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Biegus J, Cotter G, Metra M, Ponikowski P. Decongestion in acute heart failure: Is it time to change diuretic-centred paradigm? Eur J Heart Fail 2024. [PMID: 39169731 DOI: 10.1002/ejhf.3423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/18/2024] [Accepted: 07/25/2024] [Indexed: 08/23/2024] Open
Abstract
Congestion is a common cause of clinical deterioration and the most common clinical presentation at admission in acute heart failure (HF). Therefore, finding effective and sustainable ways to alleviate congestion has become a crucial goal for treating HF patients. Congestion is a result of complex underlying pathophysiology; therefore, it is not a direct cause of the disease but its consequence. Any therapy that directly promotes sodium/water removal only, thus targeting only clinical symptoms, neither modifies the natural course of the disease nor improves prognosis. This review aims to provide a comprehensive evaluation of the current decongestive therapies and propose a new (not diuretic-centred) paradigm of long-term congestion management in HF that attempts to correct the underlying pathophysiology, thus improving congestion, preventing its development, and favourably altering the natural course of the disease rather than merely treating its symptoms.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Gad Cotter
- Momentum Research, Inc., Chapel Hill, NC, USA
- U 942 Inserm MASCOT, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
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2
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Siddiqi HK, Cox ZL, Stevenson LW, Damman K, Ter Maaten JM, Bales B, Han JH, Ivey-Miranda JB, Lindenfeld J, Miller KF, Ooi H, Rao VS, Schlendorf K, Storrow AB, Walsh R, Wrenn J, Testani JM, Collins SP. The utility of urine sodium-guided diuresis during acute decompensated heart failure. Heart Fail Rev 2024:10.1007/s10741-024-10424-8. [PMID: 39128947 DOI: 10.1007/s10741-024-10424-8] [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] [Accepted: 07/16/2024] [Indexed: 08/13/2024]
Abstract
Diuresis to achieve decongestion is a central aim of therapy in patients hospitalized for acute decompensated heart failure (ADHF). While multiple approaches have been tried to achieve adequate decongestion rapidly while minimizing adverse effects, no single diuretic strategy has shown superiority, and there is a paucity of data and guidelines to utilize in making these decisions. Observational cohort studies have shown associations between urine sodium excretion and outcomes after hospitalization for ADHF. Urine chemistries (urine sodium ± urine creatinine) may guide diuretic titration during ADHF, and multiple randomized clinical trials have been designed to compare a strategy of urine chemistry-guided diuresis to usual care. This review will summarize current literature for diuretic monitoring and titration strategies, outline evidence gaps, and describe the recently completed and ongoing clinical trials to address these gaps in patients with ADHF with a particular focus on the utility of urine sodium-guided strategies.
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Affiliation(s)
- Hasan K Siddiqi
- Department of Medicine, Vanderbilt University Medical Center, North Tower, 1215 21st Avenue South, 5th Floor, Office 5033C, Nashville, TN, 37232-8802, USA.
| | - Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, Nashville, TN, USA
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lynne W Stevenson
- Department of Medicine, Vanderbilt University Medical Center, North Tower, 1215 21st Avenue South, 5th Floor, Office 5033C, Nashville, TN, 37232-8802, USA
| | - Kevin Damman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jozine M Ter Maaten
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Brian Bales
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric, Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, North Tower, 1215 21st Avenue South, 5th Floor, Office 5033C, Nashville, TN, 37232-8802, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Henry Ooi
- Department of Medicine, Vanderbilt University Medical Center, North Tower, 1215 21st Avenue South, 5th Floor, Office 5033C, Nashville, TN, 37232-8802, USA
- Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Veena S Rao
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kelly Schlendorf
- Department of Medicine, Vanderbilt University Medical Center, North Tower, 1215 21st Avenue South, 5th Floor, Office 5033C, Nashville, TN, 37232-8802, USA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan Walsh
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jesse Wrenn
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric, Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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3
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Leung CJ, Bhatt AS, Go AS, Parikh RV, Garcia EA, LE KC, Low D, Allen AR, Fitzpatrick JK, Adatya S, Sax DR, Goyal P, Varshney AS, Sandhu AT, Gustafson SE, Ambrosy AP. Sex-Based Differences in the Epidemiology, Clinical Characteristics, and Outcomes Associated with Worsening Heart Failure Events in a Learning Health System. J Card Fail 2024; 30:981-990. [PMID: 38697466 DOI: 10.1016/j.cardfail.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Differences in demographics, risk factors, and clinical characteristics may contribute to variations in men and women in terms of the prevalence, clinical setting, and outcomes associated with worsening heart failure (WHF) events. We sought to describe sex-based differences in the epidemiology, clinical characteristics, and outcomes associated with WHF events across clinical settings. METHODS AND RESULTS We examined adults diagnosed with HF from 2010 to 2019 within a large, integrated health care delivery system. Electronic health record data were accessed for hospitalizations, emergency department (ED) visits and observation stays, and outpatient encounters. WHF was identified using validated natural language processing algorithms and defined as ≥1 symptom, ≥2 objective findings (including ≥1 sign), and ≥1 change in HF-related therapy. Incidence rates and associated outcomes for WHF were compared across care setting by sex. We identified 1,122,368 unique clinical encounters with a diagnosis code for HF, with 124,479 meeting WHF criteria. These WHF encounters existed among 102,116 patients, of whom 48,543 (47.5%) were women and 53,573 (52.5%) were men. Women experiencing WHF were older and more likely to have HF with preserved ejection fraction compared with men. The clinical settings of WHF were similar among women and men: hospitalizations (36.8% vs 37.7%), ED visits or observation stays (11.8% vs 13.4%), and outpatient encounters (4.4% vs 4.9%). Women had lower odds of 30-day mortality after an index hospitalization (adjusted odds ratio 0.88, 95% confidence interval 0.83-0.93) or ED visit or observation stay (adjusted odds ratio 0.86, 95% confidence interval 0.75-0.98) for WHF. CONCLUSIONS Women and men contribute similarly to WHF events across diverse clinical settings despite marked differences in age and left ventricular ejection fraction.
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Affiliation(s)
- Chloe J Leung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Ankeet S Bhatt
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Epidemiology and Population Health, Stanford University, Palo Alto, California; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California; Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, California; Department of Medicine, Stanford University, Palo Alto, California
| | - Rishi V Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Epidemiology and Population Health, Stanford University, Palo Alto, California
| | - Elisha A Garcia
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kathy C LE
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Deborah Low
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Amanda R Allen
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jesse K Fitzpatrick
- Department of Cardiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Sirtaz Adatya
- Department of Cardiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Dana R Sax
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California; Medical Service, VA Palo Alto Health Care System, Palo Alto, California
| | - Shanshan E Gustafson
- Department of Medicine, Kaiser Permanente Mid-Atlantic Medical Group, Gaithersburg, Maryland
| | - Andrew P Ambrosy
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California.
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4
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Zandijk AJL, Boorsma EM, Maaten JMT, Rienstra M, Voors AA. Characteristics and Clinical Outcomes of Patients Hospitalized for Acute Heart Failure Who Develop Atrial Fibrillation or Convert to Sinus Rhythm. J Card Fail 2024:S1071-9164(24)00233-1. [PMID: 39029616 DOI: 10.1016/j.cardfail.2024.05.017] [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: 12/22/2023] [Revised: 05/23/2024] [Accepted: 05/23/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia in acute heart failure (AHF), with a prevalence of approximately 35%. However, little is known about the clinical characteristics and outcomes of in-hospital conversion from AF to sinus rhythm and vice versa. METHODS In a post hoc secondary analysis of the randomized, double-blind, placebo-controlled PROTECT trial in patients with AHF, we identified 4 groups of patients: AF at admission and in-hospital conversion to sinus rhythm (n = 44); in-hospital development of AF (n = 31); persistent AF (n = 278); and continuous sinus rhythm (n = 410). RESULTS Conversion from AF to sinus rhythm (13.7%) and from sinus rhythm to AF (7.0%) occurred only in a minority of patients. Patients with AF who converted to sinus rhythm were more often classified as being in New York Heart Association class IV, had higher heart rates and higher respiratory rates at hospital admission, whereas patients who developed AF were older, more likely to be female and had the highest ejection fractions compared to continuous sinus rhythm (all P < 0.05). Conversion to sinus rhythm or development of AF occurred mainly within the first 24 hours after hospital admission. Patients with persistent AF and those who developed AF had longer median lengths of hospital stay (8 vs 7 days; P < 0.001 and 9 vs 7 days; P < 0.001, respectively), compared to those with continuous sinus rhythm. In both univariable and multivariable analyses, there was no significant association between the AF groups and the primary clinical outcomes of either 180-day all-cause mortality or 60-day death or readmission for heart failure. CONCLUSION In patients hospitalized for AHF, only few converted from AF to sinus rhythm or sinus rhythm to AF. Although development of AF or persistent AF was associated with longer lengths of hospitalization, midterm mortality and readmission rates were similar in the groups.
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Affiliation(s)
- Arietje J L Zandijk
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eva M Boorsma
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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5
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Iyer SPN, Pino CJ, Yessayan LT, Goldstein SL, Weir MR, Westover AJ, Catanzaro DA, Chung KK, Humes HD. Increasing Eligibility to Transplant Through the Selective Cytopheretic Device: A Review of Case Reports Across Multiple Clinical Conditions. Transplant Direct 2024; 10:e1627. [PMID: 38769980 PMCID: PMC11104718 DOI: 10.1097/txd.0000000000001627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 05/22/2024] Open
Abstract
A stable, minimum physiological health status is required for patients to qualify for transplant or artificial organ support eligibility to ensure the recipient has enough reserve to survive the perioperative transplant period. Herein, we present a novel strategy to stabilize and improve patient clinical status through extracorporeal immunomodulation of systemic hyperinflammation with impact on multiple organ systems to increase eligibility and feasibility for transplant/device implantation. This involves treatment with the selective cytopheretic device (SCD), a cell-directed extracorporeal therapy shown to adhere and immunomodulate activated neutrophils and monocytes toward resolution of systemic inflammation. In this overview, we describe a case series of successful transition of pediatric and adult patients with multiorgan failure to successful transplant/device implantation procedures by treatment with the SCD in the following clinical situations: pediatric hemophagocytic lymphohistiocytosis, and adult hepatorenal and cardiorenal syndromes. Application of the SCD in these cases may represent a novel paradigm in increasing clinical eligibility of patients to successful transplant outcomes.
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Affiliation(s)
| | - Christopher J. Pino
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Lenar T. Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Stuart L. Goldstein
- Division of Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Matthew R. Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Angela J. Westover
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | | | - Kevin K. Chung
- Department of Medical Affairs, SeaStar Medical, Denver, CO
| | - H. David Humes
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
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6
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Areias F, Correia C, Rocha A, Teixeira S, Castro M, Brea J, Hu H, Carlsson J, Loza MI, Proença MF, Carvalho MA. 2-Aryladenine Derivatives as a Potent Scaffold for Adenosine Receptor Antagonists: The 6-Morpholino Derivatives. Molecules 2024; 29:2543. [PMID: 38893418 PMCID: PMC11173536 DOI: 10.3390/molecules29112543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/06/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
A set of 2-aryl-9-H or methyl-6-morpholinopurine derivatives were synthesized and assayed through radioligand binding tests at human A1, A2A, A2B, and A3 adenosine receptor subtypes. Eleven purines showed potent antagonism at A1, A3, dual A1/A2A, A1/A2B, or A1/A3 adenosine receptors. Additionally, three compounds showed high affinity without selectivity for any specific adenosine receptor. The structure-activity relationships were made for this group of new compounds. The 9-methylpurine derivatives were generally less potent but more selective, and the 9H-purine derivatives were more potent but less selective. These compounds can be an important source of new biochemical tools and/or pharmacological drugs.
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Affiliation(s)
- Filipe Areias
- Centre of Chemistry of University of Minho (CQUM), Campus de Gualtar, Universidade do Minho, 4710-057 Braga, Portugal; (F.A.); (C.C.); (A.R.); (S.T.); (M.F.P.)
- Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), Universidade de Santiago de Compostela, Avda de Barcelona, E-15782 Santiago de Compostela, Spain; (M.C.); (J.B.); (M.I.L.)
- School of Chemical Sciences & Engineering, Yachay Tech University, Yachay City of Knowledge, Urcuqui 100119, Ecuador
| | - Carla Correia
- Centre of Chemistry of University of Minho (CQUM), Campus de Gualtar, Universidade do Minho, 4710-057 Braga, Portugal; (F.A.); (C.C.); (A.R.); (S.T.); (M.F.P.)
| | - Ashly Rocha
- Centre of Chemistry of University of Minho (CQUM), Campus de Gualtar, Universidade do Minho, 4710-057 Braga, Portugal; (F.A.); (C.C.); (A.R.); (S.T.); (M.F.P.)
| | - Sofia Teixeira
- Centre of Chemistry of University of Minho (CQUM), Campus de Gualtar, Universidade do Minho, 4710-057 Braga, Portugal; (F.A.); (C.C.); (A.R.); (S.T.); (M.F.P.)
| | - Marián Castro
- Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), Universidade de Santiago de Compostela, Avda de Barcelona, E-15782 Santiago de Compostela, Spain; (M.C.); (J.B.); (M.I.L.)
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Travesía da Choupana s/n, E-15706 Santiago de Compostela, Spain
| | - Jose Brea
- Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), Universidade de Santiago de Compostela, Avda de Barcelona, E-15782 Santiago de Compostela, Spain; (M.C.); (J.B.); (M.I.L.)
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Travesía da Choupana s/n, E-15706 Santiago de Compostela, Spain
| | - Huabin Hu
- Science for Life Laboratory, Department of Cell and Molecular Biology, Uppsala University, SE-75124 Uppsala, Sweden; (H.H.); (J.C.)
| | - Jens Carlsson
- Science for Life Laboratory, Department of Cell and Molecular Biology, Uppsala University, SE-75124 Uppsala, Sweden; (H.H.); (J.C.)
| | - Maria I. Loza
- Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), Universidade de Santiago de Compostela, Avda de Barcelona, E-15782 Santiago de Compostela, Spain; (M.C.); (J.B.); (M.I.L.)
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Travesía da Choupana s/n, E-15706 Santiago de Compostela, Spain
| | - M. Fernanda Proença
- Centre of Chemistry of University of Minho (CQUM), Campus de Gualtar, Universidade do Minho, 4710-057 Braga, Portugal; (F.A.); (C.C.); (A.R.); (S.T.); (M.F.P.)
| | - M. Alice Carvalho
- Centre of Chemistry of University of Minho (CQUM), Campus de Gualtar, Universidade do Minho, 4710-057 Braga, Portugal; (F.A.); (C.C.); (A.R.); (S.T.); (M.F.P.)
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7
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Lala A, Hamo CE, Bozkurt B, Fiuzat M, Blumer V, Bukhoff D, Butler J, Costanzo MR, Felker GM, Filippatos G, Konstam MA, McMurray JJV, Mentz RJ, Metra M, Psotka MA, Solomon SD, Teerlink J, Abraham WT, O'Connor CM. Standardized Definitions for Evaluation of Acute Decompensated Heart Failure Therapies: HF-ARC Expert Panel Paper. JACC. HEART FAILURE 2024; 12:1-15. [PMID: 38069997 DOI: 10.1016/j.jchf.2023.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 01/06/2024]
Abstract
Acute decompensated heart failure (ADHF) is one of the most common reasons for hospitalizations or urgent care and is associated with poor outcomes. Therapies shown to improve outcomes are limited, however, and innovation in pharmacologic and device-based therapeutics are therefore actively being sought. Standardizing definitions for ADHF and its trajectory is complex, limiting the generalizability and translation of clinical trials to effect clinical care and policy change. The Heart Failure Collaboratory is a multistakeholder organization comprising clinical investigators, clinicians, patients, government representatives (including U.S. Food and Drug Administration and National Institutes of Health participants), payors, and industry collaborators. The following expert consensus document is the product of the Heart Failure Collaboratory convening with the Academic Research Consortium, including members from academia, the U.S. Food and Drug Administration, and industry, for the purposes of proposing standardized definitions for ADHF and highlighting important endpoint considerations to inform the design and conduct of clinical trials for drugs and devices in this clinical arena.
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Affiliation(s)
- Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute and Department of Population Health Science and Policy, Mount Sinai, New York, New York, USA.
| | - Carine E Hamo
- New York University School of Medicine, Leon H. Charney Division of Cardiology, New York University Langone Health, New York, New York, USA
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiology, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vanessa Blumer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel Bukhoff
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Javed Butler
- Baylor Scott & White Research Institute, Dallas, Texas, USA; University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gerasimos Filippatos
- University of Cyprus Medical School, Shakolas Educational Center for Clinical Medicine, Nicosia, Cyprus
| | - Marvin A Konstam
- The CardioVascular Center of Tufts Medical Center, Boston, Massachusetts, USA
| | - John J V McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Marco Metra
- Cardiology, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Christopher M O'Connor
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Inova Heart and Vascular Institute, Falls Church, Virginia, USA
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8
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Helberg J, Bensimhon D, Katsadouros V, Schmerge M, Smith H, Peck K, Williams K, Winfrey W, Nanavati A, Knapp J, Schmidt M, Curran L, McCarthy M, Sawulski M, Harbrecht L, Santos I, Masoudi E, Narendra N. Heart failure management at home: a non-randomised prospective case-controlled trial (HeMan at Home). Open Heart 2023; 10:e002371. [PMID: 38065589 PMCID: PMC10711907 DOI: 10.1136/openhrt-2023-002371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 11/05/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND/OBJECTIVES Heart failure (HF) is a growing clinical and economic burden for patients and health systems. The COVID-19 pandemic has led to avoidance and delay in care, resulting in increased morbidity and mortality among many patients with HF. The increasing burden of HF during the COVID-19 pandemic led us to evaluate the quality and safety of the Hospital at Home (HAH) for patients presenting to their community providers or emergency department (ED) with symptoms of acute on chronic HF (CHF) requiring admission. DESIGN/OUTCOMES A non-randomised prospective case-controlled of patients enrolled in the HAH versus admission to the hospital (usual care, UC). Primary outcomes included length of stay (LOS), adverse events, discharge disposition and patient satisfaction. Secondary outcomes included 30-day readmission rates, 30-day ED usage and ED dwell time. RESULTS Sixty patients met inclusion/exclusion criteria and were included in the study. Of the 60 patients, 40 were in the HAH and 20 were in the UC group. Primary outcomes demonstrated that HAH patients had slightly longer LOS (6.3 days vs 4.7 days); however, fewer adverse events (12.5% vs 35%) compared with the UC group. Those enrolled in the HAH programme were less likely to be discharged with postacute services (skilled nursing facility or home health). HAH was associated with increased patient satisfaction compared with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score in North Carolina. Secondary outcomes of 30-day readmission and ED usage were similar between HAH and UC. CONCLUSIONS The HAH pilot programme was shown to be a safe and effective alternative to hospitalisation for the appropriately selected patient presenting with acute on CHF.
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Affiliation(s)
- Justin Helberg
- Internal Medicine Teaching Service, Cone Health, Greensboro, North Carolina, USA
| | | | - Vasili Katsadouros
- Internal Medicine Teaching Service, Cone Health, Greensboro, North Carolina, USA
| | - Michelle Schmerge
- Remote Health Services, PLLC, Greensboro, North Carolina, USA
- Remote Health Services, PLLC, Greensboro, North Carolina, USA
| | - Heather Smith
- Remote Health Services, PLLC, Greensboro, North Carolina, USA
| | - Kelly Peck
- Triad Healthcare Network, Greensboro, North Carolina, USA
| | - Kim Williams
- Remote Health Services, PLLC, Greensboro, North Carolina, USA
| | - William Winfrey
- Internal Medicine Teaching Service, Cone Health, Greensboro, North Carolina, USA
| | | | - Jon Knapp
- Cone Health, Greensboro, North Carolina, USA
| | | | - Lisa Curran
- Cone Health, Greensboro, North Carolina, USA
| | | | | | - Lawrence Harbrecht
- Internal Medicine Teaching Service, Cone Health, Greensboro, North Carolina, USA
| | - Idalys Santos
- Internal Medicine Teaching Service, Cone Health, Greensboro, North Carolina, USA
| | - Ellie Masoudi
- Internal Medicine Teaching Service, Cone Health, Greensboro, North Carolina, USA
| | - Nischal Narendra
- Internal Medicine Teaching Service, Cone Health, Greensboro, North Carolina, USA
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Cotter G, Davison BA, Lam CSP, Metra M, Ponikowski P, Teerlink JR, Mebazaa A. Acute Heart Failure Is a Malignant Process: But We Can Induce Remission. J Am Heart Assoc 2023; 12:e031745. [PMID: 37889197 PMCID: PMC10727371 DOI: 10.1161/jaha.123.031745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Acute heart failure is a common and increasingly prevalent condition, affecting >10 million people annually. For those patients who survive to discharge, early readmissions and death rates are >30% everywhere on the planet, making it a malignant condition. Beyond these adverse outcomes, it represents one of the largest drivers of health care costs globally. Studies in the past 2 years have demonstrated that we can induce remissions in this malignant process if therapy is instituted rapidly, at the first acute heart failure episode, using full doses of all available effective medications. Multiple studies have demonstrated that this goal can be achieved safely and effectively. Now the urgent call is for all stakeholders, patients, physicians, payers, politicians, and the public at large to come together to address the gaps in implementation and enable health care providers to induce durable remissions in patients with acute heart failure.
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Affiliation(s)
- Gad Cotter
- Heart InitiativeDurhamNC
- Momentum Research, IncDurhamNC
- Université Paris Cité, INSERM UMR‐S 942 (MASCOT)ParisFrance
| | - Beth A. Davison
- Heart InitiativeDurhamNC
- Momentum Research, IncDurhamNC
- Université Paris Cité, INSERM UMR‐S 942 (MASCOT)ParisFrance
| | - Carolyn S. P. Lam
- National Heart Centre SingaporeSingapore
- Duke–National University of SingaporeSingapore
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical UniversityWrocławPoland
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of MedicineUniversity of California San FranciscoSan FranciscoCA
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR‐S 942 (MASCOT)ParisFrance
- Department of Anesthesiology and Critical Care and Burn UnitSaint‐Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP NordParisFrance
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10
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Georges G, Fudim M, Burkhoff D, Leon MB, Généreux P. Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 1. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101060. [PMID: 39131061 PMCID: PMC11307876 DOI: 10.1016/j.jscai.2023.101060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 08/13/2024]
Abstract
Despite recent advances in the treatment of patients with chronic heart failure, acute decompensated heart failure remains associated with significant mortality and morbidity because many novel therapies have failed to demonstrate meaningful benefit. Persistent congestion in the setting of escalating diuretic therapy has been repeatedly shown to be a marker of poor prognosis and is currently being targeted by various emerging device-based therapies. Because these therapies inherently carry procedural risk, patient selection is key in the future trial design. However, it remains unclear which patients are at a higher risk of residual congestion or adverse outcomes despite maximally tolerated decongestive therapy. In the first part of this 2-part review, we aimed to outline patient risk factors and summarize current evidence for early recognition of high-risk profile for residual congestion and adverse outcomes. These factors are classified as relating to the following: (1) previous clinical course, (2) severity of congestion, (3) diuretic response, and (4) degree of renal impairment. We also aimed to provide an overview of key inclusion criteria in recent acute decompensated heart failure trials and investigational device studies and propose potential criteria for selection of high-risk patients in future trials.
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Affiliation(s)
- Gabriel Georges
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Martin B. Leon
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
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11
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Parikh RV, Go AS, Bhatt AS, Tan TC, Allen AR, Feng KY, Hamilton SA, Tai AS, Fitzpatrick JK, Lee KK, Adatya S, Avula HR, Sax DR, Shen X, Cristino J, Sandhu AT, Heidenreich PA, Ambrosy AP. Developing Clinical Risk Prediction Models for Worsening Heart Failure Events and Death by Left Ventricular Ejection Fraction. J Am Heart Assoc 2023; 12:e029736. [PMID: 37776209 PMCID: PMC10727243 DOI: 10.1161/jaha.122.029736] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/24/2023] [Indexed: 10/02/2023]
Abstract
Background There is a need to develop electronic health record-based predictive models for worsening heart failure (WHF) events across clinical settings and across the spectrum of left ventricular ejection fraction (LVEF). Methods and Results We studied adults with heart failure (HF) from 2011 to 2019 within an integrated health care delivery system. WHF encounters were ascertained using natural language processing and structured data. We conducted boosted decision tree ensemble models to predict 1-year hospitalizations, emergency department visits/observation stays, and outpatient encounters for WHF and all-cause death within each LVEF category: HF with reduced ejection fraction (EF) (LVEF <40%), HF with mildly reduced EF (LVEF 40%-49%), and HF with preserved EF (LVEF ≥50%). Model discrimination was evaluated using area under the curve and calibration using mean squared error. We identified 338 426 adults with HF: 61 045 (18.0%) had HF with reduced EF, 49 618 (14.7%) had HF with mildly reduced EF, and 227 763 (67.3%) had HF with preserved EF. The 1-year risks of any WHF event and death were, respectively, 22.3% and 13.0% for HF with reduced EF, 17.0% and 10.1% for HF with mildly reduced EF, and 16.3% and 10.3% for HF with preserved EF. The WHF model displayed an area under the curve of 0.76 and mean squared error of 0.13, whereas the model for death displayed an area under the curve of 0.83 and mean squared error of 0.076. Performance and predictors were similar across WHF encounter types and LVEF categories. Conclusions We developed risk prediction models for 1-year WHF events and death across the LVEF spectrum using structured and unstructured electronic health record data and observed no substantial differences in model performance or predictors except for death, despite differences in underlying HF cause.
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Affiliation(s)
- Rishi V. Parikh
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of Epidemiology and Population HealthStanford UniversityPalo AltoCAUSA
| | - Alan S. Go
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of Health Systems ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCAUSA
- Departments of Epidemiology, Biostatistics and MedicineUniversity of California, San FranciscoSan FranciscoCAUSA
- Department of MedicineStanford UniversityPalo AltoCAUSA
| | - Ankeet S. Bhatt
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Thida C. Tan
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Amanda R. Allen
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Kent Y. Feng
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Steven A. Hamilton
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Andrew S. Tai
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Jesse K. Fitzpatrick
- Department of CardiologyKaiser Permanente Santa Clara Medical CenterSanta ClaraCAUSA
| | - Keane K. Lee
- Department of CardiologyKaiser Permanente Santa Clara Medical CenterSanta ClaraCAUSA
| | - Sirtaz Adatya
- Department of CardiologyKaiser Permanente Santa Clara Medical CenterSanta ClaraCAUSA
| | - Harshith R. Avula
- Department of CardiologyKaiser Permanente Walnut Creek Medical CenterWalnut CreekCAUSA
| | - Dana R. Sax
- Department of Emergency MedicineKaiser Permanente Oakland Medical CenterOaklandCAUSA
| | - Xian Shen
- Novartis Pharmaceuticals CorporationEast HanoverNJUSA
| | | | - Alexander T. Sandhu
- Division of Cardiovascular Medicine, Department of MedicineStanford UniversityStanfordCAUSA
- Medical Service, VA Palo Alto Health Care SystemPalo AltoCAUSA
| | - Paul A. Heidenreich
- Division of Cardiovascular Medicine, Department of MedicineStanford UniversityStanfordCAUSA
- Medical Service, VA Palo Alto Health Care SystemPalo AltoCAUSA
| | - Andrew P. Ambrosy
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of Health Systems ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCAUSA
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
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12
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Mehta A, Chandiramani R, Spirito A, Vogel B, Mehran R. Significance of Kidney Disease in Cardiovascular Disease Patients. Interv Cardiol Clin 2023; 12:453-467. [PMID: 37673491 DOI: 10.1016/j.iccl.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Cardiorenal syndrome is a condition where is a bidirectional and mutually detrimental relationship between the heart and kidneys. The mechanisms underlying cardiorenal syndrome are multifactorial and complex. Patients with kidney disease exhibit increased cardiovascular risk, presenting as coronary and peripheral artery disease, structural heart disease, arrhythmias, heart failure, and sudden cardiac death, largely occurring because of a systemic proinflammatory state, causing myocardial and vascular remodeling, manifesting as atherosclerotic lesions, vascular and valvular calcification, and myocardial fibrosis, particularly among those with advanced disease. This review summarizes the current understanding and clinical implications of kidney disease in patients with cardiovascular disease.
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Affiliation(s)
- Adhya Mehta
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham Parkway South, Bronx, NY 10461, USA
| | - Rishi Chandiramani
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham Parkway South, Bronx, NY 10461, USA; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Roxana Mehran
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA.
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13
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Martens P, Burkhoff D, Cowger JA, Jorde UP, Kapur NK, Tang WHW. Emerging Individualized Approaches in the Management of Acute Cardiorenal Syndrome With Renal Assist Devices. JACC. HEART FAILURE 2023; 11:1289-1303. [PMID: 37676211 DOI: 10.1016/j.jchf.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 09/08/2023]
Abstract
Growing insights into the pathophysiology of acute cardiorenal syndrome (CRS) in acute decompensated heart failure have indicated that not every rise in creatinine is associated with adverse outcomes. Detection of persistent volume overload and diuretic resistance associated with creatinine rise may identify patients with true acute CRS. More in-depth phenotyping is needed to identify pathologic processes in renal arterial perfusion, venous outflow, and microcirculatory-interstitial-lymphatic axis alterations that can contribute to acute CRS. Recently, various novel device-based interventions designed to target different pathophysiologic components of acute CRS are in early feasibility and proof-of-concept studies. However, appropriate trial endpoints that reflect improvement in cardiorenal trajectories remain elusive and highly debated. In this review the authors describe the variety of physiological derangements leading to acute CRS and the opportunity to individualize the management of acute CRS with novel renal assist devices that can target specific components of these alterations.
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Affiliation(s)
- Pieter Martens
- Kaufman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jennifer A Cowger
- Division of Cardiovascular Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ulrich P Jorde
- Department of Medicine, Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Navin K Kapur
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
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14
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Cooper L, DeVore A, Cowger J, Pinney S, Baran D, DeWald TA, Burt T, Pietzsch JB, Walton A, Aaronson K, Shah P. Patients hospitalized with acute heart failure, worsening renal function, and persistent congestion are at high risk for adverse outcomes despite current medical therapy. Clin Cardiol 2023; 46:1163-1172. [PMID: 37464579 PMCID: PMC10577559 DOI: 10.1002/clc.24080] [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: 09/24/2022] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Approximately 1/3 of patients with acute decompensated heart failure (ADHF) are discharged with persistent congestion. Worsening renal function (WRF) occurs in approximately 50% of patients hospitalized for ADHF and the combination of WRF and persistent congestion are associated with higher risk of mortality and HF readmissions. METHODS We designed a multicenter, prospective registry to describe current treatments and outcomes for patients hospitalized with ADHF complicated by WRF (defined as a creatinine increase ≥0.3 mg/dL) and persistent congestion at 96 h. Study participants were followed during the hospitalization and through 90-day post-discharge. Hospitalization costs were analyzed in an economic substudy. RESULTS We enrolled 237 patients hospitalized with ADHF, who also had WRF and persistent congestion. Among these, the average age was 66 ± 13 years and 61% had a left ventricular ejection fraction (LVEF) ≤ 40%. Mean baseline creatinine was 1.7 ± 0.7 mg/dL. Patients with persistent congestion had a high burden of clinical events during the index hospitalization (7.6% intensive care unit transfer, 2.1% intubation, 1.7% left ventricular assist device implantation, and 0.8% dialysis). At 90-day follow-up, 33% of patients were readmitted for ADHF or died. Outcomes and costs were similar between patients with reduced and preserved LVEF. CONCLUSIONS Many patients admitted with ADHF have WRF and persistent congestion despite diuresis and are at high risk for adverse events during hospitalization and early follow-up. Novel treatment strategies are urgently needed for this high-risk population.
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Affiliation(s)
- Lauren Cooper
- Department of CardiologyNorth Shore University HospitalManhassetNew YorkUSA
- Inova Heart & Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Adam DeVore
- Department of MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Jennifer Cowger
- Division of Cardiovascular MedicineHenry Ford HospitalsDetroitMichiganUSA
| | - Sean Pinney
- Heart & Vascular CenterUniversity of Chicago MedicineChicagoIllinoisUSA
| | | | - Tracy A. DeWald
- Department of MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
| | | | | | | | - Keith Aaronson
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Palak Shah
- Inova Heart & Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
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15
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Epps KC, Tehrani BN, Rosner C, Bagchi P, Cotugno A, Damluji AA, deFilippi C, Desai S, Ibrahim N, Psotka M, Raja A, Sherwood MW, Singh R, Sinha SS, Tang D, Truesdell AG, O’Connor C, Batchelor W. Sex-Related Differences in Patient Characteristics, Hemodynamics, and Outcomes of Cardiogenic Shock: INOVA-SHOCK Registry. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100978. [PMID: 38504778 PMCID: PMC10950300 DOI: 10.1016/j.jscai.2023.100978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Background Little is known about sex-related differences in outcomes of patients with cardiogenic shock (CS) treated within a standardized team-based approach (STBA). Methods We evaluated 520 consecutive patients (151 women and 369 men) with CS due to acute myocardial infarction (AMI) and heart failure (HF) in a single-center registry (January 2017-December 2019) and examined outcomes according to sex and CS phenotype. The primary outcome was in-hospital mortality. Secondary outcomes included major adverse cardiac events, 30-day mortality, major bleeding, vascular complications, and stroke. Results Women with AMI-CS had higher baseline acuity (CardShock score: female [F]: 5.5 vs male [M]: 4.0; P = .04). Women with HF-CS more often presented with cardiac arrest (F: 12.4% vs M: 2.4%; P< .01) and had higher rates of vasopressor use (F: 70.8% vs M: 58.0%; P = .04) and mechanical circulatory support (F: 46.1% vs M: 32.5%; P = .04). There were no sex-related differences in in-hospital mortality for AMI-CS (F: 45.2% vs M: 36.9%; P = .28) and HF-CS (F: 28.1% vs M: 24.5%; P = .56). Women with HF-CS experienced higher rates of major bleeding (F: 25.8% vs M: 13.7%; P = .02) and vascular complications (F: 15.7% vs M: 6.1%; P = .01). However, female sex was not an independent predictor of these complications. No sex differences in survival were noted at 1 year. Conclusions Within an STBA, although women with AMI-CS and HF-CS presented with higher acuity, they experienced similar in-hospital mortality, major adverse cardiac events, 30-day mortality, stroke, and 30-day readmissions as men. Further research is needed to better understand the extent to which historical differences in CS outcomes can be mitigated by an STBA.
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Affiliation(s)
- Kelly C. Epps
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Pramita Bagchi
- Department of Statistics, George Mason University, Fairfax, Virginia
| | - Annunziata Cotugno
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Institute of Cardiology, University of Brescia, Brescia, Italy
| | | | | | - Shashank Desai
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | | | - Anika Raja
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Ramesh Singh
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Daniel Tang
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Alexander G. Truesdell
- Inova Heart and Vascular Institute, Falls Church, Virginia
- Virginia Heart, Falls Church, Virginia
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16
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Dmour BA, Costache AD, Dmour A, Huzum B, Duca ȘT, Chetran A, Miftode RȘ, Afrăsânie I, Tuchiluș C, Cianga CM, Botnariu G, Șerban LI, Ciocoiu M, Bădescu CM, Costache II. Could Endothelin-1 Be a Promising Neurohormonal Biomarker in Acute Heart Failure? Diagnostics (Basel) 2023; 13:2277. [PMID: 37443671 DOI: 10.3390/diagnostics13132277] [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: 05/24/2023] [Revised: 06/20/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
Acute heart failure (AHF) is a life-threatening condition with high morbidity and mortality. Even though this pathology has been extensively researched, there are still challenges in establishing an accurate and early diagnosis, determining the long- and short-term prognosis and choosing a targeted therapeutic strategy. The use of reliable biomarkers to support clinical judgment has been shown to improve the management of AHF patients. Despite a large pool of interesting candidate biomarkers, endothelin-1 (ET-1) appears to be involved in multiple aspects of AHF pathogenesis that include neurohormonal activation, cardiac remodeling, endothelial dysfunction, inflammation, atherosclerosis and alteration of the renal function. Since its discovery, numerous studies have shown that the level of ET-1 is associated with the severity of symptoms and cardiac dysfunction in this pathology. The purpose of this paper is to review the existing information on ET-1 and answer the question of whether this neurohormone could be a promising biomarker in AHF.
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Affiliation(s)
- Bianca-Ana Dmour
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Alexandru Dan Costache
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iași, Romania
| | - Awad Dmour
- Department of Orthopedics and Traumatology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Orthopaedics and Traumatology, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Bogdan Huzum
- Department of Orthopaedics and Traumatology, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Physiology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Ștefania Teodora Duca
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Cardiology Clinic, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Adriana Chetran
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Cardiology Clinic, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Radu Ștefan Miftode
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Cardiology Clinic, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Irina Afrăsânie
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Cardiology Clinic, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Cristina Tuchiluș
- Department of Microbiology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Microbiology Laboratory, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Corina Maria Cianga
- Immunology Laboratory, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Immunology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Gina Botnariu
- Unit of Diabetes, Nutrition and Metabolic Diseases, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Clinical Center of Diabetes, Nutrition and Metabolic Diseases, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Lăcrămioara Ionela Șerban
- Department of Physiology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Manuela Ciocoiu
- Department of Morpho-Functional Sciences II, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Codruța Minerva Bădescu
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Internal Medicine Clinic, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Irina Iuliana Costache
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Cardiology Clinic, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
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17
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McCallum W, Sarnak MJ. Cardiorenal Syndrome in the Hospital. Clin J Am Soc Nephrol 2023; 18:933-945. [PMID: 36787124 PMCID: PMC10356127 DOI: 10.2215/cjn.0000000000000064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/22/2022] [Indexed: 01/22/2023]
Abstract
The cardiorenal syndrome refers to a group of complex, bidirectional pathophysiological pathways involving dysfunction in both the heart and kidney. Upward of 60% of patients admitted for acute decompensated heart failure have CKD, as defined by an eGFR of <60 ml/min per 1.73 m 2 . CKD, in turn, is one of the strongest risk factors for mortality and cardiovascular events in acute decompensated heart failure. Although not well understood, the mechanisms in the cardiorenal syndrome include venous congestion, arterial underfilling, neurohormonal activation, inflammation, and endothelial dysfunction. Arterial underfilling may lead to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, leading to sodium reabsorption and vasoconstriction. Venous congestion likely also mediates and perpetuates these maladaptive pathways. To rule out intrinsic kidney disease that is distinct from the cardiorenal syndrome, one should obtain a careful history, review longitudinal eGFR trends, assess albuminuria and proteinuria, and review the urine sediment and kidney imaging. The hallmark of the cardiorenal syndrome is intense sodium avidity and diuretic resistance, often requiring a combination of diuretics with varying pharmacological targets, and monitoring of urinary response to guide escalations in therapy. Invasive means of decongestion may be required including ultrafiltration or KRT such as peritoneal dialysis, which is often better tolerated from a hemodynamic perspective than intermittent hemodialysis. Strategies for increasing forward perfusion in states of low cardiac output and cardiogenic shock may include afterload reduction and inotropes and, in the most severe cases, mechanical circulatory support devices, many of which have kidney-specific considerations.
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Affiliation(s)
- Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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18
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Nguyen ATN, Tran QL, Baltos JA, McNeill SM, Nguyen DTN, May LT. Small molecule allosteric modulation of the adenosine A 1 receptor. Front Endocrinol (Lausanne) 2023; 14:1184360. [PMID: 37435481 PMCID: PMC10331460 DOI: 10.3389/fendo.2023.1184360] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/23/2023] [Indexed: 07/13/2023] Open
Abstract
G protein-coupled receptors (GPCRs) represent the target for approximately a third of FDA-approved small molecule drugs. The adenosine A1 receptor (A1R), one of four adenosine GPCR subtypes, has important (patho)physiological roles in humans. A1R has well-established roles in the regulation of the cardiovascular and nervous systems, where it has been identified as a potential therapeutic target for a number of conditions, including cardiac ischemia-reperfusion injury, cognition, epilepsy, and neuropathic pain. A1R small molecule drugs, typically orthosteric ligands, have undergone clinical trials. To date, none have progressed into the clinic, predominantly due to dose-limiting unwanted effects. The development of A1R allosteric modulators that target a topographically distinct binding site represent a promising approach to overcome current limitations. Pharmacological parameters of allosteric ligands, including affinity, efficacy and cooperativity, can be optimized to regulate A1R activity with high subtype, spatial and temporal selectivity. This review aims to offer insights into the A1R as a potential therapeutic target and highlight recent advances in the structural understanding of A1R allosteric modulation.
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Affiliation(s)
- Anh T. N. Nguyen
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Quan L. Tran
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Jo-Anne Baltos
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Samantha M. McNeill
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Diep T. N. Nguyen
- Department of Information Technology, Faculty of Engineering and Technology, Vietnam National University, Hanoi, Vietnam
| | - Lauren T. May
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
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19
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Rodriguez R, Kaluzna SD. Sodium-glucose cotransporter 2 inhibitors and cardiovascular clinical outcomes in acute heart failure: A narrative review. Am J Health Syst Pharm 2023; 80:818-826. [PMID: 36971375 DOI: 10.1093/ajhp/zxad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2023] Open
Abstract
PURPOSE This review describes the evidence from randomized controlled trials (RCTs) regarding the effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors on cardiovascular (CV) clinical outcomes when therapy is initiated during acute heart failure (HF). SUMMARY SGLT2 inhibitors have become a cornerstone of guideline-directed medical therapy (GDMT) for type 2 diabetes mellitus, chronic kidney disease, and HF. Because of their ability to promote natriuresis and diuresis as well as other potentially beneficial CV effects, use of SGLT2 inhibitors has been investigated when therapy is initiated during hospitalization for acute HF. We identified 5 placebo-controlled RCTs that reported CV clinical outcomes incorporating one or more components of all-cause mortality, CV mortality, CV hospitalization, HF worsening, and hospitalization for HF in patients treated with empagliflozin (n = 3 trials), dapagliflozin (n = 1 trial), and sotagliflozin (n = 1 trial). Nearly all CV outcomes in these trials showed benefit with SGLT2 inhibitor use during acute HF. Incidence of hypotension, hypokalemia, and acute renal failure was generally similar to that with placebo. These findings are limited by heterogeneous outcome definitions, variation in time to SGLT2 inhibitor initiation, and small sample sizes. CONCLUSION SGLT2 inhibitors may have a role in inpatient management of acute HF, provided there is close monitoring for fluctuations in hemodynamic, fluid, and electrolyte status. Initiation of SGLT2 inhibitors at the time of acute HF may promote optimized GDMT, continued medication adherence, and reduced risk of CV outcomes.
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Affiliation(s)
- Ryan Rodriguez
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Stephanie Dwyer Kaluzna
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
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20
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Anglada-Huguet M, Endepols H, Sydow A, Hilgers R, Neumaier B, Drzezga A, Kaniyappan S, Mandelkow E, Mandelkow EM. Reversal of Tau-Dependent Cognitive Decay by Blocking Adenosine A1 Receptors: Comparison of Transgenic Mouse Models with Different Levels of Tauopathy. Int J Mol Sci 2023; 24:ijms24119260. [PMID: 37298211 DOI: 10.3390/ijms24119260] [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: 03/16/2023] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 06/12/2023] Open
Abstract
The accumulation of tau is a hallmark of several neurodegenerative diseases and is associated with neuronal hypoactivity and presynaptic dysfunction. Oral administration of the adenosine A1 receptor antagonist rolofylline (KW-3902) has previously been shown to reverse spatial memory deficits and to normalize the basic synaptic transmission in a mouse line expressing full-length pro-aggregant tau (TauΔK) at low levels, with late onset of disease. However, the efficacy of treatment remained to be explored for cases of more aggressive tauopathy. Using a combination of behavioral assays, imaging with several PET-tracers, and analysis of brain tissue, we compared the curative reversal of tau pathology by blocking adenosine A1 receptors in three mouse models expressing different types and levels of tau and tau mutants. We show through positron emission tomography using the tracer [18F]CPFPX (a selective A1 receptor ligand) that intravenous injection of rolofylline effectively blocks A1 receptors in the brain. Moreover, when administered to TauΔK mice, rolofylline can reverse tau pathology and synaptic decay. The beneficial effects are also observed in a line with more aggressive tau pathology, expressing the amyloidogenic repeat domain of tau (TauRDΔK) with higher aggregation propensity. Both models develop a progressive tau pathology with missorting, phosphorylation, accumulation of tau, loss of synapses, and cognitive decline. TauRDΔK causes pronounced neurofibrillary tangle assembly concomitant with neuronal death, whereas TauΔK accumulates only to tau pretangles without overt neuronal loss. A third model tested, the rTg4510 line, has a high expression of mutant TauP301L and hence a very aggressive phenotype starting at ~3 months of age. This line failed to reverse pathology upon rolofylline treatment, consistent with a higher accumulation of tau-specific PET tracers and inflammation. In conclusion, blocking adenosine A1 receptors by rolofylline can reverse pathology if the pathological potential of tau remains below a threshold value that depends on concentration and aggregation propensity.
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Affiliation(s)
- Marta Anglada-Huguet
- German Center for Neurodegenerative Diseases (DZNE), Building 99, Venusberg Campus 1, 53127 Bonn, Germany
| | - Heike Endepols
- Institute of Radiochemistry and Experimental Molecular Imaging, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
- Forschungszentrum Jülich GmbH, Institute of Neuroscience and Medicine, Nuclear Chemistry (INM-5), Wilhelm-Johnen-Straße, 52428 Jülich, Germany
| | - Astrid Sydow
- German Center for Neurodegenerative Diseases (DZNE), Building 99, Venusberg Campus 1, 53127 Bonn, Germany
| | - Ronja Hilgers
- German Center for Neurodegenerative Diseases (DZNE), Building 99, Venusberg Campus 1, 53127 Bonn, Germany
| | - Bernd Neumaier
- Institute of Radiochemistry and Experimental Molecular Imaging, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
- Forschungszentrum Jülich GmbH, Institute of Neuroscience and Medicine, Nuclear Chemistry (INM-5), Wilhelm-Johnen-Straße, 52428 Jülich, Germany
- Max Planck Institute for Metabolism Research, 50931 Cologne, Germany
| | - Alexander Drzezga
- German Center for Neurodegenerative Diseases (DZNE), Building 99, Venusberg Campus 1, 53127 Bonn, Germany
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
- Forschungszentrum Jülich GmbH, Institute of Neuroscience and Medicine, Molecular Organization of the Brain (INM-2), Wilhelm-Johnen-Straße, 52428 Jülich, Germany
| | - Senthilvelrajan Kaniyappan
- German Center for Neurodegenerative Diseases (DZNE), Building 99, Venusberg Campus 1, 53127 Bonn, Germany
- MPI Neurobiology Behavior-caesar, Ludwig-Erhard-Allee 2, 53175 Bonn, Germany
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, 53127 Bonn, Germany
| | - Eckhard Mandelkow
- German Center for Neurodegenerative Diseases (DZNE), Building 99, Venusberg Campus 1, 53127 Bonn, Germany
- MPI Neurobiology Behavior-caesar, Ludwig-Erhard-Allee 2, 53175 Bonn, Germany
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, 53127 Bonn, Germany
| | - Eva-Maria Mandelkow
- German Center for Neurodegenerative Diseases (DZNE), Building 99, Venusberg Campus 1, 53127 Bonn, Germany
- MPI Neurobiology Behavior-caesar, Ludwig-Erhard-Allee 2, 53175 Bonn, Germany
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21
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Beldhuis IE, Ter Maaten JM, Figarska SM, Damman K, Pang PS, Greenberg B, Davison BA, Cotter G, Severin T, Gimpelewicz C, Felker GM, Filippatos G, Teerlink JR, Metra M, Voors AA. Disconnect between the effects of serelaxin on renal function and outcome in acute heart failure. Clin Res Cardiol 2023:10.1007/s00392-022-02144-6. [PMID: 36656377 DOI: 10.1007/s00392-022-02144-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/19/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND We aimed to study whether improvement in renal function by serelaxin in patients who were hospitalized for acute heart failure (HF) might explain any potential effect on clinical outcomes. METHODS We included 6318 patients from the RELAXin in AHF-2 (RELAX-AHF2) study. Improvement in renal function was defined as a decrease in serum creatinine of ≥ 0.3 mg/dL and ≥ 25%, or increase in estimated glomerular filtration rate of ≥ 25% between baseline and day 2. Worsening renal function (WRF) was defined as the reverse. We performed causal mediation analyses regarding 180-day all-cause mortality (ACM), cardiovascular death (CVD), and hospitalization for HF/renal failure. RESULTS Improvement in renal function was more frequently observed with serelaxin when compared with placebo [OR 1.88 (95% CI 1.64-2.15, p < 0.0001)], but was not associated with subsequent clinical outcomes. WRF occurred less frequent with serelaxin [OR 0.70 (95% CI 0.60-0.83, p < 0.0001)] and was associated with increased risk of ACM, worsening HF and the composite of CVD and HF or renal failure hospitalization. Improvement in renal function did not mediate the treatment effect of serelaxin [CVD HR 1.01 (0.99-1.04), ACM HR 1.01 (0.99-1.03), HF/renal failure hospitalization HR 0.99 (0.97-1.00)]. CONCLUSIONS Despite the significant improvement in renal function by serelaxin in patients with acute HF, the potential beneficial treatment effect was not mediated by improvement in renal function. These data suggest that improvement in renal function might not be a suitable surrogate marker for potential treatment efficacy in future studies with novel relaxin agents in acute HF. Central illustration. Conceptual model explaining mediation analysis; treatment efficacy of heart failure therapies mediated by renal function.
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Affiliation(s)
- I E Beldhuis
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - J M Ter Maaten
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - S M Figarska
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - K Damman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - P S Pang
- Department of Emergency Medicine, Indiana University, Indianapolis, IN, USA
| | - B Greenberg
- Sulpizio Family Cardiovascular Center, University of California San Diego Health, La Jolla, CA, USA
| | - B A Davison
- Momentum Research and Inserm U942 MASCOT, Paris, France
| | - G Cotter
- Momentum Research and Inserm U942 MASCOT, Paris, France
| | | | | | - G M Felker
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC, USA
| | - G Filippatos
- Department of Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - J R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, CA, USA
| | - M Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiologic Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - A A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
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22
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Aronson D. The interstitial compartment as a therapeutic target in heart failure. Front Cardiovasc Med 2022; 9:933384. [PMID: 36061549 PMCID: PMC9428749 DOI: 10.3389/fcvm.2022.933384] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/15/2022] [Indexed: 12/23/2022] Open
Abstract
Congestion is the single most important contributor to heart failure (HF) decompensation. Most of the excess volume in patients with HF resides in the interstitial compartment. Inadequate decongestion implies persistent interstitial congestion and is associated with worse outcomes. Therefore, effective interstitial decongestion represents an unmet need to improve quality of life and reduce clinical events. The key processes that underlie incomplete interstitial decongestion are often ignored. In this review, we provide a summary of the pathophysiology of the interstitial compartment in HF and the factors governing the movement of fluids between the interstitial and vascular compartments. Disruption of the extracellular matrix compaction occurs with edema, such that the interstitium becomes highly compliant, and large changes in volume marginally increase interstitial pressure and allow progressive capillary filtration into the interstitium. Augmentation of lymph flow is required to prevent interstitial edema, and the lymphatic system can increase fluid removal by at least 10-fold. In HF, lymphatic remodeling can become insufficient or maladaptive such that the capacity of the lymphatic system to remove fluid from the interstitium is exceeded. Increased central venous pressure at the site of the thoracic duct outlet also impairs lymphatic drainage. Owing to the kinetics of extracellular fluid, microvascular absorption tends to be transient (as determined by the revised Starling equation). Therefore, effective interstitial decongestion with adequate transcapillary plasma refill requires a substantial reduction in plasma volume and capillary pressure that are prolonged and sustained, which is not always achieved in clinical practice. The critical importance of the interstitium in the congestive state underscores the need to directly decongest the interstitial compartment without relying on the lowering of intracapillary pressure with diuretics. This unmet need may be addressed by novel device therapies in the near future.
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Affiliation(s)
- Doron Aronson
- Department of Cardiology, Rambam Health Care Campus, B. Rappaport Faculty of Medicine, Technion Medical School, Haifa, Israel
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23
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Antohi LE, Adamo M, Chioncel O. Long-term Survival after Acute Heart Failure Hospitalization; From Observation to Collaborative Interventions. Eur J Heart Fail 2022; 24:1529-1531. [PMID: 35918910 DOI: 10.1002/ejhf.2645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Laura E Antohi
- Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', Bucharest, Romania
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', Bucharest, Romania
- University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
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24
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Ambrosy AP, Parikh RV, Sung SH, Tan TC, Narayanan A, Masson R, Lam PQ, Kheder K, Iwahashi A, Hardwick AB, Fitzpatrick JK, Avula HR, Selby VN, Ku IA, Shen X, Sanghera N, Cristino J, Go AS. Analysis of Worsening Heart Failure Events in an Integrated Health Care System. J Am Coll Cardiol 2022; 80:111-122. [DOI: 10.1016/j.jacc.2022.04.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/30/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022]
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25
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Emara AN, Mansour NO, Elnaem MH, Wadie M, Dehele IS, Shams MEE. Efficacy of Nondiuretic Pharmacotherapy for Improving the Treatment of Congestion in Patients with Acute Heart Failure: A Systematic Review of Randomised Controlled Trials. J Clin Med 2022; 11:3112. [PMID: 35683505 PMCID: PMC9181246 DOI: 10.3390/jcm11113112] [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: 03/11/2022] [Revised: 05/22/2022] [Accepted: 05/26/2022] [Indexed: 11/16/2022] Open
Abstract
Diuretic therapy is the mainstay during episodes of acute heart failure (AHF). Diuretic resistance is often encountered and poses a substantial challenge for clinicians. There is a lack of evidence on the optimal strategies to tackle this problem. This review aimed to compare the outcomes associated with congestion management based on a strategy of pharmacological nondiuretic-based regimens. The PubMed, Cochrane Library, Scopus, and ScienceDirect databases were systematically searched for all randomised controlled trials (RCTs) of adjuvant pharmacological treatments used during hospitalisation episodes of AHF patients. Congestion relief constitutes the main target in AHF; hence, only studies with efficacy indicators related to decongestion enhancement were included. The Cochrane risk-of-bias tool was used to evaluate the methodological quality of the included RCTs. Twenty-three studies were included; dyspnea relief constituted the critical efficacy endpoint in most included studies. However, substantial variations in dyspnea measurement were found. Tolvaptan and serelaxin were found to be promising options that might improve decongestion in AHF patients. However, further high-quality RCTs using a standardised approach to diuretic management, including dosing and monitoring strategies, are crucial to provide new insights and recommendations for managing heart failure in acute settings.
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Affiliation(s)
- Abdelrahman N. Emara
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt; (A.N.E.); (N.O.M.); (M.E.E.S.)
| | - Noha O. Mansour
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt; (A.N.E.); (N.O.M.); (M.E.E.S.)
| | - Mohamed Hassan Elnaem
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan 25200, Pahang, Malaysia
- Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan 25200, Pahang, Malaysia
| | - Moheb Wadie
- Cardiology Department, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt;
| | | | - Mohamed E. E. Shams
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt; (A.N.E.); (N.O.M.); (M.E.E.S.)
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26
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27
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IJzerman AP, Jacobson KA, Müller CE, Cronstein BN, Cunha RA. International Union of Basic and Clinical Pharmacology. CXII: Adenosine Receptors: A Further Update. Pharmacol Rev 2022; 74:340-372. [PMID: 35302044 PMCID: PMC8973513 DOI: 10.1124/pharmrev.121.000445] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Our previous International Union of Basic and Clinical Pharmacology report on the nomenclature and classification of adenosine receptors (2011) contained a number of emerging developments with respect to this G protein-coupled receptor subfamily, including protein structure, protein oligomerization, protein diversity, and allosteric modulation by small molecules. Since then, a wealth of new data and results has been added, allowing us to explore novel concepts such as target binding kinetics and biased signaling of adenosine receptors, to examine a multitude of receptor structures and novel ligands, to gauge new pharmacology, and to evaluate clinical trials with adenosine receptor ligands. This review should therefore be considered a further update of our previous reports from 2001 and 2011. SIGNIFICANCE STATEMENT: Adenosine receptors (ARs) are of continuing interest for future treatment of chronic and acute disease conditions, including inflammatory diseases, neurodegenerative afflictions, and cancer. The design of AR agonists ("biased" or not) and antagonists is largely structure based now, thanks to the tremendous progress in AR structural biology. The A2A- and A2BAR appear to modulate the immune response in tumor biology. Many clinical trials for this indication are ongoing, whereas an A2AAR antagonist (istradefylline) has been approved as an anti-Parkinson agent.
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Affiliation(s)
- Adriaan P IJzerman
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands (A.P.IJ.); National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Molecular Recognition Section, Bethesda, Maryland (K.A.J.); Universität Bonn, Bonn, Germany (C.E.M.); New York University School of Medicine, New York, New York (B.N.C.); and Center for Neurosciences and Cell Biology and Faculty of Medicine, University of Coimbra, Coimbra, Portugal (R.A.C.)
| | - Kenneth A Jacobson
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands (A.P.IJ.); National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Molecular Recognition Section, Bethesda, Maryland (K.A.J.); Universität Bonn, Bonn, Germany (C.E.M.); New York University School of Medicine, New York, New York (B.N.C.); and Center for Neurosciences and Cell Biology and Faculty of Medicine, University of Coimbra, Coimbra, Portugal (R.A.C.)
| | - Christa E Müller
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands (A.P.IJ.); National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Molecular Recognition Section, Bethesda, Maryland (K.A.J.); Universität Bonn, Bonn, Germany (C.E.M.); New York University School of Medicine, New York, New York (B.N.C.); and Center for Neurosciences and Cell Biology and Faculty of Medicine, University of Coimbra, Coimbra, Portugal (R.A.C.)
| | - Bruce N Cronstein
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands (A.P.IJ.); National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Molecular Recognition Section, Bethesda, Maryland (K.A.J.); Universität Bonn, Bonn, Germany (C.E.M.); New York University School of Medicine, New York, New York (B.N.C.); and Center for Neurosciences and Cell Biology and Faculty of Medicine, University of Coimbra, Coimbra, Portugal (R.A.C.)
| | - Rodrigo A Cunha
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands (A.P.IJ.); National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Molecular Recognition Section, Bethesda, Maryland (K.A.J.); Universität Bonn, Bonn, Germany (C.E.M.); New York University School of Medicine, New York, New York (B.N.C.); and Center for Neurosciences and Cell Biology and Faculty of Medicine, University of Coimbra, Coimbra, Portugal (R.A.C.)
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28
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Voors AA, Angermann CE, Teerlink JR, Collins SP, Kosiborod M, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Tromp J, Borleffs CJW, Ma C, Comin-Colet J, Fu M, Janssens SP, Kiss RG, Mentz RJ, Sakata Y, Schirmer H, Schou M, Schulze PC, Spinarova L, Volterrani M, Wranicz JK, Zeymer U, Zieroth S, Brueckmann M, Blatchford JP, Salsali A, Ponikowski P. The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure: a multinational randomized trial. Nat Med 2022; 28:568-574. [PMID: 35228754 PMCID: PMC8938265 DOI: 10.1038/s41591-021-01659-1] [Citation(s) in RCA: 377] [Impact Index Per Article: 188.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/14/2021] [Indexed: 12/22/2022]
Abstract
The sodium–glucose cotransporter 2 inhibitor empagliflozin reduces the risk of cardiovascular death or heart failure hospitalization in patients with chronic heart failure, but whether empagliflozin also improves clinical outcomes when initiated in patients who are hospitalized for acute heart failure is unknown. In this double-blind trial (EMPULSE; NCT04157751), 530 patients with a primary diagnosis of acute de novo or decompensated chronic heart failure regardless of left ventricular ejection fraction were randomly assigned to receive empagliflozin 10 mg once daily or placebo. Patients were randomized in-hospital when clinically stable (median time from hospital admission to randomization, 3 days) and were treated for up to 90 days. The primary outcome of the trial was clinical benefit, defined as a hierarchical composite of death from any cause, number of heart failure events and time to first heart failure event, or a 5 point or greater difference in change from baseline in the Kansas City Cardiomyopathy Questionnaire Total Symptom Score at 90 days, as assessed using a win ratio. More patients treated with empagliflozin had clinical benefit compared with placebo (stratified win ratio, 1.36; 95% confidence interval, 1.09–1.68; P = 0.0054), meeting the primary endpoint. Clinical benefit was observed for both acute de novo and decompensated chronic heart failure and was observed regardless of ejection fraction or the presence or absence of diabetes. Empagliflozin was well tolerated; serious adverse events were reported in 32.3% and 43.6% of the empagliflozin- and placebo-treated patients, respectively. These findings indicate that initiation of empagliflozin in patients hospitalized for acute heart failure is well tolerated and results in significant clinical benefit in the 90 days after starting treatment. In a multinational trial, empagliflozin has clinical benefit when administered to hospitalized patients with acute heart failure, extending the reach of SGLT2 inhibitor therapy to this patient population.
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Affiliation(s)
- Adriaan A Voors
- University of Groningen Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, Würzburg, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.,George Institute for Global Health, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - João Pedro Ferreira
- Université de Lorraine, Inserm INI-CRCT (Cardiovascular and Renal Clinical Trialists), Centre Hospitalier Régional Universitaire, Nancy, France.,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, and the National University Health System, Singapore, Singapore
| | | | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | - Michael Fu
- Section of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Stefan P Janssens
- Department of Cardiovascular Sciences, Clinical Cardiology, Belgium University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Robert G Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.,Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Henrik Schirmer
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Morten Schou
- Department of Cardiology, Gentofte University Hospital Copenhagen, Copenhagen, Denmark
| | | | - Lenka Spinarova
- First Department of Medicine, Masaryk University Hospital, Brno, Czech Republic
| | | | - Jerzy K Wranicz
- Department of Electrocardiology, Medical University of Lodz, Central Clinical Hospital, Lodz, Poland
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA.,Faculty of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
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29
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Boorsma EM, Ter Maaten JM, Voors AA, van Veldhuisen DJ. Renal Compression in Heart Failure: The Renal Tamponade Hypothesis. JACC. HEART FAILURE 2022; 10:175-183. [PMID: 35241245 DOI: 10.1016/j.jchf.2021.12.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/08/2021] [Accepted: 12/18/2021] [Indexed: 12/28/2022]
Abstract
Renal dysfunction is one of the strongest predictors of outcome in heart failure. Several studies have revealed that both reduced perfusion and increased congestion (and central venous pressure) contribute to worsening renal function in heart failure. This paper proposes a novel factor in the link between cardiac and renal dysfunction: "renal tamponade" or compression of renal structures caused by the limited space for expansion. This space can be limited either by the rigid renal capsule that encloses the renal interstitial tissue or by the layer of fat around the kidneys or by the peritoneal space exerting pressure on the retroperitoneal kidneys. Renal decapsulation in animal models of heart failure and acute renal ischemia has been shown effective in alleviating pressure-related injury within the kidney itself, thus supporting this concept and making it a potentially interesting novel treatment in heart failure.
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Affiliation(s)
- Eva M Boorsma
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Jozine M Ter Maaten
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands.
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30
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Mumtaz S, Sharma M, Fu MP, Sharma A, Mir J, Rehman A, Vranian MN. Prognostic role of diuretic failure in determining mortality for patients hospitalized with acute decompensated heart failure. Heart Vessels 2022; 37:1373-1379. [PMID: 35178605 DOI: 10.1007/s00380-022-02042-x] [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: 07/02/2021] [Accepted: 02/03/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Worsening heart failure (WHF) is defined as persistent or worsening symptoms of heart failure that require an escalation in intravenous therapy or initiation of mechanical and ventilatory support during hospitalization. We assessed a simplified version of WHF called diuretic failure (DF), defined as an escalation of loop diuretic dosing after 48 h, and assessed its effects on mortality and rehospitalizations at 60-days. METHODS We conducted a multicenter retrospective study between December 1, 2017 and January 1, 2020. We identified 1389 patients of which 6.4% experienced DF. RESULTS There was a significant relationship between DF and cumulative rates of 60-day mortality and 60-day rehospitalizations (p = 0.0002 and p = 0.0214). After multivariate adjustment, DF was associated with longer hospital stay (p < 0.0001), increased rate of 60-day mortality (p = 0.026), 60-day rehospitalizations (p = 0.036), and a composite outcome of 60-day mortality and 60-day cardiac rehospitalizations (p = 0.018). CONCLUSIONS DF has a strong relationship with adverse heart failure outcomes suggesting it is a simple yet robust prognostic indicator which can be used in real time to identify high-risk patients during hospitalization and beyond.
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Affiliation(s)
- Salmaan Mumtaz
- Department of Medicine, WellSpan York Hospital, York, PA, USA.
| | - Mehul Sharma
- British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Maggie P Fu
- British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Abhinav Sharma
- Department of Family and Community Medicine, Sunnybrook Health and Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Junaid Mir
- Department of Medicine, WellSpan York Hospital, York, PA, USA
| | - Aisha Rehman
- Department of Medicine, WellSpan York Hospital, York, PA, USA
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31
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Abstract
Despite recent advances in the treatment of chronic heart failure, therapeutic options for acute heart failure (AHF) remain limited. AHF admissions are associated with significant multi-organ dysfunction, especially worsening renal failure, which results in significant morbidity and mortality. There are several aspects of AHF management: diagnosis, decongestion, vasoactive therapy, goal-directed medical therapy initiation and safe transition of care. Effective diagnosis and prognostication could be very helpful in an acute setting and rely upon biomarker evaluation with noninvasive assessment of fluid status. Decongestive strategies could be tailored to include pharmaceutical options along with consideration of utilizing ultrafiltration for refractory hypervolemia. Vasoactive agents to augment cardiac function have been evaluated in patients with AHF but have shown to only have limited efficacy. Post stabilization, initiation of quadruple goal-directed medical therapy—angiotensin receptor-neprilysin inhibitors, mineral receptor antagonists, sodium glucose type 2 (SGLT-2) inhibitors, and beta blockers—to prevent myocardial remodeling is being advocated as a standard of care. Safe transition of care is needed prior to discharge to prevent heart failure rehospitalization and mortality. Post-discharge close ambulatory monitoring (including remote hemodynamic monitoring), virtual visits, and rehabilitation are some of the strategies to consider. We hereby review the contemporary approach in AHF diagnosis and management.
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Affiliation(s)
- Hayaan Kamran
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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32
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Warraich HJ, Nohria A. Is Worsening Renal Function Relevant without Clinical Context? Eur J Heart Fail 2021; 24:375-377. [PMID: 34969171 DOI: 10.1002/ejhf.2416] [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: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Anju Nohria
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
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33
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Emmens JE, Ter Maaten JM, Matsue Y, Figarska SM, Sama IE, Cotter G, Cleland JGF, Davison BA, Felker GM, Givertz MM, Greenberg B, Pang PS, Severin T, Gimpelewicz C, Metra M, Voors AA, Teerlink JR. Worsening renal function in acute heart failure in the context of diuretic response. Eur J Heart Fail 2021; 24:365-374. [PMID: 34786794 PMCID: PMC9300008 DOI: 10.1002/ejhf.2384] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/19/2021] [Accepted: 11/15/2021] [Indexed: 11/28/2022] Open
Abstract
Background For patients with acute heart failure (AHF), substantial diuresis after administration of loop diuretics is generally associated with better clinical outcomes but may cause creatinine to rise, suggesting renal function decline. We investigated the interaction between diuretic response and worsening renal function (WRF) on clinical outcomes in patients with AHF. Methods and results In two AHF cohorts (PROTECT, n = 1698 and RELAX‐AHF‐2, n = 5586 in current analysis), the prognostic impact of WRF (creatinine ≥0.3 mg/dl increase baseline—day 4; sensitivity analyses incorporated baseline renal function) by diuretic response (kg weight loss/40 mg furosemide equivalent baseline—day 4) was investigated with regard to (cardiovascular) death or cardiovascular/renal hospitalization using subpopulation treatment effect pattern plots (STEPP) and survival analyses. WRF occurred in 286 (16.8%) and 1031 (18.5%) patients in PROTECT and RELAX‐AHF‐2, respectively. Patients with WRF had higher left ventricular ejection fraction and lower estimated glomerular filtration rate at baseline (p < 0.05), and received higher doses of loop diuretics and had a worse diuretic response (p < 0.001). In patients with a poor diuretic response (≤0.35 kg weight loss/40 mg furosemide equivalent as identified by STEPP), WRF was associated with higher risk of (cardiovascular) death or cardiovascular/renal hospitalization (p < 0.001 both cohorts), but this was not the case for patients with a good diuretic response (p = 0.900 both cohorts). Conclusion In two large cohorts of patients with AHF, WRF in the first 4 days was not associated with worse outcomes when patients had a good diuretic response. The occurrence of WRF in patients with AHF should therefore be considered in the context of diuretic response.
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Affiliation(s)
- Johanna E Emmens
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Sylwia M Figarska
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iziah E Sama
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gad Cotter
- Momentum Research and Inserm U942 MASCOT, Paris, France
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-Being, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK.,National Heart & Lung Institute, Imperial College, London, UK
| | | | - G Michael Felker
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Barry Greenberg
- University of California San Diego Health, Sulpizio Cardiovascular Institute, La Jolla, CA, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, CA, USA
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34
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Ambrosy AP, Parikh RV, Sung SH, Narayanan A, Masson R, Lam PQ, Kheder K, Iwahashi A, Hardwick AB, Fitzpatrick JK, Avula HR, Selby VN, Shen X, Sanghera N, Cristino J, Go AS. A Natural Language Processing-Based Approach for Identifying Hospitalizations for Worsening Heart Failure Within an Integrated Health Care Delivery System. JAMA Netw Open 2021; 4:e2135152. [PMID: 34807259 PMCID: PMC8609413 DOI: 10.1001/jamanetworkopen.2021.35152] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE The current understanding of epidemiological mechanisms and temporal trends in hospitalizations for worsening heart failure (WHF) is based on claims and national reporting databases. However, these data sources are inherently limited by the accuracy and completeness of diagnostic coding and/or voluntary reporting. OBJECTIVE To assess the overall burden of and temporal trends in the rate of hospitalizations for WHF. DESIGN, SETTING, AND PARTICIPANTS This cohort study, performed from January 1, 2010, to December 31, 2019, used electronic health record (EHR) data from a large integrated health care delivery system. EXPOSURES Calendar year trends. MAIN OUTCOMES AND MEASURES Hospitalizations for WHF (ie, excluding observation stays) were defined as 1 symptom or more, 2 objective findings or more including 1 sign or more, and 2 doses or more of intravenous loop diuretics and/or new hemodialysis or continuous kidney replacement therapy. Symptoms and signs were identified using natural language processing (NLP) algorithms applied to EHR data. RESULTS The study population was composed of 118 002 eligible patients experiencing 287 992 unique hospitalizations (mean [SD] age, 75.6 [13.1] years; 147 203 [51.1%] male; 1655 [0.6%] American Indian or Alaska Native, 28 451 [9.9%] Asian or Pacific Islander, 34 903 [12.1%] Black, 23 452 [8.1%] multiracial, 175 840 [61.1%] White, and 23 691 [8.2%] unknown), including 65 357 with a principal discharge diagnosis and 222 635 with a secondary discharge diagnosis of HF. The study population included 59 868 patients (20.8%) with HF with a reduced ejection fraction (HFrEF) (<40%), 33 361 (11.6%) with HF with a midrange EF (HFmrEF) (40%-49%), 142 347 (49.4%) with HF with a preserved EF (HFpEF) (≥50%), and 52 416 (18.2%) with unknown EF. A total of 58 042 admissions (88.8%) with a primary discharge diagnosis of HF and 62 764 admissions (28.2%) with a secondary discharge diagnosis of HF met the prespecified diagnostic criteria for WHF. Overall, hospitalizations for WHF identified on NLP-based algorithms increased from 5.2 to 7.6 per 100 hospitalizations per year during the study period. Subgroup analyses found an increase in hospitalizations for WHF based on NLP from 1.5 to 1.9 per 100 hospitalizations for HFrEF, from 0.6 to 1.0 per 100 hospitalizations for HFmrEF, and from 2.6 to 3.9 per 100 hospitalizations for HFpEF. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that the burden of hospitalizations for WHF may be more than double that previously estimated using only principal discharge diagnosis. There has been a gradual increase in the rate of hospitalizations for WHF with a more noticeable increase observed for HFpEF.
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Affiliation(s)
- Andrew P. Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Rishi V. Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Anand Narayanan
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Rajeev Masson
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Phuong-Quang Lam
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Kevin Kheder
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Alan Iwahashi
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Alexander B. Hardwick
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Jesse K. Fitzpatrick
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Harshith R. Avula
- Department of Cardiology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, California
| | - Van N. Selby
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Joaquim Cristino
- Department of Cardiology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, California
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco
- Department of Medicine, Stanford University, Palo Alto, California
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35
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Zhang X, Zhao C, Zhang H, Liu W, Zhang J, Chen Z, You L, Wu Y, Zhou K, Zhang L, Liu Y, Chen J, Shang H. Dyspnea Measurement in Acute Heart Failure: A Systematic Review and Evidence Map of Randomized Controlled Trials. Front Med (Lausanne) 2021; 8:728772. [PMID: 34692723 PMCID: PMC8526558 DOI: 10.3389/fmed.2021.728772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/31/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Dyspnea is the most common presenting symptom among patients hospitalized for acute heart failure (AHF). Dyspnea relief constitutes a clinically relevant therapeutic target and endpoint for clinical trials and regulatory approval. However, there have been no widely accepted dyspnea measurement standards in AHF. By systematic review and mapping the current evidence of the applied scales, timing, and results of measurement, we hope to provide some new insights and recommendations for dyspnea measurement. Methods: PubMed, Embase, Cochrane Library, and Web of Science were searched from inception until August 27, 2020. Randomized controlled trials (RCTs) with dyspnea severity measured as the endpoint in patients with AHF were included. Results: Out of a total of 63 studies, 28 had dyspnea as the primary endpoint. The Likert scale (34, 54%) and visual analog scale (VAS) (22, 35%) were most widely used for dyspnea assessment. Among the 43 studies with detailed results, dyspnea was assessed most frequently on days 1, 2, 3, and 6 h after randomization or drug administration. Compared with control groups, better dyspnea relief was observed in the experimental groups in 21 studies. Only four studies that assessed tolvaptan compared with control on the proportion of dyspnea improvement met the criteria for meta-analyses, which did not indicate beneficial effect of dyspnea improvement on day 1 (RR: 1.16; 95% CI: 0.99-1.37; p = 0.07; I 2 = 61%). Conclusion: The applied scales, analytical approaches, and timing of measurement are in diversity, which has impeded the comprehensive evaluation of clinical efficacy of potential therapies managing dyspnea in patients with AHF. Developing a more general measurement tool established on the unified unidimensional scales, standardized operation protocol to record the continuation, and clinically significant difference of dyspnea variation may be a promising approach. In addition, to evaluate the effect of experimental therapies on dyspnea more precisely, the screening time and blinded assessment are factors that need to be considered.
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Affiliation(s)
- Xiaoyu Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China.,School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Chen Zhao
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Houjun Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Wenjing Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jingjing Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Zhao Chen
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Liangzhen You
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yuzhuo Wu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Kehua Zhou
- Department of Hospital Medicine, ThedaCare Regional Medical Center-Appleton, Appleton, WI, United States
| | - Lijing Zhang
- Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yan Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jianxin Chen
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China.,College of Integrated Traditional Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, China
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36
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Lombardi CM, Cimino G, Pellicori P, Bonelli A, Inciardi RM, Pagnesi M, Tomasoni D, Ravera A, Adamo M, Carubelli V, Metra M. Congestion in Patients with Advanced Heart Failure: Assessment and Treatment. Heart Fail Clin 2021; 17:575-586. [PMID: 34511206 DOI: 10.1016/j.hfc.2021.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Heart failure (HF) is characterized by frequent hospital admissions due to acute decompensation and shortened life span with a progressive clinical course leading to an advanced stage where traditional therapies become ineffective. Due to aging of the population and improved therapies, only a small of proportion of patients with advanced HF are candidates for surgical treatments, such as mechanical circulatory support or heart transplantation. In most cases, prompt identification and management of congestion is paramount to improving symptoms and quality of life and avoiding progression to severe multiorgan dysfunction and death.
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Affiliation(s)
- Carlo Mario Lombardi
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Giuliana Cimino
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Andrea Bonelli
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Maria Inciardi
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alice Ravera
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Valentina Carubelli
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
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37
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Meijers WC, Bayes-Genis A, Mebazaa A, Bauersachs J, Cleland JGF, Coats AJS, Januzzi JL, Maisel AS, McDonald K, Mueller T, Richards AM, Seferovic P, Mueller C, de Boer RA. Circulating heart failure biomarkers beyond natriuretic peptides: review from the Biomarker Study Group of the Heart Failure Association (HFA), European Society of Cardiology (ESC). Eur J Heart Fail 2021; 23:1610-1632. [PMID: 34498368 PMCID: PMC9292239 DOI: 10.1002/ejhf.2346] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 08/13/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022] Open
Abstract
New biomarkers are being evaluated for their ability to advance the management of patients with heart failure. Despite a large pool of interesting candidate biomarkers, besides natriuretic peptides virtually none have succeeded in being applied into the clinical setting. In this review, we examine the most promising emerging candidates for clinical assessment and management of patients with heart failure. We discuss high-sensitivity cardiac troponins (Tn), procalcitonin, novel kidney markers, soluble suppression of tumorigenicity 2 (sST2), galectin-3, growth differentiation factor-15 (GDF-15), cluster of differentiation 146 (CD146), neprilysin, adrenomedullin (ADM), and also discuss proteomics and genetic-based risk scores. We focused on guidance and assistance with daily clinical care decision-making. For each biomarker, analytical considerations are discussed, as well as performance regarding diagnosis and prognosis. Furthermore, we discuss potential implementation in clinical algorithms and in ongoing clinical trials.
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Affiliation(s)
- Wouter C Meijers
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, CIBERCV, Barcelona, Spain
| | - Alexandre Mebazaa
- Inserm U942-MASCOT; Université de Paris; Department of Anesthesia and Critical Care, Hôpitaux Saint Louis & Lariboisière; FHU PROMICE, Paris, France.,Université de Paris, Paris, France.,Department of Anesthesia and Critical Care, Hôpitaux Saint Louis & Lariboisière, Paris, France.,FHU PROMICE, Paris, France
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow; National Heart & Lung Institute, Imperial College London, London, UK
| | - Andrew J S Coats
- Monash University, Melbourne, Australia.,University of Warwick, Coventry, UK
| | | | | | | | - Thomas Mueller
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy
| | - A Mark Richards
- Christchurch Heart Institute, Christchurch, New Zealand.,Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Petar Seferovic
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgarde, Serbia
| | | | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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38
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Pérez-Belmonte LM, Ricci M, Sanz-Cánovas J, Millán-Gómez M, Osuna-Sánchez J, Ruiz-Moreno MI, Bernal-López MR, López-Carmona MD, Jiménez-Navarro M, Gómez-Doblas JJ, Lara JP, Gómez-Huelgas R. Efficacy and Safety of Empagliflozin Continuation in Patients with Type 2 Diabetes Hospitalised for Acute Decompensated Heart Failure. J Clin Med 2021; 10:jcm10163540. [PMID: 34441835 PMCID: PMC8396978 DOI: 10.3390/jcm10163540] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/05/2021] [Accepted: 08/10/2021] [Indexed: 12/28/2022] Open
Abstract
There is little evidence on the use of sodium-glucose cotransporter 2 inhibitors in hospitalised patients. This work aims to analyse the glycaemic and clinical efficacy and safety of empagliflozin continuation in patients with type 2 diabetes hospitalised for acute decompensated heart failure. This real-world observational study includes patients treated using our in-hospital antihyperglycaemic regimens (basal-bolus insulin vs. empagliflozin-basal insulin) between 2017 and 2020. A propensity matching analysis was used to match a patient on one regimen with a patient on the other regimen. Our primary endpoints were the differences in glycaemic control, as measured via mean daily blood glucose levels, and differences in the visual analogue scale dyspnoea score, NT-proBNP levels, diuretic response, and cumulative urine output. Safety endpoints were also analysed. After a propensity matching analysis, 91 patients were included in each group. There were no differences in mean blood glucose levels (152.1 ± 17.8 vs. 155.2 ± 19.7 mg/dL, p = 0.289). At discharge, NT-proBNP levels were lower and cumulative urine output greater in the empagliflozin group versus the basal-bolus insulin group (1652 ± 501 vs. 2101 ± 522 pg/mL, p = 0.032 and 16,100 ± 1510 vs. 13,900 ± 1220 mL, p = 0.037, respectively). Patients who continued empagliflozin had a lower total number of hypoglycaemic episodes (36 vs. 64, p < 0.001). No differences were observed in adverse events, length of hospital stay, or in-hospital deaths. For patients with acute heart failure, an in-hospital antihyperglycaemic regimen that includes continuation of empagliflozin achieved effective glycaemic control, lower NT-proBNP, and greater urine output. It was also safer, as it reduced hypoglycaemic episodes without increasing other safety endpoints.
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Affiliation(s)
- Luis M. Pérez-Belmonte
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain; (M.R.); (J.S.-C.); (M.I.R.-M.); (M.D.L.-C.); (R.G.-H.)
- Unidad de Neurofisiología Cognitiva, Centro de Investigaciones Médico Sanitarias (CIMES), Facultad de Medicina, Universidad de Málaga (UMA), 29010 Málaga, Spain; (J.O.-S.); (J.P.L.)
- Servicio de Medicina Interna, Hospital Helicópteros Sanitarios, 29660 Marbella, Spain;
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain; (M.J.-N.); (J.J.G.-D.)
- Correspondence: (L.M.P.-B.); (M.R.B.-L.); Tel.: +34-951-032-560 (L.M.P.-B.); +34-951-291-169 (M.R.B.-L.)
| | - Michele Ricci
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain; (M.R.); (J.S.-C.); (M.I.R.-M.); (M.D.L.-C.); (R.G.-H.)
| | - Jaime Sanz-Cánovas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain; (M.R.); (J.S.-C.); (M.I.R.-M.); (M.D.L.-C.); (R.G.-H.)
| | - Mercedes Millán-Gómez
- Servicio de Medicina Interna, Hospital Helicópteros Sanitarios, 29660 Marbella, Spain;
| | - Julio Osuna-Sánchez
- Unidad de Neurofisiología Cognitiva, Centro de Investigaciones Médico Sanitarias (CIMES), Facultad de Medicina, Universidad de Málaga (UMA), 29010 Málaga, Spain; (J.O.-S.); (J.P.L.)
- Servicio de Medicina Interna, Hospital Comarcal de La Axarquía, 29700 Vélez-Málaga, Spain
| | - M. Isabel Ruiz-Moreno
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain; (M.R.); (J.S.-C.); (M.I.R.-M.); (M.D.L.-C.); (R.G.-H.)
| | - M. Rosa Bernal-López
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain; (M.R.); (J.S.-C.); (M.I.R.-M.); (M.D.L.-C.); (R.G.-H.)
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: (L.M.P.-B.); (M.R.B.-L.); Tel.: +34-951-032-560 (L.M.P.-B.); +34-951-291-169 (M.R.B.-L.)
| | - María D. López-Carmona
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain; (M.R.); (J.S.-C.); (M.I.R.-M.); (M.D.L.-C.); (R.G.-H.)
| | - Manuel Jiménez-Navarro
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain; (M.J.-N.); (J.J.G.-D.)
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain
| | - Juan J. Gómez-Doblas
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain; (M.J.-N.); (J.J.G.-D.)
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain
| | - José P. Lara
- Unidad de Neurofisiología Cognitiva, Centro de Investigaciones Médico Sanitarias (CIMES), Facultad de Medicina, Universidad de Málaga (UMA), 29010 Málaga, Spain; (J.O.-S.); (J.P.L.)
| | - Ricardo Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain; (M.R.); (J.S.-C.); (M.I.R.-M.); (M.D.L.-C.); (R.G.-H.)
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Abstract
Acute decompensated heart failure (ADHF) is one of the leading admission diagnoses worldwide, yet it is an entity with incompletely understood pathophysiology and limited therapeutic options. Patients admitted for ADHF have high in-hospital morbidity and mortality, as well as frequent rehospitalizations and subsequent cardiovascular death. This devastating clinical course is partly due to suboptimal medical management of ADHF with persistent congestion upon hospital discharge and inadequate predischarge initiation of life-saving guideline-directed therapies. While new drugs for the treatment of chronic HF continue to be approved, there has been no new therapy approved for ADHF in decades. This review will focus on the current limited understanding of ADHF pathophysiology, possible therapeutic targets, and current limitations in expanding available therapies in light of the unmet need among these high-risk patients.
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Affiliation(s)
- Joyce N. Njoroge
- Division of Cardiology, School of Medicine, University of California San Francisco (J.N.N., J.R.T.), San Francisco, CA
| | - John R. Teerlink
- Division of Cardiology, School of Medicine, University of California San Francisco (J.N.N., J.R.T.), San Francisco, CA
- Section of Cardiology, San Francisco Veterans Affairs Medical Center (J.R.T.), San Francisco, CA
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Tromp J, Ponikowski P, Salsali A, Angermann CE, Biegus J, Blatchford J, Collins SP, Ferreira JP, Grauer C, Kosiborod M, Nassif ME, Psotka MA, Brueckmann M, Teerlink JR, Voors AA. Sodium-glucose co-transporter 2 inhibition in patients hospitalized for acute decompensated heart failure: rationale for and design of the EMPULSE trial. Eur J Heart Fail 2021; 23:826-834. [PMID: 33609072 PMCID: PMC8358952 DOI: 10.1002/ejhf.2137] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/02/2021] [Accepted: 02/16/2021] [Indexed: 12/12/2022] Open
Abstract
AIMS Treatment with sodium-glucose co-transporter 2 (SGLT2) inhibitors improves outcomes in patients with chronic heart failure (HF) with reduced ejection fraction. There is limited experience with the in-hospital initiation of SGLT2 inhibitors in patients with acute HF (AHF) with or without diabetes. EMPULSE is designed to assess the clinical benefit and safety of the SGLT2 inhibitor empagliflozin compared with placebo in patients hospitalized with AHF. METHODS EMPULSE is a randomized, double-blind, parallel-group, placebo-controlled multinational trial comparing the in-hospital initiation of empagliflozin (10 mg once daily) with placebo. Approximately 500 patients admitted for AHF with dyspnoea, signs of fluid overload, and elevated natriuretic peptides will be randomized 1:1 stratified to HF status (de-novo and decompensated chronic HF) to either empagliflozin or placebo at approximately 165 sites across North America, Europe and Asia. Patients will be enrolled regardless of ejection fraction and diabetes status and will be randomized during hospitalization and after stabilization (between 24 h and 5 days after admission), with treatment continued up to 90 days after initiation. The primary outcome is clinical benefit at 90 days, consisting of a composite of all-cause death, HF events, and ≥5 point change from baseline in Kansas City Cardiomyopathy Questionnaire total symptom score (KCCQ-TSS), assessed using a 'win-ratio' approach. Secondary outcomes include assessments of safety, change in KCCQ-TSS from baseline to 90 days and change in natriuretic peptides from baseline to 30 days. CONCLUSION The EMPULSE trial will evaluate the clinical benefit and safety of empagliflozin in patients hospitalized for AHF.
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Affiliation(s)
- Jasper Tromp
- Department of CardiologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
- Duke‐NUS Medical SchoolSingapore
- National Heart Centre SingaporeSingapore
| | | | - Afshin Salsali
- Boehringer Ingelheim PharmaceuticalsRidgefieldCTUSA
- Faculty of MedicineRutgers UniversityNew BrunswickNJUSA
| | - Christiane E. Angermann
- Comprehensive Heart Failure CenterUniversity and University Hospital, Würzburg, University Hospital WürzburgWürzburgGermany
| | - Jan Biegus
- Department of Heart DiseasesMedical UniversityWroclawPoland
| | | | - Sean P. Collins
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, CHRU de Nancy, F‐CRIN INI‐CRCTNancyFrance
| | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and the University of MissouriKansas CityMOUSA
- The George Institute for Global Health and the University of New South WalesSydneyNSWAustralia
| | - Michael E. Nassif
- Saint Luke's Mid America Heart Institute and the University of MissouriKansas CityMOUSA
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbHIngelheimGermany
- Faculty of Medicine MannheimUniversity of HeidelbergMannheimGermany
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of MedicineUniversity of California, San FranciscoSan FranciscoCAUSA
| | - Adriaan A. Voors
- Department of CardiologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
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41
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Comeo E, Trinh P, Nguyen AT, Nowell CJ, Kindon ND, Soave M, Stoddart LA, White JM, Hill SJ, Kellam B, Halls ML, May LT, Scammells PJ. Development and Application of Subtype-Selective Fluorescent Antagonists for the Study of the Human Adenosine A 1 Receptor in Living Cells. J Med Chem 2021; 64:6670-6695. [PMID: 33724031 DOI: 10.1021/acs.jmedchem.0c02067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The adenosine A1 receptor (A1AR) is a G-protein-coupled receptor (GPCR) that provides important therapeutic opportunities for a number of conditions including congestive heart failure, tachycardia, and neuropathic pain. The development of A1AR-selective fluorescent ligands will enhance our understanding of the subcellular mechanisms underlying A1AR pharmacology facilitating the development of more efficacious and selective therapies. Herein, we report the design, synthesis, and application of a novel series of A1AR-selective fluorescent probes based on 8-functionalized bicyclo[2.2.2]octylxanthine and 3-functionalized 8-(adamant-1-yl) xanthine scaffolds. These fluorescent conjugates allowed quantification of kinetic and equilibrium ligand binding parameters using NanoBRET and visualization of specific receptor distribution patterns in living cells by confocal imaging and total internal reflection fluorescence (TIRF) microscopy. As such, the novel A1AR-selective fluorescent antagonists described herein can be applied in conjunction with a series of fluorescence-based techniques to foster understanding of A1AR molecular pharmacology and signaling in living cells.
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Affiliation(s)
- Eleonora Comeo
- Medicinal Chemistry, Monash University, Parkville, Victoria 3052, Australia.,Division of Biomolecular Sciences and Medicinal Chemistry, School of Pharmacy, Biodiscovery Institute, University of Nottingham, Nottingham NG7 2RD, United Kingdom.,Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham, B15 2TT and University of Nottingham, Birmingham NG7 2UH, United Kingdom
| | - Phuc Trinh
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria 3052, Australia
| | - Anh T Nguyen
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria 3052, Australia
| | - Cameron J Nowell
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria 3052, Australia
| | - Nicholas D Kindon
- Division of Biomolecular Sciences and Medicinal Chemistry, School of Pharmacy, Biodiscovery Institute, University of Nottingham, Nottingham NG7 2RD, United Kingdom.,Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham, B15 2TT and University of Nottingham, Birmingham NG7 2UH, United Kingdom
| | - Mark Soave
- Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queens Medical Centre, University of Nottingham, Nottingham NG7 2UH, United Kingdom.,Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham, B15 2TT and University of Nottingham, Birmingham NG7 2UH, United Kingdom
| | - Leigh A Stoddart
- Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queens Medical Centre, University of Nottingham, Nottingham NG7 2UH, United Kingdom.,Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham, B15 2TT and University of Nottingham, Birmingham NG7 2UH, United Kingdom
| | - Jonathan M White
- School of Chemistry and the Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Melbourne, Victoria 3010, Australia
| | - Stephen J Hill
- Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queens Medical Centre, University of Nottingham, Nottingham NG7 2UH, United Kingdom.,Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham, B15 2TT and University of Nottingham, Birmingham NG7 2UH, United Kingdom
| | - Barrie Kellam
- Division of Biomolecular Sciences and Medicinal Chemistry, School of Pharmacy, Biodiscovery Institute, University of Nottingham, Nottingham NG7 2RD, United Kingdom.,Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham, B15 2TT and University of Nottingham, Birmingham NG7 2UH, United Kingdom
| | - Michelle L Halls
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria 3052, Australia
| | - Lauren T May
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria 3052, Australia
| | - Peter J Scammells
- Medicinal Chemistry, Monash University, Parkville, Victoria 3052, Australia
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El Iskandarani M, El Kurdi B, Murtaza G, Paul TK, Refaat MM. Prognostic role of albumin level in heart failure: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24785. [PMID: 33725833 PMCID: PMC7969328 DOI: 10.1097/md.0000000000024785] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 01/26/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Hypoalbuminemia (HA) is common in HF, however, its pathophysiology and clinical implications are poorly understood. While multiple studies have been published in the past decade investigating the role of serum albumin in HF, there is still no consensus on the prognostic value of this widely available measure. The objective of this study is to assess the prognostic role of albumin in heart failure (HF) patient. METHODS Unrestricted searches of MEDLINE, EMBASE, Cochrane databases were performed. The results were screened for relevance and eligibility criteria. Relevant data were extracted and analyzed using Comprehensive Meta-Analysis software. The Begg and Mazumdar rank correlation test was utilized to evaluate for publication bias. RESULTS A total of 48 studies examining 44,048 patients with HF were analyzed. HA was found in 32% (95% confidence interval [CI] 28.4%-37.4%) HF patients with marked heterogeneity (I2 = 98%). In 10 studies evaluating acute HF, in-hospital mortality was almost 4 times more likely in HA with an odds ratios (OR) of 3.77 (95% CI 1.96-7.23). HA was also associated with a significant increase in long-term mortality (OR: 1.5; 95% CI: 1.36-1.64) especially at 1-year post-discharge (OR: 2.44; 95% CI: 2.05-2.91; I2 = 11%). Pooled area under the curve (AUC 0.73; 95% CI 0.67-0.78) was comparable to serum brain natriuretic peptide (BNP) in predicting mortality in HF patients. CONCLUSION Our results suggest that HA is associated with significantly higher in-hospital mortality as well as long-term mortality with a predictive accuracy comparable to that reported for serum BNP. These findings suggest that serum albumin may be useful in determining high-risk patients.
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Affiliation(s)
| | | | - Ghulam Murtaza
- Cardiology Division, East Tennessee State University, Johnson City, Tennessee
| | - Timir K. Paul
- Cardiology Division, East Tennessee State University, Johnson City, Tennessee
| | - Marwan M. Refaat
- Cardiology Division, American University of Beirut Faculty of Medicine and Medical Center, Beirut, Lebanon
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43
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Patel RB, Maaten JMT, Ferreira JP, Causland FRM, Shah SJ, Rossignol P, Solomon SD, Vaduganathan M, Packer M, Thompson A, Stockbridge N, Zannad F. Challenges of Cardio-Kidney Composite Outcomes in Large-Scale Clinical Trials. Circulation 2021; 143:949-958. [PMID: 33406882 PMCID: PMC7920916 DOI: 10.1161/circulationaha.120.049514] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with chronic cardiovascular or metabolic diseases, including diabetes, hypertension, obesity, and heart failure, often have comorbid kidney disease. Long-term outcomes are worse in the setting of both cardiac and kidney disease compared with either disease in isolation. In addition, the clinical presentations of certain acute cardiovascular events (such as heart failure) and worsening kidney function overlap and may be challenging to distinguish. Recently, certain novel treatments have demonstrated beneficial effects on both cardiac and kidney outcomes. Sodium-glucose cotransporter-2 inhibitors have exhibited concordant risk reduction and clinically important benefits in chronic kidney disease with and without diabetes, diabetes and established cardiovascular disease or multiple atherosclerotic vascular disease risk factors, and heart failure with reduced ejection fraction with and without diabetes. Primary trial results have revealed that sacubitril-valsartan therapy improves cardiovascular outcomes in patients with chronic heart failure with reduced ejection fraction and post hoc analyses suggest favorable kidney effects. A concordant pattern of kidney benefit with sacubitril-valsartan has also been observed in chronic heart failure with preserved ejection fraction. Given the complex interplay between cardiac and kidney disease and the possibility that treatments may show concordant cardio-kidney benefits, there has been recent interest in formally acknowledging, defining, and using composite cardio-kidney outcomes in future cardiovascular trials. This review describes potential challenges in use of such outcomes that should be considered and addressed before their incorporation into such trials.
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Affiliation(s)
- Ravi B. Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jozine M. Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, The Netherlands
| | - João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d’Investigations Cliniques – 1433, INI CRCT, and INSERM U1116, CHRU Nancy, France
| | - Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Patrick Rossignol
- Université de Lorraine, INSERM, Centre d’Investigations Cliniques – 1433, INI CRCT, and INSERM U1116, CHRU Nancy, France
| | - Scott D. Solomon
- Brigham and Women’s Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Muthiah Vaduganathan
- Brigham and Women’s Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Aliza Thompson
- Division of Cardiology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Norman Stockbridge
- Division of Cardiology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d’Investigations Cliniques – 1433, INI CRCT, and INSERM U1116, CHRU Nancy, France
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44
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McNeill SM, Baltos JA, White PJ, May LT. Biased agonism at adenosine receptors. Cell Signal 2021; 82:109954. [PMID: 33610717 DOI: 10.1016/j.cellsig.2021.109954] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 01/14/2023]
Abstract
Adenosine modulates many aspects of human physiology and pathophysiology through binding to the adenosine family of G protein-coupled receptors, which are comprised of four subtypes, the A1R, A2AR, A2BR and A3R. Modulation of adenosine receptor function by exogenous agonists, antagonists and allosteric modulators can be beneficial for a number of conditions including cardiovascular disease, Parkinson's disease, and cancer. Unfortunately, many preclinical drug candidates targeting adenosine receptors have failed in clinical trials due to limited efficacy and/or severe on-target undesired effects. To overcome the key barriers typically encountered when transitioning adenosine receptor ligands into the clinic, research efforts have focussed on exploiting the phenomenon of biased agonism. Biased agonism provides the opportunity to develop ligands that favour therapeutic signalling pathways, whilst avoiding signalling associated with on-target undesired effects. Recent studies have begun to define the structure-function relationships that underpin adenosine receptor biased agonism and establish how this phenomenon can be harnessed therapeutically. In this review we describe the recent advancements made towards achieving therapeutically relevant biased agonism at adenosine receptors.
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Affiliation(s)
- Samantha M McNeill
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Jo-Anne Baltos
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; Department of Pharmacology, Monash University, Melbourne, VIC, Australia.
| | - Paul J White
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Lauren T May
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; Department of Pharmacology, Monash University, Melbourne, VIC, Australia.
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Chen Y, Voors AA, Jaarsma T, Lang CC, Sama IE, Akkerhuis KM, Boersma E, Hillege HL, Postmus D. A heart failure phenotype stratified model for predicting 1-year mortality in patients admitted with acute heart failure: results from an individual participant data meta-analysis of four prospective European cohorts. BMC Med 2021; 19:21. [PMID: 33499866 PMCID: PMC7839199 DOI: 10.1186/s12916-020-01894-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/21/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Prognostic models developed in general cohorts with a mixture of heart failure (HF) phenotypes, though more widely applicable, are also likely to yield larger prediction errors in settings where the HF phenotypes have substantially different baseline mortality rates or different predictor-outcome associations. This study sought to use individual participant data meta-analysis to develop an HF phenotype stratified model for predicting 1-year mortality in patients admitted with acute HF. METHODS Four prospective European cohorts were used to develop an HF phenotype stratified model. Cox model with two rounds of backward elimination was used to derive the prognostic index. Weibull model was used to obtain the baseline hazard functions. The internal-external cross-validation (IECV) approach was used to evaluate the generalizability of the developed model in terms of discrimination and calibration. RESULTS 3577 acute HF patients were included, of which 2368 were classified as having HF with reduced ejection fraction (EF) (HFrEF; EF < 40%), 588 as having HF with midrange EF (HFmrEF; EF 40-49%), and 621 as having HF with preserved EF (HFpEF; EF ≥ 50%). A total of 11 readily available variables built up the prognostic index. For four of these predictor variables, namely systolic blood pressure, serum creatinine, myocardial infarction, and diabetes, the effect differed across the three HF phenotypes. With a weighted IECV-adjusted AUC of 0.79 (0.74-0.83) for HFrEF, 0.74 (0.70-0.79) for HFmrEF, and 0.74 (0.71-0.77) for HFpEF, the model showed excellent discrimination. Moreover, there was a good agreement between the average observed and predicted 1-year mortality risks, especially after recalibration of the baseline mortality risks. CONCLUSIONS Our HF phenotype stratified model showed excellent generalizability across four European cohorts and may provide a useful tool in HF phenotype-specific clinical decision-making.
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Affiliation(s)
- Yuntao Chen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands.
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Tiny Jaarsma
- Department of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Iziah E Sama
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - K Martijn Akkerhuis
- Department of Cardiology, Thoraxcenter, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Thoraxcenter, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Hans L Hillege
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Douwe Postmus
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
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Titko T, Perekhoda L, Drapak I, Tsapko Y. Modern trends in diuretics development. Eur J Med Chem 2020; 208:112855. [PMID: 33007663 DOI: 10.1016/j.ejmech.2020.112855] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/06/2020] [Accepted: 09/15/2020] [Indexed: 01/02/2023]
Abstract
Diuretics are the first-line therapy for widespread cardiovascular and non-cardiovascular diseases. Traditional diuretics are commonly prescribed for treatment in patients with hypertension, edema and heart failure, as well as with a number of kidney problems. They are diseases with high mortality, and the number of patients suffering from heart and kidney diseases is increasing year by year. The use of several classes of diuretics currently available for clinical use exhibits an overall favorable risk/benefit balance. However, they are not devoid of side effects. Hence, pharmaceutical researchers have been making efforts to develop new drugs with a better pharmacological profile. High-throughput screening, progress in protein structure analysis and modern methods of chemical modification have opened good possibilities for identification of new promising agents for preclinical and clinical testing. In this review, we provide an overview of the medicinal chemistry approaches toward the development of small molecule compounds showing diuretic activity that have been discovered over the past decade and are interesting drug candidates. We have discussed promising natriuretics/aquaretics/osmotic diuretics from such classes as: vasopressin receptor antagonists, SGLT2 inhibitors, urea transporters inhibitors, aquaporin antagonists, adenosine receptor antagonists, natriuretic peptide receptor agonists, ROMK inhibitors, WNK-SPAK inhibitors, and pendrin inhibitors.
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Affiliation(s)
- Tetiana Titko
- Department of Medicinal Chemistry, National University of Pharmacy, 53 Pushkinska Str., 61002, Kharkiv, Ukraine.
| | - Lina Perekhoda
- Department of Medicinal Chemistry, National University of Pharmacy, 53 Pushkinska Str., 61002, Kharkiv, Ukraine.
| | - Iryna Drapak
- Department of General, Bioinorganic, Physical and Colloidal Chemistry, Danylo Halytsky Lviv National Medical University, 69 Pekarska Str., 79010, Lviv, Ukraine.
| | - Yevgen Tsapko
- Department of Inorganic Chemistry, National University of Pharmacy, 53 Pushkinska Str., 61002, Kharkiv, Ukraine.
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Zhao TJ, Yang QK, Bi LD, Li J, Tan CY, Miao ZL. Prognostic value of DCTA scoring system in heart failure. Herz 2020; 46:243-252. [PMID: 33084909 DOI: 10.1007/s00059-020-04993-1] [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: 06/06/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the prognostic value of a novel scoring system, based on D‑dimer, total cholesterol, high-sensitivity cardiac troponin T (hs-cTnT), and serum albumin levels, in patients with heart failure. METHODS A total of 221 patients diagnosed with heart failure between May 2016 to January 2020 were enrolled in this retrospective study. The prognostic significance of the biomarkers D‑dimer, total cholesterol, hs-cTnT, and serum albumin was determined with univariate and multivariate Cox proportional hazard models. A novel prognostic score based on these predictors was established. The Kaplan-Meier method and log-rank test were used to compare the adverse outcomes of patients in different risk groups. RESULT Results from univariate and multivariate analyses showed that high D‑dimer, low serum albumin, high hs-cTnT, and low total cholesterol levels were independent prognostic factors for adverse outcomes (D-dimer >0.63 mg/l, HR = 1.84, 95% CI = 1.16-2.94, p = 0.010; serum albumin >34 g/l, HR = 0.67, 95% CI = 0.45-0.99, p = 0.046; hs-cTnT >24.06 pg/ml, HR = 1.65, 95% CI = 1.08-2.53, p = 0.020; total cholesterol >3.68 mmol/l, HR = 0.63, 95% CI = 0.43-0.92, p = 0.017). Moreover, all the patients were stratified into low-risk or high-risk group according to a scoring system based on these four markers. Kaplan-Meier analyses demonstrated that patients in the high-risk group were more prone to having adverse outcomes compared with patients in the low-risk group. CONCLUSION D‑dimer, total cholesterol, hs-cTnT, and serum albumin levels were independent prognostic factors in the setting of heart failure. A novel and comprehensive scoring system based on these biomarkers is an easily available and effective tool for predicting the adverse outcomes of patients with heart failure.
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Affiliation(s)
- Tian-Jun Zhao
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No.33 Wenyi Road, Shenhe District, 110016, Shenyang, China
| | - Qian-Kun Yang
- Department of Bone and Soft Tissue Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, 110042, Shenyang, China
| | - Li-Dan Bi
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No.33 Wenyi Road, Shenhe District, 110016, Shenyang, China
| | - Jie Li
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No.33 Wenyi Road, Shenhe District, 110016, Shenyang, China
| | - Chun-Yu Tan
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No.33 Wenyi Road, Shenhe District, 110016, Shenyang, China
| | - Zhi-Lin Miao
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No.33 Wenyi Road, Shenhe District, 110016, Shenyang, China.
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48
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In-hospital resource utilization, worsening heart failure, and factors associated with length of hospital stay in patients with hospitalized heart failure: A Japanese database cohort study. J Cardiol 2020; 76:342-349. [DOI: 10.1016/j.jjcc.2020.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 04/10/2020] [Accepted: 05/07/2020] [Indexed: 01/13/2023]
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49
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50
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Brown PM, Rogne T, Solligård E. The promise and pitfalls of composite endpoints in sepsis and COVID-19 clinical trials. Pharm Stat 2020; 20:413-417. [PMID: 32893957 DOI: 10.1002/pst.2070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/18/2020] [Accepted: 08/25/2020] [Indexed: 01/19/2023]
Abstract
Composite endpoints reveal the tendency for statistical convention to arise locally within subfields. Composites are familiar in cardiovascular trials, yet almost unknown in sepsis. However, the VITAMINS trial in patients with septic shock adopted a composite of mortality and vasopressor-free days, and an ordinal scale describing patient status rapidly became standard in COVID studies. Aware that recent use could incite interest in such endpoints, we are motivated to flag their potential value and pitfalls for sepsis research and COVID studies.
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Affiliation(s)
- P M Brown
- Gemini Center for Sepsis Research, Clinic of Anesthesia and Intensive Care, St. Olav's hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tormod Rogne
- Gemini Center for Sepsis Research, Clinic of Anesthesia and Intensive Care, St. Olav's hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Erik Solligård
- Gemini Center for Sepsis Research, Clinic of Anesthesia and Intensive Care, St. Olav's hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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