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Mazón-Ruiz J, Romero-González G, Sánchez E, Banegas-Deras EJ, Salgado-Barquinero M, la Varga LGD, Bande-Fernández JJ, Gorostidi M, Alcázar R. Hypertonic saline and heart failure: "sodium-centric" or "chlorine-centric"? Nefrologia 2024; 44:338-343. [PMID: 38964947 DOI: 10.1016/j.nefroe.2024.06.009] [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: 06/07/2023] [Revised: 08/14/2023] [Accepted: 08/19/2023] [Indexed: 07/06/2024] Open
Abstract
Up to 50% of patients admitted for heart failure (HF) have congestion at discharge despite diagnostic and therapeutic advances. Both persistent congestion and diuretic resistance are associated with worse prognosis. The combination of hypertonic saline and loop diuretic has shown promising results in different studies. However, it has not yet achieved a standardized use, partly because of the great heterogeneity in the concentration of sodium chloride, the dose of diuretic or the amount of sodium in the diet. Classically, the movement of water from the intracellular space due to an increase in extracellular osmolarity has been postulated as the main mechanism involved. However, chloride deficit is postulated as the main up-regulator of plasma volume changes, and its correction may be the main mechanism involved. This "chloride centric" approach to heart failure opens the door to therapeutic strategies that would include diuretics to correct hypochloremia, as well as sodium free chloride supplementation.
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Affiliation(s)
- Jaime Mazón-Ruiz
- Servicio de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Spain.
| | - Gregorio Romero-González
- Servicio de Nefrología, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; International Renal Research Institute Vicenza, Italy
| | - Emilio Sánchez
- Servicio de Nefrología, Hospital Universitario de Cabueñes, Gijón, Spain
| | | | | | | | | | - Manuel Gorostidi
- Servicio de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Roberto Alcázar
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
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Deniau B, Costanzo MR, Sliwa K, Asakage A, Mullens W, Mebazaa A. Acute heart failure: current pharmacological treatment and perspectives. Eur Heart J 2023; 44:4634-4649. [PMID: 37850661 DOI: 10.1093/eurheartj/ehad617] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 08/23/2023] [Accepted: 09/08/2023] [Indexed: 10/19/2023] Open
Abstract
Acute heart failure (AHF) represents the most frequent cause of unplanned hospital admission in patients older than 65 years. Symptoms and clinical signs of AHF (e.g. dyspnoea, orthopnoea, oedema, jugular vein distension, and variation of body weight) are mostly related to systemic venous congestion secondary to various mechanisms including extracellular fluids, increased ventricular filling pressures, and/or auto-transfusion of blood from the splanchnic into the pulmonary circulation. Thus, the initial management of AHF patients should be mostly based on decongestive therapies on admission followed, before discharge, by rapid implementation of guideline-directed oral medical therapies for heart failure. The therapeutic management of AHF requires the identification and rapid diagnosis of the disease, the diagnosis of the cause (or triggering factor), the evaluation of severity, the presence of comorbidities, and, finally, the initiation of a rapid treatment. The most recent guidelines from ESC and ACC/AHA/HFSA have provided updated recommendations on AHF management. Recommended pharmacological treatment for AHF includes diuretic therapy aiming to relieve congestion and achieve optimal fluid status, early and rapid initiation of oral therapies before discharge combined with a close follow-up. Non-pharmacological AHF management requires risk stratification in the emergency department and non-invasive ventilation in case of respiratory failure. Vasodilators should be considered as initial therapy in AHF precipitated by hypertension. On the background of recent large randomized clinical trials and international guidelines, this state-of-the-art review describes current pharmacological treatments and potential directions for future research in AHF.
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Affiliation(s)
- Benjamin Deniau
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, 2 rue Ambroise Paré, 75010 Paris, France
- UMR-S 942, INSERM, MASCOT, Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, France
| | | | - Karen Sliwa
- Cape Heart Institute, Department of Cardiology and Medicine, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, South Africa
| | - Ayu Asakage
- UMR-S 942, INSERM, MASCOT, Université de Paris Cité, Paris, France
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg A.V., Genk, Belgium
- Hasselt University, Diepenbeek/Hasselt, Belgium
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, 2 rue Ambroise Paré, 75010 Paris, France
- UMR-S 942, INSERM, MASCOT, Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, France
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Feng R, Zhang Z, Fan Q. Carbohydrate antigen 125 in congestive heart failure: ready for clinical application? Front Oncol 2023; 13:1161723. [PMID: 38023127 PMCID: PMC10644389 DOI: 10.3389/fonc.2023.1161723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Congestion is the permanent mechanism driving disease progression in patients with acute heart failure (AHF) and also is an important treatment target. However, distinguishing between the two different phenotypes (intravascular congestion and tissue congestion) for personalized treatment remains challenging. Historically, carbohydrate antigen 125 (CA125) has been a frequently used biomarker for the screening, diagnosis, and prognosis of ovarian cancer. Interestingly, CA125 is highly sensitive to tissue congestion and shows potential for clinical monitoring and optimal treatment of congestive heart failure (HF). Furthermore, in terms of right heart function parameters, CA125 levels are more advantageous than other biomarkers of HF. CA125 is expected to become a new biological alternative marker for congestive HF and thereby is expected be widely used in clinical practice.
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Affiliation(s)
- Rui Feng
- Department of Laboratory Medicine, Wuhan Asian Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
- School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Zhenlu Zhang
- Department of Laboratory Medicine, Wuhan Asian Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Qingkun Fan
- Department of Laboratory Medicine, Wuhan Asian Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
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Bertomeu‐Gonzalez V, Fácila L, Palau P, Miñana G, Núñez G, Espriella R, Santas E, Núñez E, Bodí V, Chorro FJ, Cordero A, Sanchis J, Lupón J, Bayés‐Genís A, Núñez J. Effect of insulin on readmission for heart failure following a hospitalization for acute heart failure. ESC Heart Fail 2020; 7:3320-3328. [PMID: 32790113 PMCID: PMC7754754 DOI: 10.1002/ehf2.12944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/18/2020] [Accepted: 07/19/2020] [Indexed: 01/10/2023] Open
Abstract
Aims Type 2 diabetes mellitus (T2DM) is common in patients with heart failure (HF) and is related with worse outcomes. Insulin treatment is associated with sodium and water retention, weight gain, and hypoglycaemia—all pathophysiological mechanisms related to HF decompensation. This study aimed to evaluate the association between insulin treatment and the risk of 1 year readmission for HF in patients discharged for acute HF. Methods and results We prospectively included 2895 consecutive patients discharged after an episode of acute HF in a single tertiary hospital. Multivariable Cox regression, adapted for competing events, was used to assess the association between insulin treatment and 1 year readmission for HF in patients discharged after acute HF. Participants' mean age was 73.4 ± 11.2 years, 50.8% were women, 44.7% had T2DM [including 527 (18.2%) on insulin therapy], and 52.7% had preserved ejection fraction. At 1 year follow‐up, 518 (17.9%) patients had died and 693 (23.9%) were readmitted for HF. The crude risk of readmission for HF was higher in patients on insulin, with no differences in 1 year mortality. After multivariable adjustment, patients on insulin were at significantly higher risk of 1 year readmission for HF than patients with diabetes who were not on insulin (hazard ratio 1.28; 95% confidence interval 1.04–1.59, P = 0.022) and patients without diabetes (hazard ratio 1.26; 95% confidence interval 1.02–1.55, P = 0.035). Conclusion Following acute HF, patients with T2DM on insulin therapy are at increased risk of readmission for HF. Further studies unravelling the mechanisms behind this association are warranted.
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Affiliation(s)
- Vicente Bertomeu‐Gonzalez
- Cardiology Service Hospital Universitario San Juan de Alicante Alicante Spain
- Clinical Medicine Department Universidad Miguel Hernández Alicante Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV) Madrid Spain
| | - Lorenzo Fácila
- Cardiology Service Hospital General Universitario de Valencia Valencia Spain
| | - Patricia Palau
- Cardiology Service Hospital Clínico Universitario, INCLIVA Valencia Spain
- Department of Medicine Universitat de València Valencia Spain
| | - Gema Miñana
- Cardiology Service Hospital Clínico Universitario, INCLIVA Valencia Spain
| | - Gonzalo Núñez
- Cardiology Service Hospital Clínico Universitario, INCLIVA Valencia Spain
| | - Rafael Espriella
- Cardiology Service Hospital Clínico Universitario, INCLIVA Valencia Spain
| | - Enrique Santas
- Cardiology Service Hospital Clínico Universitario, INCLIVA Valencia Spain
| | - Eduardo Núñez
- Cardiology Service Hospital Clínico Universitario, INCLIVA Valencia Spain
| | - Vicent Bodí
- Cardiology Service Hospital Clínico Universitario, INCLIVA Valencia Spain
- Department of Medicine Universitat de València Valencia Spain
| | - Francisco Javier Chorro
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV) Madrid Spain
- Cardiology Service Hospital Clínico Universitario, INCLIVA Valencia Spain
- Department of Medicine Universitat de València Valencia Spain
| | - Alberto Cordero
- Cardiology Service Hospital Universitario San Juan de Alicante Alicante Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV) Madrid Spain
| | - Juan Sanchis
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV) Madrid Spain
- Cardiology Service Hospital Clínico Universitario, INCLIVA Valencia Spain
- Department of Medicine Universitat de València Valencia Spain
| | - Josep Lupón
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV) Madrid Spain
- Heart Failure Unit, Cardiology Service Hospital Universitari Germans Trias i Pujol Barcelona Spain
- Department of Medicine Autonomous University of Barcelona Barcelona Spain
| | - Antoni Bayés‐Genís
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV) Madrid Spain
- Heart Failure Unit, Cardiology Service Hospital Universitari Germans Trias i Pujol Barcelona Spain
- Department of Medicine Autonomous University of Barcelona Barcelona Spain
| | - Julio Núñez
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV) Madrid Spain
- Cardiology Service Hospital Clínico Universitario, INCLIVA Valencia Spain
- Department of Medicine Universitat de València Valencia Spain
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Núñez J, Llàcer P, García-Blas S, Bonanad C, Ventura S, Núñez JM, Sánchez R, Fácila L, de la Espriella R, Vaquer JM, Cordero A, Roqué M, Chamorro C, Bodi V, Valero E, Santas E, Moreno MDC, Miñana G, Carratalá A, Rodríguez E, Mollar A, Palau P, Bosch MJ, Bertomeu-González V, Lupón J, Navarro J, Chorro FJ, Górriz JL, Sanchis J, Voors AA, Bayés-Genís A. CA125-Guided Diuretic Treatment Versus Usual Care in Patients With Acute Heart Failure and Renal Dysfunction. Am J Med 2020; 133:370-380.e4. [PMID: 31422111 DOI: 10.1016/j.amjmed.2019.07.041] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 06/27/2019] [Accepted: 07/19/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The optimal diuretic treatment strategy for patients with acute heart failure and renal dysfunction remains unclear. Plasma carbohydrate antigen 125 (CA125) is a surrogate of fluid overload and a potentially valuable tool for guiding decongestion therapy. The aim of this study was to determine if a CA125-guided diuretic strategy is superior to usual care in terms of short-term renal function in patients with acute heart failure and renal dysfunction at presentation. METHODS This multicenter, open-label study randomized 160 patients with acute heart failure and renal dysfunction into 2 groups (1:1). Loop diuretics doses were established according to CA125 levels in the CA125-guided group (n = 79) and in clinical evaluation in the usual-care group (n = 81). Changes in estimated glomerular filtration rate (eGFR) at 72 and 24 hours were the co-primary endpoints, respectively. RESULTS The mean age was 78 ± 8 years, the median amino-terminal pro-brain natriuretic peptide was 7765 pg/mL, and the mean eGFR was 33.7 ± 11.3 mL/min/1.73m2. Over 72 hours, the CA125-guided group received higher furosemide equivalent dose compared to usual care (P = 0.011), which translated into higher urine volume (P = 0.042). Moreover, patients in the active arm with CA125 >35 U/mL received the highest furosemide equivalent dose (P <0.001) and had higher diuresis (P = 0.013). At 72 hours, eGFR (mL/min/1.73m2) significantly improved in the CA125-guided group (37.5 vs 34.8, P = 0.036), with no significant changes at 24 hours (35.8 vs 39.5, P = 0.391). CONCLUSION A CA125-guided diuretic strategy significantly improved eGFR and other renal function parameters at 72 hours in patients with acute heart failure and renal dysfunction.
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Affiliation(s)
- Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain.
| | - Pau Llàcer
- Internal Medicine Department, Hospital de Manises, Manises, Valencia, Spain
| | - Sergio García-Blas
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Silvia Ventura
- Internal Medicine Department, Hospital de La Plana, Villa-Real, Castellón, Spain
| | - José María Núñez
- Critical Care Unit, Hospital Universitario del Vinalopó, Elche, Alicante, Spain
| | - Ruth Sánchez
- Internal Medicine Department, Hospital Virgen de Los Lirios, Alcoy, Spain
| | - Lorenzo Fácila
- Cardiology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Juana María Vaquer
- Biochemistry Department, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Alberto Cordero
- Cardiology Department, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Mercè Roqué
- Cardiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carlos Chamorro
- Internal Medicine Department, Hospital Virgen de Los Lirios, Alcoy, Spain
| | - Vicent Bodi
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Ernesto Valero
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | | | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Arturo Carratalá
- Biochemistry Department, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Enrique Rodríguez
- Biochemistry Department, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Anna Mollar
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Patricia Palau
- Cardiology Department, Hospital General Universitario de Castellón. Universitat Jaume I, Castellón, Spain
| | - María José Bosch
- Internal Medicine Department, Hospital de La Plana, Villa-Real, Castellón, Spain
| | - Vicente Bertomeu-González
- Cardiology Department, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Josep Lupón
- CIBER Cardiovascular, Madrid, Spain; Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Jorge Navarro
- Hospital Clínico Universitario, INCLIVA. Universitat de València, Valencia, Spain
| | - Francisco J Chorro
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Jose L Górriz
- Nephrology Department, Hospital Clínico Universitario, INCLIVA. Universitat de València, Valencia, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Adriaan A Voors
- Cardiology Department, University Medical Center Groningen, Netherlands
| | - Antoni Bayés-Genís
- CIBER Cardiovascular, Madrid, Spain; Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
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