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Locatelli F, Paoletti E, Ravera M, Pucci Bella G, Del Vecchio L. Can we effectively manage chronic kidney disease with a precision-based pharmacotherapy plan? Where are we? Expert Opin Pharmacother 2024; 25:1145-1161. [PMID: 38940769 DOI: 10.1080/14656566.2024.2374039] [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: 04/22/2024] [Accepted: 06/25/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION In recent years, thanks to significant advances in basic science and biotechnologies, nephrology has witnessed a deeper understanding of the mechanisms leading to various conditions associated with or causing kidney disease, opening new perspectives for developing specific treatments. These new possibilities have brought increased challenges to physicians, who face with a new complexity in disease characterization and selection the right treatment for individual patients. AREAS COVERED We chose four therapeutic situations: anaemia in chronic kidney disease (CKD), heart failure in CKD, IgA nephropathy (IgAN) and membranous nephropathy (MN). The literature search was made through PubMed. EXPERT OPINION Anaemia management remains challenging in CKD; a personalized therapeutic approach is often needed. Identifying patients who could benefit from a specific therapy is also an important goal for patients with CKD and heart failure with reduced ejection fraction. Several new treatments are under clinical development for IgAN; interestingly, they target specifically the pathogenetic mechanisms of the disease. The understanding of MN pathogenesis as an autoimmune disease and the discovery of several autoantibodies allows a better characterization of patients. High-sensible techniques for lymphocyte counting open the possibility of more personalized use of anti CD20 therapies.
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Affiliation(s)
- Francesco Locatelli
- Past Director, Department of Nephrology and Dialysis, A Manzoni Hospital, Lecco, Italy
| | - Ernesto Paoletti
- Department of Nephrology and Dialysis, ASL 1 Imperiese - Stabilimento Ospedaliero di Imperia, Imperia, Liguria, Italy
| | - Maura Ravera
- Nephrology, Dialysis and Transplantation Unit, Policlinico San Martino, Genoa, Italy
| | - Giulio Pucci Bella
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
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Jain R, Kittleson MM. Evolutions in Combined Heart-Kidney Transplant. Curr Heart Fail Rep 2024; 21:139-146. [PMID: 38231443 PMCID: PMC10923997 DOI: 10.1007/s11897-024-00646-0] [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] [Accepted: 01/08/2024] [Indexed: 01/18/2024]
Abstract
PURPOSE OF REVIEW This review describes management practices, outcomes, and allocation policies in candidates for simultaneous heart-kidney transplantation (SHKT). RECENT FINDINGS In patients with heart failure and concomitant kidney disease, SHKT confers a survival advantage over heart transplantation (HT) alone in patients with dialysis dependence or an estimated glomerular filtration rate (eGFR) < 40 mL/min/1.73 m2. However, when compared to kidney transplantation (KT) alone, SHKT is associated with worse patient and kidney allograft survival. In September 2023, the United Network of Organ Sharing adopted a new organ allocation policy, with strict eligibility criteria for SHKT and a safety net for patients requiring KT after HT alone. While the impact of the policy change on SHKT outcomes remains to be seen, strategies to prevent and slow development of kidney disease in patients with heart failure and to prevent kidney dysfunction after HT and SHKT are necessary.
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Affiliation(s)
- Rashmi Jain
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, 2nd floor, 8670 Wilshire Boulevard, Los Angeles, CA, 90211, USA
| | - Michelle M Kittleson
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, 2nd floor, 8670 Wilshire Boulevard, Los Angeles, CA, 90211, USA.
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Franczyk B, Rysz J, Olszewski R, Gluba-Sagr A. Do Implantable Cardioverter-Defibrillators Prevent Sudden Cardiac Death in End-Stage Renal Disease Patients on Dialysis? J Clin Med 2024; 13:1176. [PMID: 38398488 PMCID: PMC10889557 DOI: 10.3390/jcm13041176] [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: 11/06/2023] [Revised: 01/23/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Chronic kidney disease patients appear to be predisposed to heart rhythm disorders, including atrial fibrillation/atrial flutter, ventricular arrhythmias, and supraventricular tachycardias, which increase the risk of sudden cardiac death. The pathophysiological factors underlying arrhythmia and sudden cardiac death in patients with end-stage renal disease are unique and include timing and frequency of dialysis and dialysate composition, vulnerable myocardium, and acute proarrhythmic factors triggering asystole. The high incidence of sudden cardiac deaths suggests that this population could benefit from implantable cardioverter-defibrillator therapy. The introduction of implantable cardioverter-defibrillators significantly decreased the rate of all-cause mortality; however, the benefits of this therapy among patients with chronic kidney disease remain controversial since the studies provide conflicting results. Electrolyte imbalances in haemodialysis patients may result in ineffective shock therapy or the appearance of non-shockable underlying arrhythmic sudden cardiac death. Moreover, the implantation of such devices is associated with a risk of infections and central venous stenosis. Therefore, in the population of patients with heart failure and severe renal impairment, periprocedural risk and life expectancy must be considered when deciding on potential device implantation. Harmonised management of rhythm disorders and renal disease can potentially minimise risks and improve patients' outcomes and prognosis.
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Affiliation(s)
- Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Lodz, Poland; (B.F.); (J.R.)
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Lodz, Poland; (B.F.); (J.R.)
| | - Robert Olszewski
- Department of Gerontology, Public Health and Didactics, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Anna Gluba-Sagr
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Lodz, Poland; (B.F.); (J.R.)
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Ostrominski JW, Vaduganathan M. Chapter 2: Clinical and Mechanistic Potential of Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors in Heart Failure with Preserved Ejection Fraction. Am J Med 2024; 137:S9-S24. [PMID: 37160196 DOI: 10.1016/j.amjmed.2023.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/18/2023] [Indexed: 05/11/2023]
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have emerged as an important approach for the treatment of heart failure in patients with or without diabetes. Although the precise mechanisms underpinning their clinical impact remain incompletely resolved, mechanistic studies and insights from major clinical trials have demonstrated the impact of SGLT2 inhibitors on numerous cardio-renal-metabolic pathways of relevance to heart failure with preserved ejection fraction (HFpEF), which, in the contemporary era, constitutes approximately half of all patients with heart failure. Despite rates of morbidity and mortality that are commensurate with those of heart failure with reduced ejection fraction, disease-modifying therapies have comparatively been severely lacking. As such, HFpEF remains among the greatest unmet needs in cardiovascular medicine. Within the past decade, HFpEF has been established as a highly integrated disorder, involving not only the cardiovascular system, but also the lungs, kidneys, skeletal muscle, and adipose tissue. Given their multisystem impact, SGLT2i offer unique promise in addressing the complex pathophysiology of HFpEF, and in recent randomized controlled trials, were shown to significantly reduce heart failure events and cardiovascular death in patients with HFpEF. Herein, we discuss several proposed mechanisms of clinical benefit of SGLT2i in HFpEF.
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Affiliation(s)
- John W Ostrominski
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass.
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Bánfi-Bacsárdi F, Vámos M, Majoros Z, Török G, Pilecky D, Duray GZ, Kiss RG, Nyolczas N, Muk B. [The effect of kidney function on the optimization of medical therapy and on mortality in heart failure with reduced ejection fraction]. Orv Hetil 2023; 164:1387-1396. [PMID: 37660348 DOI: 10.1556/650.2023.32836] [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: 04/16/2023] [Accepted: 05/23/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Renal dysfunction is a main limiting factor of applying and up-titrating guideline-directed medical therapy (GDMT) among patients with heart failure with reduced ejection fraction (HFrEF). OBJECTIVE Our retrospective monocentric observational study aimed to analyse the application ratio of combined neurohormonal antagonist therapy (RASi: ACEI/ARB/ARNI + βB + MRA) and 12-month all-cause mortality differences in terms of renal dysfunction among HFrEF patients hospitalized for heart failure. METHOD We retrospectively analysed the cohort of consecutive HFrEF patients, hospitalized at the Heart Failure Unit of our tertiary cardiological centre in 2019-2021. The application ratio of discharge triple therapy (TT) in five groups established on admission eGFR parameters, representing severity of renal dysfunction (eGFR≥90, eGFR = 60-89, eGFR = 45-59, eGFR = 30-44, eGFR<30 ml/min/1.73 m2) was investigated with chi-square test, while 12-month mortality differences were analysed with Kaplan-Meier method and log-rank test. RESULTS 257 patients were included. Median eGFR was 57 (39-75) ml/min/1.73 m2, 54% of patients had eGFR<60 ml/min/1.73 m2. The proportion of patients in eGFR≥90, 60-89, 45-59, 30-44, <30 ml/min/1.73 m2 subgroups was 12%, 34%, 18%, 21%, 15%, respectively. 2% of patients were on dialysis. Even though the application rate of TT was notably high (77%) in the total cohort, more severe renal dysfunction led to a significantly lower implementation rate of TT (94%, 86%, 91%, 70%, 34%; p<0.0001): the application rate of RASi (100%, 98%, 96%, 89%, 50%, p<0.0001), βB (94%, 88%, 96%, 79%, 68%; p = 0.003) and MRA therapy (97%, 99%, 98%, 94%, 82%; p = 0.001) differed significantly. 12-month all-cause mortality was 23% in the whole cohort. Mortality rates were higher in more severe renal dysfunction (3%, 15%, 22%, 31%, 46%; p<0.0001). CONCLUSION Even though the proportion of patients on TT in the whole cohort was remarkably high, renal dysfunction led to a significantly lower application ratio of TT, associating with worse survival. Our results highlight that despite renal dysfunction the application of HFrEF cornerstone pharmacotherapy is essential. Orv Hetil. 2023; 164(35): 1387-1396.
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Affiliation(s)
- Fanni Bánfi-Bacsárdi
- 1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország
- 2 Gottsegen György Országos Kardiovaszkuláris Intézet, Felnőtt Kardiológiai Osztály Budapest, Haller u. 29., 1096 Magyarország
| | - Máté Vámos
- 3 Szegedi Tudományegyetem, Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Elektrofiziológiai Részleg Szeged Magyarország
| | - Zsuzsanna Majoros
- 1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország
| | - Gábor Török
- 1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország
| | - Dávid Pilecky
- 2 Gottsegen György Országos Kardiovaszkuláris Intézet, Felnőtt Kardiológiai Osztály Budapest, Haller u. 29., 1096 Magyarország
- 4 Szegedi Tudományegyetem, Szent-Györgyi Albert Orvostudományi Kar, Klinikai Orvostudományi Doktori Iskola Szeged Magyarország
| | - Gábor Zoltán Duray
- 1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország
| | - Róbert Gábor Kiss
- 1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország
| | - Noémi Nyolczas
- 2 Gottsegen György Országos Kardiovaszkuláris Intézet, Felnőtt Kardiológiai Osztály Budapest, Haller u. 29., 1096 Magyarország
- 4 Szegedi Tudományegyetem, Szent-Györgyi Albert Orvostudományi Kar, Klinikai Orvostudományi Doktori Iskola Szeged Magyarország
| | - Balázs Muk
- 2 Gottsegen György Országos Kardiovaszkuláris Intézet, Felnőtt Kardiológiai Osztály Budapest, Haller u. 29., 1096 Magyarország
- 4 Szegedi Tudományegyetem, Szent-Györgyi Albert Orvostudományi Kar, Klinikai Orvostudományi Doktori Iskola Szeged Magyarország
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Kittleson MM, Sharma K, Brennan DC, Cheng XS, Chow SL, Colvin M, DeVore AD, Dunlay SM, Fraser M, Garonzik-Wang J, Khazanie P, Korenblat KM, Pham DT. Dual-Organ Transplantation: Indications, Evaluation, and Outcomes for Heart-Kidney and Heart-Liver Transplantation: A Scientific Statement From the American Heart Association. Circulation 2023; 148:622-636. [PMID: 37439224 DOI: 10.1161/cir.0000000000001155] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Although heart transplantation is the preferred therapy for appropriate patients with advanced heart failure, the presence of concomitant renal or hepatic dysfunction can pose a barrier to isolated heart transplantation. Because donor organ supply limits the availability of organ transplantation, appropriate allocation of this scarce resource is essential; thus, clear guidance for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation is urgently required. The purposes of this scientific statement are (1) to describe the impact of pretransplantation renal and hepatic dysfunction on posttransplantation outcomes; (2) to discuss the assessment of pretransplantation renal and hepatic dysfunction; (3) to provide an approach to patient selection for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation and posttransplantation management; and (4) to explore the ethics of multiorgan transplantation.
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Patel S, Lam PH, Kanonidis E, Ahmed AA, Raman VK, Wu WC, Rossignol P, Arundel C, Faselis C, Kanonidis IE, Deedwania P, Allman RM, Sheikh FH, Fonarow GC, Pitt B, Ahmed A. Renin-Angiotensin Inhibition and Outcomes in HFrEF and Advanced Kidney Disease. Am J Med 2023; 136:677-686. [PMID: 37019372 PMCID: PMC10466279 DOI: 10.1016/j.amjmed.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/18/2023] [Accepted: 03/08/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Renin-angiotensin system inhibitors improve outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, less is known about their effectiveness in patients with HFrEF and advanced kidney disease. METHODS In the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF), 1582 patients with HFrEF (ejection fraction ≤40%) had advanced kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m2). Of these, 829 were not receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) prior to admission, of whom 214 were initiated on these drugs prior to discharge. We calculated propensity scores for receipt of these drugs for each of the 829 patients and assembled a matched cohort of 388 patients, balanced on 47 baseline characteristics (mean age 78 years; 52% women; 10% African American; 73% receiving beta-blockers). Hazard ratios (HR) and 95% confidence intervals (CI) were estimated comparing 2-year outcomes in 194 patients initiated on ACE inhibitors or ARBs to 194 patients not initiated on those drugs. RESULTS The combined endpoint of heart failure readmission or all-cause mortality occurred in 79% and 84% of patients initiated and not initiated on ACE inhibitors or ARBs, respectively (HR associated with initiation, 0.79; 95% CI, 0.63-0.98). Respective HRs (95% CI) for the individual endpoints of - Respective HRs (95% CI) for the individual endpoints of all-cause mortality and heart failure readmission were 0.81 (0.63-1.03) and 0.63 (0.47-0.85). CONCLUSIONS The findings from our study add new information to the body of cumulative evidence that suggest that renin-angiotensin system inhibitors may improve clinical outcomes in patients with HFrEF and advanced kidney disease. These hypothesis-generating findings need to be replicated in contemporary patients.
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Affiliation(s)
- Samir Patel
- Veterans Affairs Medical Center, Washington, DC
- George Washington University, Washington, DC
| | - Phillip H. Lam
- Veterans Affairs Medical Center, Washington, DC
- Georgetown University, Washington, DC
- MedStar Washington Hospital Center, Washington, DC
| | | | - Amiya A. Ahmed
- University of Maryland, Baltimore, MD
- Yale University, New Haven, CT
| | - Venkatesh K. Raman
- Veterans Affairs Medical Center, Washington, DC
- Georgetown University, Washington, DC
| | - Wen-Chih Wu
- Veterans Affairs Medical Center, Providence, RI
- Brown University, Providence, RI
| | | | - Cherinne Arundel
- Veterans Affairs Medical Center, Washington, DC
- George Washington University, Washington, DC
- Georgetown University, Washington, DC
| | - Charles Faselis
- Veterans Affairs Medical Center, Washington, DC
- George Washington University, Washington, DC
- Uniformed Services University, Washington, DC
| | | | - Prakash Deedwania
- Veterans Affairs Medical Center, Washington, DC
- University of California, San Francisco, CA
| | - Richard M. Allman
- George Washington University, Washington, DC
- University of Alabama at Birmingham, Birmingham, AL
| | - Farooq H. Sheikh
- Veterans Affairs Medical Center, Washington, DC
- Georgetown University, Washington, DC
- MedStar Washington Hospital Center, Washington, DC
| | | | | | - Ali Ahmed
- Veterans Affairs Medical Center, Washington, DC
- George Washington University, Washington, DC
- Georgetown University, Washington, DC
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Lorente-Ros M, Aguilar-Gallardo JS, Shah A, Narasimhan B, Aronow WS. An overview of mineralocorticoid receptor antagonists as a treatment option for patients with heart failure: the current state-of-the-art and future outlook. Expert Opin Pharmacother 2022; 23:1737-1751. [PMID: 36262014 DOI: 10.1080/14656566.2022.2138744] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in patients with heart failure. These benefits of MRAs vary in different heart failure populations based on left ventricular ejection fraction and associated comorbidities. AREAS COVERED We define the pharmacologic properties of MRAs and the pathophysiological rationale for their utility in heart failure. We outline the current literature on the use of MRAs in different heart failure populations, including reduced and preserved ejection fraction (HFrEF/ HFpEF), and acute heart failure decompensation. Finally, we describe the limitations of currently available data and propose future directions of study. EXPERT OPINION While there is strong evidence supporting the use of MRAs in HFrEF, evidence in patients with HFpEF or acute heart failure is less definitive. Comorbidities such as obesity or atrial fibrillation could be clinical modifiers of the response to MRAs and potentially alter the risk/benefit ratio in these subpopulations. Emerging evidence for new non-steroidal MRAs reveal promising preliminary results that, if confirmed in large randomized clinical trials, could favor a change in clinical practice.
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Affiliation(s)
- Marta Lorente-Ros
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Jose S Aguilar-Gallardo
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Aayush Shah
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Bharat Narasimhan
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Wilbert S Aronow
- Department of Cardiology, New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY 10901, USA
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Barry AR. Managing Heart Failure With Reduced Ejection Fraction in Patients With Chronic Kidney Disease: A Case-Based Approach and Contemporary Review. CJC Open 2022; 4:802-809. [PMID: 36148258 PMCID: PMC9486859 DOI: 10.1016/j.cjco.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/21/2022] [Indexed: 11/23/2022] Open
Abstract
Patients with heart failure with reduced ejection fraction (HFrEF) often have concurrent chronic kidney disease (CKD), which can make initiating and titrating the 4 standard pharmacologic therapies a challenge. Drug dosing is often based on a calculation of the patient’s creatine clearance or estimated glomerular filtration rate (eGFR), but it should also incorporate the trend in their renal function over time and the risk of toxicity of the drug. The presence of CKD in a patient should not preclude the use of a renin-angiotensin system inhibitor, although patients should be monitored frequently for worsening renal function and hyperkalemia. Sacubitril/valsartan is not recommended in patients with an eGFR < 30 mL/min per 1.73 m2. Of the 3 ß-blockers recommended in the management of HFrEF, only bisoprolol may accumulate in patients with renal impairment; however, patients should still be titrated to the target dose (10 mg daily) or the maximally tolerated dose, depending on their clinical response. The sodium-glucose cotransporter 2 inhibitors are effective at reducing adverse cardiovascular and renal outcomes in patients with HFrEF and CKD (eGFR ≥ 25 mL/min per 1.73 m2 with dapagliflozin or ≥ 20 mL/min per 1.73 m2 with empagliflozin), although declining kidney function is a risk, due to the osmotic diuretic effect. Finally, mineralocorticoid receptor antagonist therapy should be considered in all patients with HFrEF and an eGFR ≥ 30 mL/min per 1.73 m2. The starting dose should be low (eg, 6.25-12.5 mg daily or 12.5 mg every other day) and can be uptitrated based on the patient’s renal function and serum potassium.
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Abstract
Mechanistic Insights in Cardiorenal SyndromeLo and Rangaswami review the pathophysiology and management of cardiorenal syndrome, with a focus on decongestion, interpretation of kidney function, and implementation of guideline directed medical therapies.
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Affiliation(s)
- Kevin Bryan Lo
- Einstein Medical Center, Jefferson Health System, Philadelphia
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11
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Takeuchi S, Kohno T, Goda A, Shiraishi Y, Kawana M, Saji M, Nagatomo Y, Nishihata Y, Takei M, Nakano S, Soejima K, Kohsaka S, Yoshikawa T. Multimorbidity, guideline-directed medical therapies, and associated outcomes among hospitalized heart failure patients. ESC Heart Fail 2022; 9:2500-2510. [PMID: 35561100 PMCID: PMC9288806 DOI: 10.1002/ehf2.13954] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 03/03/2022] [Accepted: 04/13/2022] [Indexed: 12/11/2022] Open
Abstract
Aims Multimorbidity is common among heart failure (HF) patients and may attenuate guideline‐directed medical therapy (GDMT). Multimorbid patients are under‐represented in clinical trials; therefore, the effect of multimorbidity clustering on the prognosis of HF patients remains unknown. We evaluated the prevalence of multimorbidity clusters among consecutively registered hospitalized HF patients and assessed whether GDMT attenuated outcomes. Methods and results We examined 1924 hospitalized HF patients with reduced left ventricular ejection fraction (<50%) in a multicentre registry (West Tokyo HF Registry: WET‐HF). Ten comorbid conditions in the WET‐HF were abstracted: coronary artery disease, atrial fibrillation, stroke, anaemia, chronic obstructive pulmonary disease, renal dysfunction, obesity, hypertension, dyslipidaemia, and diabetes. Patients were divided into three groups (0–2: n = 451; 3–4: n = 787; and ≥5: n = 686) based on the number of comorbid conditions. The primary composite endpoint was all‐cause mortality and HF rehospitalization. The most prevalent comorbidities were renal dysfunction (67.9%), hypertension (66.0%), and anaemia (53.8%). Increased comorbidity was associated with increased adverse outcomes [3–4: hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.13–1.77, P = 0.003; ≥5: HR 2.12, 95%CI 1.69–2.65, P < 0.001; and reference: 0–2] and lower GDMT prescription rate (0–2: 69.2%; 3–4: 57.7%; and ≥5: 57.6%). GDMT was associated with decreased adverse outcomes; this association was maintained even as the comorbidity burden increased but tended to weaken (0–2: HR 0.53, 95%CI 0.35–0.78; P = 0.001; 3–4: HR 0.82, 95%CI 0.65–1.04, P = 0.095; and ≥5: HR 0.81, 95%CI 0.65–1.00, P = 0.053; P for interaction = 0.156). Conclusions Comorbidity clusters were prevalent and associated with poorer outcomes. GDMT remained beneficial regardless of the comorbidity burden but tended to weaken with increasing comorbidity burden. Further research is required to optimize medical care in these patients.
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Affiliation(s)
- Shinsuke Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, 181-8611, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, 181-8611, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, 181-8611, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masataka Kawana
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Saitama, Japan
| | - Yosuke Nishihata
- Department of Cardiology, St. Lukes International Hospital, Tokyo, Japan
| | - Makoto Takei
- Department of Cardiology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, 181-8611, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Sinha A, Yancy CW, Patel RB. Tipping the Scale Toward a More Accurate and Equitable Assessment of HFrEF Pharmacotherapy Eligibility: A Call to Incorporate Cystatin C in Estimating Glomerular Filtration Rate. Eur J Heart Fail 2022; 24:867-870. [PMID: 35415943 PMCID: PMC9133180 DOI: 10.1002/ejhf.2505] [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: 03/30/2022] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Arjun Sinha
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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13
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Shoji S, Kohsaka S, Shiraishi Y, Kohno T, Sawano M, Ikemura N, Niimi N, Nagatomo Y, Tanaka TD, Takei M, Ono T, Sakamoto M, Nakano S, Nakamura I, Inoue S, Fukuda K, Yoshikawa T. Conventional medical therapy in heart failure patients eligible for the PARADIGM-HF, DAPA-HF, and SHIFT trials. Int J Cardiol 2022; 359:76-83. [PMID: 35421518 DOI: 10.1016/j.ijcard.2022.04.020] [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: 02/08/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recent trials on novel heart failure (HF) treatments (angiotensin receptor-neprilysin inhibitor, sodium-glucose cotransporter 2 inhibitor, and ivabradine) emphasize the use of conventional medical therapy (angiotensin-converting enzyme inhibitors, beta-blockers [BB], and mineral corticosteroid receptor antagonists). We aimed to evaluate the prescription rate of conventional medical therapy and its association with long-term outcomes in patients eligible for recent trials. METHODS We examined 1295 consecutive patients with HF with reduced ejection fraction (HFrEF) from a multicenter registry (WET-HF registry). We assessed conventional medical therapy implementation among patients meeting the PARADIGM-HF/DAPA-HF and SHIFT enrollment criteria. We also examined the association between conventional medical therapy use and long-term outcomes within each enrollment criterion. RESULTS Overall, 62.2% and 35.3% of HFrEF patients met the enrollment criteria of the PARADIGM-HF/DAPA-HF and SHIFT trials. Only 33.9% and 31.9% received full conventional medical therapy within each patient subset. Notably, 84.2% of patients who met the SHIFT enrollment criteria were on BB, and only 23.0% and 4.4% were on ≥50% or the full recommended dose, respectively. Implementation of full conventional medical therapy use was associated with lower 2-year mortality and HF readmission rates in the PARADIGM-HF/ DAPA-HF eligible group (HR 0.68, 95% CI 0.50-0.92). The use of BB at ≥50% of the recommended dose was associated with lower 2-year mortality and HF readmission rates in the SHIFT-eligible group (HR 0.50, 95% CI 0.30-0.84). CONCLUSIONS Conventional medical therapy was underutilized among patients eligible for novel trials within a Japanese HF registry. Further efforts to optimize conventional medical therapy are needed.
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Affiliation(s)
- Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan; Department of Cardiology, Hino Municipal Hospital, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Nobuhiro Ikemura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Nozomi Niimi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College Hospital, Saitama, Japan
| | - Toshikazu D Tanaka
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Makoto Takei
- Department of Cardiology, Saiseikai Central Hospital, Tokyo, Japan
| | - Tomohiko Ono
- Department of Cardiology, National Hospital Organization Saitama National Hospital, Saitama, Japan
| | - Munehisa Sakamoto
- Department of Cardiology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Iwao Nakamura
- Department of Cardiology, Hino Municipal Hospital, Tokyo, Japan
| | - Soushin Inoue
- Department of Cardiology, Hino Municipal Hospital, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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14
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Beldhuis IE, Lam CSP, Testani JM, Voors AA, Van Spall HG, ter Maaten JM, Damman K. Evidence-Based Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction and Chronic Kidney Disease. Circulation 2022; 145:693-712. [PMID: 35226558 PMCID: PMC9074837 DOI: 10.1161/circulationaha.121.052792] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease (CKD) as identified by a reduced estimated glomerular filtration rate (eGFR) is a common comorbidity in patients with heart failure with reduced ejection fraction (HFrEF). The presence of CKD is associated with more severe heart failure, and CKD itself is a strong independent risk factor of poor cardiovascular outcome. Furthermore, the presence of CKD often influences the decision to start, uptitrate, or discontinue possible life-saving HFrEF therapies. Because pivotal HFrEF randomized clinical trials have historically excluded patients with stage 4 and 5 CKD (eGFR <30 mL/min/1.73 m2), information on the efficacy and tolerability of HFrEF therapies in these patients is limited. However, more recent HFrEF trials with novel classes of drugs included patients with more severe CKD. In this review on medical therapy in patients with HFrEF and CKD, we show that for both all-cause mortality and the combined end point of cardiovascular death or heart failure hospitalization, most drug classes are safe and effective up to CKD stage 3B (eGFR minimum 30 mL/min/1.73 m2). For more severe CKD (stage 4), there is evidence of safety and efficacy of sodium glucose cotransporter 2 inhibitors, and to a lesser extent, angiotensin-converting enzyme inhibitors, vericiguat, digoxin and omecamtiv mecarbil, although this evidence is restricted to improvement of cardiovascular death/heart failure hospitalization. Data are lacking on the safety and efficacy for any HFrEF therapies in CKD stage 5 (eGFR < 15 mL/min/1.73 m2 or dialysis) for either end point. Last, although an initial decline in eGFR is observed on initiation of several HFrEF drug classes (angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers/mineralocorticoid receptor antagonists/angiotensin receptor blocker neprilysin inhibitors/sodium glucose cotransporter 2 inhibitors), renal function often stabilizes over time, and the drugs maintain their clinical efficacy. A decline in eGFR in the context of a stable or improving clinical condition should therefore not be cause for concern and should not lead to discontinuation of life-saving HFrEF therapies.
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Affiliation(s)
- Iris E. Beldhuis
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Carolyn S. P. Lam
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands,National Heart Centre Singapore and Duke-National University of Singapore
| | - Jeffrey M. Testani
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Adriaan A. Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Harriette G.C. Van Spall
- Department of Medicine, McMaster University, Hamilton, Ontario,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario,Population Health Research Institute, Hamilton, Ontario
| | - Jozine M. ter Maaten
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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15
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Rudolph V. Heart and kidney: towards an integrated approach to secondary mitral regurgitation. Eur Heart J 2022; 43:1649-1651. [PMID: 35178564 DOI: 10.1093/eurheartj/ehac084] [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: 11/15/2022] Open
Affiliation(s)
- Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-2545 Bad Oeynhausen, Germany
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16
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Mitsuboshi S, Niimura T, Aizawa F, Goda M, Zamami Y, Ishizawa K. Atenolol and mortality events in patients with chronic kidney disease: analysis of data from the Japanese Adverse Drug Event Report database. Basic Clin Pharmacol Toxicol 2022; 130:553-556. [PMID: 35174631 DOI: 10.1111/bcpt.13717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
| | - Takahiro Niimura
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Fuka Aizawa
- Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Mitsuhiro Goda
- Clinical Research Centre for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Yoshito Zamami
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan.,Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Keisuke Ishizawa
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan.,Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
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17
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de la Espriella R, Bayés-Genís A, Llàcer P, Palau P, Miñana G, Santas E, Pellicer M, González M, Górriz JL, Bodi V, Sanchis J, Núñez J. Prognostic value of NT-proBNP and CA125 across glomerular filtration rate categories in acute heart failure. Eur J Intern Med 2022; 95:67-73. [PMID: 34507853 DOI: 10.1016/j.ejim.2021.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/17/2021] [Accepted: 08/27/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study aimed to evaluate whether glomerular filtration rate (eGFR) during admission modifies the predictive value of plasma amino-terminal pro-brain natriuretic peptide (NT-proBNP) and carbohydrate antigen 125 (CA125) in patients hospitalized for acute heart failure (AHF). METHODS We retrospectively evaluated 4595 patients consecutively discharged after admission for AHF at three tertiary-care hospitals from January 2008 through October 2019. To investigate the effect of kidney function on the association of NT-proBNP and CA125 with 1-year mortality (all-cause and cardiovascular mortality), we stratified patients according to four eGFR categories: <30 mL•min-1•1.73 m-2, 30-44 mL•min-1•1.73 m-2, 44-59 mL•min-1•1.73 m-2, and ≥60 mL•min-1•1.73 m-2. Biomarkers were assessed within the first 24 hours following admission. RESULTS At 1-year follow-up, 748 of 4595 (16.3%) patients died after discharge (of all deaths, 575 [12.5%] were cardiovascular). After multivariate adjustment, both NT-proBNP and CA125 remained independently associated with a higher risk of death when modeled as main effects (P<0.001). However, we found a differential prognostic effect of NT-proBNP across eGFR categories for both endpoints (all-cause mortality, P-value for interaction=0.002; CV mortality, P-value for interaction=0.001). Whereas NT-proBNP was positively and linearly associated with mortality in the subset of patients with normal or mildly reduced eGFR, its predictive ability progressively decreased at the lower extreme of eGFR (<45 mL•min-1•1.73 m-2). In contrast, the association between CA125 and survival remained consistent across all eGFR categories (all-cause mortality, P-value for interaction=0.559; CV mortality, P-value for interaction=0.855). CONCLUSIONS In patients with AHF and severely reduced eGFR, CA125 outperforms NT-proBNP in predicting 1-year mortality.
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Affiliation(s)
- Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Antoni Bayés-Genís
- CIBER Cardiovascular, Madrid, Spain; Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona. Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Pau Llàcer
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Patricia Palau
- 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
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Mauricio Pellicer
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Miguel González
- Nephrology Department. Hospital Clínico Universitario de Valencia, Universitat de València. Valencia, INCLIVA, Valencia, Spain
| | - José Luis Górriz
- Nephrology Department. Hospital Clínico Universitario de Valencia, Universitat de València. Valencia, INCLIVA, Valencia, Spain
| | - Vicent Bodi
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain.
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18
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Ortiz A, Navarro-González JF, Núñez J, de la Espriella R, Cobo M, Santamaría R, de Sequera P, Díez J. The unmet need of evidence-based therapy for patients with advanced chronic kidney disease and heart failure: Position paper from the Cardiorenal Working Groups of the Spanish Society of Nephrology and the Spanish Society of Cardiology. Clin Kidney J 2021; 15:865-872. [PMID: 35498889 PMCID: PMC9050562 DOI: 10.1093/ckj/sfab290] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Indexed: 01/09/2023] Open
Abstract
Despite the high prevalence of chronic kidney disease (CKD) and its high cardiovascular risk, patients with CKD, especially those with advanced CKD (stages 4-5 and patients on kidney replacement therapy), are excluded from most cardiovascular clinical trials. It is particularly relevant in patients with advanced CKD and heart failure (HF) who have been underrepresented in many pivotal randomized trials that have modified the management of HF. For this reason, there is little or no direct evidence for HF therapies in patients with advanced CKD and treatment is extrapolated from patients without CKD or patients with earlier CKD stages. The major consequence of the lack of direct evidence is the under-prescription of HF drugs to this patient population. As patients with advanced CKD and HF represent probably the highest cardiovascular risk population, the exclusion of these patients from HF trials is a serious deontological fault that must be solved. There is an urgent need to generate evidence on how to treat HF in patients with advanced CKD. This article briefly reviews the management challenges posed by HF in patients with CKD and proposes a road map to address them.
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Affiliation(s)
- Alberto Ortiz
- Division of Nephrology IIS-Fundacion Jimenez Diaz, Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain,RICORS2040, Carlos III Institute of Health, Madrid, Spain
| | - Juan F Navarro-González
- RICORS2040, Carlos III Institute of Health, Madrid, Spain,Division of Nephrology and Research Unit, University Hospital Nuestra Señora de Candelaria, and Universitary Institute of Biomedical Technologies, University of La Laguna, Santa Cruz de Tenerife, Spain
| | - Julio Núñez
- Division of Cardiology, University Hospital, INCLIVA, Universitat de Valencia, Valencia, Spain,Department of Medicine, University of Valencia, Valencia, Spain,Centro de Investigación Biomédica en Red de las Enfermedades Cardiovasculares, Carlos III Institute of Health, Madrid, Spain
| | - Rafael de la Espriella
- Division of Cardiology, University Hospital, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Marta Cobo
- Centro de Investigación Biomédica en Red de las Enfermedades Cardiovasculares, Carlos III Institute of Health, Madrid, Spain,Division of Cardiology, University Hospital Puerta de Hierro, University Autónoma of Madrid, Madrid, Spain
| | - Rafael Santamaría
- RICORS2040, Carlos III Institute of Health, Madrid, Spain,Division of Nephrology, University Hospital Reina Sofia, Cordoba, Spain,Maimonides Biomedical Research Institute of Cordoba, Cordoba, Spain
| | - Patricia de Sequera
- Department of Nephrology, University Hospital Infanta Leonor, University Complutense of Madrid, Madrid, Spain
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19
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Xu Y, Chen Y, Zhao JW, Li C, Wang AY. Effect of Angiotensin-Neprilysin Versus Renin-Angiotensin System Inhibition on Renal Outcomes: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:604017. [PMID: 34867310 PMCID: PMC8640344 DOI: 10.3389/fphar.2021.604017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/21/2021] [Indexed: 11/23/2022] Open
Abstract
Aims: We aim to perform a systematic review and meta-analysis examining randomized controlled trials assessing the efficacy and safety of sacubitril/valsartan in patients on renal outcomes, in comparison with the renin–angiotensin–aldosterone system inhibitor (RAASi). Methods: Eligible studies were retrieved on MEDLINE, EMBASE, and Cochrane until September 2021. The primary outcome was the incidence of renal impairment, which was defined as the composite of increases in serum creatinine by >0.3 mg/dl and/or a reduction in eGFR ≥25%, development of ESRD, or renal death. We pooled relative risks (RRs) with 95% confidence intervals (CIs) or the mean difference with 95% CIs for the variables. Results: Our search yielded 10 randomized controlled trials with a total of 18,362 patients. Compared with RAASi treatment, patients treated with sacubitril/valsartan had lower incidence of composite renal impairment (10 studies, 18,362 patients, RR 0.84; 95% CI 0.72–0.96, p = 0.01; I2 = 22%), ESRD development (3 studies, 13,609 patients, RR 0.53; 95% CI 0.30–0.96, p = 0.03; I2 = 0%), drug discontinuation due to renal events (4 studies, 9,995 patients, RR 0.58; 95% CI 0.40–0.83, p = 0.003; I2 = 47%), severe hyperkalemia (6 studies, 16,653 patients, RR 0.80; 95% CI 0.68–0.93, p = 0.01; I2 = 25%) and a slower eGFR decline (4 studies, 13,608 patients, WMD 0.56; 95% CI 0.36–0.76, p < 0.00001; I2 = 65%). Subgroup analysis demonstrated that sacubitril/valsartan was associated with a lower incidence of renal impairment in patients with heart failure and preserved ejection fraction (HFpEF), but not in those with heart failure and reduced ejection fraction (HFrEF). The superior renal function preservation of sacubitril/valsartan treatment was not associated with different baseline eGFR levels and follow-up duration. There was a smaller increase in the change in the urine albumin-to-creatinine ratio (UACR) (3 studies, 9,114 patients, SMD 0.06; 95% CI 0.02–0.10, p = 0.003; I2 = 14%) with sacubitril/valsartan treatment. However, patients with heart failure appeared to have increased microalbuminuria, not patients without HF (p = 0.80 for interaction). Conclusion: Sacubitril/valsartan was associated with a lower incidence of composite renal impairment especially in patients with HFpEF, but higher microalbuminuria in patients with heart failure (both HFrEF and HFpEF) compared with RAASi. The lower incidence of severe hyperkalemia and drug discontinuation due to renal events in patients with sacubitril/valsartan treatment demonstrated its superior safety compared with RAASi.
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Affiliation(s)
- Ying Xu
- The Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,The Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia.,The Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
| | - Yang Chen
- The Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,The Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
| | - Jia Wei Zhao
- The Faculty of Medicine, Bond University, Gold Coast, QLD, Australia
| | - Chao Li
- The Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia.,Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Amanda Y Wang
- The Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia.,The Department of Renal Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia.,Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
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20
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Jha R, Mukku KK, Rakesh AK, Sinha S. Successful Treatment of Severe Heart Failure in Advanced Diabetic Kidney Disease Using Angiotensin-neprilysin Inhibitors (Sacubitril/Valsartan) - Report of Two Cases with Review of Options in Literature. Indian J Nephrol 2021; 31:587-591. [PMID: 35068771 PMCID: PMC8722547 DOI: 10.4103/ijn.ijn_298_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/08/2020] [Accepted: 09/04/2020] [Indexed: 12/11/2022] Open
Abstract
Patients with heart failure (HF) and advanced chronic kidney disease (CKD) constitute a special population that experience poor outcomes due to poor adherence to established therapies because of potential safety concerns. Role of newer agents like angiotensin–receptor neprilysin inhibitors (ARNI) in early stages of CKD is well elucidated. We report two cases of HF with reduced ejection fraction, who received ARNI in advanced stage of CKD (stage 5) and achieved remarkable outcomes in terms of quality of life and longevity.
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Affiliation(s)
- Ratan Jha
- Department of Nephrology, Virinchi Hospital, Banjara Hills, Hyderabad, Telangana, India
| | - Kiran K Mukku
- Department of Nephrology, Virinchi Hospital, Banjara Hills, Hyderabad, Telangana, India
| | - Ambati K Rakesh
- Department of Nephrology, Virinchi Hospital, Banjara Hills, Hyderabad, Telangana, India
| | - Sumeet Sinha
- Department of Cardiology, Virinchi Hospital, Banjara Hills, Hyderabad, Telangana, India
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21
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Effects of Epoxyeicosatrienoic Acid-Enhancing Therapy on the Course of Congestive Heart Failure in Angiotensin II-Dependent Rat Hypertension: From mRNA Analysis towards Functional In Vivo Evaluation. Biomedicines 2021; 9:biomedicines9081053. [PMID: 34440257 PMCID: PMC8393645 DOI: 10.3390/biomedicines9081053] [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: 07/08/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 12/27/2022] Open
Abstract
This study evaluates the effects of chronic treatment with EET-A, an orally active epoxyeicosatrienoic acid (EETs) analog, on the course of aorto-caval fistula (ACF)-induced heart failure (HF) in Ren-2 transgenic rats (TGR), a model characterized by hypertension and augmented activity of the renin-angiotensin system (RAS). The results were compared with standard pharmacological blockade of the RAS using angiotensin-converting enzyme inhibitor (ACEi). The rationale for employing EET-A as a new treatment approach is based on our findings that apart from increased RAS activity, untreated ACF TGR also shows kidney and left ventricle (LV) tissue deficiency of EETs. Untreated ACF TGR began to die 17 days after creating ACF and were all dead by day 84. The treatment with EET-A alone or ACEi alone improved the survival rate: in 156 days after ACF creation, it was 45.5% and 59.4%, respectively. The combined treatment with EET-A and ACEi appeared to improve the final survival to 71%; however, the difference from either single treatment regimen did not reach significance. Nevertheless, our findings support the notion that targeting the cytochrome P-450-dependent epoxygenase pathway of arachidonic acid metabolism should be considered for the treatment of HF.
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22
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Laffin LJ, Bakris GL. Intersection Between Chronic Kidney Disease and Cardiovascular Disease. Curr Cardiol Rep 2021; 23:117. [PMID: 34269921 DOI: 10.1007/s11886-021-01546-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW The incidence of chronic kidney disease is increasing worldwide, and the previously decreasing incidence of cardiovascular disease has now plateaued. Understanding the intersection of both heart and kidney disease is crucial. RECENT FINDINGS Chronic kidney disease and cardiovascular disease share common risk factors and specific pathogenic mechanisms and impact a significant segment of the population. Patients with chronic kidney disease are more likely to have cardiovascular disease than progress to end-stage kidney disease requiring renal replacement therapy. We discuss shared risk factors and mechanisms for cardiovascular and chronic kidney disease. The following also addresses contemporary cardiovascular treatment considerations in patients with chronic kidney disease with a focus on atherosclerotic cardiovascular disease and heart failure.
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Affiliation(s)
- Luke J Laffin
- Section of Preventive Cardiology and Rehabilitation, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - George L Bakris
- Am. Heart Assoc. Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Chicago Medicine, 5841 S. Maryland Ave, MC 1027, Chicago, IL, 60637, USA.
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23
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Raphael DM, Liu Z, Jin Z, Cui X, Han D, He W, Shangguan J, Shen D. Effects of sacubitril/valsartan on clinical symptoms, echocardiographic parameters, and outcomes in HFrEF and HFmrEF patients with coronary heart disease and chronic kidney disease. Curr Med Res Opin 2021; 37:1071-1078. [PMID: 33764230 DOI: 10.1080/03007995.2021.1908243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To compare the effects of Angiotensin Receptor-Neprilysin inhibitor (ARNI) on the clinical symptoms, echocardiographic parameters, and outcomes (cardiovascular death and hospitalization) in heart failure with reduced ejection fraction (HFrEF) and heart failure with mid-range ejection fraction (HFmrEF) patients with coronary heart disease and chronic kidney disease. METHOD A retrospective observational study was conducted from January 2018 to May 2019, with a follow-up period of 95.4 ± 57.8 days (8 months). Data from 127 patients were included. RESULTS A statistically significant increase of 68.8% was observed in left ventricular ejection fraction (LVEF) in HFrEF patients compared to that in HFmrEF patients, with an increase of 27.2% at 8 months of follow-up. Sacubitril/valsartan significantly reduced left ventricular end-systolic volumes (LVESV) in HFrEF patients unlike in HFmrEF patients. The decrease in LVESV was 28.8% in HFrEF patients and 17.1% in HFmrEF patients. A significant reduction in the prevalence of severe secondary mitral regurgitation (EROA > 0.4 cm2) was observed in HFrEF compared to that in HFmrEF patients with the use of sacubitril/valsartan. A reduction of 15.6% was observed in HFrEF patients, whereas a reduction of 7.1% was observed in HFmrEF patients. Improvement in functional classification (NYHA) was observed during follow-up. The prevalence of (NYHA III) reduced from 50% to 15.7% in HFrEF patients, whereas a reduction from 21.1% to 8.8% was observed in HFmrEF patients. There was a significant reduction in NT-proBNP in HFrEF patients compared to that in HFmrEF patients. A reduction of 52% was observed in HFrEF patients, whereas a reduction of 28.7% was observed in HFmrEF pateints. Sacubitril/valsartan reduced primary endpoint events in both groups. The prevalence of HF-related hospitalization was higher in HFrEF than in HFmrEF patients: 12.1% vs 7.5%, respectively. The prevalence of CV death in HFrEF vs HFmrEF patients was 3.7% vs 0.5%, respectively. Cardiovascular (CV) death was higher in patients with atrial fibrillation in both groups. CONCLUSION Sacubitril/valsartan significantly improved morphofunctional remodeling parameters and clinical symptoms in HFrEF patients than in HFmrEF patients.
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Affiliation(s)
| | - Zhiyu Liu
- Cardiology Department, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Zhi Jin
- Cardiology Department, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xinyue Cui
- Cardiology Department, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Dongjian Han
- Cardiology Department, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Weiwei He
- Cardiology Department, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Jiahong Shangguan
- Cardiology Department, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Deliang Shen
- Cardiology Department, First Affiliated Hospital of Zhengzhou University, Henan, China
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24
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Honetschlagerová Z, Škaroupková P, Kikerlová S, Husková Z, Maxová H, Melenovský V, Kompanowska-Jezierska E, Sadowski J, Gawrys O, Kujal P, Červenka L, Čertíková Chábová V. Effects of renal sympathetic denervation on the course of congestive heart failure combined with chronic kidney disease: Insight from studies with fawn-hooded hypertensive rats with volume overload induced using aorto-caval fistula. Clin Exp Hypertens 2021; 43:522-535. [PMID: 33783285 DOI: 10.1080/10641963.2021.1907398] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: The coincidence of congestive heart failure (CHF) and chronic kidney disease (CKD) results in poor survival rate. The aim of the study was to examine if renal denervation (RDN) would improve the survival rate in CHF induced by creation of aorto-caval fistula (ACF).Methods: Fawn-hooded hypertensive rats (FHH), a genetic model of spontaneous hypertension associated with CKD development, were used. Fawn-hooded low-pressure rats (FHL), without CKD, served as controls. RDN was performed 4 weeks after creation of ACF and the follow-up period was 10 weeks.Results: We found that intact (non-denervated) ACF FHH exhibited survival rate of 58.8% (20 out of 34 rats), significantly lower than in intact ACF FHL (81.3%, 26/32 rats). In intact ACF FHL albuminuria remained stable throughout the study, whereas in ACF FHH it increased significantly, up to a level 40-fold higher than the basal values. ACF FHL did not show increases in renal glomerular and tubulointerstitial injury as compared with FHL, while ACF FHH exhibited marked increases in kidney injury as compared with FHH. RDN did not improve the survival rate in either ACF FHL or ACF FHH and did not alter the course of albuminuria in ACF FHL. RDN attenuated the albuminuria, but did not reduce the kidney injury in ACF FHH.Conclusions: Our present results support the notion that even modest CKD increases CHF-related mortality. RDN did not attenuate CHF-dependent mortality in ACF FHH, it delayed the progressive rise in albuminuria, but it did not reduce the degree of kidney injury.
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Affiliation(s)
- Zuzana Honetschlagerová
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petra Škaroupková
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Soňa Kikerlová
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Zuzana Husková
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hana Maxová
- Department of Pathophysiology, Medicine, Charles University, Prague, Czech Republic
| | - Vojtěch Melenovský
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Elzbieta Kompanowska-Jezierska
- Department of Renal and Body Fluid Physiology, Mossakowski Medical Research Institute, Polish Academy of Science, Warsaw, Poland
| | - Janusz Sadowski
- Department of Renal and Body Fluid Physiology, Mossakowski Medical Research Institute, Polish Academy of Science, Warsaw, Poland
| | - Olga Gawrys
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Renal and Body Fluid Physiology, Mossakowski Medical Research Institute, Polish Academy of Science, Warsaw, Poland
| | - Petr Kujal
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Pathology, Medicine, Charles University, Prague, Czech Republic
| | - Luděk Červenka
- Department of Pathophysiology, Medicine, Charles University, Prague, Czech Republic
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25
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Varma N, Bourge RC, Stevenson LW, Costanzo MR, Shavelle D, Adamson PB, Ginn G, Henderson J, Abraham WT. Remote Hemodynamic-Guided Therapy of Patients With Recurrent Heart Failure Following Cardiac Resynchronization Therapy. J Am Heart Assoc 2021; 10:e017619. [PMID: 33626889 PMCID: PMC8174266 DOI: 10.1161/jaha.120.017619] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Patients with recurring heart failure (HF) following cardiac resynchronization therapy fare poorly. Their management is undecided. We tested remote hemodynamic‐guided pharmacotherapy. Methods and Results We evaluated cardiac resynchronization therapy subjects included in the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in New York Heart Association Class III Heart Failure Patients) trial, which randomized patients with persistent New York Heart Association Class III symptoms and ≥1 HF hospitalization in the previous 12 months to remotely managed pulmonary artery (PA) pressure‐guided management (treatment) or usual HF care (control). Diuretics and/or vasodilators were adjusted conventionally in control and included remote PA pressure information in treatment. Annualized HF hospitalization rates, changes in PA pressures over time (analyzed by area under the curve), changes in medications, and quality of life (Minnesota Living with Heart Failure Questionnaire scores) were assessed. Patients who had cardiac resynchronization therapy (n=190, median implant duration 755 days) at enrollment had poor hemodynamic function (cardiac index 2.00±0.59 L/min per m2), high comorbidity burden (67% had secondary pulmonary hypertension, 61% had estimated glomerular filtration rate <60 mL/min per 1.73 m2), and poor Minnesota Living with Heart Failure Questionnaire scores (57±24). During 18 months randomized follow‐up, HF hospitalizations were 30% lower in treatment (n=91, 62 events, 0.46 events/patient‐year) versus control patients (n=99, 93 events, 0.68 events/patient‐year) (hazard ratio, 0.70; 95% CI, 0.51–0.96; P=0.028). Treatment patients had more medication up‐/down‐titrations (847 versus 346 in control, P<0.001), mean PA pressure reduction (area under the curve −413.2±123.5 versus 60.1±88.0 in control, P=0.002), and quality of life improvement (Minnesota Living with Heart Failure Questionnaire decreased −13.5±23 versus −4.9±24.8 in control, P=0.006). Conclusions Remote hemodynamic‐guided adjustment of medical therapies decreased PA pressures and the burden of HF symptoms and hospitalizations in patients with recurring Class III HF and hospitalizations, beyond the effect of cardiac resynchronization therapy. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00531661.
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26
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Edmonston DL, Roe MT, Block G, Conway PT, Dember LM, DiBattiste PM, Greene T, Hariri A, Inker LA, Isakova T, Montez-Rath ME, Nkulikiyinka R, Polidori D, Roessig L, Tangri N, Wyatt C, Chertow GM, Wolf M. Drug Development in Kidney Disease: Proceedings From a Multistakeholder Conference. Am J Kidney Dis 2020; 76:842-850. [DOI: 10.1053/j.ajkd.2020.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/27/2020] [Indexed: 01/02/2023]
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27
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Shoji S, Kohsaka S, Shiraishi Y, Oishi S, Kato M, Shiota S, Takada Y, Mizuno A, Yumino D, Yokoyama H, Watanabe N, Isobe M. Appropriateness rating for the application of optimal medical therapy and multidisciplinary care among heart failure patients. ESC Heart Fail 2020; 8:300-308. [PMID: 33201597 PMCID: PMC7835502 DOI: 10.1002/ehf2.13062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/04/2020] [Accepted: 09/25/2020] [Indexed: 11/12/2022] Open
Abstract
Aims Clinical guidelines for improving the patients' quality of care vary in clinical practice, particularly in super‐aging societies, like in Japan. We aimed to develop a set of appropriate‐use criteria (AUC) for contemporary heart failure (HF) management to assist physicians in decision making. Methods and results With the use of the RAND methodology, a multidisciplinary writing group developed patient‐based clinical scenarios in 10 selected key topics, stratified mainly by HF stage, age, and renal function. Nine nationally recognized expert panellists independently rated the clinical scenario appropriateness twice on a scale of 1–9, as ‘appropriate’ (7–9), ‘may be appropriate’ (4–6), or ‘rarely appropriate’ (1–3). Decisions were based on clinical evidence and professional opinions in the context of available resource use and costs. An interactive round‐table discussion was held between the first and second ratings; the median score of the nine experts was then assigned to an appropriate‐use category. Most clinical scenarios without strong evidence were evaluated as ‘may be appropriate’. Frailty assessments in elderly patients (age ≥ 75 years), regardless of the HF stage, and advanced care planning in patients with stage C/D HF, regardless of age, were considered ‘appropriate’. For HF with reduced ejection fraction, beta‐blocker administration in elderly patients (age ≥ 75 years) with heart rate < 50 b.p.m. and mineral corticosteroid receptor antagonist use in elderly patients (age ≥ 75 years) with an estimated glomerular filtration rate < 30 mL/min/1.73 m2 were considered ‘rarely appropriate’. Conclusions The HF management AUC provide a practical guide for physicians regarding scenarios commonly encountered in daily practice.
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Affiliation(s)
- Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shogo Oishi
- Department of Cardiology, Himeji Cardiovascular Center, Himeji, Japan
| | | | - Shigehito Shiota
- Department of Rehabilitation, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasuko Takada
- Department of Nursing, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Atsushi Mizuno
- Department of Cardiology, St Luke's International Hospital, Tokyo, Japan
| | | | | | - Noboru Watanabe
- Department of Cardiology, Hokushin General Hospital, Nagano, Japan
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28
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Amrute JM, Zhang D, Padovano WM, Kovács SJ. E-wave asymmetry elucidates diastolic ventricular stiffness-relaxation coupling: model-based prediction with in vivo validation. Am J Physiol Heart Circ Physiol 2020; 320:H181-H189. [PMID: 33185111 DOI: 10.1152/ajpheart.00650.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Load, chamber stiffness, and relaxation are the three established determinants of global diastolic function (DF). Coupling of systolic stiffness and isovolumic relaxation has been hypothesized; however, diastolic stiffness-relaxation coupling (DSRC) remains unknown. The parametrized diastolic filling (PDF) formalism, a validated DF model incorporates DSRC. PDF model-predicted DSRC was validated by analysis of 159 Doppler E-waves from a published data set (22 healthy volunteers undergoing bicycle exercise). E-waves at varying (46-120 bpm) heart rates (HR) demonstrated variation in acceleration time (AT), deceleration time (DT), and E-wave peak velocity. AT, DT, and Epeak were converted into PDF parameters: stiffness ([Formula: see text]), relaxation ([Formula: see text]), and load (xo) using published numerical methods. Univariate linear regression showed that over a twofold increase in HR, AT, and DT decrease ([Formula: see text] = -0.44; P < 0.001 and r = -0.42; P < 0.001, respectively), while, DT/AT remains constant (r = -0.04; P = 0.67). Similarly, [Formula: see text] increases with HR (r = 0.55; P < 0.001), while [Formula: see text] has no significant correlation with HR (r = 0.08; P = 0.32). However, the dimensionless DSRC parameter ψ = c2/4k shows no significant correlation with HR (r = -0.03; P = 0.7). Furthermore, ψ is uniquely determined by DT/AT rather than AT or DT independently. Constancy of ψ in spite of a twofold increase in HR establishes that stiffness (k) and relaxation (c) are coupled and manifest via a HR-invariant parameter of E-wave asymmetry and should not be considered independent of each other. The manifestation of DSRC through E-wave asymmetry via ψ underscores the value of DT/AT as a physiological, mechanism-derived index of DF.NEW & NOTEWORTHY: Although diastolic stiffness and relaxation are considered independent chamber properties, the cardio-hemic inertial oscillation that generates E-waves obeys Newton's law. E-waves vary with heart rate requiring simultaneous change in stiffness and relaxation. By retrospective analysis of human heart-rate varying transmitral Doppler-data, we show that diastolic stiffness and relaxation are coupled and that the coupling manifests through E-wave asymmetry, quantified through a parametrized diastolic filling model-derived dimensionless parameter, which only depends on deceleration time and acceleration time, readily obtainable via standard echocardiography.
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Affiliation(s)
- Junedh M Amrute
- Cardiovascular Biophysics Laboratory, Cardiovascular Division, Washington University in St. Louis, School of Medicine, St. Louis, Missouri.,Center for Cardiovascular Research, Cardiovascular Division, Department of Medicine, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - David Zhang
- Cardiovascular Biophysics Laboratory, Cardiovascular Division, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - William M Padovano
- Cardiovascular Biophysics Laboratory, Cardiovascular Division, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - Sándor J Kovács
- Cardiovascular Biophysics Laboratory, Cardiovascular Division, Washington University in St. Louis, School of Medicine, St. Louis, Missouri.,Center for Cardiovascular Research, Cardiovascular Division, Department of Medicine, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
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29
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Fu EL, Uijl A, Dekker FW, Lund LH, Savarese G, Carrero JJ. Association Between β-Blocker Use and Mortality/Morbidity in Patients With Heart Failure With Reduced, Midrange, and Preserved Ejection Fraction and Advanced Chronic Kidney Disease. Circ Heart Fail 2020; 13:e007180. [DOI: 10.1161/circheartfailure.120.007180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background:
It is unknown if β-blockers reduce mortality/morbidity in patients with heart failure (HF) and advanced chronic kidney disease (CKD), a population underrepresented in HF trials.
Methods:
Observational cohort of HF patients with advanced CKD (estimated glomerular filtration rate <30 mL/min per 1.73 m
2
) from the Swedish Heart Failure Registry between 2001 and 2016. We first explored associations between β-blocker use, 5-year death, and the composite of cardiovascular death/HF hospitalization among 3775 patients with HF with reduced ejection fraction (HFrEF) and advanced CKD. We compared observed hazards with those from a control cohort of 15 346 patients with HFrEF and moderate CKD (estimated glomerular filtration rate <60–30 mL/min per 1.73 m
2
), for whom β-blocker trials demonstrate benefit. Second, we explored outcomes associated to β-blocker among advanced CKD participants with preserved (HFpEF; N=2009) and midrange ejection fraction (HFmrEF; N=1514).
Results:
During a median follow-up of 1.3 years, 2012 patients had a subsequent HF hospitalization, and 2849 died in the HFrEF cohort, of which 2016 died due to cardiovascular causes. Among patients with HFrEF, β-blocker use was associated with lower risk of death (adjusted hazard ratio 0.85 [95% CI, 0.75–0.96]) and cardiovascular mortality/HF hospitalization (0.87 [0.77–0.98]) compared with nonuse. The magnitude of the associations was similar to that observed for HFrEF patients with moderate CKD. Conversely, no significant association was observed for β-blocker users in advanced CKD with HFpEF (death: 0.88 [0.77–1.02], cardiovascular mortality/HF hospitalization: 1.05 [0.90–1.23]) or HFmrEF (death: 0.95 [0.79–1.14], cardiovascular mortality/HF hospitalization: 1.09 [0.90–1.31]).
Conclusions:
In HFrEF patients with advanced CKD, the use of β-blockers was associated with lower morbidity and mortality. Although inconclusive due to limited power, these benefits were not observed in similar patients with HFpEF or HFmrEF.
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Affiliation(s)
- Edouard L. Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands (E.L.F., F.W.D.)
| | - Alicia Uijl
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, The Netherlands (A.U.)
- Division of Cardiology, Department of Medicine (A.U., L.H.L., G.S.), Karolinska Institutet, Stockholm, Sweden
| | - Friedo W. Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands (E.L.F., F.W.D.)
| | - Lars H. Lund
- Division of Cardiology, Department of Medicine (A.U., L.H.L., G.S.), Karolinska Institutet, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine (A.U., L.H.L., G.S.), Karolinska Institutet, Stockholm, Sweden
| | - Juan J. Carrero
- Department of Medical Epidemiology and Biostatistics (J.J.C.), Karolinska Institutet, Stockholm, Sweden
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30
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Agarwal R, Rossignol P. Beta-blockers in heart failure patients with severe chronic kidney disease-time for a randomized controlled trial? Nephrol Dial Transplant 2020; 35:728-731. [PMID: 31578572 PMCID: PMC7203559 DOI: 10.1093/ndt/gfz187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 08/14/2019] [Indexed: 01/13/2023] Open
Affiliation(s)
- Rajiv Agarwal
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Patrick Rossignol
- University of Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Nancy, France
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31
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Aortic Stiffness and Heart Failure in Chronic Kidney Disease. CURRENT CARDIOVASCULAR IMAGING REPORTS 2020. [DOI: 10.1007/s12410-020-9534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Purpose of Review
To provide an update on the recent findings in the field of aortic stiffness and heart failure in patients with chronic kidney disease (CKD).
Recent Findings
Stratification of cardiovascular risk in CKD remains an open question. Recent reports suggest that aortic stiffness, an independent predictor of cardiovascular events in many patient populations, is also an important prognostic factor in CKD. Also, novel measures of myocardial tissue characterization, native T1 and T2 mapping techniques, have potential as diagnostic and prognostic factors in CKD.
Summary
Cardiovascular magnetic resonance has the ability to thoroughly evaluate novel imaging markers: aortic stiffness, native T1, and native T2. Novel imaging markers can be used for diagnostic and prognostic purposes as well as potential therapeutic targets in CKD population.
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32
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Burden and challenges of heart failure in patients with chronic kidney disease. A call to action. Nefrologia 2019; 40:223-236. [PMID: 31901373 DOI: 10.1016/j.nefro.2019.10.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/16/2019] [Indexed: 01/16/2023] Open
Abstract
Patients with the dual burden of chronic kidney disease (CKD) and chronic congestive heart failure (HF) experience unacceptably high rates of symptom load, hospitalization, and mortality. Currently, concerted efforts to identify, prevent and treat HF in CKD patients are lacking at the institutional level, with emphasis still being placed on individual specialty views on this topic. The authors of this review paper endorse the need for a dedicated cardiorenal interdisciplinary team that includes nephrologists and renal nurses and jointly manages appropriate clinical interventions across the inpatient and outpatient settings. There is a critical need for guidelines and best clinical practice models from major cardiology and nephrology professional societies, as well as for research funding in both specialties to focus on the needs of future therapies for HF in CKD patients. The implementation of cross-specialty educational programs across all levels in cardiology and nephrology will help train future specialists and nurses who have the ability to diagnose, treat, and prevent HF in CKD patients in a precise, clinically effective, and cost-favorable manner.
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33
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Kim HJ, Lee MH, Jo SH, Seo WW, Kim SE, Kim KJ, Choi JO, Ahn HS, Choi DJ, Ryu KH. Effects of Angiotensin-Converting Enzyme Inhibitors and Angiotensin-Receptor Blockers in Heart Failure With Chronic Kidney Disease - Propensity Score Matching Analysis. Circ J 2019; 84:83-90. [PMID: 31776309 DOI: 10.1253/circj.cj-19-0782] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Whether angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) exert beneficial effects in patients with concomitant heart failure (HF) and chronic kidney disease (CKD) remains uncertain. In this study, the effects of ACEI and ARB on long-term clinical outcomes in such patients were investigated.Methods and Results:Study data were obtained from a multicenter cohort that included patients hospitalized for HF. A total of 1,601 patients with both HF and CKD were classified according to prescription of ACEI or ARB at discharge. The mortality rate was 19.0% in the ACEI/ARB treatment group (n=943) and 33.6% in the no ACEI/ARB treatment group (n=658) during follow-up. The ACEI/ARB treatment group had a significantly higher cumulative death-free survival rate than the no ACEI/ARB treatment group. Cox regression analysis showed that using ACEI or ARB was independently associated with reduced risk of all-cause death after adjusting for confounding factors. The beneficial effects of ACEI or ARB were retained after propensity score matching. CONCLUSIONS Prescription of an ACEI or ARB at discharge was associated with reduction in all-cause mortality in patients with acute HF and CKD. Clinicians need to be aware of the prognostic value and consider prescribing ACEI or ARB to high-risk patients.
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Affiliation(s)
- Hyun-Jin Kim
- Cardiovascular Center, Hanyang University Guri Hospital
| | - Min-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital
| | - Sang-Ho Jo
- Cardiovascular Center, Hallym University Sacred Heart Hospital
| | - Won-Woo Seo
- Department of Internal Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine
| | - Sung Eun Kim
- Department of Internal Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine
| | - Kyung-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University School of Medicine
| | - Jin-Oh Choi
- Division of Cardiology, Cardiovascular and Stroke Imaging Center, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Hyo-Suk Ahn
- Cardiovascular Center, Uijeongbu St. Mary's Hospital
| | - Dong-Ju Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Bundang Hospital
| | - Kyu-Hyung Ryu
- Department of Cardiovascular Medicine, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University
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