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Abdin A, Böhm M, Shahim B, Karlström P, Kulenthiran S, Skouri H, Lund LH. Heart failure with preserved ejection fraction epidemiology, pathophysiology, diagnosis and treatment strategies. Int J Cardiol 2024; 412:132304. [PMID: 38944348 DOI: 10.1016/j.ijcard.2024.132304] [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] [Received: 12/31/2023] [Revised: 06/11/2024] [Accepted: 06/26/2024] [Indexed: 07/01/2024]
Abstract
The prevalence of HF with preserved ejection raction (HFpEF, with EF ≥50%) is increasing across all populations with high rates of hospitalization and mortality, reaching up to 80% and 50%, respectively, within a 5-year timeframe. Comorbidity-driven systemic inflammation is thought to cause coronary microvascular dysfunction and increased epicardial adipose tissue, leading to downstream friborsis and molecular changes in the cardiomyocyte, leading to increased stiffness and diastolic dynsfunction. HFpEF poses unique challenges in terms of diagnosis due to its complex and diverse nature. The diagnosis of HFpEF relies on a combination of clinical assessment, imaging studies, and biomarkers. An additional important step in diagnosing HFpEF involves excluding certain cardiac diagnoses that may be specific underlying causes of HFpEF or may be masquerading as HFpEF and require specific alternative treatment approaches. In addition to administering sodium-glucose cotransporter 2 inhibitors to all patients, the most effective approach to enhance clinical outcomes may involve tailored therapy based on each patient's unique clinical profile. Exercise should be recommended for all patients to improve the quality of life. Glucagon-like peptide-1 1 agonists are a promising treatment option in obese HFpEF patients. Novel approaches targeting inflammation are also in early phase trials.
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Affiliation(s)
- Amr Abdin
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Bahira Shahim
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Patric Karlström
- Department of Internal Medicine, Ryhov County Hospital, Jönköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hadi Skouri
- Division of Cardiology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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2
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Bozkurt B. Contemporary pharmacological treatment and management of heart failure. Nat Rev Cardiol 2024; 21:545-555. [PMID: 38532020 DOI: 10.1038/s41569-024-00997-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/28/2024]
Abstract
The prevention and treatment strategies for heart failure (HF) have evolved in the past two decades. The stages of HF have been redefined, with recognition of the pre-HF state, which encompasses asymptomatic patients who have developed either structural or functional cardiac abnormalities or have elevated plasma levels of natriuretic peptides or cardiac troponin. The first-line treatment of patients with HF with reduced ejection fraction includes foundational therapies with angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors and diuretics. The first-line treatment of patients with HF with mildly reduced ejection fraction or with HF with preserved ejection fraction includes SGLT2 inhibitors and diuretics. The timely initiation of these disease-modifying therapies and the optimization of treatment are crucial in all patients with HF. Reassessment after initiation of these therapies is recommended to evaluate patient symptoms, health status and left ventricular function, and timely referral to a HF specialist is necessary if a patient has persistent advanced HF symptoms or worsening HF. Lifestyle modification and treatment of comorbidities such as diabetes mellitus, ischaemic heart disease and atrial fibrillation are crucial through each stage of HF. This Review provides an overview of the management strategies for HF according to disease stages that are derived from the recommendations in the latest US and European HF guidelines.
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Affiliation(s)
- Biykem Bozkurt
- Winters Center for Heart Failure Research, Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX, USA.
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3
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Scatularo CE, Battioni L, Guazzone A, Esperón G, Corsico L, Grancelli HO. Basal natriuresis as a predictor of diuretic resistance and clinical evolution in acute heart failure. Curr Probl Cardiol 2024; 49:102674. [PMID: 38795800 DOI: 10.1016/j.cpcardiol.2024.102674] [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: 05/20/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Some clinical guidelines recommend serial measurement of natriuresis to detect diuretic resistance (DR) in acute heart failure (AHF) patients, but it adds complexity to the management. OBJECTIVES To correlate a single measurement of basal natriuresis (BN) on admission with the development of DR and clinical evolution in AHF hospitalized patients. METHODS Prospective and multicenter study included AHF hospitalized patients, without shock or creatinine >2.5mg%. Patients received 40mg of intravenous furosemide on admission, then BN was measured, and diuretic treatment was guided by protocol. BN was considered low if <70 meq/L. DR was defined as the need of furosemide >240mg/day, tubular blockade (TB), hypertonic saline solution (HSS) or renal replacement therapy (RRT). In-hospital cardiovascular (CV) mortality, CV mortality and AHF readmissions at 60-day post-discharge were evaluated. RESULTS 157 patients were included. BN was low in 22%. DR was development in 19% (12.7% furosemide >240mg/day, 8% TB, 4% RRT). Low NB was associated with DR (44% vs 12%; p 0.0001), persistence of congestion (26.5% vs 11.4%; p 0.05), furosemide >240 mg/day (29% vs 8%; p 0.003), higher cumulative furosemide dose at 72 hours (220 vs 160mg; p 0.0001), TB (20.6 vs 4.9%; p 0.008), RRT (11.8 vs 1.6%; p 0.02), worsening of AHF (27% vs 9%; p 0.01), inotropes use (21% vs 7%; p 0.48), respiratory assistance (12% vs 2%; p 0.02) and a higher in-hospital CV mortality (12% vs 4%; p 0.1). No association was demonstrated with post-discharge endpoints. CONCLUSIONS In AHF patients, low BN was associated with DR, persistent congestion, need for aggressive decongestion strategies, and worse in-hospital evolution.
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Affiliation(s)
- Cristhian E Scatularo
- Department of Cardiology, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina.
| | - Luciano Battioni
- Council of heart failure and pulmonary hypertension, Argentine Society of Cardiology, Argentina
| | - Analía Guazzone
- Department of Cardiology, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
| | - Guillermina Esperón
- Department of Cardiology, Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | - Luciana Corsico
- Department of Cardiology, Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | - Hugo O Grancelli
- Department of Cardiology, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
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4
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Trullàs JC, Peláez AI, Blázquez J, Sánchez-Biosca A, López-Reborio ML, Salamanca-Bautista P, Fernández-Rodríguez JM, Vázquez-Ronda MÁ, Dávila-Ramos MF, Mendoza-Ruiz-De-Zuazu H, Morales-Rull JL, Olmedo-Llanes J, Llàcer P, Conde-Martel A. The significance of metabolic alkalosis on acute decompensated heart failure: the ALCALOTIC study. Clin Res Cardiol 2024; 113:1251-1262. [PMID: 38709335 DOI: 10.1007/s00392-024-02452-z] [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] [Received: 05/19/2023] [Accepted: 04/23/2024] [Indexed: 05/07/2024]
Abstract
AIMS To determine the prevalence and the impact on prognosis of metabolic alkalosis (MA) in patients admitted for acute heart failure (AHF). METHODS AND RESULTS The ALCALOTIC is a multicenter, observational cohort study that prospectively included patients admitted for AHF. Patients were classified into four groups according to their acid-base status on admission: acidosis, MA, respiratory alkalosis, and normal pH (reference group for comparison). Primary endpoint was all-cause in-hospital mortality, and secondary endpoints included 30/90-day all-cause mortality, all-cause readmission, and readmission for HF. Associations between endpoints and acid-base alterations were estimated in a multivariate Cox regression model including sex, age, comorbidities, and Barthel index and expressed as hazard ratio (HR) with 95% confidence interval (95% CI). Six hundred sixty-five patients were included (84 years and 57% women), and 40% had acid-base alterations on admission: 188 (28%) acidosis and 78 (12%) alkalosis. The prevalence (95% CI) of MA was 9% (6.8-11.2%). Patients with MA were more women; had fewer comorbidities, better renal function, and higher left ventricle ejection fraction values; and received more treatment with oral acetazolamide during hospitalization and at discharge. MA was not associated with a higher risk of in-hospital mortality and 30/90-day all-cause mortality or readmissions but was associated with a significant increase in readmissions for HF at 30 and 90 days (adjusted HR [95% CI] 3.294 [1.397-7.767], p = 0.006 and 2.314 [1.075-4.978], p = 0.032). CONCLUSION The prevalence of MA in patients admitted for AHF was 9%, and its presence was associated with more readmissions for HF but not with all-cause mortality.
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Affiliation(s)
- Joan Carles Trullàs
- Internal Medicine Department, Hospital d'Olot i Comarcal de La Garrotxa, Girona, Av Dels Països Catalans, 86, Olot, 17800, Girona, Catalonia, Spain.
- Laboratori de Reparació i Regeneració Tissular (TR2Lab), Facultat de Medicina, Universitat de Vic-Universitat Central de Catalunya, Carretera de Roda, 70, Vic, 08500, Barcelona, Catalonia, Spain.
| | - Ana Isabel Peláez
- Internal Medicine Department, Hospital Universitario Rafael Méndez, Ctra.N-340, 30813, Lorca, Murcia, Spain
| | - Julio Blázquez
- Internal Medicine Department, Hospital Universitario de Torrevieja, Carretera CV 95, S/N, 03186, Torrevieja, Alicante, Spain
| | - Anna Sánchez-Biosca
- Internal Medicine Department, Fundació Hospital de L'Esperit Sant, Avinguda Mossèn Josep Pons I Rabadà, S/N, Santa Coloma de Gramenet, 08923, Barcelona, Catalonia, Spain
| | - Manuel Lorenzo López-Reborio
- Internal Medicine Department, Hospital Comarcal Monforte de Lemos, Rúa Corredoira, S/N, Monforte de Lemos, 27400, Lugo, Spain
| | - Prado Salamanca-Bautista
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Avenida Dr. Fedriani, 3, 41009, Seville, Spain
| | - José María Fernández-Rodríguez
- Internal Medicine Department, Hospital Carmen y Severo Ochoa, Calle Sienra, 11, Cangas del Narcea, 33800, Asturias, Spain
| | - Miguel Ángel Vázquez-Ronda
- Internal Medicine Department, Hospital Universitario Infanta Sofía, P.º de Europa, 34, San Sebastián de los Reyes, 28703, Madrid, Spain
| | - Melitón Francisco Dávila-Ramos
- Internal Medicine Department, Hospital Universitario Nuestra Señora de La Candelaria, Carretera Gerenal del Rosario, 145, 38010, Santa Cruz de Tenerife, Spain
| | | | - José Luís Morales-Rull
- Internal Medicine Department, Heart Failure Unit, Hospital Universitari Arnau de Villanova, Institut de Recerca Biomédica (IRBLleida), Avinguda Alcalde Rovira Roure, 80, 25198, Lleida, Catalonia, Spain
| | - Jesús Olmedo-Llanes
- Internal Medicine Department, Hospital de Antequera, Avenida Poeta Muñoz Rojas, S/N, Málaga, 29200, Antequera, Spain
| | - Pau Llàcer
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, M-607, 9, 100, 28034, Madrid, Spain
| | - Alicia Conde-Martel
- Internal Medicine Department, Hospital Universitario de Gran Canaria Dr. Negrín, C. Pl. Barranco de La Ballena, S/N, 35010, Las Palmas de Gran Canaria, Spain
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5
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Caillard A, Čerlinskaitė-Bajorė K, Mebazaa A. Rethinking diuretics for congestion in acute heart failure: insight from the STRONG-HF trial. Eur J Emerg Med 2024; 31:231-233. [PMID: 38934074 DOI: 10.1097/mej.0000000000001151] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Affiliation(s)
- Anais Caillard
- Department of Anesthesia-Reanimation, Cavale Blanche Hospital
- Laboratoire ORPHY EA 4324, University of Brest, Brest, France
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- INSERM UMR-S 942 and Paris University
| | - Alexandre Mebazaa
- INSERM UMR-S 942 and Paris University
- Department of Anesthesia-Reanimation, Lariboisière Hospital, Paris, France
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6
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Wu L, Rodriguez M, Hachem KE, Tang WHW, Krittanawong C. Management of patients with heart failure and chronic kidney disease. Heart Fail Rev 2024:10.1007/s10741-024-10415-9. [PMID: 39073666 DOI: 10.1007/s10741-024-10415-9] [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: 07/01/2024] [Indexed: 07/30/2024]
Abstract
Chronic kidney disease (CKD) and heart failure are often co-existing conditions due to a shared pathophysiological process involving neurohormonal activation and hemodynamic maladaptation. A wide range of pharmaceutical and interventional tools are available to patients with CKD, consisting of traditional ones with decades of experience and newer emerging therapies that are rapidly reshaping the landscape of medical care for this population. Management of patients with heart failure and CKD requires a stepwise approach based on renal function and the clinical phenotype of heart failure. This is often challenging due to altered drug pharmacokinetics interactions with various degrees of kidney function and frequent adverse effects from the therapy that lead to poor patient tolerance. Despite a great body of clinical evidence and guidelines that have offered various treatment options for patients with heart failure and CKD, respectively, patients with CKD are still underrepresented in heart failure clinical trials, especially for those with advanced CKD and end-stage renal disease (ESRD). Future studies are needed to better understand the generalizability of these therapeutic options among heart failures with different stages of CKD.
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Affiliation(s)
- Lingling Wu
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mario Rodriguez
- John T Milliken Department of Medicine, Division of Cardiovascular disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University in St. Louis School of Medicine, St. Louis, USA
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland, Clinic, Cleveland, OH, USA
| | - Chayakrit Krittanawong
- Cardiology Division, Section of Cardiology, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
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7
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Carnicelli AP, Diepen SV, Gage A, Berhnardt AM, Houston BA, Siuba MT, Kataria R, Beavers CJ, John KJ, Meyns B, Kapur N, Tedford RJ, Kanwar M. Pragmatic Approach to Temporary Mechanical Circulatory Support in Acute Right Ventricular Failure. J Heart Lung Transplant 2024:S1053-2498(24)01740-6. [PMID: 39059594 DOI: 10.1016/j.healun.2024.07.006] [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: 05/16/2024] [Revised: 07/02/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Acute right ventricular failure (RVF) is prevalent in multiple disease states and is associated with poor clinical outcomes. Right-sided temporary mechanical circulatory support (tMCS) devices are used to unload RV congestion and increase cardiac output in cardiogenic shock (CS) with hemodynamically significant RVF. Several RV-tMCS device platforms are available; however consensus is lacking on patient selection, timing of escalation to RV-tMCS, device management, and device weaning. The purposes of this review are to 1) describe the current state of tMCS device therapies for acute RVF with CS, 2) discuss principles of escalation to RV-tMCS device therapy, 3) examine important aspects of clinical management for patients supported by RV-tMCS devices including volume management, anticoagulation, and positive pressure ventilation, and 4) provide a framework for RV-tMCS weaning.
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Affiliation(s)
- Anthony P Carnicelli
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ann Gage
- Department of Cardiology, Centennial Medical Center, Nashville, TN, USA
| | - Alexander M Berhnardt
- Department of Cardiovascular Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Matt T Siuba
- Department of Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rachna Kataria
- Division of Cardiology, Department of Medicine, Lifespan Cardiovascular Institute, Rhode Island Hospital, Providence, RI, USA
| | - Craig J Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Kevin J John
- Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Bart Meyns
- Department of Cardiothoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Navin Kapur
- Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA, USA
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8
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Trullàs JC, Moreno-García MC, Mittelbrunn-Alquézar V, Conde-Martel A, Soler-Rangel L, Montero-Pérez-Barquero M, Casado J, Sánchez-Marteles M, Arévalo-Lorido JC, Pérez-Silvestre J. The RICA-2 registry: Design and baseline characteristics of the first 1,000 patients. Rev Clin Esp 2024:S2254-8874(24)00102-4. [PMID: 39053884 DOI: 10.1016/j.rceng.2024.07.008] [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: 06/19/2024] [Accepted: 06/25/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND AND OBJECTIVE Heart failure (HF) is a syndrome of epidemic proportions and one of the main reasons for hospital admission. Patient registries provide real-world clinical practice information which is complementary to clinical trials. RICA-2 is a registry of the Spanish Society of Internal Medicine. Its main goal is to know the clinical and epidemiological characteristics and prognostic factors of patients with HF treated in Internal Medicine Departments. The objective of this study is to present the design of the RICA-2, the baseline characteristics of the first 1000 patients included and their comparison with those of the historical cohort of the RICA registry. METHODS Observational, multicentre and prospective study of patients with HF with the following inclusion criteria: age equal to or greater than 18 years old, diagnosis of HF according to the European Guidelines, indistinct inclusion in decompensation or stable phase, of patients with "de novo" HF or chronic HF, regardless of left ventricular ejection fraction, aetiology and comorbidities. RESULTS RICA-2 patients have advanced age (83 years old) and 51% are women. The comorbidity burden is higher than in the RICA registry (5 points in the Charlson comorbidity index), with predominating chronic decompensated HF (74%), hypertensive aetiology (39%) and preserved ejection fraction (52%). Most patients are pre-frail or vulnerable and are at risk of malnutrition. CONCLUSION The RICA-2 represents a contemporary cohort of patients that will provide us with clinical, epidemiological and prognostic information on patients with acute and chronic HF treated in Internal Medicine.
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Affiliation(s)
- J C Trullàs
- Servicio de Medicina Interna, Hospital d'Olot i Comarcal de La Garrotxa, Girona, Catalonia, Spain; Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca i Innovació en Ciències de La Vida i de La Salut a La Catalunya Central (IrisCC), Barcelona, Spain.
| | | | | | - A Conde-Martel
- Servicio de Medicina Interna, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain; Facultad de Ciencias de la Salud, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - L Soler-Rangel
- Servicio de Medicina Interna, Hospital Universitario Infanta Sofía, FIIB HUIS HHEN, Madrid, Spain
| | | | - J Casado
- Servicio de Medicina Interna, Hospital Universitario de Getafe, Madrid, Spain
| | - M Sánchez-Marteles
- Servicio de Medicina Interna, Hospital Clínico Universitario «Lozano Blesa», Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, Spain
| | - J C Arévalo-Lorido
- Servicio de Medicina Interna, Hospital Universitario de Badajoz, Badajoz, Spain
| | - J Pérez-Silvestre
- UMIPIC, Servicio de Medicina Interna, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
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9
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Bozkurt B, Nair A. Early Uptitration of GDMT Is Associated With More Successful Decongestion and Better Outcomes. J Am Coll Cardiol 2024; 84:337-339. [PMID: 39019528 DOI: 10.1016/j.jacc.2024.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/10/2024] [Indexed: 07/19/2024]
Affiliation(s)
- Biykem Bozkurt
- Winters Center for Heart Failure Research, Cardiovascular Research Institute, Michael E. DeBakey VA Medical Center, Houston, Texas, USA; Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA.
| | - Ajith Nair
- Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
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10
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Biegus J, Mebazaa A, Davison B, Cotter G, Edwards C, Čelutkienė J, Chioncel O, Cohen-Solal A, Filippatos G, Novosadova M, Sliwa K, Adamo M, Arrigo M, Lam CSP, Ter Maaten JM, Deniau B, Barros M, Čerlinskaitė-Bajorė K, Damasceno A, Diaz R, Gayat E, Kimmoun A, Pang PS, Pagnesi M, Saidu H, Takagi K, Tomasoni D, Voors AA, Metra M, Ponikowski P. Effects of Rapid Uptitration of Neurohormonal Blockade on Effective, Sustainable Decongestion and Outcomes in STRONG-HF. J Am Coll Cardiol 2024; 84:323-336. [PMID: 39019527 DOI: 10.1016/j.jacc.2024.04.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/16/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Comprehensive uptitration of neurohormonal blockade targets fundamental mechanisms underlying development of congestion and may be an additional approach for decongestion after acute heart failure (AHF). OBJECTIVES This hypothesis was tested in the STRONG-HF (Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by N-Terminal Pro-Brain Natriuretic Peptide Testing of Heart Failure Therapies) trial. METHODS In STRONG-HF, patients with AHF were randomized to the high-intensity care (HIC) arm with fast up-titration of neurohormonal blockade or to usual care (UC). Successful decongestion was defined as an absence of peripheral edema, pulmonary rales, and jugular venous pressure <6 cm. RESULTS At baseline, the same proportion of patients in both arms had successful decongestion (HIC 48% vs UC 46%; P = 0.52). At day 90, higher proportion of patients in the HIC arm (75%) experienced successful decongestion vs the UC arm (68%) (P = 0.0001). Each separate component of the congestion score was significantly better in the HIC arm (all, P < 0.05). Additional markers of decongestion also favored the HIC: weight reduction (adjusted mean difference: -1.36 kg; 95% CI: -1.92 to -0.79 kg), N-terminal pro-B-type natriuretic peptide level, and lower orthopnea severity (all, P < 0.001). More effective decongestion was achieved despite a lower mean daily dose of loop diuretics at day 90 in the HIC arm. Among patients with successful decongestion at baseline, those in the HIC arm had a significantly better chance of sustaining decongestion at day 90. Successful decongestion in all subjects was associated with a lower risk of 180-day HF readmission or all-cause death (HR: 0.40; 95% CI: 0.27-0.59; P < 0.0001). CONCLUSIONS In STRONG-HF, intensive uptitration of neurohormonal blockade was associated with more efficient and sustained decongestion at day 90 and a lower risk of the primary endpoint.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina, USA; Heart Initiative, Durham, North Carolina, USA
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina, USA; Heart Initiative, Durham, North Carolina, USA
| | | | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C.Iliescu," University of Medicine "Carol Davila," Bucharest, Romania
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | | | - Karen Sliwa
- Cape Heart Institute, Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Benjamin Deniau
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | | | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | - Antoine Kimmoun
- Université de Lorraine, Nancy, France; INSERM, Défaillance Circulatoire Aigue et Chronique; Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Hadiza Saidu
- Department of Medicine, Murtala Muhammed Specialist Hospital/Bayero University Kano, Kano, Nigeria
| | - Koji Takagi
- Momentum Research Inc, Durham, North Carolina, USA
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - 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, Wroclaw, Poland. https://twitter.com/ppponikowski
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11
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Pfortmueller CA, Dabrowski W, Wise R, van Regenmortel N, Malbrain MLNG. Fluid accumulation syndrome in sepsis and septic shock: pathophysiology, relevance and treatment-a comprehensive review. Ann Intensive Care 2024; 14:115. [PMID: 39033219 PMCID: PMC11264678 DOI: 10.1186/s13613-024-01336-9] [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: 12/28/2023] [Accepted: 06/17/2024] [Indexed: 07/23/2024] Open
Abstract
In this review, we aimed to comprehensively summarize current literature on pathophysiology, relevance, diagnosis and treatment of fluid accumulation in patients with sepsis/septic shock. Fluid accumulation syndrome (FAS) is defined as fluid accumulation (any degree, expressed as percentage from baseline body weight) with new onset organ-failure. Over the years, many studies have described the negative impact of FAS on clinically relevant outcomes. While the relationship between FAS and ICU outcomes is well described, uncertainty exists regarding its diagnosis, monitoring and treatment. A stepwise approach is suggested to prevent and treat FAS in patients with septic shock, including minimizing fluid intake (e.g., by limiting intravenous fluid administration and employing de-escalation whenever possible), limiting sodium and chloride administration, and maximizing fluid output (e.g., with diuretics, or renal replacement therapy). Current literature implies the need for a multi-tier, multi-modal approach to de-resuscitation, combining a restrictive fluid management regime with a standardized early active de-resuscitation, maintenance fluid reduction (avoiding fluid creep) and potentially using physical measures such as compression stockings.Trial registration: Not applicable.
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Affiliation(s)
- Carmen Andrea Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
| | - Wojciech Dabrowski
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Rob Wise
- Department of Anaesthesia and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Intensive Care Department, John Radcliffe Hospital, Oxford University Trust Hospitals, Oxford, UK
| | - Niels van Regenmortel
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg/Cadix, Antwerp, Belgium
- Department of Intensive Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
- International Fluid Academy, Lovenjoel, Belgium
- Medical Data Management, Medaman, Geel, Belgium
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12
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Boorsma EM, Docherty KF, Campbell RT. Simplifying Treatment of Congestion: Diuretic Response With Sequential Nephron Blockade Is Independent of Ejection Fraction. JACC. HEART FAILURE 2024:S2213-1779(24)00496-7. [PMID: 39066757 DOI: 10.1016/j.jchf.2024.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 07/30/2024]
Affiliation(s)
- Eva M Boorsma
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Kieran F Docherty
- School of Cardiovascular and Metabolic Health, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Ross T Campbell
- School of Cardiovascular and Metabolic Health, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom.
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13
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Moll V, Khanna AK, Kurz A, Huang J, Smit M, Swaminathan M, Minear S, Parr KG, Prabhakar A, Zhao M, Malbrain MLNG. Optimization of kidney function in cardiac surgery patients with intra-abdominal hypertension: expert opinion. Perioper Med (Lond) 2024; 13:72. [PMID: 38997752 PMCID: PMC11245849 DOI: 10.1186/s13741-024-00416-5] [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: 12/28/2023] [Accepted: 06/09/2024] [Indexed: 07/14/2024] Open
Abstract
Cardiac surgery-associated acute kidney injury (CSA-AKI) affects up to 42% of cardiac surgery patients. CSA-AKI is multifactorial, with low abdominal perfusion pressure often overlooked. Abdominal perfusion pressure is calculated as mean arterial pressure minus intra-abdominal pressure (IAP). IAH decreases cardiac output and compresses the renal vasculature and renal parenchyma. Recent studies have highlighted the frequent occurrence of IAH in cardiac surgery patients and have linked the role of low perfusion pressure to the occurrence of AKI. This review and expert opinion illustrate current evidence on the pathophysiology, diagnosis, and therapy of IAH and ACS in the context of AKI.
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Affiliation(s)
- Vanessa Moll
- Department of Anesthesiology, Division of Critical Care Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Ashish K Khanna
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Andrea Kurz
- Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Anesthesiology, Emergency Medicine and Intensive Care Medicine, Medical University Graz, Graz, Austria
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Marije Smit
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Madhav Swaminathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Steven Minear
- Department of Anesthesiology, Cleveland Clinic Florida, Weston Hospital, Weston, FL, USA
| | - K Gage Parr
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Amit Prabhakar
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Manxu Zhao
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University Lublin, Lublin, Poland.
- Medical Data Management, Medaman, Geel, Belgium.
- International Fluid Academy, Lovenjoel, Belgium.
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14
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Milbradt TL, Sudo RYU, Gobbo MODS, Akinfenwa S, Moura B. Acetazolamide therapy in patients with acute heart failure: a systematic review and meta-analysis of randomized controlled trials. Heart Fail Rev 2024:10.1007/s10741-024-10417-7. [PMID: 38985385 DOI: 10.1007/s10741-024-10417-7] [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: 07/03/2024] [Indexed: 07/11/2024]
Abstract
Acute heart failure (AHF) often leads to unfavorable outcomes due to fluid overload. While diuretics are the cornerstone treatment, acetazolamide may enhance diuretic efficiency by reducing sodium reabsorption. We performed a systematic review and meta-analysis on the effects of acetazolamide as an add-on therapy in patients with AHF compared to diuretic therapy. PubMed, Embase, and Cochrane databases were searched for randomized controlled trials (RCT). A random-effects model was employed to compute mean differences and risk ratios. Statistical analysis was performed using R software. The GRADE approach was used to rate the certainty of the evidence. We included 4 RCTs with 634 patients aged 68 to 81 years. Over a mean follow-up of 3 days to 34 months, acetazolamide significantly increased diuresis (MD 899.2 mL; 95% CI 249.5 to 1549; p < 0.01) and natriuresis (MD 72.44 mmol/L; 95% CI 39.4 to 105.4; p < 0.01) after 48 h of its administration. No association was found between acetazolamide use and WRF (RR 2.4; 95% CI 0.4 to 14.2; p = 0.3) or all-cause mortality (RR 1.2; 95% CI 0.8 to 1.9; p = 0.3). Clinical decongestion was significantly higher in the intervention group (RR 1.35; 95% CI 1.09 to 1.68; p = 0.01). Acetazolamide is an effective add-on therapy in patients with AHF, increasing diuresis, natriuresis, and clinical decongestion, but it was not associated with differences in mortality.
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Affiliation(s)
| | - Renan Yuji Ura Sudo
- Division of Medicine, Federal University of Grande Dourados, Dourados, Brazil
| | | | - Stephen Akinfenwa
- Division of Internal Medicine, University of Connecticut, Farmington, United States of America
| | - Brenda Moura
- Division of Cardiology, Porto Armed Forces Hospital, Porto, Portugal
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15
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Misaka T, Sato Y, Sugawara Y, Ogawara R, Ichimura S, Tomita Y, Anzai F, Yokokawa T, Sato A, Shimizu T, Sato T, Oikawa M, Kobayashi A, Yoshihisa A, Takeishi Y. Elevated blood bicarbonate levels and long-term adverse outcomes in patients with chronic heart failure. ESC Heart Fail 2024. [PMID: 38970235 DOI: 10.1002/ehf2.14900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/13/2024] [Accepted: 05/24/2024] [Indexed: 07/08/2024] Open
Abstract
AIMS The bicarbonate (HCO3 -) buffer system is crucial for maintaining acid-base homeostasis and blood pH. Recent studies showed that elevated serum HCO3 - levels serve as an indicator of the beneficial effects of acetazolamide in improving decongestion in acute heart failure. In this study, we sought to clarify the clinical relevance and prognostic impact of HCO3 - in chronic heart failure (CHF). METHODS This cohort study enrolled 694 hospitalized patients with CHF (mean age 68.6 ± 14.6, 62% male) who underwent arterial blood sampling and exhibited neutral pH ranging from 7.35 to 7.45. We characterized the patients based on HCO3 - levels and followed them to register cardiac events. RESULTS Among the patients, 17.3% (120 patients) had HCO3 - levels exceeding 26 mmol/L. Patients presenting HCO3 - > 26 mmol/L were more likely to use loop diuretics and had higher serum sodium and lower potassium levels, but left ventricular ejection fraction did not differ compared with those with HCO3 - between 22 and 26 (379 patients) or those with HCO3 - < 22 mmol/L (195 patients). During a median follow-up period of 1950 days, Kaplan-Meier analysis revealed that patients with HCO3 - > 26 mmol/L had the lowest event-free survival rate from either cardiac deaths or heart failure-related rehospitalization (P < 0.01 and 0.03, respectively). In the multivariable Cox model, the presence of HCO3 - > 26 mmol/L independently predicted increased risks of each cardiac event with a hazard ratio of 2.31 and 1.69 (P < 0.01 and 0.02, respectively), while HCO3 - < 22 mmol/L was not associated with these events (hazard ratios, 0.99 and 1.19; P = 0.98 and 0.43, respectively). CONCLUSIONS Elevated blood HCO3 - levels may signify enhanced proximal nephron activation and loop diuretic resistance, leading to long-term adverse outcomes in patients with CHF, even within a normal pH range.
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Affiliation(s)
- Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Community Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yu Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yukiko Sugawara
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Ryo Ogawara
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Shohei Ichimura
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yusuke Tomita
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Fumiya Anzai
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Tetsuro Yokokawa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Akihiko Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takeshi Shimizu
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takamasa Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Atsushi Kobayashi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Community Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Clinical Laboratory Sciences, Fukushima Medical University School of Health Sciences, Fukushima, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
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16
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Stankowski K, Villaschi A, Tartaglia F, Figliozzi S, Pini D, Chiarito M, Stefanini G, Cannata F, Condorelli G. Prognostic value of hypochloremia on mortality in patients with heart failure: a systematic review and meta-analysis. J Cardiovasc Med (Hagerstown) 2024; 25:499-510. [PMID: 38809244 DOI: 10.2459/jcm.0000000000001644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
AIMS Electrolyte imbalances are common in patients with heart failure. Several studies have shown that a low serum chloride level is associated with adverse outcomes in hospitalized patients with acute heart failure and in outpatients with chronic heart failure. We performed a systematic review and meta-analysis to assess the association of hypochloremia with all-cause mortality in patients with heart failure. METHODS Data search was conducted from inception through 1 February 2023, using the following MeSH terms: ('chloride' OR 'hypochloremia') AND 'heart failure'. Studies evaluating the association between serum chloride and all-cause mortality in patients with heart failure were included. The predefined primary outcome was all-cause mortality. Pooled hazard ratios and 95% confidence intervals (CIs) were used as effect estimates and calculated with a random-effects model; fixed-effects model and leave-one-out sensitivity analyses were also performed. RESULTS A total of 15 studies, involving 25 848 patients, were included. The prevalence of hypochloremia ranged from 8.6 to 31.5%. Follow-up time ranged from 6 to 67 months. Hypochloremia as a categorical variable was associated with an increased risk of all-cause mortality [hazard ratio 1.56; 95% confidence interval (CI) 1.38-1.75; P < 0.001]. As a continuous variable, serum chloride was associated with all-cause mortality (hazard ratio per mmol/l decrease in serum chloride: 1.06; 95% CI 1.05-1.07; P < 0.001). Results were confirmed by using several sensitivity analyses. CONCLUSION Hypochloremia exhibits a significant prognostic value in patients with heart failure. Serum chloride can be used as an effective tool for risk stratifying in patients with heart failure.
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Affiliation(s)
- Kamil Stankowski
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele
- IRCCS Humanitas Research Hospital, Rozzano, Milan
| | - Alessandro Villaschi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele
- IRCCS Humanitas Research Hospital, Rozzano, Milan
| | - Francesco Tartaglia
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele
- IRCCS Humanitas Research Hospital, Rozzano, Milan
| | | | - Daniela Pini
- Cardio-Thoracic and Vascular Department, San Gerardo Hospital, ASST-Monza, Monza
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele
- IRCCS Humanitas Research Hospital, Rozzano, Milan
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele
- IRCCS Humanitas Research Hospital, Rozzano, Milan
| | - Francesco Cannata
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele
- IRCCS Humanitas Research Hospital, Rozzano, Milan
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17
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Llàcer P, Romero G, Trullàs JC, de la Espriella R, Cobo M, Quiroga B, Casado J, Slon-Roblero MF, Morales-Rull JL, Morgado JI, Ortiz A, Formiga F, Melendo-Viu M, de Sequera P, Recio A, Díez J, Manzano L, Núñez J. Consensus on the approach to hydrosaline overload in acute heart failure. SEMI/SEC/S.E.N. recommendations. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:556-565. [PMID: 38432324 DOI: 10.1016/j.rec.2024.01.008] [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: 09/13/2023] [Accepted: 01/09/2024] [Indexed: 03/05/2024]
Abstract
Most of the signs and symptoms of heart failure can be explained by fluid overload, which is also related to disease progression. Fluid overload is a complex phenomenon that extends beyond increased intravascular pressures and poses challenges for accurate diagnosis and effective treatment. Current recommendations advise a multiparametric approach, including clinical data (symptoms/signs), imaging tests, and biomarkers. This article proposes a practical therapeutic approach to managing hydrosaline overload in heart failure in both inpatient and outpatient settings. This document is an initiative of the Spanish Society of Internal Medicine (SEMI) in collaboration with the Spanish Society of Cardiology (SEC) and the Spanish Society of Nephrology (S.E.N.).
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Affiliation(s)
- Pau Llàcer
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (Irycis), Madrid, Spain; Departamento de Medicina y Especialidades Médicas, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Gregorio Romero
- Servicio de Nefrología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain; Grupo de Trabajo de Medicina CardioRenal (CaReSEN), Sociedad Española de Nefrología (S.E.N.)
| | - Joan Carles Trullàs
- Servicio de Medicina Interna, Hospital d'Olot i Comarcal de la Garrotxa, Olot, Girona, Spain; Laboratori de Reparació i Regeneració Tissular (TRbLab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Barcelona, Spain
| | - Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria del Hospital Clínico de Valencia (Incliva), Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Marta Cobo
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA), Majadahonda, Madrid, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Borja Quiroga
- Servicio de Nefrología, Hospital Universitario de La Princesa, Instituto de Investigación del Hospital de La Princesa (IIS-La Princesa), Madrid, Spain
| | - Jesús Casado
- Servicio de Medicina Interna, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - María F Slon-Roblero
- Servicio de Nefrología, Hospital Universitario de Navarra, Pamplona, Navarra, Spain; Área de las Enfermedades Cardiovasculares y Renales, Instituto Navarro para la Investigación de la Salud (IdiSNA), Pamplona, Navarra, Spain
| | - José Luis Morales-Rull
- Servicio de Medicina Interna, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica (IRBLleida), Lleida, Spain
| | | | - Alberto Ortiz
- Servicio de Nefrología e Hipertensión, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (iiS-FJD), Universidad Autónoma de Madrid (UAM), Red de Investigación Cooperativa Orientada a Resultados en Salud b0d0 (RICORSb0d0), Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Francesc Formiga
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - María Melendo-Viu
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Patricia de Sequera
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, Spain
| | - Alejandro Recio
- Servicio de Cardiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Javier Díez
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Centro de Investigación Médica Aplicada (CIMA), Universidad de Navarra, Pamplona, Navarra, Spain
| | - Luis Manzano
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (Irycis), Madrid, Spain; Departamento de Medicina y Especialidades Médicas, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria del Hospital Clínico de Valencia (Incliva), Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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18
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Kanbay M, Copur S, Guldan M, Ozbek L, Hatipoglu A, Covic A, Mallamaci F, Zoccali C. Proximal tubule hypertrophy and hyperfunction: a novel pathophysiological feature in disease states. Clin Kidney J 2024; 17:sfae195. [PMID: 39050867 PMCID: PMC11267238 DOI: 10.1093/ckj/sfae195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Indexed: 07/27/2024] Open
Abstract
The role of proximal tubules (PTs), a major component of the renal tubular structure in the renal cortex, has been examined extensively. Along with its physiological role in the reabsorption of various molecules, including electrolytes, amino acids and monosaccharides, transcellular transport of different hormones and regulation of homeostasis, pathological events affecting PTs may underlie multiple disease states. PT hypertrophy or a hyperfunctioning state, despite being a compensatory mechanism at first in response to various stimuli or alterations at tubular transport proteins, have been shown to be critical pathophysiological events leading to multiple disorders, including diabetes mellitus, obesity, metabolic syndrome and congestive heart failure. Moreover, pharmacotherapeutic agents have primarily targeted PTs, including sodium-glucose cotransporter 2, urate transporters and carbonic anhydrase enzymes. In this narrative review, we focus on the physiological role of PTs in healthy states and the current understanding of the PT pathologies leading to disease states and potential therapeutic targets.
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Affiliation(s)
- Mehmet Kanbay
- Department of Internal Medicine, Division of Nephrology, Koç University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Koç University School of Medicine, Istanbul, Turkey
| | - Mustafa Guldan
- Department of Internal Medicine, Division of Internal Medicine, Koç University School of Medicine, Istanbul, Turkey
| | - Lasin Ozbek
- Department of Internal Medicine, Division of Internal Medicine, Koç University School of Medicine, Istanbul, Turkey
| | - Alper Hatipoglu
- Department of Internal Medicine, Division of Internal Medicine, Koç University School of Medicine, Istanbul, Turkey
| | - Adrian Covic
- Nephrology, Dialysis and Transplantation, University Grigore T Popa, Iasi, Romania
| | - Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
- CNR-IFC, Research Unit of Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Institute of Clinical Physiology, Reggio Calabria, Italy
| | - Carmine Zoccali
- Renal Research Institute, New York, NY, USA
- Institute of Molecular Biology and Genetics, Ariano Irpino, Italy
- Associazione Ipertensione Nefrologia Trapianto Renale, Grande Ospedale Metropolitano, c/o Nefrologia, Reggio Calabria, Italy
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19
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Lichtblau M, Saxer S, Müller J, Appenzeller P, Berlier C, Schneider SR, Mayer L, Furian M, Schwarz EI, Swenson ER, Bloch KE, Ulrich S. Effect of 5 weeks of oral acetazolamide on patients with pulmonary vascular disease: A randomized, double-blind, cross-over trial. Pulmonology 2024; 30:362-369. [PMID: 36639329 DOI: 10.1016/j.pulmoe.2022.11.004] [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: 08/18/2022] [Revised: 11/08/2022] [Accepted: 11/08/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The carbonic anhydrase inhibitor acetazolamide stimulates ventilation through metabolic acidosis mediated by renal bicarbonate excretion. In animal models, acetazolamide attenuates acute hypoxia-induced pulmonary hypertension (PH), but its efficacy in treating patients with PH due to pulmonary vascular disease (PVD) is unknown. METHODS 28 PVD patients (15 pulmonary arterial hypertension, 13 distal chronic thromboembolic PH), 13 women, mean±SD age 61.6±15.0 years stable on PVD medications, were randomised in a double-blind crossover protocol to 5 weeks acetazolamide (250mg b.i.d) or placebo separated by a ≥2 week washout period. Primary endpoint was the change in 6-minute walk distance (6MWD) at 5 weeks. Additional endpoints included safety, tolerability, WHO functional class, quality of life, arterial blood gases, and hemodynamics (by echocardiography). RESULTS Acetazolamide had no effect on 6MWD compared to placebo (treatment effect: mean change [95%CI] -18 [-40 to 4]m, p=0.102) but increased arterial blood oxygenation through hyperventilation induced by metabolic acidosis. Other measures including pulmonary hemodynamics were unchanged. No severe adverse effects occurred, side effects that occurred significantly more frequently with acetazolamide vs. placebo were change in taste (22/0%), paraesthesia (37/4%) and mild dyspnea (26/4%). CONCLUSIONS In patients with PVD, acetazolamide did not change 6MWD compared to placebo despite improved blood oxygenation. Some patients reported a tolerable increase in dyspnoea during acetazolamide treatment, related to hyperventilation, induced by the mild drug-induced metabolic acidosis. Our findings do not support the use of acetazolamide to improve exercise in patients with PVD at this dosing. CLINICALTRIALS GOV IDENTIFIER NCT02755298.
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Affiliation(s)
- M Lichtblau
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - S Saxer
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - J Müller
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - P Appenzeller
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - C Berlier
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - S R Schneider
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - L Mayer
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - M Furian
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - E I Schwarz
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - E R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, VA Puget Sound Health Care System, University of Washington, Seattle, Washington, USA
| | - K E Bloch
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland; Center for Human Integrative Physiology, and Zurich Center for Interdisciplinary Sleep Research, University of Zurich, Switzerland
| | - S Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland; Center for Human Integrative Physiology, and Zurich Center for Interdisciplinary Sleep Research, University of Zurich, Switzerland.
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20
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Mansoor T, Khalid SN, Bilal MI, Ijaz SH, Fudim M, Greene SJ, Warraich HJ, Nambi V, Virani SS, Fonarow GC, Abramov D, Minhas AMK. Ongoing and Future Clinical Trials of Pharmacotherapy for Heart Failure. Am J Cardiovasc Drugs 2024; 24:481-504. [PMID: 38907865 DOI: 10.1007/s40256-024-00658-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2024] [Indexed: 06/24/2024]
Abstract
Increasing knowledge of the processes leading to heart failure (HF) has allowed significant developments in therapies for HF over the past few decades. Despite the evolution of HF treatment, it still places a large burden on patients and health care systems across the world.We used clinicaltrials.gov to gather information about clinical trials as of August 2023 studying pharmacotherapy for HF. We included interventional trials that were "active, not recruiting", "recruiting", or looking for participants but "not yet recruiting". In total, 119 studies met our criteria of ongoing clinical trials studying novel as well as currently approved HF pharmacotherapies. The major interventions were novel medications/already approved medications for other diseases 29 % (34 trials), sodium-glucose co-transporter inhibitors 21 % (25 trials), angiotensin receptor blocker-neprilysin inhibitors 10 % (12 trials), diuretics 14 % (17 trials) and mineralocorticoid receptor antagonists 5 % (6 trials). Ongoing research will aid in reducing the impact of HF and we summarize clinical trials leading the way to better HF treatment in this review.
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Affiliation(s)
- Taha Mansoor
- Department of Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, 49008, USA.
| | - Subaina N Khalid
- Department of Internal Medicine, SUNY Upstate Medical University, Syracruse, NY, USA
| | | | | | - Marat Fudim
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Haider J Warraich
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Vijay Nambi
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
- Michael E. DeBakey, Veterans Affair Medical Center, Houston, TX, USA
| | - Salim S Virani
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
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21
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Cotter G, Davison B, Freund Y, Mebazaa A, Voors A, Edwards C, Novosadova M, Takagi K, Hayrapetyan H, Mshetsyan A, Mayranush D, Cohen-Solal A, Ter Maaten JM, Biegus J, Ponikowski P, Filippatos G, Chioncel O, Pagnesi M, Simon T, Metra M, Mann DL. Corticosteroid burst therapy in patients with acute heart failure: Design of the CORTAHF pilot study. ESC Heart Fail 2024. [PMID: 38943232 DOI: 10.1002/ehf2.14930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/07/2024] [Accepted: 06/14/2024] [Indexed: 07/01/2024] Open
Abstract
AIMS Inflammation has emerged as a potential key pathophysiological mechanism in heart failure (HF) in general and acute HF (AHF) specifically, with inflammatory biomarkers shown to be highly predictive of adverse outcomes in these patients. The CORTAHF study builds on both these data and the fact that steroid burst therapy has been shown to be effective in the treatment of respiratory diseases and COVID-19. Our hypothesis is that in patients with AHF and elevated C-reactive protein (CRP) levels without symptoms or signs of infection, a 7-day course of steroid therapy will lead to reduced inflammation and short-term improvement in quality of life and a reduced risk of worsening HF (WHF) events. METHODS AND RESULTS The study, which is currently ongoing, will include 100 patients with AHF ages 18-85, regardless of ejection fraction, screened within 12 h of presentation. Patients will be included who have NT-proBNP > 1500 pg/mL and CRP > 20 mg/L at screening. Exclusion criteria include haemodynamic instability and symptoms and signs of infection. After signed consent, eligible patients will be randomized according to a central randomization scheme stratified by centre 1:1 to either treatment once daily for 7 days with 40 mg prednisone orally or to standard care. Patients will be assessed at study day 2, day 4 or at discharge if earlier, and at days 7 and 31 at the hospital; and at day 91 through a telephone follow-up. The primary endpoint is the change in CRP level from baseline to day 7, estimated from a mixed model for repeated measures (MMRM) including all measured timepoints, in patients without a major protocol violation. Secondary endpoints include the time to the first event of WHF adverse event, readmission for HF, or death through day 91; and changes to day 7 in EQ-5D visual analogue scale score and utility index. Additional clinical and laboratory measures will be assessed. CONCLUSIONS The results of the study will add to the knowledge of the role of inflammation in AHF and potentially inform the design of larger studies with possibly longer duration of anti-inflammatory therapies in AHF.
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Affiliation(s)
- Gad Cotter
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Heart Initiative, Durham, NC, USA
- Momentum Research, Inc., Durham, NC, USA
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Heart Initiative, Durham, NC, USA
- Momentum Research, Inc., Durham, NC, USA
| | - Yonathan Freund
- IMProving Emergency Care FHU, Sorbonne Université, Paris, France
- Emergency Department and Service Mobile d'Urgence et de Réanimation (SMUR), Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | - Adriaan Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | | | | | | | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| | - Jozine M Ter Maaten
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclawa, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclawa, Poland
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Haidari, Greece
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine 'Carol Davila', Bucharest, Romania
| | - Matteo Pagnesi
- Department of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Tabassome Simon
- IMProving Emergency Care FHU, Sorbonne Université, Paris, France
- Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), St Antoine Hospital, APHP, Paris, France
| | - Marco Metra
- Department of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Douglas L Mann
- Department of Medicine, Division of Cardiovascular, Center for Cardiovascular Research, Washington University School of Medicine, St. Louis, MO, USA
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22
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Horiuchi Y, Wettersten N. Treatment strategies for diuretic resistance in patients with heart failure. J Cardiol 2024:S0914-5087(24)00122-9. [PMID: 38914279 DOI: 10.1016/j.jjcc.2024.06.005] [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: 04/01/2024] [Revised: 06/13/2024] [Accepted: 06/18/2024] [Indexed: 06/26/2024]
Abstract
Improving congestion with diuretic therapy is crucial in the treatment of heart failure (HF). However, despite the use of loop diuretics, diuresis may be inadequate and congestion persists, which is known as diuretic resistance. Diuretic resistance and residual congestion are associated with a higher risk of rehospitalization and mortality. Causes of diuretic resistance in HF include diuretic pharmacokinetic changes, renal hemodynamic perturbations, neurohumoral activations, renal tubular remodeling, and use of nephrotoxic drugs as well as patient comorbidities. Combination diuretic therapy (CDT) has been advocated for the treatment of diuretic resistance. Thiazides, acetazolamides, tolvaptan, mineralocorticoid receptor antagonist, and sodium-glucose co-transporter-2 inhibitors are among the candidates, but none of these treatments has yet demonstrated significant diuretic efficacy or improved prognosis. At present, it is essential to identify and treat the causes of diuretic resistance in individual patients and to use CDT based on a better understanding of the characteristics of each drug to achieve adequate diuresis. Further research is needed to effectively assess and manage diuretic resistance and ultimately improve patient outcomes.
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Affiliation(s)
- Yu Horiuchi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan.
| | - Nicholas Wettersten
- Division of Cardiovascular Medicine, San Diego Veterans Affairs Medical Center, San Diego, CA, USA; Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, CA, USA
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23
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Zhang Y, Bock F, Ferdaus M, Arroyo JP, L Rose K, Patel P, Denton JS, Delpire E, Weinstein AM, Zhang MZ, Harris RC, Terker AS. Low potassium activation of proximal mTOR/AKT signaling is mediated by Kir4.2. Nat Commun 2024; 15:5144. [PMID: 38886379 PMCID: PMC11183202 DOI: 10.1038/s41467-024-49562-w] [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: 08/31/2023] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
The renal epithelium is sensitive to changes in blood potassium (K+). We identify the basolateral K+ channel, Kir4.2, as a mediator of the proximal tubule response to K+ deficiency. Mice lacking Kir4.2 have a compensated baseline phenotype whereby they increase their distal transport burden to maintain homeostasis. Upon dietary K+ depletion, knockout animals decompensate as evidenced by increased urinary K+ excretion and development of a proximal renal tubular acidosis. Potassium wasting is not proximal in origin but is caused by higher ENaC activity and depends upon increased distal sodium delivery. Three-dimensional imaging reveals Kir4.2 knockouts fail to undergo proximal tubule expansion, while the distal convoluted tubule response is exaggerated. AKT signaling mediates the dietary K+ response, which is blunted in Kir4.2 knockouts. Lastly, we demonstrate in isolated tubules that AKT phosphorylation in response to low K+ depends upon mTORC2 activation by secondary changes in Cl- transport. Data support a proximal role for cell Cl- which, as it does along the distal nephron, responds to K+ changes to activate kinase signaling.
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Affiliation(s)
- Yahua Zhang
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Kidney Disease, Nashville, TN, USA
| | - Fabian Bock
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Kidney Disease, Nashville, TN, USA
| | - Mohammed Ferdaus
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Juan Pablo Arroyo
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Kidney Disease, Nashville, TN, USA
| | - Kristie L Rose
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, TN, USA
- Mass Spectrometry Research Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Purvi Patel
- Mass Spectrometry Research Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jerod S Denton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric Delpire
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan M Weinstein
- Department of Physiology and Biophysics, Weil Medical College, New York, NY, USA
| | - Ming-Zhi Zhang
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Kidney Disease, Nashville, TN, USA
| | - Raymond C Harris
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Kidney Disease, Nashville, TN, USA
- Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Andrew S Terker
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Vanderbilt Center for Kidney Disease, Nashville, TN, USA.
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24
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Guzmán-Carreras A, Vellisca-González AM, Molina-Puente JI, García-Alonso R, Paz-Cabezas M, Sánchez-Sauce B, Aguilar-Rodríguez F, Iguarán-Bermúdez MDR, Andrès E, Lorenzo-Villalba N, Méndez-Bailón M. Sodium-Glucose Cotransporter Type 2 Inhibitors Use in Elderly Polypathological Patients with Acute Heart Failure: PROFUND-IC Registry. J Clin Med 2024; 13:3485. [PMID: 38930015 PMCID: PMC11204832 DOI: 10.3390/jcm13123485] [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: 05/06/2024] [Revised: 06/02/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
Background/Objectives: Heart failure (HF) is a highly prevalent clinical syndrome with serious morbidity and mortality. Furthermore, acute heart failure (AHF) is the main cause of hospital admission in people aged 65 years or more. Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) have been shown to improve the survival and quality of life in patients with HF regardless of left ventricular ejection fraction (LVEF). Our aims were to describe the characteristics of adults with multiple pathologies admitted with acute heart failure as the main diagnosis and of the population treated with SGLT2is, as well as to evaluate if their use was associated with lower readmission and mortality rates. Methods: A prospective study of patients from the PROFUND-IC registry who were admitted with AHF as the main diagnosis was conducted. Clinical and analytical characteristics were analyzed, as well as readmissions and mortality. Descriptive and bivariate analyses of the sample between those taking SGLT2is and those who were not were performed, using the chi-square test for qualitative variables and Welch's test for quantitative measures, as well as the Fisher and Wilcoxon tests as indicated for nonparametric tests. Kaplan-Meier curves were constructed to analyze the readmission and mortality of patients at 12 months based on SGLT2i treatment. Finally, a propensity score matching was performed, guaranteeing that the observed effect of the drug was not influenced by the differences in the characteristics between the groups. Results: There were 750 patients included: 58% were women, and the mean age was 84 years. Functional class II according to the NYHA scale predominated (54%), and the mean LVEF was 51%. SGLT2 inhibitors were prescribed to only 28% of patients. Most of the patients were men (48.6% vs. 39.8%, p = 0.029), they were younger (82 vs. 84 years, p = 0.002), and their LVEF was lower (48% vs. 52%, p < 0.001). Lower mortality was observed in the group treated with SGLT2is, both during baseline admission (2.4% vs. 6.9%, p = 0.017) and at the 12-month follow-up (6.2% vs. 13%, p = 0.023); as well as a lower readmission rate (23.8% vs. 38.9%, p < 0.001). After the propensity score matching, a decrease in the 12-month readmission rate continued to be observed in the group treated with SGLT2is (p = 0.03). Conclusions: SGLT2is use was associated with lower readmission rates at the 12-month follow-up in older adults with multiple pathologies admitted with acute heart failure.
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Affiliation(s)
- Alicia Guzmán-Carreras
- Servicio de Medicina Interna, Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Andrea María Vellisca-González
- Servicio de Medicina Interna, Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | | | - Rocío García-Alonso
- Servicio de Medicina Interna, Complejo Asistencial de Ávila, 05071 Ávila, Spain
| | - Mateo Paz-Cabezas
- Unidad de Apoyo Metodológico a la Investigación, Servicio de Medicina Preventiva, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | | | | | - María Del Rosario Iguarán-Bermúdez
- Servicio de Medicina Interna, Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Emmanuel Andrès
- Service de Médecine Interne, Hôpitaux Universitaires de Strasbourg, 67200 Strasbourg, France
| | - Noel Lorenzo-Villalba
- Service de Médecine Interne, Hôpitaux Universitaires de Strasbourg, 67200 Strasbourg, France
| | - Manuel Méndez-Bailón
- Servicio de Medicina Interna, Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
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25
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Buttar C, Alai H, Matanes FN, Cassidy MM, Stencel J, Le Jemtel TH. Full decongestion in acute heart failure therapy. Am J Med Sci 2024:S0002-9629(24)01273-4. [PMID: 38880301 DOI: 10.1016/j.amjms.2024.06.002] [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: 03/24/2024] [Revised: 06/07/2024] [Accepted: 06/07/2024] [Indexed: 06/18/2024]
Abstract
Incomplete decongestion is the main cause of readmission in the early post-discharge period of a hospitalization for acute heart failure. Recent heart failure guidelines have highlighted initiation and rapid up-titration of quadruple therapy with angiotensin receptor neprilysin inhibitor, beta adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor to prevent hospitalizations for heart failure with reduced ejection fraction. However, full decongestion remains the foremost therapeutic goal of hospitalization for heart failure. While early addition of sodium glucose cotransporter 2 inhibitors and mineralocorticoid receptor antagonists may be helpful, the value of the other therapeutics comes after decongestion is complete.
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Affiliation(s)
- Chandan Buttar
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Hamid Alai
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Faris N Matanes
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Mark M Cassidy
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Jason Stencel
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Thierry H Le Jemtel
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA.
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26
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Sánchez-Marteles M, Garcés-Horna V, Morales-Rull JL, Casado J, Carrera-Izquierdo M, Conde-Martel A, Dávila-Ramos MF, Llácer P, Salamanca-Bautista P, Ruiz R, Aramburu-Bodas O, Formiga F, Manzano L, Trullàs JC. Combining Loop and Thiazide Diuretics Across the Left Ventricular Ejection Fraction Spectrum: The CLOROTIC Trial. JACC. HEART FAILURE 2024:S2213-1779(24)00417-7. [PMID: 38934966 DOI: 10.1016/j.jchf.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 04/10/2024] [Accepted: 05/07/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The addition of hydrochlorothiazide (HCTZ) to furosemide in the CLOROTIC (Combining Loop with Thiazide Diuretics for Decompensated Heart Failure) trial improved the diuretic response in patients with acute heart failure (AHF). OBJECTIVES This work aimed to evaluate if these results differ across the spectrum of left ventricular ejection fraction (LVEF). METHODS This post hoc analysis of the randomized, double-blind, placebo-controlled CLOROTIC trial enrolled 230 patients with AHF to receive either HCTZ or a placebo in addition to an intravenous furosemide regimen. The influence of LVEF on primary and secondary outcomes was evaluated. RESULTS The median LVEF was 55%: 166 (72%) patients had LVEF >40%, and 64 (28%) had LVEF ≤40%. Patients with a lower LVEF were younger, more likely to be male, had a higher prevalence of ischemic heart disease, and had higher natriuretic peptide levels. The addition of HCTZ to furosemide was associated with the greatest weight loss at 72 of 96 hours, better metrics of diuretic response, and greater 24-hour diuresis compared with placebo, with no significant differences according to the LVEF category (using 2 LVEF cutoff points: 40% and 50%) or LVEF as a continuous variable (all P values were insignificant). There were no significant differences observed with the addition of HCTZ in terms of mortality, rehospitalizations, or safety endpoints (impaired renal function, hyponatremia, and hypokalemia) among the 2 LVEF groups (all P values were insignificant). CONCLUSIONS Adding HCTZ to intravenous furosemide seems to be effective strategy for improving diuretic response in AHF without treatment effect modification according to baseline LVEF. (Combining Loop with Thiazide Diuretics for Decompensated Heart Failure [CLOROTIC], NCT01647932; Randomized, double blinded, multicenter study, to asses Safety and Efficacy of the Combination of Loop With Thiazide-type Diuretics vs Loop diuretics with placebo in Patients With Decompensated, EudraCT Number 2013-001852-36).
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Affiliation(s)
- Marta Sánchez-Marteles
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa," Calle de San Juan Bosco, Zaragoza, Spain; Aragon Health Research Institute (IIS Aragon), Zaragoza, Spain.
| | - Vanesa Garcés-Horna
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa," Calle de San Juan Bosco, Zaragoza, Spain; Aragon Health Research Institute (IIS Aragon), Zaragoza, Spain
| | - José Luís Morales-Rull
- Internal Medicine Department, Heart Failure Unit, Hospital Universitari Arnau de Villanova, Institut de Recerca Biomédica (IRBLleida), Avinguda Alcalde Rovira Roure, Lleida, Spain
| | - Jesús Casado
- Internal Medicine Department, Hospital Universitario de Getafe, Carretera de Madrid-Toledo, Madrid, Spain
| | | | - Alicia Conde-Martel
- Internal Medicine Department, Hospital Universitario de Gran Canaria Dr. Negrín, C. Pl. Barranco de la Ballena, Las Palmas de Gran Canaria, Spain
| | - Melitón Francisco Dávila-Ramos
- Internal Medicine Department, Hospital Universitario Nuestra Señora de la Candelaria, Carretera General del Rosario, Santa Cruz de Tenerife, Spain
| | - Pau Llácer
- Internal Medicine Department, Hospital de Manises, Avinguda de la Generalitat Valenciana, Manises, Valencia, Spain
| | - Prado Salamanca-Bautista
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Avenida Dr. Fedriani, Sevilla, Spain
| | - Raúl Ruiz
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Oscar Aramburu-Bodas
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Avenida Dr. Fedriani, Sevilla, Spain
| | - Francesc Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, Carrer de la Feixa Llarga, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Luís Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Joan Carles Trullàs
- Internal Medicine Department, Hospital d'Olot i Comarcal de la Garrotxa, Avinguda dels Països Catalans Olot, Girona, Spain; Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Ctra. de Roda, Barcelona, Spain
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Schwann AN, Jaffe LM, Givertz MM, Wood KL, Engelman DT. Early Initiation of Guideline-Directed Medical Therapy for Heart Failure After Cardiac Surgery. Ann Thorac Surg 2024:S0003-4975(24)00463-6. [PMID: 38878947 DOI: 10.1016/j.athoracsur.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
There is an evolving role for guideline-directed medical therapy (GDMT) in managing heart failure with reduced ejection fraction after cardiac surgery. GDMT is based on the use of pharmacologic agents from each of 4 distinct drug classes, also known as the 4 pillars of heart failure therapy: β-blockers, renin-angiotensin system inhibitors, often paired with neprilysin inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. Despite the demonstrated benefits of GDMT in reducing mortality and hospitalization rates in the nonsurgical literature, there is conspicuous underuse of GDMT after cardiac surgery. The lack of published literature and practical challenges surrounding the timing for initiation of GDMT in the immediate postoperative period has limited standardized implementation strategies. A multidisciplinary approach will be necessary to assist in initiating, titrating, and monitoring the response to these therapies in patients with heart failure with reduced ejection fraction after cardiac surgery.
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Affiliation(s)
- Alexandra N Schwann
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Leeor M Jaffe
- Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katherine L Wood
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Daniel T Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts.
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28
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Sosa Mercado I, Putot S, Fertu E, Putot A. Acetazolamide Tolerance in Acute Decompensated Heart Failure: An Observational Study. J Clin Med 2024; 13:3421. [PMID: 38929950 PMCID: PMC11204894 DOI: 10.3390/jcm13123421] [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: 05/16/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Objectives: This real-life study aimed to evaluate the safety of acetazolamide (ACZ), a carbonic anhydrase inhibitor with diuretic effects. ACZ has recently been proven to improve decongestion in the context of patients hospitalized for acute heart failure (HF). However, data in terms of safety are lacking. Methods: We conducted a monocentric observational prospective study from November 2023 to February 2024 in a 12-bed cardiology department, recording adverse events (hypotension, severe metabolic acidosis, severe hypokalemia and renal events) during in-hospital HF treatment. All patients hospitalized for acute HF during the study period treated with ACZ (500 mg IV daily for 3 days) on top of IV furosemide (n = 28, 48.3%) were compared with patients who have been treated with IV furosemide alone (n = 30, 51.7%). Results: The patients treated with ACZ were younger than those without (median age 78 (range 67-86) vs. 85 (79-90) years, respectively, p = 0.01) and had less frequent chronic kidney disease (median estimated glomerular fraction rate (60 (35-65) vs. 38 (26-63) mL/min, p = 0.02). As concerned adverse events during HF treatment, there were no differences in the occurrences of hypotension (three patients [10.7%] in the ACZ group vs. four [13.3%], p = 0.8), renal events (four patients [14.3%] in the ACZ group vs. five [16.7%], p = 1) and severe hypokalemia (two [7.1%] in the ACZ group vs. three [10%], p = 1). No severe metabolic acidosis occurred in either group. Conclusions: Although the clinical characteristics differed at baseline, with younger age and better renal function in patients receiving ACZ, the tolerance profile did not significantly differ from patients receiving furosemide alone. Additional observational data are needed to further assess the safety of ACZ-furosemide combination in the in-hospital management of HF, especially in older, frail populations.
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Affiliation(s)
- Ignacio Sosa Mercado
- Department of Cardiology and Vascular Diseases, Hôpitaux du Pays du Mont Blanc, 74700 Sallanches, France; (I.S.M.); (S.P.); (E.F.)
| | - Sophie Putot
- Department of Cardiology and Vascular Diseases, Hôpitaux du Pays du Mont Blanc, 74700 Sallanches, France; (I.S.M.); (S.P.); (E.F.)
| | - Elena Fertu
- Department of Cardiology and Vascular Diseases, Hôpitaux du Pays du Mont Blanc, 74700 Sallanches, France; (I.S.M.); (S.P.); (E.F.)
| | - Alain Putot
- Department of Internal Medicine and Infectious Diseases, Hôpitaux du Pays du Mont Blanc, 74700 Sallanches, France
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29
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Rambarat P, Felker GM. Decongestion Strategies for Ambulatory Outpatients: The Proof Is in the Urine. JACC. HEART FAILURE 2024:S2213-1779(24)00423-2. [PMID: 39001746 DOI: 10.1016/j.jchf.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/07/2024] [Indexed: 07/15/2024]
Affiliation(s)
- Paula Rambarat
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - G Michael Felker
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina, USA.
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30
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Kapur NK, Kanwar MK, Yousefzai R, Bhimiraj A, Farber H, Esposito ML, Kiernan MS, John KJ, Burkhoff D. Mechanical Preload Reduction: Harnessing a Cornerstone of Heart Failure Management to Improve Clinical Outcomes. ASAIO J 2024:00002480-990000000-00499. [PMID: 38829983 DOI: 10.1097/mat.0000000000002240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Decongestion is a cornerstone therapeutic goal for those presenting with decompensated heart failure. Current approaches to clinical decongestion include reducing cardiac preload, which is typically limited to diuretics and hemofiltration. Several new technologies designed to mechanically reduce cardiac preload are in development. In this review, we discuss the pathophysiology of decompensated heart failure; the central role of targeting cardiac preload; emerging mechanical preload reduction technologies; and potential application of these devices.
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Affiliation(s)
- Navin K Kapur
- From the Department of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Manreet K Kanwar
- Department of Cardiology, Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Rayan Yousefzai
- Department of Cardiology, Houston Methodist Research Institute, Houston, Texas
| | - Arvind Bhimiraj
- Department of Cardiology, Houston Methodist Research Institute, Houston, Texas
| | - Harrison Farber
- From the Department of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Michele L Esposito
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Michael S Kiernan
- From the Department of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Kevin J John
- From the Department of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Daniel Burkhoff
- Department of Cardiology, The Cardiovascular Research Foundation, New York, New York
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31
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Croset F, Llàcer P, Núñez J, Campos J, García M, Pérez A, Fernández C, Fabregate M, López G, Tello S, Fernández JM, Ruiz R, Manzano L. Loop diuretic down-titration at discharge in patients hospitalized for acute heart failure. ESC Heart Fail 2024; 11:1739-1747. [PMID: 38454739 PMCID: PMC11098660 DOI: 10.1002/ehf2.14749] [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: 11/21/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 03/09/2024] Open
Abstract
AIMS The current literature provides limited guidance on the best diuretic strategy post-hospitalization for acute heart failure (AHF). It is postulated that the efficacy and safety of the outpatient diuretic regimen may be significantly influenced by the degree of fluid overload (FO) encountered during hospitalization. We hypothesize that in patients with more pronounced FO, reducing their regular oral diuretic dosage might be associated with an elevated risk of unfavourable clinical outcomes. METHODS AND RESULTS It was a retrospective observational study of 410 patients hospitalized for AHF in which the dose of furosemide at admission and discharge was collected. Patients were categorized across diuretic dose status into two groups: (i) the down-titration group and (ii) the stable/up-titration group. FO status was evaluated by a clinical congestion score and circulating biomarkers. The endpoint of interest was the composite of time to all-cause death and/or heart failure readmission. A multivariable Cox proportional hazard regression model was constructed to analyse the endpoints. The median age was 86 (78-92) years, 256 (62%) were women, and 80% had heart failure with preserved ejection fraction. After multivariate adjustment, the down-titration furosemide equivalent dose remained not associated with the risk of the combined endpoint in the whole sample (hazard ratio 1.34, 95% confidence interval 0.86-2.06, P = 0.184). The risk of the combination of death and/or worsening heart failure associated with the diuretic strategy at discharge was significantly influenced by FO status, including clinical congestion scores and circulating proxies of FO like BNP and cancer antigen 125. CONCLUSIONS In patients hospitalized for AHF, furosemide down-titration does not imply an increased risk of mortality and/or heart failure readmission. However, FO status modifies the effect of down-titration on the outcome. In patients with severe congestion or residual congestion at discharge, down-titration was associated with an increased risk of mortality and/or heart failure readmission.
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Affiliation(s)
- François Croset
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de Alcalá, IRYCISMadridSpain
| | - Pau Llàcer
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de Alcalá, IRYCISMadridSpain
| | - Julio Núñez
- Department of CardiologyHospital Clínico Universitario, Universitat de València, INCLIVAValenciaSpain
- CIBER CardiovascularMadridSpain
| | - Jorge Campos
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Marina García
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Alberto Pérez
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Cristina Fernández
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Martín Fabregate
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Genoveva López
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Susana Tello
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - José María Fernández
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Raúl Ruiz
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Luis Manzano
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de Alcalá, IRYCISMadridSpain
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32
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Lee R, Katz JN, Dudzinski DM. Vasodilate - Great, Hate, Wait, Debate, or Stalemate? NEJM EVIDENCE 2024; 3:EVIDe2400121. [PMID: 38804787 DOI: 10.1056/evide2400121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Affiliation(s)
- Ran Lee
- Department of Cardiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland
| | - Jason N Katz
- Division of Cardiology, New York University Grossman School of Medicine, New York
| | - David M Dudzinski
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston
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33
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Mondellini GM, Verbrugge FH. Evaluation and Management of Hyponatremia in Heart Failure. Curr Heart Fail Rep 2024; 21:252-261. [PMID: 38411885 DOI: 10.1007/s11897-024-00651-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW To provide a contemporary overview of the pathophysiology, evaluation, and treatment of hyponatremia in heart failure (HF). RECENT FINDINGS Potassium and magnesium losses due to poor nutritional intake and treatment with diuretics cause an intracellular sodium shift in HF that may contribute to hyponatremia. Impaired renal blood flow leading to a lower glomerular filtration rate and increased proximal tubular reabsorption lead to an impaired tubular flux through diluting distal segments of the nephron, compromising electrolyte-free water excretion. Hyponatremia in HF is typically a condition of impaired water excretion by the kidneys on a background of potassium and magnesium depletion. While those cations can and should be easily repleted, further treatment should mainly focus on improving the underlying HF and hemodynamics, while addressing congestion. For decongestive treatment, proximally acting diuretics such as sodium-glucose co-transporter-2 inhibitors, acetazolamide, and loop diuretics are the preferred options.
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Affiliation(s)
- Giulio M Mondellini
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090, Jette, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090, Jette, Belgium.
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium.
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34
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Razaghizad A, Aziz H, Zhang GK, Ferreira JP, White WB, Mehta CR, Bakris GL, Zannad F, Sharma A. Pathophysiological Sex Differences in Heart Failure Progression After Acute Coronary Syndrome: Insights From the EXAMINE Trial. J Card Fail 2024; 30:767-777. [PMID: 37939897 DOI: 10.1016/j.cardfail.2023.10.474] [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: 08/06/2023] [Revised: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Therapies can reduce the risk of heart failure (HF) development and progression in type 2 diabetes; nevertheless, the risk of these outcomes is greater in females than in males. METHODS AND RESULTS To investigate sex differences in HF development and progression, we compared baseline circulating proteins (Olink Cardiovascular II panel) in males and females with type 2 diabetes and recent acute coronary syndrome for the outcome of HF hospitalization. Data were from the placebo-controlled Examination of Cardiovascular Outcomes with Alogliptin vs Standard of Care (EXAMINE) trial. Pathophysiological sex-differences were interpreted with network and pathway over-representation analyses. The EXAMINE trial enrolled 5380 participants (32.1% females) with biomarker data available for 95.4% of individuals. Analyses revealed 43 biomarkers were differentially expressed in HF hospitalization, of which 18 were sex specific. Among these 43 biomarkers, interleukin-6 was identified as a central node for the pathogenesis of HF hospitalization in both females and in males. Additional pathway over-representation analyses demonstrated that biomarkers associated with inflammatory pathways related to endothelial dysfunction and cardiac fibrosis were more up-regulated in females than males with HF hospitalization. Differential expression of 3 biomarkers (pentraxin-related protein 3, hydroxyacid oxidase 1, and carbonic anhydrase 5A) was independently associated with an increased risk of HF hospitalization in females but not in males (interaction P < .05). CONCLUSIONS In males and females with type 2 diabetes and acute coronary syndrome, interleukin-6 seems to be central in the pathogenesis of HF. Females exhibit higher levels of circulating proteins related to immunological pathways, reflecting sex-specific differences underlying HF development and progression.
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Affiliation(s)
- Amir Razaghizad
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Haya Aziz
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Guang K Zhang
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - João Pedro Ferreira
- Inserm, Centre d'Investigation Clinique Plurithématique 1433, CHRU de Nancy, F-CRIN INI-CRCT, Université de Lorraine, Nancy, France; Department of Surgery and Physiology, Cardiovascular R&D Centre - UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - William B White
- Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Cyrus R Mehta
- Harvard School of Public Health, Boston, Massachusetts
| | | | - Faiez Zannad
- Inserm, Centre d'Investigation Clinique Plurithématique 1433, CHRU de Nancy, F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Abhinav Sharma
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada.
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35
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Damman K, Beldhuis IE, van der Meer P, Krikken JA, Coster JE, Nieuwland W, van Veldhuisen DJ, Voors AA, Ter Maaten JM. Renal function and natriuresis-guided diuretic therapy - a pre-specified analysis from the PUSH-AHF trial. Eur J Heart Fail 2024; 26:1347-1357. [PMID: 38734982 DOI: 10.1002/ejhf.3228] [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: 02/08/2024] [Revised: 02/28/2024] [Accepted: 03/24/2024] [Indexed: 05/13/2024] Open
Abstract
AIM In a randomized controlled trial, we recently showed that a natriuresis-guided diuretic approach improved natriuresis and diuresis in patients with acute heart failure (HF). In this pre-specified analysis, we investigated the association between (worsening) renal function, outcomes and the effect of intensive natriuresis-guided loop diuretic therapy as compared with standard of care. METHODS AND RESULTS The Pragmatic Urinary Sodium-based algoritHm in Acute Heart Failure (PUSH-AHF) trial randomized patients to natriuresis-guided diuretic therapy or standard of care. Serum creatinine and estimated glomerular filtration rate (eGFR) were assessed at fixed timepoints, and worsening renal function (WRF) was assessed at 72 h. The primary outcome was the interaction between randomized treatment allocation, baseline eGFR and the dual primary outcome of PUSH-AHF: total natriuresis at 24 h and time to all-cause mortality or HF rehospitalization at 180 days. In 309 patients, median baseline eGFR was 53 (35-73) ml/min/1.73 m2, and 58% had eGFR <60 ml/min/1.73 m2. Baseline eGFR did not significantly modify the treatment effect of natriuresis-guided diuretic therapy on natriuresis at 24 h (p for interaction = 0.730). However, baseline eGFR significantly modified the effect on all-cause mortality and HF rehospitalization (p for interaction = 0.017): the risk of this second primary outcome was lower in patients with lower eGFR who were randomized to the natriuresis-guided group. In the natriuresis-guided arm, eGFR decreased more (-11.0 vs. -6.91 ml/min/1.73 m2; p = 0.002) during the first 3 days, but this effect was attenuated at discharge (-10.3 vs. -8.69 ml/min/1.73 m2; p = 0.38). WRF was more frequently observed in patients randomized to natriuresis-guided treatment, but was not associated with worse clinical outcomes. CONCLUSIONS Natriuresis-guided diuretic treatment improved diuresis and natriuresis irrespective of baseline eGFR and occurrence of WRF, was effective even in patients with low eGFR, and the observed effect on eGFR was transient and not associated with worse clinical outcomes.
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Affiliation(s)
- Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Iris E Beldhuis
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jan A Krikken
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jenifer E Coster
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Wybe Nieuwland
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
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36
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Savarese G, Lindberg F, Cannata A, Chioncel O, Stolfo D, Musella F, Tomasoni D, Abdelhamid M, Banerjee D, Bayes-Genis A, Berthelot E, Braunschweig F, Coats AJS, Girerd N, Jankowska EA, Hill L, Lainscak M, Lopatin Y, Lund LH, Maggioni AP, Moura B, Rakisheva A, Ray R, Seferovic PM, Skouri H, Vitale C, Volterrani M, Metra M, Rosano GMC. How to tackle therapeutic inertia in heart failure with reduced ejection fraction. A scientific statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024; 26:1278-1297. [PMID: 38778738 DOI: 10.1002/ejhf.3295] [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] [Received: 02/29/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
Guideline-directed medical therapy (GDMT) in patients with heart failure and reduced ejection fraction (HFrEF) reduces morbidity and mortality, but its implementation is often poor in daily clinical practice. Barriers to implementation include clinical and organizational factors that might contribute to clinical inertia, i.e. avoidance/delay of recommended treatment initiation/optimization. The spectrum of strategies that might be applied to foster GDMT implementation is wide, and involves the organizational set-up of heart failure care pathways, tailored drug initiation/optimization strategies increasing the chance of successful implementation, digital tools/telehealth interventions, educational activities and strategies targeting patient/physician awareness, and use of quality registries. This scientific statement by the Heart Failure Association of the ESC provides an overview of the current state of GDMT implementation in HFrEF, clinical and organizational barriers to implementation, and aims at suggesting a comprehensive framework on how to overcome clinical inertia and ultimately improve implementation of GDMT in HFrEF based on up-to-date evidence.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Antonio Cannata
- School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', and University of Medicine Carol Davila, Bucharest, Romania
| | - Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | - Daniela Tomasoni
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Magdy Abdelhamid
- Faculty of Medicine, Kasr Al Ainy, Department of Cardiology, Cairo University, Cairo, Egypt
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, Cardiovascular and Genetics Research Institute, St George's University, London, UK
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias I Pujol, CIBERCV, Badalona, Spain
| | | | - Frieder Braunschweig
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | | | - Nicolas Girerd
- Centre d'Investigation Clinique Plurithémathique Pierre Drouin & Département de Cardiologie Institut Lorrain du Cœur et des Vaisseaux, Université de Lorraine, CHRU-Nancy, Vandœuvre-lès-Nancy, France
| | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University and Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Mitja Lainscak
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yury Lopatin
- Volgograd State Medical University, Regional Cardiology Centre, Volgograd, Russia
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Brenda Moura
- Armed Forces Hospital, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Amina Rakisheva
- City Cardiology Center, Konaev City Hospital, Almaty Region, Kazakhstan
| | - Robin Ray
- Department of Cardiology, St George's University Hospital, London, UK
| | - Petar M Seferovic
- University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Hadi Skouri
- Cardiology Division, Internal Medicine Department, Balamand University School of Medicine, Beirut, Lebanon
| | - Cristiana Vitale
- Department of Cardiology, St George's University Hospital, London, UK
| | - Maurizio Volterrani
- Department of Exercise Science and Medicine, San Raffaele Open University of Rome, Rome, Italy
- Cardiopulmonary Department, IRCCS San Raffaele Roma, Rome, Italy
| | - Marco Metra
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe M C Rosano
- Department of Cardiology, St George's University Hospital, London, UK
- Cardiology, San Raffaele Hospital, Cassino, Italy
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Beghini A, Sammartino AM, Papp Z, von Haehling S, Biegus J, Ponikowski P, Adamo M, Falco L, Lombardi CM, Pagnesi M, Savarese G, Metra M, Tomasoni D. 2024 update in heart failure. ESC Heart Fail 2024. [PMID: 38806171 DOI: 10.1002/ehf2.14857] [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: 03/20/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/30/2024] Open
Abstract
In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.
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Affiliation(s)
- Alberto Beghini
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Naples, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gianluigi Savarese
- Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
- Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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Dimopoulos S, Antonopoulos M. Portal vein pulsatility: An important sonographic tool assessment of systemic congestion for critical ill patients. World J Cardiol 2024; 16:221-225. [PMID: 38817642 PMCID: PMC11135329 DOI: 10.4330/wjc.v16.i5.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/19/2024] [Accepted: 04/01/2024] [Indexed: 05/23/2024] Open
Abstract
In this editorial we comment on the article by Kuwahara et al, published in the recent issue of the World Journal of Cardiology. In this interesting paper, the authors showed a correlation between portal vein pulsatility ratio, examined by bedside ultrasonography, and prognosis of hospitalized patients with acute heart failure. Systemic congestion is being notoriously underdetected in the acutely ill population with conventional methods like clinical examination, biomarkers, central venous pressure estimation and X-rays. However, congestion should be a key therapeutic target due to its deleterious effects to end organ function and subsequently patient prognosis. Doppler flow assessment of the abdominal veins is gaining popularity worldwide, as a valuable tool in estimating comprehensively congestion and giving a further insight into hemodynamics and patient management.
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Affiliation(s)
- Stavros Dimopoulos
- Cardiac Surgery ICU, Onassis Cardiac Surgery Center, Kallithea 17674, Greece.
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Miró Ò, Núñez J, Trullàs JC, Lopez-Ayala P, Llauger L, Alquézar-Arbé A, Miñana G, Mollar A, de la Espriella R, Lorenzo M, Jacob J, Espinosa B, Garcés-Horna V, Aguirre A, Fortuny MJ, Martínez-Nadal G, Gil V, Mueller C, Llorens P. Combining loop with thiazide diuretics in patients discharged home after a heart failure decompensation: Association with 30-day outcomes. Eur J Intern Med 2024:S0953-6205(24)00213-9. [PMID: 38763846 DOI: 10.1016/j.ejim.2024.05.009] [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: 01/05/2024] [Revised: 04/11/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE To investigate the association of the addition of thiazide diuretic on top of loop diuretic and standard of care with short-term outcomes of patients discharged after surviving an acute heart failure (AHF) episode. METHODS This is a secondary analysis of 14,403 patients from three independent cohorts representing the main departments involved in AHF treatment for whom treatment at discharge was recorded and included loop diuretics. Patients were divided according to whether treatment included or not thiazide diuretics. Short-term outcomes consisted of 30-day all-cause mortality, hospitalization (with a separate analysis for hospitalization due to AHF or to other causes) and the combination of death and hospitalization. The association between thiazide diuretics on short-term outcomes was explored by Cox regression and expressed as hazard ratios (HR) with 95 % confidence intervals, which were adjusted for 18 patient-related variables and 9 additional drugs (aside from loop and thiazide diuretics) prescribed at discharge. RESULTS The median age was 81 (interquartile range=73-86) years, 53 % were women, and patients were mainly discharged from the cardiology (42 %), internal medicine or geriatric department (29 %) and emergency department (19 %). There were 1,367 patients (9.5 %) discharged with thiazide and loop diuretics, while the rest (13,036; 90.5 %) were discharged with only loop diuretics on top of the remaining standard of care treatments. The combination of thiazide and loop diuretics showed a neutral effect on all outcomes: death (adjusted HR 1.149, 0.850-1.552), hospitalization (0.898, 0.770-1.048; hospitalization due to AHF 0.799, 0.599-1.065; hospitalization due to other causes 1.136, 0.756-1.708) and combined event (0.934, 0.811-1.076). CONCLUSION The combination of thiazide and loop diuretics was not associated with changes in risk of death, hospitalization or a combination of both.
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Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain; The GREAT network, Rome, Italy
| | - Julio Núñez
- Cardiology Department, Hospital Clínico de Valencia, INCLIVA, Valencia, Spain
| | - Joan Carles Trullàs
- Internal Medicine Department, Hospital d'Olot, Girona, Catalonia, Spain. Laboratori de Reparació i Regeneració Tissular (TR2Lab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Vic, Barcelona, Catalonia, Spain
| | - Pedro Lopez-Ayala
- The GREAT network, Rome, Italy; Cardiology Department, University Hospital of Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
| | - Lluís Llauger
- Emergency Department, Althaia Xarxa Assistencial Universitaria, Manresa, Catalonia, Spain
| | - Aitor Alquézar-Arbé
- Emergency Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico de Valencia, INCLIVA, Valencia, Spain
| | - Anna Mollar
- Cardiology Department, Hospital Clínico de Valencia, INCLIVA, Valencia, Spain
| | | | - Miguel Lorenzo
- Cardiology Department, Hospital Clínico de Valencia, INCLIVA, Valencia, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Begoña Espinosa
- Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain
| | - Vanesa Garcés-Horna
- Internal Medicine Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Alfons Aguirre
- Emergency Department, Hospital del Mar, Barcelona, Catalonia, Spain
| | | | - Gemma Martínez-Nadal
- Emergency Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
| | - Víctor Gil
- Emergency Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
| | - Christian Mueller
- The GREAT network, Rome, Italy; Cardiology Department, University Hospital of Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
| | - Pere Llorens
- Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain.
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Abbo AR, Gruber A, Volis I, Aronson D, Girerd N, Lund Kristensen S, Zukermann R, Alberkant N, Sitnitsky E, Kruger A, Khasis P, Bravo E, Elad B, Helmer Levin L, Caspi O. Diuresis Efficacy in Ambulatory Congested Heart Failure Patients: Intrapatient Comparison of 3 Diuretic Regimens (DEA-HF). JACC. HEART FAILURE 2024:S2213-1779(24)00334-2. [PMID: 38739124 DOI: 10.1016/j.jchf.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Limited evidence exists regarding efficacy and safety of diuretic regimens in ambulatory, congestion-refractory, chronic heart failure (CHF) patients. OBJECTIVES The authors sought to compare the potency and safety of commonly used diuretic regimens in CHF patients. METHODS A prospective, randomized, open-label, crossover study conducted in NYHA functional class II to IV CHF patients, treated in an ambulatory day-care unit. Each patient received 3 different diuretic regimens: intravenous (IV) furosemide 250 mg; IV furosemide 250 mg plus oral metolazone 5 mg; and IV furosemide 250 mg plus IV acetazolamide 500 mg. Treatments were administered once a week, in 1 of 6 randomized sequences. The primary endpoint was total sodium excretion, and the secondary was total urinary volume excreted, both measured for 6 hours post-treatment initiation. RESULTS A total of 42 patients were recruited. Administration of furosemide plus metolazone resulted in the highest weight of sodium excreted, 4,691 mg (95% CI: 4,153-5,229 mg) compared with furosemide alone, 3,835 mg (95% CI: 3,279-4,392 mg; P = 0.015) and to furosemide plus acetazolamide 3,584 mg (95% CI: 3,020-4,148 mg; P = 0.001). Furosemide plus metolazone resulted in 1.84 L of urine (95% CI: 1.63-2.05 L), compared with 1.58 L (95% CI: 1.37-1.8); P = 0.039 collected following administration of furosemide plus acetazolamide and 1.71 L (95% CI: 1.49-1.93 L) following furosemide alone. The incidence of worsening renal function was significantly higher when adding metolazone (39%) to furosemide compared with furosemide alone (16%) and to furosemide plus acetazolamide (2.6%) (P < 0.001). CONCLUSIONS In ambulatory CHF patients, furosemide plus metolazone resulted in a significantly higher natriuresis compared with IV furosemide alone or furosemide plus acetazolamide.
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Affiliation(s)
- Aharon Ronnie Abbo
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel
| | - Amit Gruber
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Ina Volis
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel
| | - Doron Aronson
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, CHRU Nancy, and INSERM U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Søren Lund Kristensen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Robert Zukermann
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel
| | - Natalia Alberkant
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel
| | - Elena Sitnitsky
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel
| | - Anton Kruger
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel
| | - Polina Khasis
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel
| | - Evgeny Bravo
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel
| | - Boaz Elad
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel
| | - Ludmila Helmer Levin
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel
| | - Oren Caspi
- Heart Failure Unit, Department of Cardiology and the Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Clinical Research Institute at Rambam (CRIR), Haifa, Israel.
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41
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Mullens W, Martens P. Contemporary Diuretic Therapies for Acute Heart Failure: Time for a Desalination-Guided Approach? J Card Fail 2024; 30:737-738. [PMID: 38447632 DOI: 10.1016/j.cardfail.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost-Limburg, Genk, Belgium and Hasselt University, Diepenbeek, Hasselt, Belgium.
| | - Pieter Martens
- Ziekenhuis Oost-Limburg, Genk, Belgium and Hasselt University, Diepenbeek, Hasselt, Belgium
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Mazón-Ruiz J, Romero-González G, Sánchez E, Banegas-Deras EJ, Salgado-Barquinero M, la Varga LGD, Bande-Fernández JJ, Gorostidi M, Alcázar R. Hypertonic saline and heart failure: "sodium-centric" or "chlorine-centric"? Nefrologia 2024; 44:338-343. [PMID: 38964947 DOI: 10.1016/j.nefroe.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/14/2023] [Accepted: 08/19/2023] [Indexed: 07/06/2024] Open
Abstract
Up to 50% of patients admitted for heart failure (HF) have congestion at discharge despite diagnostic and therapeutic advances. Both persistent congestion and diuretic resistance are associated with worse prognosis. The combination of hypertonic saline and loop diuretic has shown promising results in different studies. However, it has not yet achieved a standardized use, partly because of the great heterogeneity in the concentration of sodium chloride, the dose of diuretic or the amount of sodium in the diet. Classically, the movement of water from the intracellular space due to an increase in extracellular osmolarity has been postulated as the main mechanism involved. However, chloride deficit is postulated as the main up-regulator of plasma volume changes, and its correction may be the main mechanism involved. This "chloride centric" approach to heart failure opens the door to therapeutic strategies that would include diuretics to correct hypochloremia, as well as sodium free chloride supplementation.
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Affiliation(s)
- Jaime Mazón-Ruiz
- Servicio de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Spain.
| | - Gregorio Romero-González
- Servicio de Nefrología, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; International Renal Research Institute Vicenza, Italy
| | - Emilio Sánchez
- Servicio de Nefrología, Hospital Universitario de Cabueñes, Gijón, Spain
| | | | | | | | | | - Manuel Gorostidi
- Servicio de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Roberto Alcázar
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
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AlHabobi AAM, Almutairi AMS, Bohemid DASY, Sehgal AR. Nephrology: What You May Have Missed in 2023. Ann Intern Med 2024; 177:S47-S56. [PMID: 38621240 DOI: 10.7326/m24-0605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
This article highlights a selection of important nephrology studies published in 2023 that have relevance for nonnephrologist physicians. Four studies examined progression of chronic kidney disease or cardiovascular disease with respect to finerenone use, magnesium supplementation, iron markers, and COVID-19. Two studies examined treatments to improve specific aspects of chronic kidney disease management, including daprodustat to address anemia and patiromer to address hyperphosphatemia. One study showed that acetazolamide added to loop diuretics increased diuresis in acute decompensated heart failure across a wide range of renal function. Another study found that once-daily hydrochlorothiazide did not prevent kidney stone recurrence. Finally, an antibiotic stewardship intervention safely reduced antibiotic prescribing for suspected urinary tract infection in frail older adults.
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Affiliation(s)
- Ali A M AlHabobi
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada (A.A.M.A., A.M.S.A., D.A.S.Y.B.)
| | - Ashwaq M S Almutairi
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada (A.A.M.A., A.M.S.A., D.A.S.Y.B.)
| | - Danah A S Y Bohemid
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada (A.A.M.A., A.M.S.A., D.A.S.Y.B.)
| | - Ashwini R Sehgal
- Division of Nephrology, The MetroHealth System, Case Western Reserve University, Cleveland, Ohio (A.R.S.)
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Schuermans A, Verbrugge FH. Decongestion (instead of ultrafiltration?). Curr Opin Cardiol 2024; 39:188-195. [PMID: 38362936 DOI: 10.1097/hco.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE OF REVIEW To summarize the contemporary evidence on decongestion strategies in patients with acute heart failure (AHF). RECENT FINDINGS While loop diuretic therapy has remained the backbone of decongestive treatment in AHF, multiple randomized clinical trials suggest that early combination with other diuretic classes or molecules with diuretic properties should be considered. Mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors are disease-modifying drugs in heart failure that favourably influence prognosis early on, advocating their start as soon as possible in the absence of any compelling contraindications. Short-term upfront use of acetazolamide in adjunction to intravenous loop diuretic therapy relieves congestion faster, avoids diuretic resistance, and may shorten hospitalization length. Thiazide-like diuretics remain a good option to break diuretic resistance. Currently, ultrafiltration in AHF remains mainly reserved for patient with an inadequate response to pharmacological treatment. SUMMARY In most patients with AHF, decongestion can be achieved effectively and safely through combination diuretic therapies. Appropriate diuretic therapy may shorten hospitalization length and improve quality of life, but has not yet proven to reduce death or heart failure readmissions. Ultrafiltration currently has a limited role in AHF, mainly as bail-out strategy, but evidence for a more upfront use remains inconclusive.
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Affiliation(s)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
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Bismpos D, Wintrich J, Hövelmann J, Böhm M. Latest pharmaceutical approaches across the spectrum of heart failure. Heart Fail Rev 2024; 29:675-687. [PMID: 38349462 PMCID: PMC11035443 DOI: 10.1007/s10741-024-10389-8] [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] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
Despite major advances in prevention and medical therapy, heart failure (HF) remains associated with high morbidity and mortality, especially in older and frailer patients. Therefore, a complete, guideline-based treatment is essential, even in HF patients with conditions traditionally associated with a problematic initiation and escalation of the medical HF therapy, such as chronic kidney disease and arterial hypotension, as the potential adverse effects are overcome by the overall decrease of the absolute risk. Furthermore, since the latest data suggest that the benefit of a combined medical therapy (MRA, ARNI, SGLT2i, beta-blocker) may extend up to a LVEF of 65%, further trials on these subgroups of patients (HFmrEF, HFpEF) are needed to re-evaluate the guideline-directed medical therapy across the HF spectrum. In particular, the use of SGLT2i was recently extended to HFpEF patients, as evidenced by the DELIVER and EMPEROR-preserved trials. Moreover, the indication for other conservative treatments in HF patients, such as the intravenous iron supplementation, was accordingly strengthened in the latest guidelines. Finally, the possible implementation of newer substances, such as finerenone, in guideline-directed medical practice for HF is anticipated with great interest.
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Affiliation(s)
- Dimitrios Bismpos
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany.
- Department of Internal Medicine II, Cardiology and Angiology, Marien Hospital Herne, University Clinic of the Ruhr University, Bochum University, Herne, Germany.
| | - Jan Wintrich
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Julian Hövelmann
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
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Sheehan M, Sokoloff L, Reza N. Acute Heart Failure: From The Emergency Department to the Intensive Care Unit. Cardiol Clin 2024; 42:165-186. [PMID: 38631788 PMCID: PMC11064814 DOI: 10.1016/j.ccl.2024.02.005] [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] [Indexed: 04/19/2024]
Abstract
Acute heart failure (AHF) is a frequent cause of hospitalization around the world and is associated with high in-hospital and post-discharge morbidity and mortality. This review summarizes data on diagnosis and management of AHF from the emergency department to the intensive care unit. While more evidence is needed to guide risk stratification and care of patients with AHF, hospitalization is a key opportunity to optimize evidence-based medical therapy for heart failure. Close linkage to outpatient care is essential to improve post-hospitalization outcomes.
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Affiliation(s)
- Megan Sheehan
- Division of Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Maloney Building 5th Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Lara Sokoloff
- Division of Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Maloney Building 5th Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 11th Floor South Pavilion, Room 11-145, Philadelphia, PA 19104, USA.
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Kokorin VA, González-Franco A, Cittadini A, Kalejs O, Larina VN, Marra AM, Medrano FJ, Monhart Z, Morbidoni L, Pimenta J, Lesniak W. Acute heart failure - an EFIM guideline critical appraisal and adaptation for internists. Eur J Intern Med 2024; 123:4-14. [PMID: 38453571 DOI: 10.1016/j.ejim.2024.02.028] [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] [Received: 02/08/2024] [Accepted: 02/26/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Over the past two decades, several studies have been conducted that have tried to answer questions on management of patients with acute heart failure (AHF) in terms of diagnosis and treatment. Updated international clinical practice guidelines (CPGs) have endorsed the findings of these studies. The aim of this document was to adapt recommendations of existing guidelines to help internists make decisions about specific and complex scenarios related to AHF. METHODS The adaptation procedure was to identify firstly unresolved clinical problems in patients with AHF in accordance with the PICO (Population, Intervention, Comparison and Outcomes) process, then conduct a critical assessment of existing CPGs and choose recommendations that are most applicable to these specific scenarios. RESULTS Seven PICOs were identified and CPGs were assessed. There is no single test that can help clinicians in discriminating patients with acute dyspnoea, congestion or hypoxaemia. Performing of echocardiography and natriuretic peptide evaluation is recommended, and chest X-ray and lung ultrasound may be considered. Treatment strategies to manage arterial hypotension and low cardiac output include short-term continuous intravenous inotropic support, vasopressors, renal replacement therapy, and temporary mechanical circulatory support. The most updated recommendations on how to treat specific patients with AHF and certain comorbidities and for reducing post-discharge rehospitalization and mortality are provided. Overall, 51 recommendations were endorsed and the rationale for the selection is provided in the main text. CONCLUSION Through the use of appropriate tailoring process methodology, this document provides a simple and updated guide for internists dealing with AHF patients.
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Affiliation(s)
- Valentin A Kokorin
- Department of Hospital Therapy named after academician P.E. Lukomsky, Pirogov Russian National Research Medical University, Department of Hospital Therapy with courses in Endocrinology, Hematology and Clinical Laboratory Diagnostics, Peoples' Friendship University of Russia named after Patrice Lumumba, Moscow, Russia
| | - Alvaro González-Franco
- Internal Medicine Unit, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Antonio Cittadini
- Department of Translational Medical Sciences, "Federico II" University Hospital and school of medicine, Naples, Italy
| | - Oskars Kalejs
- Department of Internal Medicine, Riga Stradins University, Latvian Center of Cardiology, P. Stradins Clinical University hospital, Riga, Latvia
| | - Vera N Larina
- Department of Polyclinic Therapy, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Alberto M Marra
- Department of Translational Medical Sciences, "Federico II" University Hospital and school of medicine, Naples, Italy; Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Francisco J Medrano
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla), CIBERESP and Department of Medicine, Universidad de Sevilla, Seville, Spain.
| | - Zdenek Monhart
- Internal Medicine Department, Znojmo Hospital, Znojmo; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Laura Morbidoni
- Internal Medicine Unit "Principe di Piemonte" Hospital Senigallia (AN), Italy
| | - Joana Pimenta
- Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina da Universidade do Porto, Portugal
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Mocan D, Lala RI, Puschita M, Pilat L, Darabantiu DA, Pop-Moldovan A. The Congestion "Pandemic" in Acute Heart Failure Patients. Biomedicines 2024; 12:951. [PMID: 38790913 PMCID: PMC11117769 DOI: 10.3390/biomedicines12050951] [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: 03/01/2024] [Revised: 04/07/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
Congestion not only represents a cardinal sign of heart failure (HF) but is also now recognized as the primary cause of hospital admissions, rehospitalization, and mortality among patients with acute heart failure (AHF). Congestion can manifest through various HF phenotypes in acute settings: volume overload, volume redistribution, or both. Recognizing the congestion phenotype is paramount, as it implies different therapeutic strategies for decongestion. Among patients with AHF, achieving complete decongestion is challenging, as more than half still experience residual congestion at discharge. Residual congestion is one of the strongest predictors of future cardiovascular events and poor outcomes. Through this review, we try to provide a better understanding of the congestion phenomenon among patients with AHF by highlighting insights into the pathophysiological mechanisms behind congestion and new diagnostic and management tools to achieve and maintain efficient decongestion.
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Affiliation(s)
- Daniela Mocan
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | - Radu Ioan Lala
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
- Cardiology Department, Arad County Clinical Emergency Hospital, 310037 Arad, Romania
| | - Maria Puschita
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | - Luminita Pilat
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | | | - Adina Pop-Moldovan
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
- Cardiology Department, Arad County Clinical Emergency Hospital, 310037 Arad, Romania
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Cox ZL, Collins SP, Hernandez GA, McRae AT, Davidson BT, Adams K, Aaron M, Cunningham L, Jenkins CA, Lindsell CJ, Harrell FE, Kampe C, Miller KF, Stubblefield WB, Lindenfeld J. Efficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure. J Am Coll Cardiol 2024; 83:1295-1306. [PMID: 38569758 DOI: 10.1016/j.jacc.2024.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The primary goals during acute heart failure (AHF) hospitalization are decongestion and guideline-directed medical therapy (GDMT) optimization. Unlike diuretics or other GDMT, early dapagliflozin initiation could achieve both AHF goals. OBJECTIVES The authors aimed to assess the diuretic efficacy and safety of early dapagliflozin initiation in AHF. METHODS In a multicenter, open-label study, 240 patients were randomized within 24 hours of hospital presentation for hypervolemic AHF to dapagliflozin 10 mg once daily or structured usual care with protocolized diuretic titration until day 5 or hospital discharge. The primary outcome, diuretic efficiency expressed as cumulative weight change per cumulative loop diuretic dose, was compared across treatment assignment using a proportional odds model adjusted for baseline weight. Secondary and safety outcomes were adjudicated by a blinded committee. RESULTS For diuretic efficiency, there was no difference between dapagliflozin and usual care (OR: 0.65; 95% CI: 0.41-1.02; P = 0.06). Dapagliflozin was associated with reduced loop diuretic doses (560 mg [Q1-Q3: 260-1,150 mg] vs 800 mg [Q1-Q3: 380-1,715 mg]; P = 0.006) and fewer intravenous diuretic up-titrations (P ≤ 0.05) to achieve equivalent weight loss as usual care. Early dapagliflozin initiation did not increase diabetic, renal, or cardiovascular safety events. Dapagliflozin was associated with improved median 24-hour natriuresis (P = 0.03) and urine output (P = 0.005), expediting hospital discharge over the study period. CONCLUSIONS Early dapagliflozin during AHF hospitalization is safe and fulfills a component of GDMT optimization. Dapagliflozin was not associated with a statistically significant reduction in weight-based diuretic efficiency but was associated with evidence for enhanced diuresis among patients with AHF. (Efficacy and Safety of Dapagliflozin in Acute Heart Failure [DICTATE-AHF]; NCT04298229).
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee, USA; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, Tennessee, USA
| | - Gabriel A Hernandez
- Division of Cardiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - A Thomas McRae
- TriStar Centennial Medical Center, Nashville, Tennessee, USA
| | - Beth T Davidson
- TriStar Centennial Medical Center, Nashville, Tennessee, USA
| | - Kirkwood Adams
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Mark Aaron
- Department of Cardiac Sciences, Saint Thomas West Hospital, Nashville, Tennessee, USA
| | - Luke Cunningham
- Department of Cardiology, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christina Kampe
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Trullàs JC, Casado J, Cobo-Marcos M, Formiga F, Morales-Rull JL, Núñez J, Manzano L. Combinational Diuretics in Heart Failure. Curr Heart Fail Rep 2024:10.1007/s11897-024-00659-9. [PMID: 38589570 DOI: 10.1007/s11897-024-00659-9] [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: 03/20/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW Diuretics are the cornerstone therapy for acute heart failure (HF) and congestion. Patients chronically exposed to loop diuretics may develop diuretic resistance as a consequence of nephron remodelling, and the combination of diuretics will be necessary to improve diuretic response and achieve decongestion. This review integrates data from recent research and offers a practical approach to current pharmacologic therapies to manage congestion in HF with a focus on combinational therapy. RECENT FINDINGS Until recently, combined diuretic treatment was based on observational studies and expert opinion. Recent evidence from clinical trials has shown that combined diuretic treatment can be started earlier without escalating the doses of loop diuretics with an adequate safety profile. Diuretic combination is a promising strategy for overcoming diuretic resistance in HF. Further studies aiming to get more insights into the pathophysiology of diuretic resistance and large clinical trials confirming the safety and efficacy over standard diuretics regimens are warranted.
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Affiliation(s)
- Joan Carles Trullàs
- Internal Medicine Department, Hospital d'Olot I Comarcal de La Garrotxa, Avinguda Dels Països Catalans 86, 17800, Olot, Girona, Spain.
- Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IrisCC), Ctra. de Roda, 70 08500 Vic, Barcelona, Spain.
| | - Jesús Casado
- Internal Medicine Department, Hospital Universitario de Getafe, Carretera de Madrid - Toledo, Km 12,500, 28905, Madrid, Spain
| | - Marta Cobo-Marcos
- Cardiology Department, Hospital Universitario Puerta de Hierro Majadahonda (IDIPHISA), Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Francesc Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, Carrer de La Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - José Luís Morales-Rull
- Internal Medicine Department, Heart Failure Unit, Hospital Universitari Arnau de Villanova, Institut de Recerca Biomédica (IRBLleida), Avinguda Alcalde Rovira Roure, 80, 25198, Lleida, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Madrid, Spain
| | - Luís Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, M-607, 9, 100, 28034, Madrid, Spain
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