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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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2
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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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3
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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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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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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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6
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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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7
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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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8
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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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9
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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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10
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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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11
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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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12
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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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13
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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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14
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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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15
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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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16
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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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17
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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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18
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Tamargo J, Agewall S, Borghi C, Ceconi C, Cerbai E, Dan GA, Ferdinandy P, Grove EL, Rocca B, Magavern E, Sulzgruber P, Semb AG, Sossalla S, Niessner A, Kaski JC, Dobrev D. New pharmacological agents and novel cardiovascular pharmacotherapy strategies in 2023. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:219-244. [PMID: 38379024 PMCID: PMC11121198 DOI: 10.1093/ehjcvp/pvae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/01/2024] [Accepted: 02/19/2024] [Indexed: 02/22/2024]
Abstract
Although cardiovascular diseases (CVDs) are the leading cause of death worldwide, their pharmacotherapy remains suboptimal. Thus, there is a clear unmet need to develop more effective and safer pharmacological strategies. In this review, we summarize the most relevant advances in cardiovascular pharmacology in 2023, including the approval of first-in-class drugs that open new avenues for the treatment of atherosclerotic CVD and heart failure (HF). The new indications of drugs already marketed (repurposing) for the treatment of obstructive hypertrophic cardiomyopathy, hypercholesterolaemia, type 2 diabetes, obesity, and HF; the impact of polypharmacy on guideline-directed drug use is highlighted as well as results from negative clinical trials. Finally, we end with a summary of the most important phase 2 and 3 clinical trials assessing the efficacy and safety of cardiovascular drugs under development for the prevention and treatment of CVDs.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, 28040 Madrid, Spain
| | - Stefan Agewall
- Institute of Clinical Science, Oslo University, 0318 Oslo, Norway
- Institute of Clinical Sciences, Karolinska Institute, Danderyd Hospital, 171 77 Stockholm, Sweden
| | - Claudio Borghi
- Department of Cardiovascular Medicine, University of Bologna-IRCCS AOU S. Orsola, 40138 Bologna, Italy
| | | | - Elisabetta Cerbai
- Department Neurofarba, Section of Pharmacology and Toxicology, University of Florence, 50139 Florence, Italy
| | - Gheorghe A Dan
- Carol Davila. University of Medicine, Colentina University Hospital, 0221 Bucharest, Romania
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, H-1089, Hungary
- Pharmahungary Group, Budapest, H-1031, Hungary
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, 8200 Aarhus N, Denmark
| | - Bianca Rocca
- Department Neurofarba, Section of Pharmacology and Toxicology, University of Florence, 50139 Florence, Italy
- Section of Pharmacology, Department of Safety and Bioethics, Catholic University School of Medicine, 00168 Roma, Italy
| | - Emma Magavern
- William Harvey Research Institute, Centre of Clinical Pharmacology and Precision Medicine, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Patrick Sulzgruber
- Department of Medicine, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Anne Grete Semb
- Preventive Cario-Rheuma clinic, Division of Research and Innovation, REMEDY centre, Diakonhjemmet Hospital, 0370 Oslo, Norway
| | - Samuel Sossalla
- Cardiology and Angiology, Justus-Liebig-University, D-35392 Giessen, Germany
- Department of Cardiology, Kerckhoff-Clinic/DZHK, D-61234 Bad Nauheim, Germany
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's, University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Dobromir Dobrev
- Institute of Pharmacology, West-German Heart and Vascular Centre, University Duisburg-Essen, DE-45122 Essen, Germany
- Department of Medicine, Montreal Heart Institute and Université de Montréal, H1Y 3N1 Montréal, Canada
- Department of Integrative Physiology, Baylor College of Medicine, 77030 Houston, TX, USA
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19
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Kazory A. Contemporary Decongestive Strategies in Acute Heart Failure. Semin Nephrol 2024:151512. [PMID: 38702211 DOI: 10.1016/j.semnephrol.2024.151512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024]
Abstract
Congestion is the primary driver of hospital admissions in patients with heart failure and the key determinant of their outcome. Although intravenous loop diuretics remain the predominant agents used in the setting of acute heart failure, the therapeutic response is known to be variable, with a significant subset of patients discharged from the hospital with residual hypervolemia. In this context, urinary sodium excretion has gained attention both as a marker of response to loop diuretics and as a marker of prognosis that may be a useful clinical tool to guide therapy. Several decongestive strategies have been explored to improve diuretic responsiveness and removal of excess fluid. Sequential nephron blockade through combination diuretic therapy is one of the most used methods to enhance natriuresis and counter diuretic resistance. In this article, I provide an overview of the contemporary decongestive approaches and discuss the clinical data on the use of add-on diuretic therapy. I also discuss mechanical removal of excess fluid through extracorporeal ultrafiltration with a brief review of the results of landmark studies. Finally, I provide a short overview of the strategies that are currently under investigation and may prove helpful in this setting.
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Affiliation(s)
- Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, College of Medicine, University of Florida, Gainesville, FL.
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20
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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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21
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Rao VS, Ivey-Miranda JB, Cox ZL, Moreno-Villagomez J, Ramos-Mastache D, Neville D, Balkcom N, Asher JL, Bellumkonda L, Bigvava T, Shaburishvili T, Bartunek J, Wilson FP, Finkelstein F, Maulion C, Turner JM, Testani JM. Serial direct sodium removal in patients with heart failure and diuretic resistance. Eur J Heart Fail 2024; 26:1215-1230. [PMID: 38556717 DOI: 10.1002/ejhf.3196] [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: 01/02/2024] [Revised: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 04/02/2024] Open
Abstract
AIMS Loop diuretics may exacerbate cardiorenal syndrome (CRS) in heart failure (HF). Direct sodium removal (DSR) using the peritoneal membrane, in conjunction with complete diuretic withdrawal, may improve CRS and diuretic resistance. METHODS AND RESULTS Patients with HF requiring high-dose loop diuretics were enrolled in two prospective, single-arm studies: RED DESERT (n = 8 euvolaemic patients), and SAHARA (n = 10 hypervolaemic patients). Loop diuretics were withdrawn, and serial DSR was utilized to achieve and maintain euvolaemia. At baseline, participants required a median 240 mg (interquartile range [IQR] 200-400) oral furosemide equivalents/day, which was withdrawn in all participants during DSR (median time of DSR 4 weeks [IQR 4-6]). Diuretic response (queried by formal 40 mg intravenous furosemide challenge and 6 h urine sodium quantification) increased substantially from baseline (81 ± 37 mmol) to end of DSR (223 ± 71 mmol, p < 0.001). Median time to re-initiate diuretics was 87 days, and the median re-initiation dose was 8% (IQR 6-10%) of baseline. At 1 year, diuretic dose remained substantially below baseline (30 [IQR 7.5-40] mg furosemide equivalents/day). Multiple dimensions of kidney function such as filtration, uraemic toxin excretion, kidney injury, and electrolyte handling improved (p < 0.05 for all). HF-related biomarkers including N-terminal pro-B-type natriuretic peptide, carbohydrate antigen-125, soluble ST2, interleukin-6, and growth differentiation factor-15 (p < 0.003 for all) also improved. CONCLUSIONS In patients with HF and diuretic resistance, serial DSR therapy with loop diuretic withdrawal was feasible and associated with substantial and persistent improvement in diuretic resistance and several cardiorenal parameters. If replicated in randomized controlled studies, DSR may represent a novel therapy for diuretic resistance and CRS. CLINICAL TRIAL REGISTRATION RED DESERT (NCT04116034), SAHARA (NCT04882358).
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Affiliation(s)
- Veena S Rao
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Juan B Ivey-Miranda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, USA
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Julieta Moreno-Villagomez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Daniela Ramos-Mastache
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Daniel Neville
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Natasha Balkcom
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer L Asher
- Division of Comparative Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | | | | | - F Perry Wilson
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT, USA
| | - Fredrick Finkelstein
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher Maulion
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jeffrey M Turner
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jeffrey M Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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22
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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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23
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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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24
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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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25
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Hiraiwa H, Okumura T, Murohara T. Drug Therapy for Acute and Chronic Heart Failure with Preserved Ejection Fraction with Hypertension: A State-of-the-Art Review. Am J Cardiovasc Drugs 2024; 24:343-369. [PMID: 38575813 PMCID: PMC11093799 DOI: 10.1007/s40256-024-00641-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/06/2024]
Abstract
In this comprehensive state-of-the-art review, we provide an evidence-based analysis of current drug therapies for patients with heart failure with preserved ejection fraction (HFpEF) in the acute and chronic phases with concurrent hypertension. Additionally, we explore the latest developments and emerging evidence on the efficacy, safety, and clinical outcomes of common and novel drug treatments in the management of HFpEF with concurrent hypertension. During the acute phase of HFpEF, intravenous diuretics, mineralocorticoid receptor antagonists (MRAs), and vasodilators are pivotal, while in the chronic phase, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have proven effective in enhancing clinical outcomes. However, the use of calcium channel blockers in HFpEF with hypertension should be approached with caution, owing to their potential negative inotropic effects. We also explored emerging drug therapies for HFpEF, such as sodium-glucose co-transporter 2 (SGLT2) inhibitors, angiotensin receptor-neprilysin inhibitor (ARNI), soluble guanylate cyclase (sGC) stimulators, novel MRAs, and ivabradine. Notably, SGLT2 inhibitors have shown promise in reducing heart failure hospitalizations and cardiovascular mortality in patients with HFpEF, regardless of their diabetic status. Additionally, ARNI and sGC stimulators have demonstrated potential in improving symptoms, functional capacity, and quality of life. Nonetheless, additional research is necessary to pinpoint optimal treatment strategies for HFpEF with concurrent hypertension. Furthermore, long-term studies are essential to assess the durability and sustained benefits of emerging drug therapies. Identification of novel targets and mechanisms underlying HFpEF pathophysiology will pave the way for innovative drug development approaches in the management of HFpEF with concurrent hypertension.
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Affiliation(s)
- Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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26
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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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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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Van den Eynde J, Verbrugge FH. Renal Sodium Avidity in Heart Failure. Cardiorenal Med 2024; 14:270-280. [PMID: 38565080 DOI: 10.1159/000538601] [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: 01/28/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Increased renal sodium avidity is a hallmark feature of the heart failure syndrome. SUMMARY Increased renal sodium avidity refers to the inability of the kidneys to elicit potent natriuresis in response to sodium loading. This eventually causes congestion, which is a major contributor to hospital admissions and mortality in heart failure. KEY MESSAGES Important novel concepts such as the renal tamponade hypothesis, accelerated nephron loss, and the role of hypochloremia, the sympathetic nervous system, inflammation, the lymphatic system, and interstitial sodium buffers are involved in the pathophysiology of renal sodium avidity. A good understanding of these concepts is crucially important with respect to treatment recommendations regarding dietary sodium restriction, fluid restriction, rapid up-titration of guideline-directed medical therapies, combination diuretic therapy, natriuresis-guided diuretic therapy, use of hypertonic saline, and ultrafiltration.
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Affiliation(s)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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Comments on the 2023 update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:281-284. [PMID: 38048844 DOI: 10.1016/j.rec.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 12/06/2023]
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Tomasoni D, Cannatà A, Adamo M, Metra M. 2023 focused update of the 2021 ESC heart failure guidelines: Key messages for clinical practice. Eur J Clin Invest 2024; 54:e14163. [PMID: 38235824 DOI: 10.1111/eci.14163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/01/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Cannatà
- King's College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, UK
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Umeh CA, Mohta T, Kaur G, Truong R, Darji P, Vue C, Cherukuri VB, Eghreriniovo B, Gupta R. Acetazolamide and Hydrochlorothiazide in Patients With Acute Decompensated Heart Failure: Insights From Recent Trials. Cardiol Res 2024; 15:69-74. [PMID: 38645830 PMCID: PMC11027779 DOI: 10.14740/cr1627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/05/2024] [Indexed: 04/23/2024] Open
Abstract
Acetazolamide and thiazide diuretics have been combined with loop diuretics to overcome diuretic resistance in heart failure patients. However, recent studies have assessed the upfront combination of acetazolamide and hydrochlorothiazide with loop diuretics in hospitalized patients with acute decompensated heart failure without loop diuretic resistance. We reviewed two recent randomized controlled trials on the upfront use of acetazolamide and thiazide diuretics in acute decompensated heart failure, respectively. When the two trials on acetazolamide are considered together, adding oral or intravenous acetazolamide to loop diuretics in decompensated heart failure patients resulted in increased diuresis and natriuresis. However, the effects were significantly higher in patients with serum bicarbonate ≥ 27 mmol/L and those with higher baseline glomerular filtration rate (GFR). Similarly, when the two trials on thiazide diuretics are considered together, adding hydrochlorothiazide to loop diuretics in decompensated heart failure patients resulted in increased diuresis and weight loss. However, it increases the risk of impaired renal function. When all the trials are considered together, the upfront use of acetazolamide may be helpful in carefully selected patients, including patients with underlying elevated bicarbonate levels (≥ 27 mmol/L) and those with good renal function (GFR > 50). Conversely, though the upfront use of thiazide diuretic added to intravenous furosemide improved diuretic response in acute decompensated heart failure, it causes an increased risk of worsening renal function and lack of clear evidence of reducing hospital length of stay.
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Affiliation(s)
- Chukwuemeka A. Umeh
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
- School of Medicine, St. George’s University, Grenada, West Indies, Grenada
- American University of Antigua, Osbourn, Antigua and Barbuda
| | - Tamanna Mohta
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Gagan Kaur
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Roland Truong
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Puja Darji
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Chong Vue
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
- American University of Antigua, Osbourn, Antigua and Barbuda
| | - Vijaya Bhargavi Cherukuri
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
- American University of Antigua, Osbourn, Antigua and Barbuda
| | - Benson Eghreriniovo
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Rahul Gupta
- Department of Internal Medicine, University of California, San Diego, CA 92122, USA
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Siddiqi AK, Maniya MT, Alam MT, Ambrosy AP, Fudim M, Greene SJ, Khan MS. Acetazolamide as an Adjunctive Diuretic Therapy for Patients with Acute Decompensated Heart Failure: A Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs 2024; 24:273-284. [PMID: 38416359 DOI: 10.1007/s40256-024-00633-9] [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: 01/29/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Recent evidence suggests that acetazolamide may be beneficial as an adjunctive diuretic therapy in patients with acute decompensated heart failure (HF). We aim to pool all the studies conducted until now and provide updated evidence regarding the role of acetazolamide as adjunctive diuretic in patients with acute decompensated HF. METHODS PubMed/Medline, Cochrane Library, and Scopus were searched from inception until July 2023, for randomized and nonrandomized studies evaluating acetazolamide as add-on diuretic in patients with acute decompensated HF. Data about natriuresis, urine output, decongestion, and the clinical signs of congestion were extracted, pooled, and analyzed. Data were pooled using a random effects model. Results were presented as risk ratios (RRs), odds ratios (ORs), or weighted mean differences (WMD) with 95% confidence intervals (95% CIs). Certainty of evidence was assessed using the grading of recommendation, assessment, development, and evaluation (GRADE) approach. A P value of < 0.05 was considered significant in all cases. RESULTS A total of 5 studies (n = 684 patients) were included with a median follow-up time of 3 months. Pooled analysis demonstrated significantly increased natriuresis (MD 55.07, 95% CI 35.1-77.04, P < 0.00001; I2 = 54%; moderate certainty), urine output (MD 1.04, 95% CI 0.10-1.97, P = 0.03; I2 = 79%; moderate certainty) and decongestion [odds ratio (OR) 1.62, 95% CI 1.14-2.31, P = 0.007; I2 = 0%; high certainty] in the acetazolamide group, as compared with controls. There was no significant difference in ascites (RR 0.56, 95% CI 0.23-1.36, P = 0.20; I2 = 0%; low certainty), edema (RR 1.02, 95% CI 0.52-2.0, P = 0.95; I2 = 45%; very low certainty), raised jugular venous pressure (JVP) (RR 0.86, 95% CI 0.63-1.17, P = 0.35; I2 = 0%; low certainty), and pulmonary rales (RR 0.82, 95% CI 0.44-1.51, P = 0.52; I2 = 25%; low certainty) between the two groups. CONCLUSIONS Acetazolamide as an adjunctive diuretic significantly improves global surrogate endpoints for decongestion therapy but not all individual signs and symptoms of volume overload. SYSTEMATIC REVIEW REGISTRATION This systematic review was prospectively registered on the PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/ ), registration number CRD498330.
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Affiliation(s)
| | | | | | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Duke University Medical Center, 2301 Erwin Rd., Durham, NC, 27705, USA
| | - Stephen J Greene
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Duke University Medical Center, 2301 Erwin Rd., Durham, NC, 27705, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Duke University Medical Center, 2301 Erwin Rd., Durham, NC, 27705, USA.
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Ter Maaten JM, Zonneveld LEEC. Personalized Diuretic Therapy in Acute Heart Failure: The Holy Grail? JACC. HEART FAILURE 2024; 12:521-524. [PMID: 38206231 DOI: 10.1016/j.jchf.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/27/2023] [Indexed: 01/12/2024]
Affiliation(s)
- Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands.
| | - Lara E E C Zonneveld
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
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Abstract
Acute heart failure (AHF) is a clinical complex disease and a worldwide issue due to its inconsistent diagnosis and poor prognosis. The cornerstone of pathophysiology of AHF is systemic venous congestion, which is led by the underlying structural and functional cardiac condition. Systemic venous congestion is a major target for AHF management because it causes symptoms and organs dysfunction, and is associated with poor prognosis. The mainstay of decongestive therapy is diuresis with intravenous loop diuretics combined with other diuretics including thiazides when necessary, and non-invasive ventilation. The presence of unresolved congestion at discharge can lead heart failure related rehospitalization, and careful follow-up is required especially during "vulnerable phase", several months after discharge. The updated recommendation for management of AHF has been provided by latest guidelines from European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Failure Society of America. Several large studies have currently demonstrated the benefits of guideline-directed oral medical therapies, and trials are ongoing on medication such as selective sodium-glucose transport proteins 2 inhibitors and protocols for congestive therapy. This review aimed to summarize the latest insights in AHF, based primarily on the most recent guidelines and large randomized controlled trials.
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Affiliation(s)
- Ayu Asakage
- Université de Paris Cité, Paris, France; INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France.
| | - Alexandre Mebazaa
- Université de Paris Cité, Paris, France; INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France; Department of Anesthesiology, Critical Care and Burn Unit, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; FHU PROMICE
| | - Benjamin Deniau
- Université de Paris Cité, Paris, France; INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France; Department of Anesthesiology, Critical Care and Burn Unit, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; FHU PROMICE; INI-CRCT
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Kapelios CJ, Greene SJ, Mentz RJ, Ikeaba U, Wojdyla D, Anstrom KJ, Eisenstein EL, Pitt B, Velazquez EJ, Fang JC. Torsemide Versus Furosemide After Discharge in Patients Hospitalized With Heart Failure Across the Spectrum of Ejection Fraction: Findings From TRANSFORM-HF. Circ Heart Fail 2024; 17:e011246. [PMID: 38436075 PMCID: PMC10950535 DOI: 10.1161/circheartfailure.123.011246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/04/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND The TRANSFORM-HF trial (Torsemide Comparison With Furosemide for Management of Heart Failure) found no significant difference in all-cause mortality or hospitalization among patients randomized to a strategy of torsemide versus furosemide following a heart failure (HF) hospitalization. However, outcomes and responses to some therapies differ by left ventricular ejection fraction (LVEF). Thus, we sought to explore the effect of torsemide versus furosemide by baseline LVEF and to assess outcomes across LVEF groups. METHODS We compared baseline patient characteristics and randomized treatment effects for various end points in TRANSFORM-HF stratified by LVEF: HF with reduced LVEF, ≤40% versus HF with mildly reduced LVEF, 41% to 49% versus HF with preserved LVEF, ≥50%. We also evaluated associations between LVEF and clinical outcomes. Study end points were all-cause mortality or hospitalization at 30 days and 12 months, total hospitalizations at 12 months, and change from baseline in Kansas City Cardiomyopathy Questionnaire clinical summary score. RESULTS Overall, 2635 patients (median 64 years, 36% female, 34% Black) had LVEF data. Compared with HF with reduced LVEF, patients with HF with mildly reduced LVEF and HF with preserved LVEF had a higher prevalence of comorbidities. After adjusting for covariates, there was no significant difference in risk of clinical outcomes across the LVEF groups (adjusted hazard ratio for 12-month all-cause mortality, 0.91 [95% CI, 0.59-1.39] for HF with mildly reduced LVEF versus HF with reduced LVEF and 0.91 [95% CI, 0.70-1.17] for HF with preserved LVEF versus HF with reduced LVEF; P=0.73). In addition, there was no significant difference between torsemide and furosemide (1) for mortality and hospitalization outcomes, irrespective of LVEF group and (2) in changes in Kansas City Cardiomyopathy Questionnaire clinical summary score in any LVEF subgroup. CONCLUSIONS Despite baseline demographic and clinical differences between LVEF cohorts in TRANSFORM-HF, there were no significant differences in the clinical end points with torsemide versus furosemide across the LVEF spectrum. There was a substantial risk for all-cause mortality and subsequent hospitalization independent of baseline LVEF. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03296813.
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Affiliation(s)
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Robert J. Mentz
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Kevin J. Anstrom
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | | | - Bertram Pitt
- Department of Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Eric J. Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - James C. Fang
- University of Utah Medical Center, Salt Lake City, UT, USA
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Crespo-Aznarez S, Campos-Saenz de Santamaría A, Sánchez-Marteles M, Josa-Laorden C, Ruiz-Laiglesia F, Amores-Arriaga B, Garcés-Horna V, Tejel-Puisac R, Julián-Ansón MA, Giménez-López I, Pérez-Calvo JI, Rubio-Gracia J. Prognostic Impact of Induced Natriuresis in Acute Decompensated Heart Failure and Its Association with Intraabdominal Pressure and Other Congestion Markers: A Multimodal Approach to Congestion Assessment. J Clin Med 2024; 13:1053. [PMID: 38398366 PMCID: PMC10888634 DOI: 10.3390/jcm13041053] [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: 01/22/2024] [Revised: 02/08/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Congestion is an essential issue in patients with heart failure (HF). Standard treatments do not usually achieve decongestion, and various strategies have been proposed to guide treatment, such as determination of natriuresis. After starting treatment with loop diuretics, we postulate that initial natriuresis might help treatment titration, decongestion, and improve prognosis. METHODS It was a prospective and observational study. Patients admitted with the diagnosis of HF decompensation were eligible. An assessment of congestion was performed during the first 48 h. RESULTS A total of 113 patients were included. A poor diuretic response was observed in 39.8%. After the first 48 h, patients with a greater diuretic response on admission (NaU > 80 mmol/L) showed fewer pulmonary b lines (12 vs. 15; p = 0.084), a lower IVC diameter (18 mm vs. 22 mm; p = 0.009), and lower IAP figures (11 mmHg vs. 13 mmHg; p = 0.041). Survival analysis tests demonstrated significant differences showing a higher proportion of all-cause mortality (ACM) and HF rehospitalization in the poor-diuretic-response group (log-rank test = 0.020). CONCLUSIONS Up to 40% of the patients presented a poorer diuretic response at baseline, translating into worse outcomes. Patients with an optimal diuretic response showed significantly higher abdominal decongestion at 48 h and a better prognosis regarding ACM and/or HF rehospitalizations.
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Affiliation(s)
- Silvia Crespo-Aznarez
- Internal Medicine Department, Hospital Clínico Lozano Blesa, 50009 Zaragoza, Spain; (S.C.-A.); (A.C.-S.d.S.); (M.S.-M.); (F.R.-L.); (V.G.-H.)
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain; (C.J.-L.); (B.A.-A.); (I.G.-L.); (J.I.P.-C.)
| | - Amelia Campos-Saenz de Santamaría
- Internal Medicine Department, Hospital Clínico Lozano Blesa, 50009 Zaragoza, Spain; (S.C.-A.); (A.C.-S.d.S.); (M.S.-M.); (F.R.-L.); (V.G.-H.)
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain; (C.J.-L.); (B.A.-A.); (I.G.-L.); (J.I.P.-C.)
| | - Marta Sánchez-Marteles
- Internal Medicine Department, Hospital Clínico Lozano Blesa, 50009 Zaragoza, Spain; (S.C.-A.); (A.C.-S.d.S.); (M.S.-M.); (F.R.-L.); (V.G.-H.)
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain; (C.J.-L.); (B.A.-A.); (I.G.-L.); (J.I.P.-C.)
| | - Claudia Josa-Laorden
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain; (C.J.-L.); (B.A.-A.); (I.G.-L.); (J.I.P.-C.)
- Internal Medicine Department, Hospital Royo Villanova, 50015 Zaragoza, Spain
| | - Fernando Ruiz-Laiglesia
- Internal Medicine Department, Hospital Clínico Lozano Blesa, 50009 Zaragoza, Spain; (S.C.-A.); (A.C.-S.d.S.); (M.S.-M.); (F.R.-L.); (V.G.-H.)
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain; (C.J.-L.); (B.A.-A.); (I.G.-L.); (J.I.P.-C.)
| | - Beatriz Amores-Arriaga
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain; (C.J.-L.); (B.A.-A.); (I.G.-L.); (J.I.P.-C.)
- Emergency Department, Hospital Clínico Lozano Blesa, 50009 Zaragoza, Spain
| | - Vanesa Garcés-Horna
- Internal Medicine Department, Hospital Clínico Lozano Blesa, 50009 Zaragoza, Spain; (S.C.-A.); (A.C.-S.d.S.); (M.S.-M.); (F.R.-L.); (V.G.-H.)
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain; (C.J.-L.); (B.A.-A.); (I.G.-L.); (J.I.P.-C.)
| | - Ruben Tejel-Puisac
- Clinical Biochemistry Deparment, Hospital Clínico Lozano Blesa, 50009 Zaragoza, Spain; (R.T.-P.); (M.A.J.-A.)
| | - María Angel Julián-Ansón
- Clinical Biochemistry Deparment, Hospital Clínico Lozano Blesa, 50009 Zaragoza, Spain; (R.T.-P.); (M.A.J.-A.)
| | - Ignacio Giménez-López
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain; (C.J.-L.); (B.A.-A.); (I.G.-L.); (J.I.P.-C.)
- School of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
- Aragon’s Institute of Health Sciences (IACS), 50009 Zaragoza, Spain
| | - Juan Ignacio Pérez-Calvo
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain; (C.J.-L.); (B.A.-A.); (I.G.-L.); (J.I.P.-C.)
- School of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
| | - Jorge Rubio-Gracia
- Internal Medicine Department, Hospital Clínico Lozano Blesa, 50009 Zaragoza, Spain; (S.C.-A.); (A.C.-S.d.S.); (M.S.-M.); (F.R.-L.); (V.G.-H.)
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain; (C.J.-L.); (B.A.-A.); (I.G.-L.); (J.I.P.-C.)
- School of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
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Ena J. Disparities based on sex in clinical trials. Rev Clin Esp 2024; 224:114-116. [PMID: 38228269 DOI: 10.1016/j.rceng.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Javier Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, Alicante, Spain.
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Conde-Martel A, Trullàs JC, Morales-Rull JL, Casado J, Carrera-Izquierdo M, Sánchez-Marteles M, Llácer P, Salamanca-Bautista P, Manzano L, Formiga F. Sex differences in clinical characteristics and outcomes in the CLOROTIC (combining loop with thiazide diuretics for decompensated heart failure) trial. Rev Clin Esp 2024; 224:67-76. [PMID: 38215973 DOI: 10.1016/j.rceng.2023.11.003] [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: 11/04/2023] [Accepted: 11/25/2023] [Indexed: 01/14/2024]
Abstract
AIMS The addition of hydrochlorothiazide (HCTZ) to furosemide improved the diuretic response in patients with acute heart failure (AHF) in the CLOROTIC trial. Our aim was to evaluate if there were differences in clinical characteristics and outcomes according to sex. METHODS This is a post-hoc analysis of the CLOROTIC trial, including 230 patients with AHF randomized to receive HCTZ or placebo in addition to an intravenous furosemide regimen. The primary and secondary outcomes included changes in weight and patient-reported dyspnoea 72 and 96 h after randomization, metrics of diuretic response and mortality/rehospitalizations at 30 and 90 days. The influence of sex on primary, secondary and safety outcomes was evaluated. RESULTS One hundred and eleven (48%) women were included in the study. Women were older and had higher values of left ventricular ejection fraction. Men had more ischemic cardiomyopathy and chronic obstructive pulmonary disease and higher values of natriuretic peptides. The addition of HCTZ to furosemide was associated to a greatest weight loss at 72/96 h, better metrics of diuretic response and higher 24-h diuresis compared to placebo without significant differences according to sex (all p-values for interaction were not significant). Worsening renal function occurred more frequently in women (OR [95%CI]: 8.68 [3.41-24.63]) than men (OR [95%CI]: 2.5 [0.99-4.87]), p = 0.027. There were no differences in mortality or rehospitalizations at 30/90 days. CONCLUSION Adding HCTZ to intravenous furosemide is an effective strategy to improve diuretic response in AHF with no difference according to sex, but worsening renal function was more frequent in women. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov: NCT01647932; EudraCT Number: 2013-001852-36.
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Affiliation(s)
- A Conde-Martel
- Internal Medicine Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain; Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
| | - J C Trullàs
- Internal Medicine Department, Hospital d'Olot i Comarcal de la Garrotxa, 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), Barcelona, Spain
| | - J L Morales-Rull
- Internal Medicine Department, Heart Failure Unit, Hospital Universitari Arnau de Villanova, Institut de Recerca Biomédica (IRBLleida), Lleida, Spain
| | - J Casado
- Internal Medicine Department, Hospital Universitario de Getafe, Madrid, Spain
| | - M Carrera-Izquierdo
- Internal Medicine Department, Complejo Hospitalario de Soria, Paseo Santa Bárbara, Soria, Spain
| | - M Sánchez-Marteles
- Internal Medicine Department, Hospital Clínico Universitario 'Lozano Blesa', Aragón Research Health Institutte (IIS Aragon), Zaragoza, Spain
| | - P Llácer
- Internal Medicine Department, Hospital de Manises, Valencia, Spain
| | - P Salamanca-Bautista
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
| | - L Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - F Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
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Cotter G, Deniau B, Davison B, Edwards C, Adamo M, Arrigo M, Barros M, Biegus J, Celutkiene J, Cerlinskaite-Bajore K, Chioncel O, Cohen-Solal A, Damasceno A, Diaz R, Filippatos G, Gayat E, Kimmoun A, Lam CSP, Metra M, Novosadova M, Pang PS, Pagnesi M, Ponikowski P, Saidu H, Sliwa K, Takagi K, Ter Maaten JM, Tomasoni D, Voors A, Mebazaa A. Optimization of Evidence-Based Heart Failure Medications After an Acute Heart Failure Admission: A Secondary Analysis of the STRONG-HF Randomized Clinical Trial. JAMA Cardiol 2024; 9:114-124. [PMID: 38150260 PMCID: PMC10753435 DOI: 10.1001/jamacardio.2023.4553] [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] [Received: 07/11/2023] [Accepted: 10/04/2023] [Indexed: 12/28/2023]
Abstract
Importance The Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by N-Terminal Pro-Brain Natriuretic Peptide Testing of Heart Failure Therapies (STRONG-HF) trial strived for rapid uptitration aiming to reach 100% optimal doses of guideline-directed medical therapy (GDMT) within 2 weeks after discharge from an acute heart failure (AHF) admission. Objective To assess the association between degree of GDMT doses achieved in high-intensity care and outcomes. Design, Setting, and Participants This was a post hoc secondary analysis of the STRONG-HF randomized clinical trial, conducted from May 2018 to September 2022. Included in the study were patients with AHF who were not treated with optimal doses of GDMT before and after discharge from an AHF admission. Data were analyzed from January to October 2023. Interventions The mean percentage of the doses of 3 classes of HF medications (renin-angiotensin system inhibitors, β-blockers, and mineralocorticoid receptor antagonists) relative to their optimal doses was computed. Patients were classified into 3 dose categories: low (<50%), medium (≥50% to <90%), and high (≥90%). Dose and dose group were included as a time-dependent covariate in Cox regression models, which were used to test whether outcomes differed by dose. Main Outcome Measures Post hoc secondary analyses of postdischarge 180-day HF readmission or death and 90-day change in quality of life. Results A total of 515 patients (mean [SD] age, 62.7 [13.4] years; 311 male [60.4%]) assigned high-intensity care were included in this analysis. At 2 weeks, 39 patients (7.6%) achieved low doses, 254 patients (49.3%) achieved medium doses, and 222 patients (43.1%) achieved high doses. Patients with lower blood pressure and more congestion were less likely to be uptitrated to optimal GDMT doses at week 2. As a continuous time-dependent covariate, an increase of 10% in the average percentage optimal dose was associated with a reduction in 180-day HF readmission or all-cause death (primary end point: adjusted hazard ratio [aHR], 0.89; 95% CI, 0.81-0.98; P = .01) and a decrease in 180-day all-cause mortality (aHR, 0.84; 95% CI, 0.73-0.95; P = .007). Quality of life at 90 days, measured by the EQ-5D visual analog scale, improved more in patients treated with higher doses of GDMT (mean difference, 0.10; 95% CI, -4.88 to 5.07 and 3.13; 95% CI, -1.98 to 8.24 points in the medium- and high-dose groups relative to the low-dose group, respectively; P = .07). Adverse events to day 90 occurred less frequently in participants with HIC who were prescribed higher GDMT doses at week 2. Conclusions and Relevance Results of this post hoc analysis of the STRONG-HF randomized clinical trial show that, among patients randomly assigned to high-intensity care, achieving higher doses of HF GDMT 2 weeks after discharge was feasible and safe in most patients. Trial Registration ClinicalTrials.gov Identifier: NCT03412201.
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Affiliation(s)
- Gad Cotter
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Momentum Research Inc, Durham, North Carolina
- Heart Initiative, Durham, North Carolina
| | - 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
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Momentum Research Inc, Durham, North Carolina
- Heart Initiative, Durham, North Carolina
| | | | - 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
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kamile Cerlinskaite-Bajore
- 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
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - 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; INSERM, Défaillance Circulatoire Aigue et Chronique; Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, 54511 Vandoeuvre-lès-Nancy, France
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital / Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Koji Takagi
- Momentum Research Inc, Durham, North Carolina
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Adriaan Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - 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
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Muller G, Laribi S, Danchin N, Delmas C, Sauvage B, Puymirat É, Chouihed T, Aissaoui N, Angoulvant D. Guideline adherence in the management of acute pulmonary oedema: Study protocol for a French survey involving cardiologists, emergency physicians and intensivists. Arch Cardiovasc Dis 2024; 117:128-133. [PMID: 38267319 DOI: 10.1016/j.acvd.2023.11.014] [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: 09/07/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Because of their high morbidity and mortality, patients with acute pulmonary oedema (APE) require early recognition of symptoms, identification of precipitating factors and admission to specialized care units (cardiac critical care or intensive care). APE is at the crossroads of different specialties (cardiology, emergency medicine and intensive care medicine). Although multidisciplinary expertise and management may be a strength, it can also be a source of confusion, with unexpected heterogeneity in patient care. We hypothesized that the management of severe APE may be heterogeneous between specialties and, in some situations, may differ from international recommendations. AIM We designed a survey to compare management of different APE phenotypes according to the physicians' medical specialty, and to compare the results with what experts would do and European guidelines. METHODS Four clinical cases of typical APE with questions pertaining to the latest guidelines were designed by a Scientific Committee designated by the French Scientific Societies for Cardiology, Emergency Medicine and Intensive Care Medicine. We focused on oxygenation and ventilation strategies, management of precipitating factors, including timing of coronary revascularization, use of diuretics and management of diuretic resistance, and discharge coverage. From 20 June 2022 until 09 September 2022, the four cases of APE (two during hypertensive crises, two during acute coronary syndromes) were proposed to French physicians involved in APE care, and to experts, using an open online survey. To avoid any diagnostic ambiguity, the diagnosis of APE was given at the beginning of each clinical case. RESULTS The intention is to present the results at national and international conferences and publish them in a peer-reviewed journal. CONCLUSIONS The results of this survey are intended to pave the way for the generation of novel hypotheses for future clinical trials in case of equipoise between subsets of therapeutic procedures in APE.
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Affiliation(s)
- Grégoire Muller
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, 45067 Orléans, France; UMR INSERM 1327 ISCHEMIA, Université de Tours, 37000 Tours, France; Clinical Research in Intensive Care and Sepsis-Trial Group for Global Evaluation and Research in Sepsis (CRICS_TRIGGERSep) French Clinical Research Infrastructure Network (F-CRIN) Research Network, France.
| | - Saïd Laribi
- Service des Urgences, CHU de Tours, Université de Tours, 37000 Tours, France
| | - Nicolas Danchin
- Service de Cardiologie, Hôpital Européen Georges-Pompidou, Université Paris Cité, 75015 Paris, France
| | - Clément Delmas
- Service de Cardiologie, CHU de Toulouse, 31400 Toulouse, France
| | - Brice Sauvage
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, 45067 Orléans, France
| | - Étienne Puymirat
- Service de Cardiologie, Hôpital Européen Georges-Pompidou, Université Paris Cité, 75015 Paris, France
| | - Tahar Chouihed
- Service d'Urgences, CHU de Nancy, Université de Loraine, 54000 Nancy, France
| | - Nadia Aissaoui
- Service de Médecine Intensive Réanimation, CHU Cochin, Université Paris Cité, 75014 Paris, France
| | - Denis Angoulvant
- UMR INSERM 1327 ISCHEMIA, Université de Tours, 37000 Tours, France; Service de Cardiologie, Hôpital Trousseau, CHU de Tours, 37000 Tours, France
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D'Amato A, Prosperi S, Severino P, Myftari V, Labbro Francia A, Cestiè C, Pierucci N, Marek-Iannucci S, Mariani MV, Germanò R, Fanisio F, Lavalle C, Maestrini V, Badagliacca R, Mancone M, Fedele F, Vizza CD. Current Approaches to Worsening Heart Failure: Pathophysiological and Molecular Insights. Int J Mol Sci 2024; 25:1574. [PMID: 38338853 PMCID: PMC10855688 DOI: 10.3390/ijms25031574] [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: 12/17/2023] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Worsening heart failure (WHF) is a severe and dynamic condition characterized by significant clinical and hemodynamic deterioration. It is characterized by worsening HF signs, symptoms and biomarkers, despite the achievement of an optimized medical therapy. It remains a significant challenge in cardiology, as it evolves into advanced and end-stage HF. The hyperactivation of the neurohormonal, adrenergic and renin-angiotensin-aldosterone system are well known pathophysiological pathways involved in HF. Several drugs have been developed to inhibit the latter, resulting in an improvement in life expectancy. Nevertheless, patients are exposed to a residual risk of adverse events, and the exploration of new molecular pathways and therapeutic targets is required. This review explores the current landscape of WHF, highlighting the complexities and factors contributing to this critical condition. Most recent medical advances have introduced cutting-edge pharmacological agents, such as guanylate cyclase stimulators and myosin activators. Regarding device-based therapies, invasive pulmonary pressure measurement and cardiac contractility modulation have emerged as promising tools to increase the quality of life and reduce hospitalizations due to HF exacerbations. Recent innovations in terms of WHF management emphasize the need for a multifaceted and patient-centric approach to address the complex HF syndrome.
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Affiliation(s)
- Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Vincenzo Myftari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Aurora Labbro Francia
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Claudia Cestiè
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Nicola Pierucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Stefanie Marek-Iannucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Rosanna Germanò
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
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Trullàs JC, Casado J. [Diuretic resistance in heart failure]. Med Clin (Barc) 2024; 162:19-21. [PMID: 37919121 DOI: 10.1016/j.medcli.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Joan Carles Trullàs
- Servicio de Medicina Interna, Hospital d'Olot i Comarcal de la Garrotxa, Girona, Catalunya, España; 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, Catalunya, España; Grupo de Trabajo de Insuficiencia Cardiaca y Fibrilación Auricular de la Sociedad Española de Medicina Interna, Madrid, España.
| | - Jesús Casado
- Grupo de Trabajo de Insuficiencia Cardiaca y Fibrilación Auricular de la Sociedad Española de Medicina Interna, Madrid, España; Servicio de Medicina Interna, Hospital Universitario de Getafe, Madrid, España
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Lasica R, Djukanovic L, Vukmirovic J, Zdravkovic M, Ristic A, Asanin M, Simic D. Clinical Review of Hypertensive Acute Heart Failure. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:133. [PMID: 38256394 PMCID: PMC10818732 DOI: 10.3390/medicina60010133] [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: 12/02/2023] [Revised: 12/20/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024]
Abstract
Although acute heart failure (AHF) is a common disease associated with significant symptoms, morbidity and mortality, the diagnosis, risk stratification and treatment of patients with hypertensive acute heart failure (H-AHF) still remain a challenge in modern medicine. Despite great progress in diagnostic and therapeutic modalities, this disease is still accompanied by a high rate of both in-hospital (from 3.8% to 11%) and one-year (from 20% to 36%) mortality. Considering the high rate of rehospitalization (22% to 30% in the first three months), the treatment of this disease represents a major financial blow to the health system of each country. This disease is characterized by heterogeneity in precipitating factors, clinical presentation, therapeutic modalities and prognosis. Since heart decompensation usually occurs quickly (within a few hours) in patients with H-AHF, establishing a rapid diagnosis is of vital importance. In addition to establishing the diagnosis of heart failure itself, it is necessary to see the underlying cause that led to it, especially if it is de novo heart failure. Given that hypertension is a precipitating factor of AHF and in up to 11% of AHF patients, strict control of arterial blood pressure is necessary until target values are reached in order to prevent the occurrence of H-AHF, which is still accompanied by a high rate of both early and long-term mortality.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (R.L.); (L.D.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (A.R.)
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (R.L.); (L.D.); (M.A.)
| | - Jovanka Vukmirovic
- Faculty of Organizational Sciences, University of Belgrade, 11000 Belgrade, Serbia;
| | - Marija Zdravkovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (A.R.)
- Clinical Center Bezanijska Kosa, 11000 Belgrade, Serbia
| | - Arsen Ristic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (A.R.)
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (R.L.); (L.D.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (A.R.)
| | - Dragan Simic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (A.R.)
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Bilgeri V, Spitaler P, Puelacher C, Messner M, Adukauskaite A, Barbieri F, Bauer A, Senoner T, Dichtl W. Decongestion in Acute Heart Failure-Time to Rethink and Standardize Current Clinical Practice? J Clin Med 2024; 13:311. [PMID: 38256444 PMCID: PMC10816514 DOI: 10.3390/jcm13020311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/31/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Most episodes of acute heart failure (AHF) are characterized by increasing signs and symptoms of congestion, manifested by edema, pleura effusion and/or ascites. Immediately and repeatedly administered intravenous (IV) loop diuretics currently represent the mainstay of initial therapy aiming to achieve adequate diuresis/natriuresis and euvolemia. Despite these efforts, a significant proportion of patients have residual congestion at discharge, which is associated with a poor prognosis. Therefore, a standardized approach is needed. The door to diuretic time should not exceed 60 min. As a general rule, the starting IV dose is 20-40 mg furosemide equivalents in loop diuretic naïve patients or double the preexisting oral home dose to be administered via IV. Monitoring responses within the following first hours are key issues. (1) After 2 h, spot urinary sodium should be ≥50-70 mmol/L. (2) After 6 h, the urine output should be ≥100-150 mL/hour. If these target measures are not reached, the guidelines currently recommend a doubling of the original dose to a maximum of 400-600 mg furosemide per day and in patients with severely impaired kidney function up to 1000 mg per day. Continuous infusion of loop diuretics offers no benefit over intermittent boluses (DOSE trial). Emerging evidence by recent randomized trials (ADVOR, CLOROTIC) supports the concept of an early combination diuretic therapy, by adding either acetazolamide (500 mg IV once daily) or hydrochlorothiazide. Acetazolamide is particularly useful in the presence of a baseline bicarbonate level of ≥27 mmol/L and remains effective in the presence of preexisting/worsening renal dysfunction but should be used only in the first three days to prevent severe metabolic disturbances. Patients should not leave the hospital when they are still congested and/or before optimized long-term guideline-directed medical therapy has been initiated. Special attention should be paid to AHF patients during the vulnerable post-discharge period, with an early follow-up visit focusing on up-titrate treatments of recommended doses within 2 weeks (STRONG-HF).
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Affiliation(s)
- Valentin Bilgeri
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Philipp Spitaler
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Christian Puelacher
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Moritz Messner
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Agne Adukauskaite
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Fabian Barbieri
- Deutsches Herzzentrum der Charité, Hindenburgdamm 30, 12203 Berlin, Germany;
| | - Axel Bauer
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Thomas Senoner
- Department of Anesthesiology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
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Sabina M, Barakat Z, Feliciano A, Lamb A, Alsamman MM. Unlocking the Potential of Acetazolamide: A Literature Review of an Adjunctive Approach in Heart Failure Management. J Clin Med 2024; 13:288. [PMID: 38202295 PMCID: PMC10780103 DOI: 10.3390/jcm13010288] [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: 12/03/2023] [Revised: 12/28/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024] Open
Abstract
Background: Heart failure (HF) patients often experience persistent fluid overload despite standard diuretic therapy. The adjunctive use of acetazolamide, a carbonic anhydrase inhibitor, in combination with loop diuretics has shown promise in improving decongestion and diuretic efficacy. This literature review aims to analyze six studies evaluating the effectiveness of acetazolamide as an additive treatment for acute decompensated heart failure (ADHF) and its impact on various outcomes. Methods: We searched the PubMed database using the terms "acetazolamide heart failure". We refined our search with specific filters (as shown our PRISMA flow diagram) and exclusion criteria, narrowing down our results to five studies. We included an extra study via expert recommendation, ultimately including six studies for comprehensive analysis. Results: The review highlights the positive effects of acetazolamide on decongestion, natriuresis, and diuresis in HF patients. However, it also showcases the limitations of these trials. Discussion: While the reviewed studies demonstrate the potential benefits of acetazolamide in enhancing decongestion and diuretic efficiency, there are limitations to consider, including small sample sizes, lack of blinding, and limited external validity. Further research is needed to confirm these findings, compare acetazolamide with other diuretic combinations, and explore its effects in a broader population of heart failure patients, including those in the United States. The use of acetazolamide in HF management warrants continued investigation to optimize its role in improving decongestion and patient outcomes.
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Affiliation(s)
- Michael Sabina
- Lakeland Regional Health Medical Center, Lakeland 33805-4500, FL, USA; (Z.B.); (A.F.); (A.L.); (M.M.A.)
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2024; 26:5-17. [PMID: 38169072 DOI: 10.1002/ejhf.3024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Abstract
Document Reviewers: Rudolf A. de Boer (CPG Review Co-ordinator) (Netherlands), P. Christian Schulze (CPG Review Co-ordinator) (Germany), Elena Arbelo (Spain), Jozef Bartunek (Belgium), Johann Bauersachs (Germany), Michael A. Borger (Germany), Sergio Buccheri (Sweden), Elisabetta Cerbai (Italy), Erwan Donal (France), Frank Edelmann (Germany), Gloria Färber (Germany), Bettina Heidecker (Germany), Borja Ibanez (Spain), Stefan James (Sweden), Lars Køber (Denmark), Konstantinos C. Koskinas (Switzerland), Josep Masip (Spain), John William McEvoy (Ireland), Robert Mentz (United States of America), Borislava Mihaylova (United Kingdom), Jacob Eifer Møller (Denmark), Wilfried Mullens (Belgium), Lis Neubeck (United Kingdom), Jens Cosedis Nielsen (Denmark), Agnes A. Pasquet (Belgium), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Bianca Rocca (Italy), Xavier Rossello (Spain), Leyla Elif Sade (United States of America/Türkiye), Hannah Schaubroeck (Belgium), Elena Tessitore (Switzerland), Mariya Tokmakova (Bulgaria), Peter van der Meer (Netherlands), Isabelle C. Van Gelder (Netherlands), Mattias Van Heetvelde (Belgium), Christiaan Vrints (Belgium), Matthias Wilhelm (Switzerland), Adam Witkowski (Poland), and Katja Zeppenfeld (Netherlands) All experts involved in the development of this Focused Update have submitted declarations of interest. These have been compiled in a report and simultaneously published in a supplementary document to the Focused Update. The report is also available on the ESC website www.escardio.org/guidelines See the European Heart Journal online for supplementary documents that include evidence tables.
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Fernandez Hazim C, Duarte G, Urena AP, Jain S, Mishra R, Vittorio TJ, Rodriguez-Guerra M. Diuretic resistance and the role of albumin in congestive heart failure. Drugs Context 2023; 12:2023-6-5. [PMID: 38188263 PMCID: PMC10768781 DOI: 10.7573/dic.2023-6-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Diuresis with loop diuretics is the mainstay treatment for volume optimization in patients with congestive heart failure, in which perfusion and volume expansion play a crucial role. There are robust guidelines with extensive evidence for the management of heart failure; however, clear guidance is needed for patients who do not respond to standard diuretic treatment. Diuretic resistance (DR) can be defined as an insufficient quantity of natriuresis with proper diuretic therapy. A combination of diuretic regimens is used to overcome DR and, more recently, SGLT2 inhibitors have been shown to improve diuresis. Despite DR being relatively common, it is challenging to treat and there remains a notable lack of substantial data guiding its management. Moreover, DR has been linked with poor prognosis. This review aims to expose the multiple approaches for treatment of patients with DR and the importance of intravascular volume expansion in the response to therapy.
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Affiliation(s)
| | | | - Ana P Urena
- Medicina Cardiovascular Asociada, Santo Domingo, Dominican Republic
| | - Swati Jain
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rishabh Mishra
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy J Vittorio
- BronxCare Health System, Icahn School of Medicine at Mt. Sinai, Bronx, NY, USA
| | - Miguel Rodriguez-Guerra
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Voors AA. Novel Recommendations for the Treatment of Patients With Heart Failure: 2023 Focused Update of the 2021 ESC Heart Failure Guidelines. J Card Fail 2023; 29:1667-1671. [PMID: 37666294 DOI: 10.1016/j.cardfail.2023.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 08/30/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.
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