular (CV) mortality. The most important causes of HF in T2DM are coronary artery disease, arterial hypertension and a direct detrimental effect of T2DM on the myocardium. T2DM is often unrecognized in HF patients, and vice versa, which emphasizes the importance of an active search for both disorders in the clinical practice. There are no specific limitations to HF treatment in T2DM. Subanalyses of trials addressing HF treatment in the general population have shown that all HF therapies are similarly effective regardless of T2DM. Concerning T2DM treatment in HF patients, most guidelines currently recommend metformin as the first-line choice. Sulphonylureas and insulin have been the traditional second- and third-line therapies although their safety in HF is equivocal. Neither glucagon-like preptide-1 (GLP-1) receptor agonists, nor dipeptidyl peptidase-4 (DPP4) inhibitors reduce the risk for HF hospitalization. Indeed, a DPP4 inhibitor, saxagliptin, has been associated with a higher risk of HF hospitalization. Thiazolidinediones (pioglitazone and rosiglitazone) are contraindicated in patients with (or at risk of) HF. In recent trials, sodium-glucose co-transporter-2 (SGLT2) inhibitors, empagliflozin and canagliflozin, have both shown a significant reduction in HF hospitalization in patients with established CV disease or at risk of CV disease. Several ongoing trials should provide an insight into the effectiveness of SGLT2 inhibitors in patients with HFrEF and HFpEF in the absence of T2DM.
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Affiliation(s)
- Petar M Seferović
- University of Belgrade School of Medicine, Belgrade University Medical Center, Belgrade, Serbia
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Gerasimos S Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Athens University Hospital "Attikon", Athens, Greece
| | - Stefan D Anker
- Division of Cardiology and Metabolism - Heart Failure, Cachexia & Sarcopenia, Department of Cardiology (CVK); and Berlin-Brandenburg Center for Regenerative Therapies (BCRT); Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) Berlin; Charité Universitätsmedizin Berlin, Germany; Department of Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy and Cardiovascular and Cell Science Institute, St George's University of London, London, UK
| | - Johann Bauersachs
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
| | - Walter J Paulus
- Department of Physiology and Institute for Cardiovascular Research VU, VU University Medical Center, Amsterdam, The Netherlands
| | - Michel Komajda
- Institute of Cardiometabolism and Nutrition (ICAN), Pierre et Marie Curie University, Paris VI, La Pitié-Salpétrière Hospital, Paris, France
| | - Francesco Cosentino
- Cardiology Unit, Department of Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Rudolf A de Boer
- University of Groningen, University Medical Centre Groningen, Department of Cardiology, Hanzeplein Groningen, The Netherlands
| | - Dimitrios Farmakis
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Wolfram Doehner
- Charité - Campus Virchow (CVK), Center for Stroke Research, Berlin, Germany
| | | | - Yuri Lopatin
- Volgograd Medical University, Cardiology Centre, Volgograd, Russian Federation
| | - Massimo F Piepoli
- Heart Failure Unit, Cardiac Department, Guglielmo da Saliceto Hospital, AUSL, Piacenza, Italy
| | - Michael J Theodorakis
- Endocrinology, Metabolism and Diabetes Unit, Evgenideion Hospital, University of Athens, Athens, Greece
| | - Henrik Wiggers
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - John Lekakis
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Alexandre Mebazaa
- University Paris Diderot, Paris, France; and Department of Anaesthesia and Critical Care, University Hospitals Saint Louis-Lariboisière, Paris, France
| | - Mamas A Mamas
- Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
| | - Carsten Tschöpe
- Department of Cardiology, Campus Virchow Klinikum, Charite - Universitaetsmedizin Berlin, Berlin, Germany
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jelena P Seferović
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Belgrade University Medical Center, Belgrade, Serbia
| | - Jennifer Logue
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Theresa McDonagh
- Department of Cardiology, King's College Hospital, Denmark Hill, London, UK
| | - Jillian P Riley
- National Heart and Lung Institute Imperial College London, London, UK
| | - Ivan Milinković
- University of Belgrade School of Medicine, Belgrade University Medical Center, Belgrade, Serbia
| | - Marija Polovina
- University of Belgrade School of Medicine, Belgrade University Medical Center, Belgrade, Serbia
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mitja Lainscak
- Department of Internal Medicine, and Department of Research and Education, General Hospital Murska Sobota, Murska Sobota, Slovenia
| | - Aldo P Maggioni
- Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy
| | - Frank Ruschitzka
- University Heart Centre, University Hospital Zurich, Zurich, Switzerland
| | - John J V McMurray
- British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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New Therapeutic Approaches for the Treatment of Hyperkalemia in Patients Treated with Renin-Angiotensin-Aldosterone System Inhibitors. Cardiovasc Drugs Ther 2018; 32:99-119. [DOI: 10.1007/s10557-017-6767-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Beusekamp JC, Tromp J, van der Wal HH, Anker SD, Cleland JG, Dickstein K, Filippatos G, van der Harst P, Hillege HL, Lang CC, Metra M, Ng LL, Ponikowski P, Samani NJ, van Veldhuisen DJ, Zwinderman AH, Rossignol P, Zannad F, Voors AA, van der Meer P. Potassium and the use of renin-angiotensin-aldosterone system inhibitors in heart failure with reduced ejection fraction: data from BIOSTAT-CHF. Eur J Heart Fail 2018; 20:923-930. [PMID: 29327797 DOI: 10.1002/ejhf.1079] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/10/2017] [Accepted: 10/15/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Hyperkalaemia is a common co-morbidity in patients with heart failure with reduced ejection fraction (HFrEF). Whether it affects the use of renin-angiotensin-aldosterone system inhibitors and thereby negatively impacts outcome is unknown. Therefore, we investigated the association between potassium and uptitration of angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB) and its association with outcome. METHODS AND RESULTS Out of 2516 patients from the BIOSTAT-CHF study, potassium levels were available in 1666 patients with HFrEF. These patients were sub-optimally treated with ACEi/ARB or beta-blockers and were anticipated and encouraged to be uptitrated. Potassium levels were available at inclusion and at 9 months. Outcome was a composite of all-cause mortality and heart failure hospitalization at 2 years. Patients' mean age was 67 ± 12 years and 77% were male. At baseline, median serum potassium was 4.3 (interquartile range 3.9-4.6) mEq/L. After 9 months, 401 (24.1%) patients were successfully uptitrated with ACEi/ARB. During this period, mean serum potassium increased by 0.16 ± 0.66 mEq/L (P < 0.001). Baseline potassium was an independent predictor of lower ACEi/ARB dosage achieved [odds ratio 0.70; 95% confidence interval (CI) 0.51-0.98]. An increase in potassium was not associated with adverse outcomes (hazard ratio 1.15; 95% CI 0.86-1.53). No interaction on outcome was found between baseline potassium, potassium increase during uptitration, or potassium at 9 months and increased dosage of ACEi/ARB (Pinteraction > 0.5 for all). CONCLUSION Higher potassium levels are an independent predictor of enduring lower dosages of ACEi/ARB. Higher potassium levels do not attenuate the beneficial effects of ACEi/ARB uptitration.
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Affiliation(s)
- Joost C Beusekamp
- Department of Cardiology, University of Groningen, Groningen, The Netherlands
| | - Jasper Tromp
- Department of Cardiology, University of Groningen, Groningen, The Netherlands
- National Heart Centre Singapore, Singapore
| | - Haye H van der Wal
- Department of Cardiology, University of Groningen, Groningen, The Netherlands
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
- Division of Cardiology and Metabolism-Heart Failure, Cachexia and Sarcopenia, Department of Cardiology, and Berlin-Brandenburg Center for Regenerative Therapies, Charité University Medicine, Berlin, Germany
| | - John G Cleland
- National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, UK
| | - Kenneth Dickstein
- University of Bergen, Bergen, Norway
- Stavanger University Hospital, Stavanger, Norway
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine and Department of Cardiology, Heart Failure Unit, Athens University Hospital Attikon, Athens, Greece
| | - Pim van der Harst
- Department of Cardiology, University of Groningen, Groningen, The Netherlands
| | - Hans L Hillege
- Department of Cardiology, University of Groningen, Groningen, The Netherlands
| | - Chim C Lang
- School of Medicine Centre for Cardiovascular and Lung Biology, Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK, and NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Poland, and Cardiology Department, Military Hospital, Wroclaw, Poland
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK, and NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | | | - Aeilko H Zwinderman
- Department of Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Patrick Rossignol
- Inserm CIC-P 1433, Université de Lorraine, CHRU de Nancy, FCRIN INI-CRCT, Nancy, France
| | - Faiez Zannad
- Inserm CIC-P 1433, Université de Lorraine, CHRU de Nancy, FCRIN INI-CRCT, Nancy, France
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University of Groningen, Groningen, The Netherlands
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van der Meulen M, Dalinghaus M, Burch M, Szatmari A, Castro Diez C, Khalil F, Swoboda V, Breur J, Bajcetic M, Jovanovic I, Lagler FB, Klingmann I, Laeer S, de Wildt SN. Question 1: How safe are ACE inhibitors for heart failure in children? Arch Dis Child 2018; 103:106-109. [PMID: 29074732 DOI: 10.1136/archdischild-2017-312774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 09/28/2017] [Indexed: 12/21/2022]
Affiliation(s)
| | - Michiel Dalinghaus
- Department of Pediatric Cardiology, Erasmus MC - Sophia, Rotterdam, The Netherlands
| | - Michael Burch
- Cardiothoracic Unit, Great Ormond Street Hospital, London, UK
| | - Andras Szatmari
- Department of Pediatric Cardiology, Göttsegen Gyorgy Hungarian Institute of Cardiology, Budapest, Hungary
| | - Cristina Castro Diez
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine Universität Düsseldorf, Dusseldorf, Germany
| | - Feras Khalil
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine Universität Düsseldorf, Dusseldorf, Germany
| | | | - Johannes Breur
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital University Medical Center, Utrecht, Utrecht, The Netherlands
| | | | - Ida Jovanovic
- Clinical Pharmacology Unit, University Children's Hospital, Belgrade, Serbia
| | | | | | - Stephanie Laeer
- Department of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University, Nijmegen, The Netherlands
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44
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Abstract
PURPOSE OF REVIEW The aim of this paper is to discuss strategies for prevention and management of hyperkalemia in patients with heart failure, including the role of novel therapies. RECENT FINDINGS Renin-angiotensin-aldosterone system (RAAS) antagonists, including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and mineralocorticoid receptor antagonists (MRA) decrease mortality and morbidity in heart failure but increase the risk of hyperkalemia, especially when used in combination. Prevention of hyperkalemia and its associated complications requires careful patient selection, counseling regarding dietary potassium intake, awareness of drug interactions, and regular laboratory surveillance. Recent data suggests that the risk of hyperkalemia may be further moderated through the use of combined angiotensin-neprilysin inhibitors, novel MRAs, and novel potassium binding agents. Clinicians should be mindful of the risk of hyperkalemia when prescribing RAAS inhibitors to patients with heart failure. In patients at highest risk, such as those with diabetes, the elderly, and advanced chronic kidney disease, more intensive laboratory surveillance of potassium and creatinine may be required. Novel therapies hold promise for reducing the risk of hyperkalemia and enhancing the tolerability of RAAS antagonists.
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Affiliation(s)
- Ersilia M DeFilippis
- Cardiovascular Division (ASD) and Department of Medicine (EMD, ASD), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division (ASD) and Department of Medicine (EMD, ASD), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Advanced Heart Disease Section, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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45
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Abstract
Electrolyte abnormalities are common in heart failure and can arise from a variety of etiologies. Neurohormonal activation from ventricular dysfunction, renal dysfunction, and heart failure medications can perturb electrolyte homeostasis which impact both heart failure-related morbidity and mortality. These include disturbances in serum sodium, chloride, acid-base, and potassium homeostasis. Pharmacological treatments differ for each electrolyte abnormality and vary from older, established treatments like the vaptans or acetazolamide, to experimental or theoretical treatments like hypertonic saline or urea, or to newer, novel agents like the potassium binders: patiromer and zirconium cyclosilicate. Pharmacologic approaches range from limiting electrolyte intake or directly repleting the electrolyte, to blocking or promoting their resorption, and to neurohormonal antagonism. Because of the prevalence and clinical impact of electrolyte abnormalities, understanding both the older and newer therapeutic options is and will continue to be necessity for the management of heart failure.
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Affiliation(s)
- Justin L Grodin
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, 44195, USA.
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46
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Abstract
Heart failure is common in adults, accounting for substantial morbidity and mortality worldwide. Its prevalence is increasing because of ageing of the population and improved treatment of acute cardiovascular events, despite the efficacy of many therapies for patients with heart failure with reduced ejection fraction, such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β blockers, and mineralocorticoid receptor antagonists, and advanced device therapies. Combined angiotensin receptor blocker neprilysin inhibitors (ARNIs) have been associated with improvements in hospital admissions and mortality from heart failure compared with enalapril, and guidelines now recommend substitution of ACE inhibitors or ARBs with ARNIs in appropriate patients. Improved safety of left ventricular assist devices means that these are becoming more commonly used in patients with severe symptoms. Antidiabetic therapies might further improve outcomes in patients with heart failure. New drugs with novel mechanisms of action, such as cardiac myosin activators, are under investigation for patients with heart failure with reduced left ventricular ejection fraction. Heart failure with preserved ejection fraction is a heterogeneous disorder that remains incompletely understood and will continue to increase in prevalence with the ageing population. Although some data suggest that spironolactone might improve outcomes in these patients, no therapy has conclusively shown a significant effect. Hopefully, future studies will address these unmet needs for patients with heart failure. Admissions for acute heart failure continue to increase but, to date, no new therapies have improved clinical outcomes.
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Affiliation(s)
- Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - John R Teerlink
- School of Medicine, University of California, San Francisco, CA, USA; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
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Nilsson E, Gasparini A, Ärnlöv J, Xu H, Henriksson KM, Coresh J, Grams ME, Carrero JJ. Incidence and determinants of hyperkalemia and hypokalemia in a large healthcare system. Int J Cardiol 2017; 245:277-284. [DOI: 10.1016/j.ijcard.2017.07.035] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/04/2017] [Accepted: 07/12/2017] [Indexed: 01/16/2023]
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Younis A, Goldenberg I, Goldkorn R, Younis A, Peled Y, Tzur B, Klempfner R. Elevated Admission Potassium Levels and 1-Year and 10-Year Mortality Among Patients With Heart Failure. Am J Med Sci 2017; 354:268-277. [DOI: 10.1016/j.amjms.2017.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/14/2017] [Accepted: 07/17/2017] [Indexed: 11/26/2022]
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Sharma DC, Asirvatham A, Singh P. Dose Modification of Antidiabetic Agents in Patients with Type 2 Diabetes Mellitus and Heart Failure. Indian J Endocrinol Metab 2017; 21:618-629. [PMID: 28670548 PMCID: PMC5477452 DOI: 10.4103/ijem.ijem_442_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Heart failure is the most common comorbidity of diabetes. The incidence of heart failure in patients with diabetes is about 9%-22%, which is four times higher Than that in patients without diabetes. Heart failure and diabetes are collectively associated with increased morbidity and mortality compared to either condition alone. Several epidemiological studies have demonstrated an increased risk of heart failure in patients with diabetes; moreover, poor glycemic control accounts for the increased risk of heart failure. At present, several oral (metformin, sulfonylureas, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, etc.) as well as injectable (insulins, glucagon-like peptide 1 receptor agonists) antidiabetic agents are available. However, optimal treatment strategy to achieve adequate glycemic control in patients with type 2 diabetes mellitus (T2DM) and heart failure has not been well studied. In the view of rising prevalence of heart failure in patients with diabetes mellitus, clinicians need to understand the potential implications of antidiabetic agents in patients with heart failure. A group of experts from across India were involved in a consensus meeting in Pondicherry during the National Insulin Summit in November 2015. They evaluated agents currently available for the treatment of diabetes looking at existing scientific evidence relevant to each class of therapy. In addition, the existing guidelines and prescribing literature available with all these agents were also reviewed. Findings from the expert evaluations were then factored into the national context incorporating personal experience and common clinical practices in India. The purpose of this consensus document is to assist the clinicians while treating patients with T2DM and heart failure.
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Affiliation(s)
- D. C. Sharma
- Department of Endocrinology, RNT Medical College, Udaipur, Rajasthan, India
| | | | - Parminder Singh
- Division of Endocrinology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Rafique Z, Weir MR, Onuigbo M, Pitt B, Lafayette R, Butler J, Lopes M, Farnum C, Peacock WF. Expert Panel Recommendations for the Identification and Management of Hyperkalemia and Role of Patiromer in Patients with Chronic Kidney Disease and Heart Failure. J Manag Care Spec Pharm 2017; 23:S10-S19. [PMID: 28485203 PMCID: PMC10408402 DOI: 10.18553/jmcp.2017.23.4-a.s10] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Virtual panel meetings were conducted among 7 physicians, all of whom are independent experts, including 3 nephrologists, 2 cardiologists, and 2 emergency medicine physicians (the panel). The panel met with the purpose of discussing the current treatment landscape, treatment challenges, economic impact, and gaps in care for patients with hyperkalemia that is associated with heart failure and chronic kidney disease. The stated goal of the panel discussion was to develop practical solutions in the identification and management of hyperkalemia in this patient population. The panel noted that hyperkalemia is a serious condition that can lead to life-threatening complications, yet the treatment paradigm for hyperkalemia has remained without major advances for approximately 50 years, until the approval of patiromer. A number of issues still exist in the management of this patient population, including the lack of uniform treatment guidelines and consensus regarding the approach to treatment. As part of its effort, the panel developed an algorithm, the Proposed Diagnostic Algorithm for Hyperkalemia Treatment in the Acute Care Setting/Chronic Care. The panel agreed that patiromer appears to be a viable option for the management of hyperkalemia in patients with chronic kidney disease and/or heart failure and in patients who experience chronic hyperkalemia. DISCLOSURES This panel discussion was funded by Relypsa and facilitated by Magellan Rx Management. Rafique is a principal investigator for Relypsa and serves as a consultant for Instrumentation Laboratory, Magellan Health, Relypsa, and ZS-Pharma. Butler serves as consultant for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, CardioCell, Janssen, Merck, Novartis, Relypsa, and ZS-Pharma. Lopes and Farnum are employed by Magellan Rx Management. Rafique designed the management protocol for this panel discussion and contributed to the writing and editing of this report document. The other authors report no conflicting interests. Relypsa is the manufacturer of Veltassa (patiromer).
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Affiliation(s)
- Zubaid Rafique
- 1 Baylor College of Medicine, Texas Medical Center, Houston
| | | | - Macaulay Onuigbo
- 3 Mayo Clinic Health System, Eau Claire, Wisconsin, and Mayo Clinic, Rochester, Minnesota
| | - Bertram Pitt
- 4 University of Michigan School of Medicine, Ann Arbor
| | | | | | - Maria Lopes
- 7 Magellan Rx Management, Newport, Rhode Island
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