Aldosterone and Volume Management in Hypertensive Heart Disease

Pharmacotherapeutic principles of fluid management in heart failure

Introduction: Heart failure is a major public health concern that is expected to increase over the decades to come. Despite significant advances, fluid overload and congestion remain a major therapeutic challenge. Vascular congestion and neurohormonal activation are intricately linked and the goal of therapy fundamentally aims to reduce both.Areas covered: The authors briefly review a number of core concepts that elucidate the link between fluid overload and neuro-hormonal activation. This is followed by a review of heart-kidney interactions and the impact of diuresis in this setting. Following an in-depth review of currently available pharmacological agents, the rationale and evidence behind their use, the authors end with a brief note on novel agents/approaches to aid volume management in HF.Expert opinion: A number of non-pharmacological advances in the management of volume overload in heart failure, though promising - are associated with a number of shortcomings. Pharmacological therapy remains the cornerstone of volume management. A number of novel approaches, utilizing existing therapies as well as the emergence of new agents over the past decade bode well for the vulnerable HF population.

Proteomic analysis of heart failure hospitalization among patients with chronic kidney disease: The Heart and Soul Study

Background

Patients with chronic kidney disease (CKD) are at increased risk for heart failure (HF). We aimed to investigate differences in proteins associated with HF hospitalizations among patients with and without CKD in the Heart and Soul Study.

Methods and results

We measured 1068 unique plasma proteins from baseline samples of 974 participants in The Heart and Soul Study who were followed for HF hospitalization over a median of 7 years. We sequentially applied forest regression and Cox survival analyses to select prognostic proteins. Among participants with CKD, four proteins were associated with HF at Bonferroni-level significance (p<2.5x10^-4): Angiopoietin-2 (HR[95%CI] 1.45[1.33, 1.59]), Spondin-1 (HR[95%CI] 1.13 [1.06, 1.20]), tartrate-resistant acid phosphatase type 5 (HR[95%CI] 0.65[0.53, 0.78]) and neurogenis locus notch homolog protein 1 (NOTCH1) (HR[95%CI] 0.67[0.55, 0.80]). These associations persisted at p<0.01 after adjustment for age, estimated glomerular filtration and history of HF. CKD was a significant interaction term in the associations of NOTCH1 and Spondin-1 with HF. Pathway analysis showed a trend for higher representation of the Cardiac Hypertrophy and Complement/Coagulation pathways among proteins prognostic of HF in the CKD sub-group.

Conclusions

These results suggest that markers of heart failure differ between patients with and without CKD. Further research is needed to validate novel markers in cohorts of patients with CKD and adjudicated HF events.

Mineralocorticoid Receptor Antagonists for Treatment of Hypertension and Heart Failure

Spironolactone and eplerenone are both mineralocorticoid-receptor antagonists. These compounds block both the epithelial and nonepithelial actions of aldosterone, with the latter assuming increasing clinical relevance. Spironolactone and eplerenone both affect reductions in blood pressure either as mono- or add-on therapy; moreover, they each afford survival benefits in diverse circumstances of heart failure and the probability of renal protection in proteinuric chronic kidney disease. However, as use of mineralocorticoid-blocking agents has expanded, the hazards inherent in taking such drugs have become more apparent. Whereas the endocrine side effects of spironolactone are in most cases little more than a cosmetic annoyance, the potassium-sparing effects of both spironolactone and eplerenone can prove disastrous, even fatal, if sufficient degrees of hyperkalemia emerge. For most patients, however, the risk of developing hyperkalemia in and of itself should not discourage the sensible clinician from bringing these compounds into play. Hyperkalemia should always be considered a possibility in patients receiving either of these medications; therefore, anticipatory steps should be taken to minimize the likelihood of its occurrence if long-term therapy of these agents is being considered.

Aldosterone Levels, Aortic Stiffness, and Wave Reflection in Essential Hypertensive Patients

BACKGROUND

The aim of the present study was to evaluate the grade of arterial stiffening, in relation to aldosterone (ALDO) and plasma renin activity (PRA) levels, in essential never-treated hypertensive patients.

MATERIALS AND METHODS

We studied 1,330 consecutive patients without clinical and/or laboratory findings of primary or secondary aldosteronism. Arterial stiffness indices Aix75 and carotid-femoral pulse wave velocity (PWVc-f) were measured and a 24-hour urine collection for ALDO was carried out to classify patients with low ALDO <12 mcg/24 hours and high ALDO >12 but <24 mcg/24 hours. Patients were divided according to PRA (high PRA > 1ng/ml/hour, low PRA < 1ng/ml/hour) and ALDO levels (high ALDO > 12 but <24 mcg/24 hours, low ALDO < 12 mcg/24 hours) in four groups. Also patients were grouped according to serum ALDO quartiles, 24-hour urine ALDO quartiles, PRA quartiles, and serum ALDO/PRA quartiles.

RESULTS

Patients were classified in 4 groups: group I (high ALDO and low PRA), group II (high ALDO and high PRA), group III (low ALDO and low PRA), and finally group IV (low ALDO and high PRA). PWVc-f and AoAIx75 were significantly higher in group I followed by group II, III, and IV (P < 0.001). Comparison of arterial stiffness indices according to PRA quartiles and PWVc-f and AoAIx75 showed significantly higher in the 1st quartile compared to 2nd, 3rd, and 4th, respectively (P < 0.001). PWVc-f and AoAIx75 were also compared among the four quartiles of aldosterone-renin ratio and they were significantly higher (P < 0.001) in the 4th quartile followed by the 3rd, 2nd, and 1st, respectively.

CONCLUSIONS

Arterial stiffness indices are higher among essential hypertensive patients with high normal serum and urine ALDO levels, pointing to a causal relationship between renin-angiotensin-aldosterone system activation and large artery properties.