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Rasoul D, Zhang J, Farnell E, Tsangarides AA, Chong SC, Fernando R, Zhou C, Ihsan M, Ahmed S, Lwin TS, Bateman J, Hill RA, Lip GY, Sankaranarayanan R. Continuous infusion versus bolus injection of loop diuretics for acute heart failure. Cochrane Database Syst Rev 2024; 5:CD014811. [PMID: 38775253 PMCID: PMC11110107 DOI: 10.1002/14651858.cd014811.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Acute heart failure (AHF) is new onset of, or a sudden worsening of, chronic heart failure characterised by congestion in about 95% of cases or end-organ hypoperfusion in 5% of cases. Treatment often requires urgent escalation of diuretic therapy, mainly through hospitalisation. This Cochrane review evaluated the efficacy of intravenous loop diuretics strategies in treating AHF in individuals with New York Heart Association (NYHA) classification III or IV and fluid overload. OBJECTIVES To assess the effects of intravenous continuous infusion versus bolus injection of loop diuretics for the initial treatment of acute heart failure in adults. SEARCH METHODS We identified trials through systematic searches of bibliographic databases and in clinical trials registers including CENTRAL, MEDLINE, Embase, CPCI-S on the Web of Science, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry platform (ICTRP), and the European Union Trials register. We conducted reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was performed on 29 February 2024. SELECTION CRITERIA We included randomised controlled trials (RCTs) involving adults with AHF, NYHA classification III or IV, regardless of aetiology or ejection fraction, where trials compared intravenous continuous infusion of loop diuretics with intermittent bolus injection in AHF. We excluded trials with chronic stable heart failure, cardiogenic shock, renal artery stenosis, or end-stage renal disease. Additionally, we excluded studies combining loop diuretics with hypertonic saline, inotropes, vasoactive medications, or renal replacement therapy and trials where diuretic dosing was protocol-driven to achieve a target urine output, due to confounding factors. DATA COLLECTION AND ANALYSIS Two review authors independently screened papers for inclusion and reviewed full-texts. Outcomes included weight loss, all-cause mortality, length of hospital stay, readmission following discharge, and occurrence of acute kidney injury. We performed risk of bias assessment and meta-analysis where data permitted and assessed certainty of the evidence. MAIN RESULTS The review included seven RCTs, spanning 32 hospitals in seven countries in North America, Europe, and Asia. Data collection ranged from eight months to six years. Following exclusion of participants in subgroups with confounding treatments and different clinical settings, 681 participants were eligible for review. These additional study characteristics, coupled with our strict inclusion and exclusion criteria, improve the applicability of the body of the evidence as they reflect real-world clinical practice. Meta-analysis was feasible for net weight loss, all-cause mortality, length of hospital stay, readmission, and acute kidney injury. Literature review and narrative analysis explored daily fluid balance; cardiovascular mortality; B-type natriuretic peptide (BNP) change; N-terminal-proBNP change; and adverse incidents such as ototoxicity, hypotension, and electrolyte imbalances. Risk of bias assessment revealed two studies with low overall risk, four with some concerns, and one with high risk. All sensitivity analyses excluded trials at high risk of bias. Only narrative analysis was conducted for 'daily fluid balance' due to diverse data presentation methods across two studies (169 participants, the evidence was very uncertain about the effect). Results of narrative analysis varied. For instance, one study reported higher daily fluid balance within the first 24 hours in the continuous infusion group compared to the bolus injection group, whereas there was no difference in fluid balance beyond this time point. Continuous intravenous infusion of loop diuretics may result in mean net weight loss of 0.86 kg more than bolus injection of loop diuretics, but the evidence is very uncertain (mean difference (MD) 0.86 kg, 95% confidence interval (CI) 0.44 to 1.28; 5 trials, 497 participants; P < 0.001, I2 = 21%; very low-certainty evidence). Importantly, sensitivity analysis excluding trials with high risk of bias showed there was insufficient evidence for a difference in bodyweight loss between groups (MD 0.70 kg, 95% CI -0.06 to 1.46; 3 trials, 378 participants; P = 0.07, I2 = 0%). There may be little to no difference in all-cause mortality between continuous infusion and bolus injection (risk ratio (RR) 1.53, 95% CI 0.81 to 2.90; 5 trials, 530 participants; P = 0.19, I2 = 4%; low-certainty evidence). Despite sensitivity analysis, the direction of the evidence remained unchanged. No trials measured cardiovascular mortality. There may be little to no difference in the length of hospital stay between continuous infusion and bolus injection of loop diuretics, but the evidence is very uncertain (MD -1.10 days, 95% CI -4.84 to 2.64; 4 trials, 211 participants; P = 0.57, I2 = 88%; very low-certainty evidence). Sensitivity analysis improved heterogeneity; however, the direction of the evidence remained unchanged. There may be little to no difference in the readmission to hospital between continuous infusion and bolus injection of loop diuretics (RR 0.85, 95% CI 0.63 to 1.16; 3 trials, 400 participants; P = 0.31, I2 = 0%; low-certainty evidence). Sensitivity analysis continued to show insufficient evidence for a difference in the readmission to hospital between groups. There may be little to no difference in the occurrence of acute kidney injury as an adverse event between continuous infusion and bolus injection of intravenous loop diuretics (RR 1.02, 95% CI 0.70 to 1.49; 3 trials, 491 participants; P = 0.92, I2 = 0%; low-certainty evidence). Sensitivity analysis continued to show that continuous infusion may make little to no difference on the occurrence of acute kidney injury as an adverse events compared to the bolus injection of intravenous loop diuretics. AUTHORS' CONCLUSIONS Analysis of available data comparing two delivery methods of diuretics in acute heart failure found that the current data are insufficient to show superiority of one strategy intervention over the other. Our findings were based on trials meeting stringent inclusion and exclusion criteria to ensure validity. Despite previous reviews suggesting advantages of continuous infusion over bolus injections, our review found insufficient evidence to support or refute this. However, our review, which excluded trials with clinical confounders and RCTs with high risk of bias, offers the most robust conclusion to date.
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Affiliation(s)
- Debar Rasoul
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Cardiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Juqian Zhang
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Ebony Farnell
- General Medicine, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Andreas A Tsangarides
- Emergency Department, The University of New South Wales, The Prince of Wales Hospital, Sydney, Australia
| | - Shiau Chin Chong
- Pharmacy, Hospital Sultan Ismail, Ministry of Health Malaysia, Johor Bahru, Malaysia
| | - Ranga Fernando
- General Medicine, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Can Zhou
- Cardiology, King's College Hospital, London, UK
| | - Mahnoor Ihsan
- Acute Medicine, Mid-Cheshire Hospital NHS Foundation Trust, Crewe, UK
| | - Sarah Ahmed
- Nephrology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Tin S Lwin
- Cardiology, Castle Hill Hospital, Hull, UK
| | | | - Ruaraidh A Hill
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Liverpool John Moores University, Liverpool, UK
- Cardiology, Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Rajiv Sankaranarayanan
- Cardiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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Hiraiwa H, Okumura T, Murohara T. Drug Therapy for Acute and Chronic Heart Failure with Preserved Ejection Fraction with Hypertension: A State-of-the-Art Review. Am J Cardiovasc Drugs 2024; 24:343-369. [PMID: 38575813 PMCID: PMC11093799 DOI: 10.1007/s40256-024-00641-9] [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: 03/12/2024] [Indexed: 04/06/2024]
Abstract
In this comprehensive state-of-the-art review, we provide an evidence-based analysis of current drug therapies for patients with heart failure with preserved ejection fraction (HFpEF) in the acute and chronic phases with concurrent hypertension. Additionally, we explore the latest developments and emerging evidence on the efficacy, safety, and clinical outcomes of common and novel drug treatments in the management of HFpEF with concurrent hypertension. During the acute phase of HFpEF, intravenous diuretics, mineralocorticoid receptor antagonists (MRAs), and vasodilators are pivotal, while in the chronic phase, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have proven effective in enhancing clinical outcomes. However, the use of calcium channel blockers in HFpEF with hypertension should be approached with caution, owing to their potential negative inotropic effects. We also explored emerging drug therapies for HFpEF, such as sodium-glucose co-transporter 2 (SGLT2) inhibitors, angiotensin receptor-neprilysin inhibitor (ARNI), soluble guanylate cyclase (sGC) stimulators, novel MRAs, and ivabradine. Notably, SGLT2 inhibitors have shown promise in reducing heart failure hospitalizations and cardiovascular mortality in patients with HFpEF, regardless of their diabetic status. Additionally, ARNI and sGC stimulators have demonstrated potential in improving symptoms, functional capacity, and quality of life. Nonetheless, additional research is necessary to pinpoint optimal treatment strategies for HFpEF with concurrent hypertension. Furthermore, long-term studies are essential to assess the durability and sustained benefits of emerging drug therapies. Identification of novel targets and mechanisms underlying HFpEF pathophysiology will pave the way for innovative drug development approaches in the management of HFpEF with concurrent hypertension.
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Affiliation(s)
- Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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von Haehling S, Assmus B, Bekfani T, Dworatzek E, Edelmann F, Hashemi D, Hellenkamp K, Kempf T, Raake P, Schütt KA, Wachter R, Schulze PC, Hasenfuss G, Böhm M, Bauersachs J. Heart failure with preserved ejection fraction: diagnosis, risk assessment, and treatment. Clin Res Cardiol 2024:10.1007/s00392-024-02396-4. [PMID: 38602566 DOI: 10.1007/s00392-024-02396-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/02/2024] [Indexed: 04/12/2024]
Abstract
The aetiology of heart failure with preserved ejection fraction (HFpEF) is heterogenous and overlaps with that of several comorbidities like atrial fibrillation, diabetes mellitus, chronic kidney disease, valvular heart disease, iron deficiency, or sarcopenia. The diagnosis of HFpEF involves evaluating cardiac dysfunction through imaging techniques and assessing increased left ventricular filling pressure, which can be measured directly or estimated through various proxies including natriuretic peptides. To better narrow down the differential diagnosis of HFpEF, European and American heart failure guidelines advocate the use of different algorithms including comorbidities that require diagnosis and rigorous treatment during the evaluation process. Therapeutic recommendations differ between guidelines. Whilst sodium glucose transporter 2 inhibitors have a solid evidence base, the recommendations differ with regard to the use of inhibitors of the renin-angiotensin-aldosterone axis. Unless indicated for specific comorbidities, the use of beta-blockers should be discouraged in HFpEF. The aim of this article is to provide an overview of the current state of the art in HFpEF diagnosis, clinical evaluation, and treatment.
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Affiliation(s)
- Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
| | - Birgit Assmus
- Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, Giessen, Germany
| | - Tarek Bekfani
- Department of Cardiology and Angiology, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Elke Dworatzek
- Institute of Gender in Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Frank Edelmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Djawid Hashemi
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin, Germany
| | - Kristian Hellenkamp
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
| | - Tibor Kempf
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Philipp Raake
- I. Medical Department, Cardiology, Pneumology, Endocrinology and Intensive Care Medicine, University Hospital Augsburg, University of Augsburg, Augsburg, Germany
| | - Katharina A Schütt
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Wachter
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Paul Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, FSU, Jena, Germany
| | - Gerd Hasenfuss
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Michael Böhm
- Kardiologie, Angiologie und Internistische Intensivmedizin, Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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Kazory A. Contemporary Decongestive Strategies in Acute Heart Failure. Semin Nephrol 2024; 44:151512. [PMID: 38702211 DOI: 10.1016/j.semnephrol.2024.151512] [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] [Indexed: 05/06/2024]
Abstract
Congestion is the primary driver of hospital admissions in patients with heart failure and the key determinant of their outcome. Although intravenous loop diuretics remain the predominant agents used in the setting of acute heart failure, the therapeutic response is known to be variable, with a significant subset of patients discharged from the hospital with residual hypervolemia. In this context, urinary sodium excretion has gained attention both as a marker of response to loop diuretics and as a marker of prognosis that may be a useful clinical tool to guide therapy. Several decongestive strategies have been explored to improve diuretic responsiveness and removal of excess fluid. Sequential nephron blockade through combination diuretic therapy is one of the most used methods to enhance natriuresis and counter diuretic resistance. In this article, I provide an overview of the contemporary decongestive approaches and discuss the clinical data on the use of add-on diuretic therapy. I also discuss mechanical removal of excess fluid through extracorporeal ultrafiltration with a brief review of the results of landmark studies. Finally, I provide a short overview of the strategies that are currently under investigation and may prove helpful in this setting.
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Affiliation(s)
- Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, College of Medicine, University of Florida, Gainesville, FL.
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Lisco G, De Tullio A, Iovino M, Disoteo O, Guastamacchia E, Giagulli VA, Triggiani V. Dopamine in the Regulation of Glucose Homeostasis, Pathogenesis of Type 2 Diabetes, and Chronic Conditions of Impaired Dopamine Activity/Metabolism: Implication for Pathophysiological and Therapeutic Purposes. Biomedicines 2023; 11:2993. [PMID: 38001993 PMCID: PMC10669051 DOI: 10.3390/biomedicines11112993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Dopamine regulates several functions, such as voluntary movements, spatial memory, motivation, sleep, arousal, feeding, immune function, maternal behaviors, and lactation. Less clear is the role of dopamine in the pathophysiology of type 2 diabetes mellitus (T2D) and chronic complications and conditions frequently associated with it. This review summarizes recent evidence on the role of dopamine in regulating insular metabolism and activity, the pathophysiology of traditional chronic complications associated with T2D, the pathophysiological interconnection between T2D and chronic neurological and psychiatric disorders characterized by impaired dopamine activity/metabolism, and therapeutic implications. Reinforcing dopamine signaling is therapeutic in T2D, especially in patients with dopamine-related disorders, such as Parkinson's and Huntington's diseases, addictions, and attention-deficit/hyperactivity disorder. On the other hand, although specific trials are probably needed, certain medications approved for T2D (e.g., metformin, pioglitazone, incretin-based therapy, and gliflozins) may have a therapeutic role in such dopamine-related disorders due to anti-inflammatory and anti-oxidative effects, improvement in insulin signaling, neuroinflammation, mitochondrial dysfunction, autophagy, and apoptosis, restoration of striatal dopamine synthesis, and modulation of dopamine signaling associated with reward and hedonic eating. Last, targeting dopamine metabolism could have the potential for diagnostic and therapeutic purposes in chronic diabetes-related complications, such as diabetic retinopathy.
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Affiliation(s)
- Giuseppe Lisco
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari, 70124 Bari, Italy; (G.L.); (A.D.T.); (M.I.); (E.G.); (V.A.G.)
| | - Anna De Tullio
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari, 70124 Bari, Italy; (G.L.); (A.D.T.); (M.I.); (E.G.); (V.A.G.)
| | - Michele Iovino
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari, 70124 Bari, Italy; (G.L.); (A.D.T.); (M.I.); (E.G.); (V.A.G.)
| | - Olga Disoteo
- Diabetology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Edoardo Guastamacchia
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari, 70124 Bari, Italy; (G.L.); (A.D.T.); (M.I.); (E.G.); (V.A.G.)
| | - Vito Angelo Giagulli
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari, 70124 Bari, Italy; (G.L.); (A.D.T.); (M.I.); (E.G.); (V.A.G.)
| | - Vincenzo Triggiani
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari, 70124 Bari, Italy; (G.L.); (A.D.T.); (M.I.); (E.G.); (V.A.G.)
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Pius R, Odukudu GDO, Olorundare I, Makanjuola DI, Komolafe R, Njoku C, Ubogun OE, Muhammad R, Osiogo EO, Anulaobi C. A Narrative Review on the Efficacy and Safety of Loop Diuretics in Patients With Heart Failure With Reduced Ejection Fraction and Preserved Ejection Fraction. Cureus 2023; 15:e45794. [PMID: 37872937 PMCID: PMC10590658 DOI: 10.7759/cureus.45794] [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: 09/22/2023] [Indexed: 10/25/2023] Open
Abstract
To date, loop diuretics are the mainstay treatment for decongestion in patients with acute decompensated heart failure (HF). In clinical practice, loop diuretics have also been utilized for patients with chronic HF with reduced and preserved ejection fractions. There is a paucity of quality evidence of the effect of loop diuretics use and dosing on clinical outcomes in HF patients beyond symptomatic relief. In this review, we aimed to summarize recently published data on the use of loop diuretics in patients with HF, focusing on efficacy and safety outcomes in patients with HF with reduced and preserved ejection fraction. We searched EMBASE, PubMed, CINAHL, and the "Web of Science" databases. Cohort studies and randomized controlled trials published after 2018 and written in English were included in this review. Case reports, case series, cross-sectional studies, review articles, commentaries, articles published more than five years ago, and studies involving children were excluded. Results were divided into the efficacy and safety of loop diuretics in HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). A registry-based study included in our review observed a reduced 30-day all-cause mortality in patients with HFrEF receiving loop diuretics compared to those not receiving loop diuretics (HR=0.73; 95% CI=0.57-0.94; p=0.016), but there was no statistically significant association at the 60-day follow-up of the same group of patients. Most studies reviewed showed that the choice of loop diuretics did not influence clinical outcomes such as mortality and HF rehospitalization in patients with HF with reduced and preserved ejection fraction despite differences in oral bioavailability and half-life. Studies have consistently shown that patients with HF who receive a higher dose of loop diuretics are likely to experience a decline in renal function and hypotension, regardless of their type of HF. Discontinuation or reduction of the dose of loop diuretics should be considered in patients with HF after decongestion.
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Affiliation(s)
- Ruth Pius
- Internal Medicine, Lincoln Medical Centre, Bronx, USA
| | | | - Israel Olorundare
- Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | | | - Chidimma Njoku
- Internal Medicine, Gomel State Medical University, Gomel, BLR
| | | | - Ramatu Muhammad
- Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Elsie O Osiogo
- Internal Medicine, Ahmadu Bello University Teaching Hospital, Zaria, NGA
| | - Caleb Anulaobi
- Internal Medicine/Infectious Diseases, Ekiti State Ministry of Health and Human Services, Ado-Ekiti, NGA
- Medicine and Surgery, Abia State University, Uturu, NGA
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Şaylık F, Cinar T. Comparison of continuous loop diuretic versus bolus injection regimens in patients with heart failure: a comprehensive meta-analysis of the literature. Rev Assoc Med Bras (1992) 2022; 68:1599-1605. [DOI: 10.1590/1806-9282.20220583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 07/08/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Tufan Cinar
- Sultan II. Abdulhamid Han Training and Research Hospital, Turkey
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8
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Peters AE, DeVore AD. Pharmacologic Therapy for Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:473-489. [DOI: 10.1016/j.ccl.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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The Application of Dopamine Combined with Intravenous Furosemide Infusion Therapy Has an Apparent Clinical Effect in Treating Patients with Heart Failure. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:1055160. [PMID: 36034940 PMCID: PMC9410776 DOI: 10.1155/2022/1055160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 07/24/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022]
Abstract
Objective To observe the efficacy and safety of dopamine plus furosemide in treating patients with heart failure. Methods This research included 150 patients with heart failure who were diagnosed and treated at our hospital between March 2018 and November 2020. The patients were randomly assigned to a study group or a reference group according to the data of admission (the cut-off date was June 2019). Patients in the reference group were given furosemide, whereas those in the study group were given dopamine plus furosemide intravenous pumping. Outcome measures included clinical effectiveness, heart function changes, and adverse responses. Results Dopamine plus furosemide resulted in higher treatment efficiency (96.00%) versus furosemide (74.67%) study group (P < 0.05). Before therapy, there was no significant change in the scores of cardiac function indices between the two groups (P > 0.05). The cardiac function of the two groups of patients was improved after treatment, and the left ventricular ejection fraction (LVEF) of the study group (44.85 ± 4.12) was higher than that of the reference group (38.45 ± 4.36), and the left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic diameter (LVESD), and plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) (43.17 ± 3.98, 51.32 ± 4.25, 3045.56 ± 365.48) were lower than the reference group (47.56 ± 4.65, 56.28 ± 4.85, 4856.48 ± 395.46) (P < 0.05). There was no significant difference in the total incidence of adverse reactions between the two groups (P > 0.05). Conclusion Dopamine plus intravenous furosemide infusion treatment has an obvious therapeutic benefit in treating patients with heart failure and dramatically enhances cardiac function without noteworthy adverse responses. It demonstrated great potential for clinical promotion.
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Yang E, Vaishnav J, Song E, Lee J, Schulman S, Calkins H, Berger R, Russell SD, Sharma K. Atrial fibrillation is an independent risk factor for heart failure hospitalization in heart failure with preserved ejection fraction. ESC Heart Fail 2022; 9:2918-2927. [PMID: 35712815 DOI: 10.1002/ehf2.13836] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/15/2022] [Accepted: 01/23/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS Atrial fibrillation (AF) is a common comorbid condition in heart failure with preserved ejection fraction (HFpEF). The effect of AF on heart failure (HF) exacerbation in HFpEF has not been well described. This study investigated how AF modifies the clinical trajectory of HFpEF patients after hospitalization for decompensated HF. METHODS AND RESULTS We stratified HFpEF subjects by AF diagnosis and performed longitudinal analysis to compare risk for HF hospitalization after index hospitalization for decompensated HF. All-cause mortality, 30 day all-cause readmissions, and response to inpatient diuresis were also evaluated. Of 90 subjects enrolled, 35.6% (n = 32) had AF. Subjects with AF were older (72.5 vs. 60.5 years; P < 0.01), more often male (46.9% vs. 24.1%; P = 0.03), and had greater left atrial diameter (4.9 vs. 3.8 cm; P < 0.01) compared with those without AF. Subjects with AF had a higher risk for HF hospitalization than their counterparts without AF (P = 0.02); this relationship remained significant following multivariable competing risk regression with propensity score weighting (hazard ratio 2.53, P = 0.04 and hazard ratio 2.91, P = 0.04, with overlap and inverse probability weighting, respectively). Although having AF appeared to increase the risk of all-cause hospital readmission within 30 days of discharge (37.5% vs. 17.5%; P = 0.036), this relationship failed to remain significant following propensity score adjustment for clinical covariates. CONCLUSIONS Atrial fibrillation is an independent risk factor for HF rehospitalization in HFpEF. Further understanding of the interplay between AF and HFpEF will be critical to guide the selection of appropriate rhythm management strategies in this population.
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Affiliation(s)
- Eunice Yang
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joban Vaishnav
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Evelyn Song
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joan Lee
- Department of Medicine, Sinai Hospital, Baltimore, MD, USA
| | - Steven Schulman
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ronald Berger
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stuart D Russell
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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11
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Cox ZL, Rao VS, Testani JM. Classic and Novel Mechanisms of Diuretic Resistance in Cardiorenal Syndrome. KIDNEY360 2022; 3:954-967. [PMID: 36128483 PMCID: PMC9438407 DOI: 10.34067/kid.0006372021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/23/2022] [Indexed: 01/10/2023]
Abstract
Despite the incompletely understood multiple etiologies and underlying mechanisms, cardiorenal syndrome is characterized by decreased glomerular filtration and sodium avidity. The underlying level of renal sodium avidity is of primary importance in driving a congested heart failure phenotype and ultimately determining the response to diuretic therapy. Historically, mechanisms of kidney sodium avidity and resultant diuretic resistance were primarily extrapolated to cardiorenal syndrome from non-heart failure populations. Yet, the mechanisms appear to differ between these populations. Recent literature in acute decompensated heart failure has refuted several classically accepted diuretic resistance mechanisms and reshaped how we conceptualize diuretic resistance mechanisms in cardiorenal syndrome. Herein, we propose an anatomically based categorization of diuretic resistance mechanisms to establish the relative importance of specific transporters and translate findings toward therapeutic strategies. Within this categorical structure, we discuss classic and novel mechanisms of diuretic resistance.
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Affiliation(s)
- Zachary L. Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee,Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Veena S. Rao
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey M. Testani
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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12
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Abstract
Despite recent advances in the treatment of chronic heart failure, therapeutic options for acute heart failure (AHF) remain limited. AHF admissions are associated with significant multi-organ dysfunction, especially worsening renal failure, which results in significant morbidity and mortality. There are several aspects of AHF management: diagnosis, decongestion, vasoactive therapy, goal-directed medical therapy initiation and safe transition of care. Effective diagnosis and prognostication could be very helpful in an acute setting and rely upon biomarker evaluation with noninvasive assessment of fluid status. Decongestive strategies could be tailored to include pharmaceutical options along with consideration of utilizing ultrafiltration for refractory hypervolemia. Vasoactive agents to augment cardiac function have been evaluated in patients with AHF but have shown to only have limited efficacy. Post stabilization, initiation of quadruple goal-directed medical therapy—angiotensin receptor-neprilysin inhibitors, mineral receptor antagonists, sodium glucose type 2 (SGLT-2) inhibitors, and beta blockers—to prevent myocardial remodeling is being advocated as a standard of care. Safe transition of care is needed prior to discharge to prevent heart failure rehospitalization and mortality. Post-discharge close ambulatory monitoring (including remote hemodynamic monitoring), virtual visits, and rehabilitation are some of the strategies to consider. We hereby review the contemporary approach in AHF diagnosis and management.
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Affiliation(s)
- Hayaan Kamran
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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13
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Fu K, Hu Y, Zhang H, Wang C, Lin Z, Lu H, Ji X. Insights of Worsening Renal Function in Type 1 Cardiorenal Syndrome: From the Pathogenesis, Biomarkers to Treatment. Front Cardiovasc Med 2022; 8:760152. [PMID: 34970606 PMCID: PMC8712491 DOI: 10.3389/fcvm.2021.760152] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/11/2021] [Indexed: 12/16/2022] Open
Abstract
Type-1 cardiorenal syndrome refers to acute kidney injury induced by acute worsening cardiac function. Worsening renal function is a strong and independent predictive factor for poor prognosis. Currently, several problems of the type-1 cardiorenal syndrome have not been fully elucidated. The pathogenesis mechanism of renal dysfunction is unclear. Besides, the diagnostic efficiency, sensitivity, and specificity of the existing biomarkers are doubtful. Furthermore, the renal safety of the therapeutic strategies for acute heart failure (AHF) is still ambiguous. Based on these issues, we systematically summarized and depicted the research actualities and predicaments of the pathogenesis, diagnostic markers, and therapeutic strategies of worsening renal function in type-1 cardiorenal syndrome.
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Affiliation(s)
- Kang Fu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Yue Hu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Hui Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Chen Wang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Zongwei Lin
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Huixia Lu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Xiaoping Ji
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
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14
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Rosalia L, Ozturk C, Shoar S, Fan Y, Malone G, Cheema FH, Conway C, Byrne RA, Duffy GP, Malone A, Roche ET, Hameed A. Device-Based Solutions to Improve Cardiac Physiology and Hemodynamics in Heart Failure With Preserved Ejection Fraction. JACC Basic Transl Sci 2021; 6:772-795. [PMID: 34754993 PMCID: PMC8559325 DOI: 10.1016/j.jacbts.2021.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/03/2021] [Indexed: 12/28/2022]
Abstract
Characterized by a rapidly increasing prevalence, elevated mortality and rehospitalization rates, and inadequacy of pharmaceutical therapies, heart failure with preserved ejection fraction (HFpEF) has motivated the widespread development of device-based solutions. HFpEF is a multifactorial disease of various etiologies and phenotypes, distinguished by diminished ventricular compliance, diastolic dysfunction, and symptoms of heart failure despite a normal ejection performance; these symptoms include pulmonary hypertension, limited cardiac reserve, autonomic imbalance, and exercise intolerance. Several types of atrial shunts, left ventricular expanders, stimulation-based therapies, and mechanical circulatory support devices are currently under development aiming to target one or more of these symptoms by addressing the associated mechanical or hemodynamic hallmarks. Although the majority of these solutions have shown promising results in clinical or preclinical studies, no device-based therapy has yet been approved for the treatment of patients with HFpEF. The purpose of this review is to discuss the rationale behind each of these devices and the findings from the initial testing phases, as well as the limitations and challenges associated with their clinical translation.
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Key Words
- BAT, baroreceptor activation therapy
- CCM, cardiac contractility modulation
- CRT, cardiac resynchronization therapy
- HF, heart failure
- HFmEF, heart failure with mid-range ejection fraction
- HFpEF
- HFpEF, heart failure with preserved ejection fraction
- HFrEF, heart failure with reduced ejection fraction
- IASD, Interatrial Shunt Device
- LAAD, left atrial assist device
- LAP, left atrial pressure
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- MCS, mechanical circulatory support
- NYHA, New York Heart Association
- PCWP, pulmonary capillary wedge pressure
- QoL, quality of life
- TAA, transapical approach
- atrial shunt devices
- electrostimulation
- heart failure devices
- heart failure with preserved ejection fraction
- left ventricular expanders
- mechanical circulatory support
- neuromodulation
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Affiliation(s)
- Luca Rosalia
- Health Sciences and Technology Program, Harvard–Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Caglar Ozturk
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | | | - Yiling Fan
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Grainne Malone
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Faisal H. Cheema
- HCA Healthcare, Houston, Texas, USA
- University of Houston, College of Medicine, Houston, Texas, USA
| | - Claire Conway
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Robert A. Byrne
- Department of Cardiology, Mater Private Hospital, Dublin, Ireland
- Cardiovascular Research, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Garry P. Duffy
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Anatomy & Regenerative Medicine Institute, School of Medicine, College of Medicine, Nursing, and Health Sciences, National University of Ireland Galway, Galway, Ireland
- Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
- Advanced Materials for Biomedical Engineering and Regenerative Medicine, Trinity College Dublin, and National University of Ireland Galway, Galway, Ireland
- Trinity Centre for Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Andrew Malone
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ellen T. Roche
- Health Sciences and Technology Program, Harvard–Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Aamir Hameed
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Trinity Centre for Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
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15
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Nandkeolyar S, Ryu R, Mohammad A, Cordero-Caban K, Abramov D, Tran H, Hauschild C, Stoletniy L, Hilliard A, Sakr A. A Review of Inotropes and Inopressors for Effective Utilization in Patients With Acute Decompensated Heart Failure. J Cardiovasc Pharmacol 2021; 78:336-345. [PMID: 34117179 DOI: 10.1097/fjc.0000000000001078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Inotropes and inopressors are often first-line treatment in patients with cardiogenic shock. We summarize the pharmacology, indications, and contraindications of dobutamine, milrinone, dopamine, norepinephrine, epinephrine, and levosimendan. We also review the data on the use of these medications for acute decompensated heart failure and cardiogenic shock in this article.
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Affiliation(s)
- Shuktika Nandkeolyar
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | | | - Adeba Mohammad
- Medicine, Loma Linda University Medical Center, Loma Linda CA
| | | | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | | | | | - Liset Stoletniy
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | - Anthony Hilliard
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | - Antoine Sakr
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
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16
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He X, Dong B, Xue R, Zhao J, Wu Z, Wu Y, Zhou Y, Wu D, Dong Y, He J, Liu C. Effect of aggressive diuresis in acute heart failure with reduced and preserved ejection fraction. ESC Heart Fail 2021; 8:3248-3256. [PMID: 34076960 PMCID: PMC8318499 DOI: 10.1002/ehf2.13453] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 05/11/2021] [Accepted: 05/21/2021] [Indexed: 01/11/2023] Open
Abstract
Aims Heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) had distinct haemodynamic characteristics in the setting of acute heart failure. The aim of our study is to evaluate the differential response to aggressive diuresis in HFrEF and HFpEF. Methods and results Patients in the Diuretic Optimization Strategies Evaluation trial with left ventricular ejection fraction measurement were included (n = 300) and classified into HFrEF [left ventricular ejection fraction (LVEF) < 40%] (n = 193) and HFpEF (LVEF ≥ 40%) (n = 107). Effect of high‐dose vs. low‐dose furosemide strategy was compared separately in HFrEF and HFpEF. In HFrEF, high‐dose strategy did not increase change in creatinine or cystatin C at 72 h [treatment difference: −0.05, 95% confidence interval (CI): −0.14 to 0.03 mg/dL; P = 0.23 for creatinine, and treatment difference: −0.06, 95% CI: −0.15 to 0.02 mg/dL; P = 0.15 for cystatin C] compared with low‐dose strategy, but there were significantly more net fluid loss, weight loss, and congestion‐free patients at 72 h in high‐dose group. It was also associated with a significantly lower risk of composite clinical outcome of death, total hospitalizations, and unscheduled visits due to heart failure. In HFpEF, high‐dose strategy significantly increased change in creatinine and cystatin C at 72 h (treatment difference: 0.16; 95% CI: 0.02–0.30 mg/dL; P = 0.03 for creatinine, and treatment difference: 0.26; 95% CI: 0.09–0.43 mg/dL; P = 0.003 for cystatin C), but did not significantly affect net fluid loss, weight loss, proportion of congestion‐free patients at 72 h, and risk of the composite clinical outcome. Conclusions Acute heart failure on the basis of HFrEF and HFpEF responded differently to aggressive diuresis. Future trials should be designed separately for HFrEF and HFpEF.
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Affiliation(s)
- Xin He
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Bin Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Ruicong Xue
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Jingjing Zhao
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Zexuan Wu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Yuzhong Wu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Yuanyuan Zhou
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Dexi Wu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Yugang Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Jiangui He
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Chen Liu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
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17
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Mishra S, Kass DA. Cellular and molecular pathobiology of heart failure with preserved ejection fraction. Nat Rev Cardiol 2021; 18:400-423. [PMID: 33432192 PMCID: PMC8574228 DOI: 10.1038/s41569-020-00480-6] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 01/30/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) affects half of all patients with heart failure worldwide, is increasing in prevalence, confers substantial morbidity and mortality, and has very few effective treatments. HFpEF is arguably the greatest unmet medical need in cardiovascular disease. Although HFpEF was initially considered to be a haemodynamic disorder characterized by hypertension, cardiac hypertrophy and diastolic dysfunction, the pandemics of obesity and diabetes mellitus have modified the HFpEF syndrome, which is now recognized to be a multisystem disorder involving the heart, lungs, kidneys, skeletal muscle, adipose tissue, vascular system, and immune and inflammatory signalling. This multiorgan involvement makes HFpEF difficult to model in experimental animals because the condition is not simply cardiac hypertrophy and hypertension with abnormal myocardial relaxation. However, new animal models involving both haemodynamic and metabolic disease, and increasing efforts to examine human pathophysiology, are revealing new signalling pathways and potential therapeutic targets. In this Review, we discuss the cellular and molecular pathobiology of HFpEF, with the major focus being on mechanisms relevant to the heart, because most research has focused on this organ. We also highlight the involvement of other important organ systems, including the lungs, kidneys and skeletal muscle, efforts to characterize patients with the use of systemic biomarkers, and ongoing therapeutic efforts. Our objective is to provide a roadmap of the signalling pathways and mechanisms of HFpEF that are being characterized and which might lead to more patient-specific therapies and improved clinical outcomes.
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Affiliation(s)
- Sumita Mishra
- Department of Medicine, Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David A. Kass
- Department of Medicine, Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,
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18
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Ying W, Sharma K, Yanek LR, Vaidya D, Schär M, Markl M, Subramanya V, Soleimani S, Ouyang P, Michos ED, Shah SJ, Hays AG. Visceral adiposity, muscle composition, and exercise tolerance in heart failure with preserved ejection fraction. ESC Heart Fail 2021; 8:2535-2545. [PMID: 33939300 PMCID: PMC8318398 DOI: 10.1002/ehf2.13382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/25/2021] [Accepted: 04/12/2021] [Indexed: 12/17/2022] Open
Abstract
Aims Visceral adipose tissue (AT) promotes inflammation and may be associated with disease progression in heart failure with preserved ejection fraction (HFpEF). We characterized regional AT distribution in HFpEF patients and controls and analysed associations with co‐morbidities and exercise tolerance. Methods and results Magnetic resonance imaging was performed to quantify epicardial, liver, abdominal, and thigh skeletal muscle AT. We assessed New York Heart Association (NYHA) class, 6 min walk distance, and global well‐being score. Multivariable linear regression models adjusting for body surface area were used. We studied 55 HFpEF patients (41 women, mean age 67 ± 11 years) and 33 controls (21 women, mean age 57 ± 10 years). Epicardial AT (median [interquartile range] 4.6 [2.0] vs. 3.2 [1.4] mm, P < 0.001), thigh intermuscular fat (11.0 [11.5] vs. 5.0 [2.7] cm2, P < 0.001) and liver fat fraction (6.4% [6.1] vs. 4.1% [5.5], P = 0.001) were higher in HFpEF patients than controls. Women with HFpEF had higher abdominal and thigh subcutaneous AT than men. Greater thigh intermuscular fat was associated with higher blood pressure (β [SE] 0.73 [0.17], P < 0.001) and diabetes (odds ratio [95% confidence interval] 1.2 [1.0–1.5], P = 0.03). Greater thigh intramuscular fat was associated with both worse NYHA class (β [SE] 2.7 [1.0], P = 0.01) and shorter 6 min walk distance (β [SE] −4.1 [1.9], P = 0.03), and greater epicardial AT (β [SE] −0.2 [0.1], P < 0.001) and liver fat fraction (β [SE] −0.4 [0.2], P = 0.04) were associated with lower global well‐being score. Conclusions Heart failure with preserved ejection fraction patients have increased epicardial, liver, and skeletal muscle fat compared with controls out of proportion to their increased body size, and adiposity was associated with worse NYHA class and exercise tolerance in HFpEF. These results provide the basis for further investigation into the effect of interventions to reduce regional AT distribution in relation to HFpEF symptoms and pathophysiology.
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Affiliation(s)
- Wendy Ying
- School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Kavita Sharma
- School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Lisa R Yanek
- School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Dhananjay Vaidya
- School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD, 21287, USA.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Schär
- School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Michael Markl
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Sahar Soleimani
- School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Pamela Ouyang
- School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Erin D Michos
- School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD, 21287, USA.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Allison G Hays
- School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD, 21287, USA
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19
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Rasalingam R, Parker R, Kurgansky KE, Djousse L, Gagnon D, Joseph J. Worsening Renal Function during Index Hospitalization Does Not Predict Prognosis in Heart Failure with Preserved Ejection Fraction Patients. Cardiology 2021; 146:179-186. [PMID: 33524973 DOI: 10.1159/000512431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 10/10/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Worsening renal function (WRF) predicts poor prognosis in patients with left ventricular systolic dysfunction. The effect of WRF in heart failure with preserved ejection fraction (HFpEF) is unclear. OBJECTIVE The objective of this study was to determine whether WRF during index hospitalization for HFpEF is associated with increased death or readmission for heart failure. METHODS National Veterans Affairs electronic medical data recorded between January 1, 2002, and December 31, 2014, were screened to identify index hospitalizations for HFpEF using an iterative algorithm. Patients were divided into 3 groups based on changes in serum Cr (sCr) during this admission. WRF was defined as a rise in sCr ≥0.3 mg/dL. Group 1 had no evidence of WRF, group 2 had transient WRF, and group 3 had persistent WRF at the time of discharge. RESULTS A total of 10,902 patients with index hospitalizations for HFpEF were identified (mean age 72, 97% male). Twenty-nine percent had WRF during this hospital admission, with 48% showing recovery of sCr and 52% with no recovery at discharge. The mortality rate over a mean follow-up duration of 3.26 years was 72%. Compared to group 1, groups 2 and 3 showed no significant difference in risk of death from any cause (hazard ratio [HR] = 0.95 [95% confidence interval [CI]: 0.87, 1.03] and 1.02 [95% CI: 0.93, 1.11], respectively), days hospitalized for any cause (incidence density ratio [IDR] = 1.01 [95% CI: 0.92, 1.11] and 1.01 [95% CI: 0.93, 1.11], respectively), or days hospitalized for heart failure (IDR = 0.94 [95% CI: 0.80, 1.10] and 0.94 [95% CI: 0.81, 1.09], respectively) in analyses adjusted for covariates affecting renal function and outcomes. CONCLUSIONS While there is a high incidence of WRF during index hospitalizations for HFpEF, WRF is not associated with an increased risk of death or hospitalization. This suggests that WRF alone should not influence decisions regarding heart failure management.
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Affiliation(s)
- Ravi Rasalingam
- Department of Medicine Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel Parker
- Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Katherine E Kurgansky
- Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Luc Djousse
- Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.,Division of Aging, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Gagnon
- Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jacob Joseph
- Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA, .,Department of Medicine Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA,
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20
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El Hussein MT, Blayney S. ABCs of Heart Failure (HFpEF) Management: Guide for Nurse Practitioners. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2020.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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21
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Starwalt JL, Ho AF, Wang H. Worsening renal function after diuresis among heart failure patients with preserved ejection fraction: a dilemma to heart failure management. Letter regarding the article 'Association of left ventricular ejection fraction with worsening renal function in patients with acute heart failure: insights from the RELAX-AHF-2 study'. Eur J Heart Fail 2020; 23:494-495. [PMID: 33161637 DOI: 10.1002/ejhf.2050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- John L Starwalt
- Department of Emergency Medicine, JPS Health Network, Fort Worth, TX, USA
| | - Amy F Ho
- Department of Emergency Medicine, JPS Health Network, Fort Worth, TX, USA
| | - Hao Wang
- Department of Emergency Medicine, JPS Health Network, Fort Worth, TX, USA
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22
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Vaishnav J, Chasler JE, Lee YJ, Ndumele CE, Hu JR, Schulman SP, Russell SD, Sharma K. Highest Obesity Category Associated With Largest Decrease in N-Terminal Pro-B-Type Natriuretic Peptide in Patients Hospitalized With Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2020; 9:e015738. [PMID: 32750299 PMCID: PMC7792252 DOI: 10.1161/jaha.119.015738] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Heart failure with preserved ejection fraction (HFpEF) constitutes half of hospitalized heart failure cases and is commonly associated with obesity. The role of natriuretic peptide levels in hospitalized obese patients with HFpEF, however, is not well defined. We sought to evaluate change in NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels by obesity category and related clinical outcomes in patients with HFpEF hospitalized for acute heart failure. Methods and Results A total of 89 patients with HFpEF hospitalized with acute decompensated heart failure were stratified into 3 obesity categories: nonobese (body mass index [BMI] <30.0 kg/m2, 19%), obese (BMI 30.0-39.9 kg/m2, 29%), and severely obese (BMI ≥40.0 kg/m2, 52%), and compared for percent change in NT-proBNP during hospitalization and clinical outcomes. Clinical characteristics were compared between patients with normal NT-proBNP (≤125 pg/mL) and elevated NT-proBNP. Admission NT-proBNP was inversely related to BMI category (nonobese, 2607 pg/mL [interquartile range, IQR: 2112-5703]; obese, 1725 pg/mL [IQR: 889-3900]; and severely obese, 770.5 pg/mL [IQR: 128-1268]; P<0.01). Severely obese patients had the largest percent change in NT-proBNP with diuresis (-64.8% [95% CI, -85.4 to -38.9] versus obese -40.4% [95% CI, -74.3 to -12.0] versus nonobese -46.9% [95% CI, -57.8 to -37.4]; P=0.03). Nonobese and obese patients had significantly worse 1-year survival compared with severely obese patients (63% versus 76% versus 95%, respectively; P<0.01). Patients with normal NT-proBNP (13%) were younger, with higher BMI, less atrial fibrillation, and less structural heart disease than those with elevated NT-proBNP. Conclusions In hospitalized patients with HFpEF, NT-proBNP was inversely related to BMI with the largest decrease in NT-proBNP seen in the highest obesity category. These findings have implications for the role of NT-proBNP in the diagnosis and assessment of treatment response in obese patients with HFpEF.
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Affiliation(s)
- Joban Vaishnav
- Department of Medicine Division of Cardiology Johns Hopkins University School of Medicine Baltimore MD
| | - Jessica E Chasler
- Department of Medicine Division of Cardiology Johns Hopkins University School of Medicine Baltimore MD
| | - Yizhen J Lee
- Department of Medicine Division of Cardiology Johns Hopkins University School of Medicine Baltimore MD
| | - Chiadi E Ndumele
- Department of Medicine Division of Cardiology Johns Hopkins University School of Medicine Baltimore MD
| | - Jiun-Ruey Hu
- Bloomberg School of Public Health Johns Hopkins University Baltimore MD
| | - Steven P Schulman
- Department of Medicine Division of Cardiology Johns Hopkins University School of Medicine Baltimore MD
| | - Stuart D Russell
- Department of Medicine Division of Cardiology Duke University Durham NC
| | - Kavita Sharma
- Department of Medicine Division of Cardiology Johns Hopkins University School of Medicine Baltimore MD
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23
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Hahn VS, Yanek LR, Vaishnav J, Ying W, Vaidya D, Lee YZJ, Riley SJ, Subramanya V, Brown EE, Hopkins CD, Ononogbu S, Perzel Mandell K, Halushka MK, Steenbergen C, Rosenberg AZ, Tedford RJ, Judge DP, Shah SJ, Russell SD, Kass DA, Sharma K. Endomyocardial Biopsy Characterization of Heart Failure With Preserved Ejection Fraction and Prevalence of Cardiac Amyloidosis. JACC-HEART FAILURE 2020; 8:712-724. [PMID: 32653448 DOI: 10.1016/j.jchf.2020.04.007] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/03/2020] [Accepted: 04/14/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study prospectively evaluated endomyocardial biopsies in patients with heart failure with preserved ejection fraction (HFpEF) to identify histopathologic phenotypes and their association with clinical characteristics. BACKGROUND Myocardial tissue analysis from a prospectively defined HFpEF cohort reflecting contemporary comorbidities is lacking. METHODS Patients with HFpEF (EF ≥50%) referred to the Johns Hopkins HFpEF Clinic between August 2014 and September 2018 were enrolled for right heart catheterization and endomyocardial biopsy. Clinical features, echocardiography, hemodynamics, and tissue histology were determined and compared with controls (unused donor hearts) and HF with reduced EF (HFrEF). RESULTS Of the 108 patients enrolled, median age was 66 years (25th to 75th percentile: 57 to 74 years), 61% were women, 57% were African American, 62% had a previous HF hospitalization, median systolic blood pressure was 141 mm Hg (25th to 75th percentile: 125 to 162 mm Hg), body mass index (BMI) was 37 kg/m2 (25th to 75th percentile: 32 to 45 kg/m2), and 97% were on a loop diuretic. Myocardial fibrosis and myocyte hypertrophy were often present (93% and 88%, respectively); however, mild in 71% with fibrosis and in 52% with hypertrophy. Monocyte infiltration (CD68+ cells/mm2) was greater in patients with HFpEF versus controls (60.4 cells/mm2 [25th to 75th percentile: 36.8 to 97.8] vs. 32.1 cells/mm2 [25th to 75th percentile: 22.3 to 59.2]; p = 0.02) and correlated with age and renal disease. Cardiac amyloidosis (CA) was diagnosed in 15 (14%) patients (HFpEF-CA: 7 patients with wild-type transthyretin amyloidosis [ATTR], 4 patients with hereditary ATTR, 3 patients with light-chain amyloidosis, and 1 patient with AA (secondary) amyloidosis), of which 7 cases were unsuspected. Patients with HFpEF-CA were older, with lower BMI, higher left ventricular mass index, and higher N-terminal pro-B-type natriuretic peptide and troponin I levels. CONCLUSIONS In this large, prospective myocardial tissue analysis of HFpEF, myocardial fibrosis and hypertrophy were common, CD68+ inflammation was increased, and CA prevalence was 14%. Tissue analysis in HFpEF might improve precision therapies by identifying relevant myocardial mechanisms.
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Affiliation(s)
- Virginia S Hahn
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa R Yanek
- Division of General Internal Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joban Vaishnav
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Wendy Ying
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dhananjay Vaidya
- Division of General Internal Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yi Zhen Joan Lee
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sarah J Riley
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Vinita Subramanya
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Emily E Brown
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - C Danielle Hopkins
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sandra Ononogbu
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kira Perzel Mandell
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Marc K Halushka
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Charles Steenbergen
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Avi Z Rosenberg
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ryan J Tedford
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel P Judge
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University, Chicago, Illinois
| | | | - David A Kass
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kavita Sharma
- Division of Cardiology, The Johns Hopkins School of Medicine, Baltimore, Maryland.
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Agrawal A, Naranjo M, Kanjanahattakij N, Rangaswami J, Gupta S. Cardiorenal syndrome in heart failure with preserved ejection fraction-an under-recognized clinical entity. Heart Fail Rev 2020; 24:421-437. [PMID: 31127482 DOI: 10.1007/s10741-018-09768-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiorenal syndrome (CRS) results from the complex and bidirectional interaction between the failing heart and the kidneys. Limited information exists about the pathophysiology and treatment options for worsening kidney function in the setting of heart failure with preserved ejection fraction (HFpEF). This review summarizes the salient pathophysiological pathways in CRS in patients with HFpEF, with emphasis on type 1 and type 2 phenotypes, and outlines diagnostic and therapeutic strategies that are applicable in this population. Elevated central venous and intra-abdominal pressure, left ventricular hypertrophy, LV strain, RAAS activation, oxidative injury, pulmonary hypertension, and RV dysfunction play key roles in the pathogenesis of CRS in the backdrop of HFpEF. The availability of biomarkers of renal and cardiac injury offer a new dimension in accurately diagnosing and quantifying end organ damage in CRS and will improve the accuracy of goal-directed therapies in this population. Novel targeted therapies such as the development of angiotensin/neprilysin inhibitors and sodium-glucose cotransporter-2 (SGLT-2) inhibitors offer new territory in realizing potential benefits in reduction of cardio-renal adverse outcomes in this population. Future studies focusing exclusively on renal outcomes in patients with HFpEF are crucial in delivering optimal therapies in this subset of patients.
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Affiliation(s)
- Akanksha Agrawal
- Department of Internal Medicine, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, 19141, USA.
| | - Mario Naranjo
- Department of Internal Medicine, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, 19141, USA
| | - Napatt Kanjanahattakij
- Department of Internal Medicine, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, 19141, USA
| | - Janani Rangaswami
- Department of Nephrology, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Shuchita Gupta
- Department of Cardiology, Albert Einstein Medical Center, Philadelphia, PA, USA
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25
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Reddy YNV, Obokata M, Testani JM, Felker GM, Tang WHW, Abou-Ezzeddine OF, Sun JL, Chakrabothy H, McNulty S, Shah SJ, Lewis GD, Stevenson LW, Redfield MM, Borlaug BA. Adverse Renal Response to Decongestion in the Obese Phenotype of Heart Failure With Preserved Ejection Fraction. J Card Fail 2019; 26:101-107. [PMID: 31618698 DOI: 10.1016/j.cardfail.2019.09.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/17/2019] [Accepted: 09/28/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with heart failure (HF) with preserved ejection fraction (HFpEF) and obesity display a number of pathophysiologic features that may render them more or less vulnerable to negative effects of decongestion on renal function, including greater right ventricular remodeling, plasma volume expansion and pericardial restraint. We aimed to contrast the renal response to decongestion in obese compared to nonobese patients with HFpEF METHODS AND RESULTS: National Institutes of Health heart failure network studies that enrolled patients with acute decompensated HFpEF (EF ≥ 50%) were included (DOSE, CARRESS, ROSE, and ATHENA). Obese HFpEF was defined as a body mass index ≥ 30 kg/m2. Compared to nonobese HFpEF (n = 118), patients with obese HFpEF (n = 214) were an average of 9 years younger (71 vs 80 years,< 0.001), were more likely to have diabetes (64% vs 31%, P< 0.001) but had less atrial fibrillation (56% vs 75%, P< 0.001). Renal dysfunction (glomerular filtration rate < 60 mL/min/1.73m2) was present in 82% of patients, and there was no difference at baseline between obese and nonobese patients. Despite similar weight loss through decongestive therapies, obese patients with HFpEF demonstrated greater rise in creatinine (Cr) and decline in glomerular filtration rate, with a 2-fold higher incidence of mild worsening renal function (rise in Cr ≥ 0.3 mg/dL) (28 vs 14%, P = 0.008) and a substantially greater increase in severe worsening of renal function (rise in Cr > 0.5 mg/dL) (9 vs 0%, P = 0.002). CONCLUSIONS Despite being nearly a decade younger, obese patients with HFpEF experience greater deterioration in renal function during decongestion than do nonobese patients with HFpEF. Further study to elucidate the complex relationships between volume distribution, cardiorenal hemodynamics and adiposity in HFpEF is needed.
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Affiliation(s)
- Yogesh N V Reddy
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Masaru Obokata
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey M Testani
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - G Michael Felker
- Deparment of Cardiovscular Medicine, Duke University, Durham, NC
| | - W H Wilson Tang
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Deparment of Cardiovscular Medicine, Duke University, Durham, NC; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Deparment of Cardiovscular Medicine, Vanderbilt University, Nashville, TN
| | | | - Jie-Lena Sun
- Deparment of Cardiovscular Medicine, Duke University, Durham, NC
| | | | - Steven McNulty
- Deparment of Cardiovscular Medicine, Duke University, Durham, NC
| | - Sanjiv J Shah
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Deparment of Cardiovscular Medicine, Duke University, Durham, NC; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Deparment of Cardiovscular Medicine, Vanderbilt University, Nashville, TN
| | - Gregory D Lewis
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Deparment of Cardiovscular Medicine, Duke University, Durham, NC; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Deparment of Cardiovscular Medicine, Vanderbilt University, Nashville, TN
| | - Lynne W Stevenson
- Deparment of Cardiovscular Medicine, Vanderbilt University, Nashville, TN
| | | | - Barry A Borlaug
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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Mariano F, Mella A, Vincenti M, Biancone L. Furosemide as a functional marker of acute kidney injury in ICU patients: a new role for an old drug. J Nephrol 2019; 32:883-893. [PMID: 31090022 DOI: 10.1007/s40620-019-00614-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/16/2019] [Indexed: 12/21/2022]
Abstract
New pharmacokinetics insight suggests that the furosemide pharmacology occurring in ICU patients with AKI is similar, but not equal to that described in chronic stable renal patients. Even if the diuretic response to furosemide is expressed by a steep dose-response curve positively correlated with renal function, pharmacodynamic limitations occur when creatinine clearance is < 20 ml/min or urine output is < 500 ml/12 h. In such cases, other factors specifically due to acute tubular injury can interfere with the furosemide-induced diuretic output. As modality of administration recent reports and metanalysis, even if not conclusive, suggest that for the same given dose a continuous infusion of furosemide was superior in diuretic response. For septic shock patients on CVVHDF where treatment adds an additional clearance of furosemide the maximum diuretic response is achieved by a continuous infusion of 20 mg/h of furosemide. At this infusion rate the reached plasma level was < 20 mg/L, a range considered safe and not ototoxic. Therefore, the severity of AKI establishes whether a patient will respond to furosemide. In this review we summarized all these recent updates, also suggesting that the diuretic response under continuous infusion may allow assessing glomerular and tubular functions with increased reliability than a bolus dose. However, validation studies are still needed to support continuous infusion as a stress test.
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Affiliation(s)
- Filippo Mariano
- Nephrology, Dialysis and Transplantation U, Department of Medical Sciences, CTO Hospital, University of Turin, City of Health and Science, Via G. Zuretti 29, 10126, Turin, Italy.
| | - Alberto Mella
- Nephrology, Dialysis and Transplantation U, Department of Medical Sciences, CTO Hospital, University of Turin, City of Health and Science, Via G. Zuretti 29, 10126, Turin, Italy
| | - Marco Vincenti
- Department of Chemistry, University of Turin, Turin, Italy
| | - Luigi Biancone
- Nephrology, Dialysis and Transplantation U, Department of Medical Sciences, CTO Hospital, University of Turin, City of Health and Science, Via G. Zuretti 29, 10126, Turin, Italy
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28
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Sinnenberg L, Givertz MM. Acute heart failure. Trends Cardiovasc Med 2019; 30:104-112. [PMID: 31006522 DOI: 10.1016/j.tcm.2019.03.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/23/2019] [Accepted: 03/25/2019] [Indexed: 12/21/2022]
Abstract
Acute heart failure (AHF) is one of the most common causes for hospital admission and is associated with a high risk of mortality. Compared to chronic heart failure, there is less robust evidence to guide diagnosis, risk stratification and management of AHF. This state-of-the art review aims to summarize new developments in this field. We also highlight areas of ongoing work including novel vasoactive agents, alternative models to traditional hospital admission and strategies to improve patient engagement.
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Affiliation(s)
- Lauren Sinnenberg
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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