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Silva G, Moura B, Moreira E, Camila Dias C, Sousa Pinto B, Campelo M, Amorim S, Martins E, Pinto R, Maia Araújo P, Resende CX, Mena B, Grácio T, Teixeira A, Silva Cardoso J. Loop diuretic discontinuation in chronic heart failure patients: A retrospective study. Rev Port Cardiol 2024; 43:513-522. [PMID: 38906521 DOI: 10.1016/j.repc.2024.02.012] [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: 06/08/2023] [Revised: 10/03/2023] [Accepted: 02/07/2024] [Indexed: 06/23/2024] Open
Abstract
INTRODUCTION AND OBJECTIVES The use of loop diuretics is central in managing congestion in heart failure (HF), but their impact on prognosis remains unclear. In euvolemic patients, dose reduction is recommended, but there is no recommendation on their discontinuation. This study aims to assess the impact of loop diuretic discontinuation on the prognosis of outpatients with HF with reduced ejection fraction. METHODS This retrospective cohort study collected data from medical records of patients followed in an outpatient HF clinic at a university hospital center. Patients were included if they had been on loop diuretics and these were discontinued. Demographic, clinical and laboratory data were collected, and number and type of congestive events during the one-year period after discontinuation were recorded. RESULTS Among 265 patients on loop diuretics, almost half (129) discontinued them at some point. Patients had optimized medical therapy, low median age, low New York Heart Association class, low B-type natriuretic peptide values, normal blood pressure, controlled heart rate and kidney function within normal limits. Among 122 patients with one year of follow-up, 18 (14.8%) had a congestive event. Fifteen events (83.3%) were low-dose diuretic reinitiation at a scheduled visit. There were only three worsening heart failure events (2.5%) during the one-year period. A significant improvement in kidney function from discontinuation to the one-year follow-up appointment was also observed. CONCLUSIONS In our cohort, loop diuretic discontinuation was possible and safe in a large proportion of patients. The results should be interpreted with caution and cannot be extrapolated to a broader population of HF patients.
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Affiliation(s)
- Gonçalo Silva
- Faculty of Medicine, University of Porto, Portugal; CINTESIS@RISE, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal.
| | - Brenda Moura
- Faculty of Medicine, University of Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal; Department of Cardiology, Hospital das Forças Armadas, Polo do Porto, Porto, Portugal; Hospital Lusíadas Porto, Porto, Portugal
| | - Emília Moreira
- Faculty of Medicine, University of Porto, Portugal; CINTESIS@RISE, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Hospital Lusíadas Porto, Porto, Portugal; Escola Superior de Educação de Coimbra, Coimbra, Portugal
| | - Cláudia Camila Dias
- Faculty of Medicine, University of Porto, Portugal; CINTESIS@RISE, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Knowledge Management Unit and Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - Bernardo Sousa Pinto
- Faculty of Medicine, University of Porto, Portugal; Knowledge Management Unit and Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Manuel Campelo
- Faculty of Medicine, University of Porto, Portugal; CINTESIS@RISE, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Sandra Amorim
- Faculty of Medicine, University of Porto, Portugal; Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Elisabete Martins
- Faculty of Medicine, University of Porto, Portugal; CINTESIS@RISE, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal; European Reference Network GUARD-Heart
| | - Roberto Pinto
- Faculty of Medicine, University of Porto, Portugal; Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Paulo Maia Araújo
- Faculty of Medicine, University of Porto, Portugal; CINTESIS@RISE, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Carlos Xavier Resende
- Faculty of Medicine, University of Porto, Portugal; CINTESIS@RISE, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Beatriz Mena
- Faculty of Medicine, University of Porto, Portugal; CINTESIS@RISE, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - Tiago Grácio
- Faculty of Medicine, University of Porto, Portugal; CINTESIS@RISE, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | | | - José Silva Cardoso
- Faculty of Medicine, University of Porto, Portugal; CINTESIS@RISE, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Escola Superior de Educação de Coimbra, Coimbra, Portugal; Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
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2
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Xanthopoulos A, Christofidis C, Pantsios C, Magouliotis D, Bourazana A, Leventis I, Skopeliti N, Skoularigki E, Briasoulis A, Giamouzis G, Triposkiadis F, Skoularigis J. The Prognostic Role of Spot Urinary Sodium and Chloride in a Cohort of Hospitalized Advanced Heart Failure Patients: A Pilot Study. Life (Basel) 2023; 13:698. [PMID: 36983853 PMCID: PMC10054455 DOI: 10.3390/life13030698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023] Open
Abstract
Recent studies have demonstrated the prognostic value of spot urinary sodium (UNa+) in acutely decompensated chronic HF (ADCHF) patients. However, data on the prognostic role of UNa+ and spot urinary chloride (UCl-) in patients with advanced HF are limited. In the present prospective pilot study, we examined the predictive value of UNa+ and UCl- concentration at baseline, at 2 h and at 24 h after admission for all-cause mortality and HF rehospitalization up to 3 months post-discharge. Consecutive advanced HF patients (n = 30) admitted with ADCHF and aged > 18 years were included in the study. Loop diuretics were administered based on the natriuresis-guided algorithm recommended by the recent HF guidelines. Exclusion criteria were cardiogenic shock, acute coronary syndrome, estimated glomerular filtration rate < 15 mL/min/1.73 m2, severe hepatic dysfunction (Child-Pugh category C), and sepsis. UNa+ at baseline (Area Under the Curve (AUC) = 0.75, 95% Confidence Interval (CI) (0.58-0.93), p = 0.019) and at 2 h after admission (AUC = 0.80, 95% CI: 0.64-0.96, p = 0.005) showed good and excellent discrimination, respectively. UCl- at 2 h after admission (AUC = 0.75, 95%CI (0.57-0.93), p = 0.017) demonstrated good discrimination. In the multivariate logistic regression analysis, UNa+ at 2 h (p = 0.02) and dose of loop diuretics at admission (p = 0.03) were the only factors independently associated with the study outcome. In conclusion, UNa+ and UCl- may have a prognostic role in hospitalized advanced HF patients.
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Affiliation(s)
- Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41100 Larissa, Greece
| | | | - Chris Pantsios
- Department of Cardiology, University Hospital of Larissa, 41100 Larissa, Greece
| | - Dimitrios Magouliotis
- Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative, Ann Arbor, MI 48105, USA
| | - Angeliki Bourazana
- Department of Cardiology, University Hospital of Larissa, 41100 Larissa, Greece
| | - Ioannis Leventis
- Department of Cardiology, University Hospital of Larissa, 41100 Larissa, Greece
| | - Niki Skopeliti
- Department of Cardiology, University Hospital of Larissa, 41100 Larissa, Greece
| | | | - Alexandros Briasoulis
- Department of Therapeutics, Faculty of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Grigorios Giamouzis
- Department of Cardiology, University Hospital of Larissa, 41100 Larissa, Greece
| | | | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41100 Larissa, Greece
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3
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Kapelios CJ, Canepa M, Savarese G, Lund LH. Use of loop diuretics in chronic heart failure: do we adhere to the Hippocratian principle 'do no harm'? Eur J Heart Fail 2021; 23:1068-1075. [PMID: 33963796 DOI: 10.1002/ejhf.2214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/22/2021] [Accepted: 05/06/2021] [Indexed: 12/28/2022] Open
Affiliation(s)
| | - Marco Canepa
- Cardiology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Gianluigi Savarese
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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4
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Verbrugge FH, Martens P, Testani JM, Tang WHW, Kuypers D, Bammens B. Measures of Loop Diuretic Efficiency and Prognosis in Chronic Kidney Disease. Cardiorenal Med 2020; 10:402-414. [PMID: 33120398 DOI: 10.1159/000509741] [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: 05/03/2020] [Accepted: 06/23/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The evolution and prognostic impact of loop diuretic efficiency according to chronic kidney disease (CKD) severity is unclear. METHODS This retrospective cohort study includes 783 CKD patients on oral loop diuretic therapy with a 24-h urine collection available. Acute kidney injury and history of renal replacement therapy were exclusion criteria. Patients were stratified according to Kidney Disease Improving Global Outcomes (KDIGO) glomerular filtration rate class. Loop diuretic efficiency was calculated as urine output, natriuresis, and chloruresis, each adjusted for loop diuretic dose, and compared among strata. Risk for onset of dialysis and all-cause mortality was evaluated. RESULTS Loop diuretic efficiency metrics decreased from KDIGO class IIIB to IV in furosemide users and from KDIGO class IV to V with all loop diuretics (p value <0.05 for all comparisons). The correlation between loop diuretic efficiency and creatinine clearance was moderate at best (Spearman's ρ 0.298-0.436; p value <0.001 for all correlations). During median follow-up of 45 months, 457 patients died (58%) and 63 received kidney transplantation (8%), while dialysis was started before in 328 (42%). All loop diuretic efficiency metrics were significantly and independently associated with both the risk for dialysis and all-cause mortality. In KDIGO class IV/V patients, low loop diuretic efficiency (i.e., urine output adjusted for loop diuretic dose ≤1,000 mL) shortened median time to dialysis with 24 months and median time to all-cause mortality with 23 months. CONCLUSION Low loop diuretic efficiency is independently associated with a shorter time to dialysis initiation and a higher risk for all-cause mortality in CKD.
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Affiliation(s)
- Frederik Hendrik Verbrugge
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium, .,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium,
| | - Pieter Martens
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Jeffrey M Testani
- Department of Cardiovascular Medicine, Yale Medical Center, New Haven, Connecticut, USA
| | - W H Wilson Tang
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dirk Kuypers
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.,Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Bert Bammens
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.,Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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5
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Jolobe OMP. Fundamental issues in the diuretic lounge strategy. QJM 2020; 113:697. [PMID: 32353119 DOI: 10.1093/qjmed/hcaa150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- O M P Jolobe
- Division of Medical, Manchester Medical Society, Simon Building Brunswick Street, Manchester M13 9PL, UK
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6
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Ioannou A, Missouris CG. Response to: Fundamental issues in the diuretic lounge strategy. QJM 2020; 113:698. [PMID: 32353122 DOI: 10.1093/qjmed/hcaa151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Ioannou
- Department of Cardiology, Royal Free Hospital, Royal Free NHS Foundation Trust, Pond Street, Hampstead, London NW3 2QG, UK
| | - C G Missouris
- Department of Cardiology, Wrexham Park Hospital, Frimley Health NHS Foundation Trust, Wexham Street, Slough, Berkshire SL2 4HL, UK
- Medical School, University of Cyprus, Kallipoleos, Nicosia 1678, Cyprus
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7
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Cautela J, Tartiere J, Cohen-Solal A, Bellemain‐Appaix A, Theron A, Tibi T, Januzzi JL, Roubille F, Girerd N. Management of low blood pressure in ambulatory heart failure with reduced ejection fraction patients. Eur J Heart Fail 2020; 22:1357-1365. [PMID: 32353213 PMCID: PMC7540603 DOI: 10.1002/ejhf.1835] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 12/11/2022] Open
Abstract
Low blood pressure is common in patients with heart failure and reduced ejection fraction (HFrEF). While spontaneous hypotension predicts risk in HFrEF, there is only limited evidence regarding the relationship between hypotension observed during heart failure (HF) drug titration and outcome. Nevertheless, hypotension (especially orthostatic hypotension) is an important factor limiting the titration of HFrEF treatments in routine practice. In patients with signs of shock and/or severe congestion, hospitalization is advised. However, in the very frequent cases of non-severe and asymptomatic hypotension observed while taking drugs with a class I indication in HFrEF, European and US guidelines recommend maintaining the same drug dosage. In instances of symptomatic or severe persistent hypotension (systolic blood pressure < 90 mmHg), it is recommended to first decrease blood pressure reducing drugs not indicated in HFrEF as well as the loop diuretic dose in the absence of associated signs of congestion. Unless the management of hypotension appears urgent, a HF specialist should then be sought rather than stopping or decreasing drugs with a class I indication in HFrEF. If symptoms or severe hypotension persist, no recommendations exist. Our HF group reviewed available evidence and proposes certain steps to follow in such situations in order to improve the pharmacological management of these patients.
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Affiliation(s)
- Jennifer Cautela
- Heart Failure and Valvular Heart Diseases Unit, Department of CardiologyMediterranean University Cardio‐Oncology Center (MEDI‐CO Center), Hôpital Nord, Aix‐Marseille I UniversityMarseilleFrance
| | | | - Alain Cohen-Solal
- CUMR‐S 942 MASCOTParis University, Cardiology Department, Hôpital Lariboisière, Assistance Publique Hôpitaux de ParisParisFrance
| | | | - Alexis Theron
- Cardio‐Thoracic Surgery DepartmentHôpital de la TimoneMarseilleFrance
| | - Thierry Tibi
- Cardiology DepartmentCentre Hospitalier de CannesCannesFrance
| | - James L. Januzzi
- Cardiology DivisionMassachusetts General Hospital, Baim Institute for Clinical Research, Harvard Medical SchoolBostonMAUSA
| | - François Roubille
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, CHU de MontpellierFrance
| | - Nicolas Girerd
- Faculté de MédecineUniversité de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre les Nancy France Groupe choc, INSERM U1116Vandoeuvre les NancyFrance
- F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists)NancyFrance
- Cardiology DepartmentInstitut Lorrain du Cœur et des Vaisseaux, CHRU NancyNancyFrance
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8
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Kapelios CJ, Laroche C, Crespo-Leiro MG, Anker SD, Coats AJS, Díaz-Molina B, Filippatos G, Lainscak M, Maggioni AP, McDonagh T, Mebazaa A, Metra M, Moura B, Mullens W, Piepoli MF, Rosano GMC, Ruschitzka F, Seferovic PM, Lund LH. Association between loop diuretic dose changes and outcomes in chronic heart failure: observations from the ESC-EORP Heart Failure Long-Term Registry. Eur J Heart Fail 2020; 22:1424-1437. [PMID: 32237110 DOI: 10.1002/ejhf.1796] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/29/2020] [Accepted: 03/02/2020] [Indexed: 02/05/2023] Open
Abstract
AIMS Guidelines recommend down-titration of loop diuretics (LD) once euvolaemia is achieved. In outpatients with heart failure (HF), we investigated LD dose changes in daily cardiology practice, agreement with guideline recommendations, predictors of successful LD down-titration and association between dose changes and outcomes. METHODS AND RESULTS We included 8130 HF patients from the ESC-EORP Heart Failure Long-Term Registry. Among patients who had dose decreased, successful decrease was defined as the decrease not followed by death, HF hospitalization, New York Heart Association class deterioration, or subsequent increase in LD dose. Mean age was 66 ± 13 years, 71% men, 62% HF with reduced ejection fraction, 19% HF with mid-range ejection fraction, 19% HF with preserved ejection fraction. Median [interquartile range (IQR)] LD dose was 40 (25-80) mg. LD dose was increased in 16%, decreased in 8.3% and unchanged in 76%. Median (IQR) follow-up was 372 (363-419) days. Diuretic dose increase (vs. no change) was associated with HF death [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.12-2.08; P = 0.008] and nominally with cardiovascular death (HR 1.25, 95% CI 0.96-1.63; P = 0.103). Decrease of diuretic dose (vs. no change) was associated with nominally lower HF (HR 0.59, 95% CI 0.33-1.07; P = 0.083) and cardiovascular mortality (HR 0.62, 95% CI 0.38-1.00; P = 0.052). Among patients who had LD dose decreased, systolic blood pressure [odds ratio (OR) 1.11 per 10 mmHg increase, 95% CI 1.01-1.22; P = 0.032], and absence of (i) sleep apnoea (OR 0.24, 95% CI 0.09-0.69; P = 0.008), (ii) peripheral congestion (OR 0.48, 95% CI 0.29-0.80; P = 0.005), and (iii) moderate/severe mitral regurgitation (OR 0.57, 95% CI 0.37-0.87; P = 0.008) were independently associated with successful decrease. CONCLUSION Diuretic dose was unchanged in 76% and decreased in 8.3% of outpatients with chronic HF. LD dose increase was associated with worse outcomes, while the LD dose decrease group showed a trend for better outcomes compared with the no-change group. Higher systolic blood pressure, and absence of (i) sleep apnoea, (ii) peripheral congestion, and (iii) moderate/severe mitral regurgitation were independently associated with successful dose decrease.
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Affiliation(s)
- Chris J Kapelios
- Department of Cardiology, Laiko General Hospital, Athens, Greece
| | - Cécile Laroche
- EURObservational Research Programme, European Society of Cardiology, Sophia-Antipolis, France
| | - Maria G Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Complexo Hospitalario Universitario A Coruna, CHUAC, INIBIC, UDC, CIBERCV, La Coruna, Spain
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) Partner Site Berlin; Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Beatria Díaz-Molina
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Gerasimos Filippatos
- Department of Cardiology, School of Medicine, University of Cyprus & Heart Failure Unit, University Hospital Attikon, National and Kapodistrian Univeristy of Athens, Athens, Greece
| | - Mitja Lainscak
- Division of Cardiology, Murska Sobota, Murska Sobota and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Aldo P Maggioni
- EURObservational Research Programme, European Society of Cardiology, Sophia-Antipolis, France
- ANMCO Research Center, Florence, Italy
| | | | - Alexandre Mebazaa
- Department of Anesthesia-Burn-Critical Care, UMR 942 Inserm - MASCOT, University of Paris; APHP Saint Louis Lariboisière University Hospitals, Paris, France
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Brenda Moura
- Department of Cardiology, Hospital Militar, Porto, Cintesis- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Massimo F Piepoli
- Heart Failure Unit, Cardiac Department, G. da Saliceto Hospital, AUSL, Piacenza, Italy
| | | | | | | | - Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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9
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Abstract
PURPOSE OF REVIEW To provide insight into the role of urine biomarkers and electrolytes for the management of heart failure. RECENT FINDINGS The age-dependent decrease in glomerular filtration rate due to loss of functional nephrons occurs at a faster pace in heart failure, potentially exacerbated by episodes of acute kidney injury. Urine biomarkers have not convincingly demonstrated to improve detection of irreversible renal damage and predict long-term renal trajectories, compared with serial creatinine measurements. Recent data show that natriuresis and diuretic response track poorly with glomerular filtration, but strongly with prognosis. Urine sodium concentration > 50-70 mmol/L was recently put forward through expert consensus as an adequate diuretic response. The value of urine biomarkers to detect structural renal damage in heart failure remains unsure and the latter is probably uncommon, especially over short-term follow-up. Urine electrolytes on the other hand predict diuretic response accurately and may allow better diuretic titration.
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10
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Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, Testani JM, Tang WHW, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic PM, Ruschitzka F, Coats AJ. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019; 21:137-155. [PMID: 30600580 DOI: 10.1002/ejhf.1369] [Citation(s) in RCA: 578] [Impact Index Per Article: 115.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/14/2018] [Accepted: 10/27/2018] [Indexed: 12/11/2022] Open
Abstract
The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of diuretic therapy. The appropriate use of diuretics however remains challenging, especially when worsening renal function, diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic diuretic strategies, based upon diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Alexandre Mebazaa
- University of Paris Diderot, Hôpitaux Universitaires Saint Louis Lariboisière, APHP, U 942 Inserm, F-CRIN INI-CRCT, Paris, France
| | | | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | | | | | | | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d'Investigations Clinique 1433 and Inserm U1116; CHRU Nancy; F-CRIN INI-CRCT, Nancy, France
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, Athens, Greece.,University of Cyprus, Nicosia, Cyprus
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11
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Martens P, Mullens W. Spot Urinary Sodium in Decompensated Heart Failure as a Prognostic Metric for Successful Ambulatory Decongestion. J Card Fail 2018; 24:355-356. [PMID: 29678728 DOI: 10.1016/j.cardfail.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 04/10/2018] [Accepted: 04/10/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
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