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Larsson JE, Denholt CS, Thune JJ, Raja AA, Fosbøl E, Schou M, Køber L, Nielsen OW, Gustafsson F, Kristensen SL. Initiation of eplerenone or spironolactone, treatment adherence, and associated outcomes in patients with new-onset heart failure with reduced ejection fraction: a nationwide cohort study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:546-552. [PMID: 37355774 DOI: 10.1093/ehjcvp/pvad045] [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: 12/19/2022] [Revised: 04/19/2023] [Accepted: 06/22/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND The mineralocorticoid receptor antagonists (MRAs) eplerenone and spironolactone are beneficial in heart failure with reduced ejection fraction (HFrEF), but have not been prospectively compared. We compared clinical outcomes, daily dosages, and discontinuation rates for the two drugs in a nationwide cohort. METHODS We identified all patients with HFrEF in the period 2016-2020, who were alive and had initiated MRA treatment at study start, 180 days after HF diagnosis. We estimated the 2-year risk of a composite of death and HF hospitalization, as well as each component separately, using Kaplan-Meier, cumulative incidence functions, and Cox proportional hazards models adjusted for age, sex, and comorbidities. Secondly, we assessed treatment withdrawal, cross-over, and daily drug dosage. RESULTS We included 7479 patients; 653 (9%) on eplerenone and 6840 (91%) on spironolactone. Patients in the eplerenone group were younger (median age 65 vs. 69 years), and more often men (91% vs. 68%), both P < 0.001. In adjusted analyses, with spironolactone as reference, there were no differences in the risk of the composite of all-cause death and HF hospitalization (HR 1.02, 95% CI 0.82-1.27), all-cause death (HR 0.93, 95% CI 0.67-1.30), or HF hospitalization (HR 1.10, 95% CI 0.84-1.42). Treatment withdrawal occurred in 34% in the eplerenone group and 53% in the spironolactone group (P < 0.001), treatment cross-over in 3%, and 10%, respectively. Daily dose >25 mg at 12 months, was observed in 230 patients (37%) in the eplerenone group and 771 patients (12%) in the spironolactone (P < 0.001). CONCLUSIONS In a contemporary nationwide cohort of patients with new-onset HFrEF who initiated MRA, we found no differences in clinical outcomes associated with initiation of eplerenone vs. spironolactone. Treatment was more frequently withdrawn, and daily drug dosage was lower among patients treated with spironolactone.
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Affiliation(s)
- Johan E Larsson
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Cæcilie Stilling Denholt
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Jens Jakob Thune
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Anna Axelsson Raja
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Emil Fosbøl
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Borgmester Ib Juuls Vej 11, 2730 Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Olav Wendelboe Nielsen
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Søren L Kristensen
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Lorente-Ros M, Aguilar-Gallardo JS, Shah A, Narasimhan B, Aronow WS. An overview of mineralocorticoid receptor antagonists as a treatment option for patients with heart failure: the current state-of-the-art and future outlook. Expert Opin Pharmacother 2022; 23:1737-1751. [PMID: 36262014 DOI: 10.1080/14656566.2022.2138744] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in patients with heart failure. These benefits of MRAs vary in different heart failure populations based on left ventricular ejection fraction and associated comorbidities. AREAS COVERED We define the pharmacologic properties of MRAs and the pathophysiological rationale for their utility in heart failure. We outline the current literature on the use of MRAs in different heart failure populations, including reduced and preserved ejection fraction (HFrEF/ HFpEF), and acute heart failure decompensation. Finally, we describe the limitations of currently available data and propose future directions of study. EXPERT OPINION While there is strong evidence supporting the use of MRAs in HFrEF, evidence in patients with HFpEF or acute heart failure is less definitive. Comorbidities such as obesity or atrial fibrillation could be clinical modifiers of the response to MRAs and potentially alter the risk/benefit ratio in these subpopulations. Emerging evidence for new non-steroidal MRAs reveal promising preliminary results that, if confirmed in large randomized clinical trials, could favor a change in clinical practice.
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Affiliation(s)
- Marta Lorente-Ros
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Jose S Aguilar-Gallardo
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Aayush Shah
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Bharat Narasimhan
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Wilbert S Aronow
- Department of Cardiology, New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY 10901, USA
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Lytvyn Y, Bjornstad P, van Raalte DH, Heerspink HL, Cherney DZI. The New Biology of Diabetic Kidney Disease-Mechanisms and Therapeutic Implications. Endocr Rev 2020; 41:5601424. [PMID: 31633153 PMCID: PMC7156849 DOI: 10.1210/endrev/bnz010] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
Diabetic kidney disease remains the most common cause of end-stage kidney disease in the world. Despite reductions in incidence rates of myocardial infarction and stroke in people with diabetes over the past 3 decades, the risk of diabetic kidney disease has remained unchanged, and may even be increasing in younger individuals afflicted with this disease. Accordingly, changes in public health policy have to be implemented to address the root causes of diabetic kidney disease, including the rise of obesity and diabetes, in addition to the use of safe and effective pharmacological agents to prevent cardiorenal complications in people with diabetes. The aim of this article is to review the mechanisms of pathogenesis and therapies that are either in clinical practice or that are emerging in clinical development programs for potential use to treat diabetic kidney disease.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Petter Bjornstad
- Department of Medicine, Division of Nephrology, Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Netherlands
| | - Hiddo L Heerspink
- The George Institute for Global Health, Sydney, Australia.,Department of Clinical Pharmacology, University of Groningen, Groningen, Netherlands
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Abstract
The epidemics of heart failure and, to a lesser extent, of pulmonary arterial hypertension continue unabated worldwide and are extremely costly in terms of loss of life and earnings, as well as the burden of health-care expenditure due to repeated hospitalization. The effectiveness of newly discovered therapies for the two conditions depends on their timely application. To date, symptoms have been used to guide the application and timing of therapy. Compelling evidence now exists that symptoms are preceded by several metabolic and haemodynamic changes, particularly a rise in intravascular pressures during exercise. These observations have stimulated the development of several implantable devices for the detection of impending unstable heart failure or pulmonary arterial hypertension, necessitating admission to hospital. In this Review, we summarize the rationale for monitoring patients with heart failure or pulmonary arterial hypertension, the transition from noninvasive to implantable devices and the current and anticipated clinical uses of these devices.
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Abstract
The treatment of cardiorenal syndrome is as complex as the various mechanisms underlying its pathophysiology. Randomized controlled data typically focus on the treatment of heart failure with cardiac specific endpoints and a lack of worsening renal function used as a surrogate for efficacy. When heart failure is considered the inciting event, the acute state is managed with vasodilators, inotropic support, and decongestion; whereas neurohormonal axis inhibition is more commonly applied to chronic state. A recent shift in thought process regarding the interplay of cardiac and renal dysfunction suggests that renal congestion may be the primary driver of worsening renal function.
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Affiliation(s)
- Jack Rubinstein
- University of Cincinnati, Medical Science Building, 231 Albert Sabin Way, MLC 0542, Cincinnati, OH 45267, USA.
| | - Darek Sanford
- University of Cincinnati, Medical Science Building, 231 Albert Sabin Way, MLC 0542, Cincinnati, OH 45267, USA
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Sparks ER, Beavers JC. Evaluation of a Pharmacist-Driven Aldosterone Antagonist Stewardship Program in Patients With Heart Failure. J Pharm Pract 2019; 32:158-162. [DOI: 10.1177/0897190017747083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To evaluate the impact of a pharmacist-driven initiative to optimize aldosterone antagonist use in patients with heart failure with reduced ejection fraction (HFrEF) at a large community hospital. Methods: This single-center, retrospective cohort study compared patients with heart failure before and after the implementation of the initiative. Data for pre- and postinitiative patients were retrospectively collected to assess patient characteristics and aldosterone antagonist use. The primary outcome was a composite of eligible patients with heart failure discharged on aldosterone antagonist therapy or with a documented reason for ineligibility before and after commencement of pharmacist-driven aldosterone antagonist initiative. Results: The preinitiative cohort included 96 patients and the postinitiative cohort contained 92 patients. When the 3 month pre- and postinitiative groups were assessed, the primary outcome was noted in 60 (63%) of 96 patients in the preinitiative group and 87 (95%) of 92 patients in the postinitiative group ( P < .0001). Conclusion: In patients with HFrEF, a pharmacist-driven aldosterone antagonist optimization initiative significantly increased appropriate prescribing and documentation for aldosterone antagonist therapy.
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Affiliation(s)
- Eric R. Sparks
- New Hanover Regional Medical Center, Wilmington, NC, USA
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Sandal S, Bansal P, Cantarovich M. The evidence and rationale for the perioperative use of loop diuretics during kidney transplantation: A comprehensive review. Transplant Rev (Orlando) 2017; 32:92-101. [PMID: 29242033 DOI: 10.1016/j.trre.2017.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/08/2017] [Accepted: 11/14/2017] [Indexed: 12/13/2022]
Abstract
PURPOSE Loop diuretics (LD) attenuate ischemic injury in nephrons. They are thought to decrease delayed graft function (DGF) during kidney transplantation (KT). This review aimed to summarize the current evidence for the perioperative use of LD during KT. METHODS We performed an analysis of all articles that were published since the inception of Medline and Embase: 26 studies were selected for inclusion. Scope was LD use during the perioperative phase of KT only. RESULTS Six animal studies demonstrated mixed results in terms of renal function and survival. Of the 20 studies performed in humans, 4 were randomized clinical trials. The risk of bias was mostly unclear. Evidence supporting the role of LD to increase diuresis was mixed and to prevent DGF was weak. There was poor evidence to support LD use to improve initial and long-term graft function. No data on patient survival could be found. Overall, there was a lack of any robust clinical evidence for LD use perioperatively during KT. IMPLICATIONS There is poor evidence to support the perioperative use of LD during KT. Well-designed trials are needed to further explore their safety and efficacy, and we summarize several rationales. Pragmatic rationales include volume management. There is evidence to suggest that LD have a vasodilatory effect, and decrease edema, congestion and oxygen requirements. Lastly, there are several theoretical rationales to explore LD use during KT, in particular, attenuating ischemia-reperfusion injury and modulating autophagy.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, 1001 boul. Decarie, Montreal, QC, Canada. H4A 3J1.
| | - Pannya Bansal
- Michigan State University College of Osteopathic Medicine, East Fee Hall, 965 Fee Rd, East Lansing, MI 48825, USA
| | - Marcelo Cantarovich
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, 1001 boul. Decarie, Montreal, QC, Canada. H4A 3J1
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Cheema B, Ambrosy AP, Kaplan RM, Senni M, Fonarow GC, Chioncel O, Butler J, Gheorghiade M. Lessons learned in acute heart failure. Eur J Heart Fail 2017; 20:630-641. [PMID: 29082676 DOI: 10.1002/ejhf.1042] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 09/18/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022] Open
Abstract
Acute heart failure (HF) is a global pandemic with more than one million admissions to hospital annually in the US and millions more worldwide. Post-discharge mortality and readmission rates remain unchanged and unacceptably high. Although recent drug development programmes have failed to deliver novel therapies capable of reducing cardiovascular morbidity and mortality in patients hospitalized for worsening chronic HF, hospitalized HF registries and clinical trial databases have generated a wealth of information improving our collective understanding of the HF syndrome. This review will summarize key insights from clinical trials in acute HF and hospitalized HF registries over the last several decades, focusing on improving the management of patients with HF and reduced ejection fraction.
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Affiliation(s)
- Baljash Cheema
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Andrew P Ambrosy
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Rachel M Kaplan
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Michele Senni
- Cardiovascular Department, Papa Giovannni XXIII Hospital, Bergamo, Italy
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USA
| | - Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases 'Prof. C.C. Iliescu', Cardiology 1, UMF Carol Davila, Bucharest, Romania
| | | | - Mihai Gheorghiade
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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9
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Association of mineralocorticoid receptor antagonist use and in-hospital outcomes in patients with acute heart failure. Clin Res Cardiol 2017; 107:76-86. [DOI: 10.1007/s00392-017-1161-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 09/13/2017] [Indexed: 12/12/2022]
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10
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Segal O, Segal G, Leibowitz A, Goldenberg I, Grossman E, Klempfner R. Elevation in systolic blood pressure during heart failure hospitalization is associated with increased short and long-term mortality. Medicine (Baltimore) 2017; 96:e5890. [PMID: 28151864 PMCID: PMC5293427 DOI: 10.1097/md.0000000000005890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The relationship between systolic blood pressure (SBP) change during hospitalization of patients with heart failure (HF) and clinical outcomes has never been thoroughly investigated.A total of 3393 patients hospitalized with HF, from 25 hospitals in Israel, were enrolled. The SBP change was calculated by subtracting the discharge SBP values from the admission values and then divided into quartiles of SBP change. We compared the group with upper quartile SBP change to the lower 3 quartiles of change. Both groups had largely similar demographics and clinical characteristics. All-cause mortality rate was 24% at 1-year and 82.6% at 10-years, whereas patients in the upper SBP change group had significantly higher cumulative mortality probability at 1-year (30% vs 22%; log-rank P <0.001), and at 10-years (86% vs 82%; log-rank P <0.001). Multivariate Cox proportional hazard analysis adjusted for comorbidities demonstrated that patients in the upper SBP change quartile have an independent 17% higher mortality risk at 10-years [hazard ratio (HR) 1.17; 95% confidence interval (CI) 1.08-1.28]. Subgroup analysis demonstrated that mortality risk was more pronounced in patients with preserved ejection fraction and in the subgroup with admission SBP ≥140 mm Hg.SBP change is significantly associated with 1- and 10-year all-cause mortality, as an increased SBP change is associated with worse prognosis. We believe that this readily available marker might facilitate risk stratification of patients and possibly improve care.
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Affiliation(s)
- Omer Segal
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv
| | - Gad Segal
- Internal Medicine “T”, Chaim Sheba Medical Center, Tel Hashomer
| | - Avshalom Leibowitz
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv
- Leviev Heart Center, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel
| | - Ilan Goldenberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv
- Leviev Heart Center, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel
- Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, NY
| | - Ehud Grossman
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv
- Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer
| | - Robert Klempfner
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv
- Cardiac Rehabilitation Institute, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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11
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Affiliation(s)
- Yasuko K Bando
- Department of Cardiology, Nagoya University Graduate School of Medicine
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12
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Kolkhof P, Jaisser F, Kim SY, Filippatos G, Nowack C, Pitt B. Steroidal and Novel Non-steroidal Mineralocorticoid Receptor Antagonists in Heart Failure and Cardiorenal Diseases: Comparison at Bench and Bedside. Handb Exp Pharmacol 2017; 243:271-305. [PMID: 27830348 DOI: 10.1007/164_2016_76] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Characterization of mice with cell-specific deletion or overexpression of the mineralocorticoid receptor (MR) shed a new light on its role in health and disease. Pathophysiological MR activation contributes to a plethora of deleterious molecular mechanisms in the development of cardiorenal diseases like chronic kidney disease (CKD) and heart failure (HF). Accordingly, the available steroidal MR antagonists (MRAs) spironolactone (first generation MRA) and eplerenone (second generation MRA) have been shown to be effective in reducing cardiovascular (CV) mortality and morbidity in patients with chronic HF and a reduced left ventricular ejection fraction (HFrEF). However, they remain underutilized, in large part owing to the risk inducing severe adverse events including hyperkalemia and worsening of kidney function, particularly when given on top of inhibitors of the renin angiotensin system (RAS) to patients with concomitant kidney dysfunction. Novel, potent, and selective non-steroidal MRAs (third generation) were identified in drug discovery campaigns and a few entered clinical development recently. One of these is finerenone with different physicochemical, pharmacokinetics, and pharmacological properties in comparison with the steroidal MRAs. Available data from five clinical phase II trials with finerenone in more than 2,000 patients with HF and additional CKD and/or diabetes as well as in patients with diabetic kidney disease demonstrated that neither hyperkalemia nor reductions in kidney function were limiting factors to its use. Moreover, finerenone demonstrated a nominally improved outcome compared to eplerenone in a phase IIb trial with 1,066 patients with HFrEF and concomitant type 2 diabetes mellitus (T2DM) and/or CKD.
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Affiliation(s)
- Peter Kolkhof
- Drug Discovery, Cardiology Research, Bayer Pharma AG, Building 500, Aprather Weg 18a, 42096, Wuppertal, Germany.
| | - Frederic Jaisser
- INSERM, UMRS 1138, Team 1, Centre de Recherche des Cordeliers, Pierre et Marie Curie University, Paris Descartes University, Paris, France
| | - So-Young Kim
- Clinical Development, Bayer Pharma AG, 42096, Wuppertal, Germany
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Rimini 1, Haidari, Athens, 12462, Greece
| | - Christina Nowack
- Clinical Development, Bayer Pharma AG, 42096, Wuppertal, Germany
| | - Bertram Pitt
- University of Michigan Medical School, Ann Arbor, MI, USA
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Pitt B, Rossignol P. The safety of mineralocorticoid receptor antagonists (MRAs) in patients with heart failure. Expert Opin Drug Saf 2016; 15:659-65. [PMID: 26958701 DOI: 10.1517/14740338.2016.1163335] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Mineralocorticoid receptor antagonists (MRAs) have been accorded a class 1 indication for patients with chronic heart failure and a reduced left ventricular ejection fraction (HFREF) in both European and American guidelines. Uptake, however, has been less than optimal largely due to concerns about their safety, in particular the risk of hyperkalemia and renal dysfunction. AREAS COVERED This review presents the current state of affairs regarding the safety of MRAs in heart failure with reduced ejection fraction. EXPERT OPINION Careful patient selection and adherence to guideline-recommended inclusion and exclusion criteria, dosing, and serial monitoring of serum potassium and renal function, along with patient education regarding the potassium content of common foods, should minimize these risks and allow increased use of MRAs. Additionally, this may also result in a further reduction in cardiovascular mortality and hospitalizations for heart failure. The development of new non-steroidal MRAs, and especially new potassium binding molecules that are well tolerated and effective, hold the promise for increased safety and, therefore, increased and more prolonged use of MRAs in patients with heart failure, especially those with chronic kidney disease, diabetes mellitus, and the elderly.
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Affiliation(s)
- Bertram Pitt
- a School of Medicine , University of Michigan , Ann Arbor , MI , USA
| | - Patrick Rossignol
- b Inserm, Centre d'Investigations Cliniques- Plurithématique 14-33, Inserm U1116, CHU Nancy , Université de Lorraine, Association Lorraine de Traitement de l'Insuffisance Rénale, and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) , Nancy , France
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Masoumi A, Ortiz F, Radhakrishnan J, Schrier RW, Colombo PC. Mineralocorticoid receptor antagonists as diuretics: Can congestive heart failure learn from liver failure? Heart Fail Rev 2015; 20:283-90. [PMID: 25447845 DOI: 10.1007/s10741-014-9467-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite significant improvements in diagnosis, understanding the pathophysiology and management of the patients with acute decompensated heart failure (ADHF), diuretic resistance, yet to be clearly defined, is a major hurdle. Secondary hyperaldosteronism is a pivotal factor in pathogenesis of sodium retention, refractory congestion in heart failure (HF) as well as diuretic resistance. In patients with decompensated cirrhosis who suffer from ascites, similar pathophysiological complications have been recognized. Administration of natriuretic doses of mineralocorticoid receptor antagonists (MRAs) has been well established in management of cirrhotic patients. However, this strategy in patients with ADHF has not been well studied. This article will discuss the potential use of natriuretic doses of MRAs to overcome the secondary hyperaldosteronism as an alternative diuretic regimen in patients with HF.
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Affiliation(s)
- Amirali Masoumi
- Division of Cardiology, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, NY, USA,
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Spot urine sodium excretion as prognostic marker in acutely decompensated heart failure: the spironolactone effect. Clin Res Cardiol 2015; 105:489-507. [PMID: 26615605 DOI: 10.1007/s00392-015-0945-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Loop diuretic resistance characterized by inefficient sodium excretion complicates many patients with acutely decompensated heart failure (ADHF). Mineralocorticoid receptor antagonists (MRAs) in natriuretic doses may improve spot urine sodium excretion and outcomes. OBJECTIVE Our primary aim was to assess the association of high-dose spironolactone with short-term spot urine sodium excretion, and our secondary aim was to determine if this higher short-term spot urine sodium excretion is associated with reduction in the composite clinical outcome (of cardiovascular mortality and/or ADHF hospitalization) event rate at 180 days. METHODS Single-centre, non-randomized, open-label study enrolling 100 patients with ADHF. Patients were treated with standard ADHF therapy alone (n = 50) or oral spironolactone 100 mg/day plus standard ADHF therapy (n = 50). Spot urine samples were collected at day 1 and day 3 of hospitalization. RESULTS Spironolactone group had significantly higher spot urine sodium levels compared to standard care group at day 3 (84.13 ± 28.71 mmol/L vs 70.74 ± 34.43 mmol/L, p = 0.04). The proportion of patients with spot urinary sodium <60 mmol/L was lower in spironolactone group at day 3 (18.8 vs 45.7, p = 0.01). In multivariate analysis, spironolactone was independently associated with increased spot urinary sodium and urinary sodium/potassium ratio of >2 at day 3 (both, p < 0.05). Higher spot urine sodium levels were associated with a lower event rate [HR for urinary sodium >100 mmol/L = 0.16 (0.06-0.42), p < 0.01, compared to <60], and provided a significant prognostic gain measured by net reclassification indexes. CONCLUSION Spot urinary sodium levels >60 mmol/L and urinary sodium/potassium ratio >2 measured at day 3 of hospitalization for ADHF are associated with improved mid-term outcomes. Spironolactone is associated with increased spot urinary sodium and sodium/potassium ratio >2.
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Brown K, Chee J, Kyung S, Vettichira B, Papadimitriou L, Butler J. Mineralocorticoid Receptor Antagonism in Acute Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015. [PMID: 26199117 DOI: 10.1007/s11936-015-0402-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OPINION STATEMENT Heart failure (HF) remains a tremendous burden to health care systems and patients worldwide. The cornerstone neurohormonal disruption that leads to the debilitating sequelae in HF patients revolves primarily around aldosterone and the renin-angiotensin-aldosterone system (RAAS). Aldosterone plays a detrimental role in tissue remodeling by inducing inflammation and fibrosis within the cardiovascular and renal systems, leaving mineralocorticoid receptor antagonists (MRAs) as key pharmacological tools to slow pathogenesis and improve patient outcomes. The role of MRA in improving morbidity and mortality in outpatients with chronic HF and low ejection fraction is well established and supported by large randomized controlled trials. However, evidence-based data relating to the use of MRA in acute HF (AHF) remain somewhat limited, and therefore, the use of MRA is not ubiquitously considered in the acute setting. Current studies for the use of MRA in AHF are limited by small sample size as well as safety concerns relating to the dose-dependent effects on electrolyte homeostasis and renal function. Here, we discuss the imperative need for additional trials elucidating the potential benefits of MRA in AHF as an adjunct diuretic therapy. We not only discuss the role of MRA in neurohormonal regulation of aldosterone but also highlight a potential dose-dependent role for MRA in natriuresis. Furthermore, we showcase existing and recent evidence-based data demonstrating the effectiveness of MRA in AHF and on long-term outcomes. Finally, we look at several treatment strategies and safety concerns as they relate to MRA use so as to aid in avoidance of MRA-related complications while facilitating achievement of treatment goals.
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Affiliation(s)
- Kemar Brown
- Division of Cardiology, Health Sciences Center, Stony Brook University, T-16, Room 080, Stony Brook, NY, 11794, USA
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Girerd N, Collier T, Pocock S, Krum H, McMurray JJ, Swedberg K, Van Veldhuisen DJ, Vincent J, Pitt B, Zannad F. Clinical benefits of eplerenone in patients with systolic heart failure and mild symptoms when initiated shortly after hospital discharge: analysis from the EMPHASIS-HF trial. Eur Heart J 2015; 36:2310-7. [PMID: 26093641 DOI: 10.1093/eurheartj/ehv273] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 05/27/2015] [Indexed: 12/25/2022] Open
Abstract
AIMS Cardiovascular hospitalization (CVH) in patients with heart failure (HF) is associated with a high post-discharge rate of early re-admission and CV death. Eplerenone might be effective in reducing the incidence of these adverse clinical outcomes during this period. METHODS AND RESULTS The EMPHASIS-HF trial compared eplerenone with placebo added to standard therapy in 2737 patients with New York Heart Association class II HF and left ventricular ejection fraction ≤35%. We conducted a post hoc analysis in the 2338 patients randomized within 180 days of a CVH. The interaction between the time from the qualifying CVH to randomization and the primary outcome of CV death or hospitalization for HF (HHF), as well as other secondary outcomes, was assessed in Cox survival models. Most of the qualifying CVHs were HHF (N = 1496, 64.0%), acute coronary syndromes (N = 390, 16.7%), and arrhythmias (N = 197, 7.2%). The median time of study drug initiation from qualifying CVH was 42 days. The relative rate reductions in CV death/HHF, HHF, and all-cause mortality were similar (P for interaction = 0.65, 0.44, and 0.40, respectively) whether the treatment was initiated <42 or 42+ days after qualifying CVH. Absolute rate reductions were -5.61 [-8.67, -2.55] events per 100 patient × years in the <42 days group and -3.58 [-6.37, -0.79] in the 42+ days group. The adverse effects of eplerenone were also unaffected by the time from the qualifying CVH. CONCLUSION Eplerenone is safe, improves survival, and may prevent re-admission when initiated soon after a hospitalization for HF or acute coronary syndromes in patients with systolic HF and mild symptoms.
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Affiliation(s)
- Nicolas Girerd
- INSERM, Centre D'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500 Vandoeuvre lès Nancy, France
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Henry Krum
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - John J McMurray
- The British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden National Heart and Lung Institute, Imperial College, London, UK
| | - Dirk J Van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Bertram Pitt
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Faiez Zannad
- INSERM, Centre D'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500 Vandoeuvre lès Nancy, France
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Di Somma S, Magrini L. Drug Therapy for Acute Heart Failure. ACTA ACUST UNITED AC 2015; 68:706-13. [PMID: 26088867 DOI: 10.1016/j.rec.2015.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/10/2015] [Indexed: 01/11/2023]
Abstract
Acute heart failure is globally one of most frequent reasons for hospitalization and still represents a challenge for the choice of the best treatment to improve patient outcome. According to current international guidelines, as soon as patients with acute heart failure arrive at the emergency department, the common therapeutic approach aims to improve their signs and symptoms, correct volume overload, and ameliorate cardiac hemodynamics by increasing vital organ perfusion. Recommended treatment for the early management of acute heart failure is characterized by the use of intravenous diuretics, oxygen, and vasodilators. Although these measures ameliorate the patient's symptoms, they do not favorably impact on short- and long-term mortality. Consequently, there is a pressing need for novel agents in acute heart failure treatment with the result that research in this field is increasing worldwide.
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Affiliation(s)
- Salvatore Di Somma
- Emergency Department Sant'Andrea Hospital, Medical-Surgery Sciences and Translational Medicine, University La Sapienza, Rome, Italy.
| | - Laura Magrini
- Emergency Department Sant'Andrea Hospital, Medical-Surgery Sciences and Translational Medicine, University La Sapienza, Rome, Italy
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Ejaz AA, Mohandas R. Are diuretics harmful in the management of acute kidney injury? Curr Opin Nephrol Hypertens 2014; 23:155-60. [PMID: 24389731 DOI: 10.1097/01.mnh.0000441150.17202.be] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW To assess the role of diuretics in acute kidney injury (AKI) and their effectiveness in preventing AKI, achieving fluid balance, and decreasing progression to chronic kidney disease (CKD). RECENT FINDINGS Diuretics are associated with increased risk for AKI. The theoretical advantage of diuretic-induced preservation of renal medullary oxygenation to prevent AKI has not been proven. A higher cumulative diuretic dose during the dialysis period can cause hypotension and increase mortality in a dose-dependent manner. Data on the use of forced euvolemic diuresis to prevent AKI remains controversial. Positive fluid balance has emerged as an independent predictor of adverse outcomes. Post-AKI furosemide dose had a favorable effect on mortality due in part to the reduction of positive fluid balance. There are exciting experimental data suggesting that spironolactone may prevent AKI once an ischemic insult has occurred and thus prevent the progression to CKD. SUMMARY Diuretics are ineffective and even detrimental in the prevention and treatment of AKI, and neither shorten the duration of AKI, nor reduce the need for renal replacement therapy. Diuretics have an important role in volume management in AKI, but they are not recommended for the prevention of AKI. There is increased emphasis on the prevention of progression of AKI to CKD.
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Affiliation(s)
- A Ahsan Ejaz
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville, Florida, USA
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Piepoli M, Binno S, Villani GQ, Cabassi A. Management of oral chronic pharmacotherapy in patients hospitalized for acute decompensated heart failure. Int J Cardiol 2014; 176:321-6. [DOI: 10.1016/j.ijcard.2014.07.085] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 07/21/2014] [Accepted: 07/26/2014] [Indexed: 11/28/2022]
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Abstract
Millions of patients are hospitalized for acute heart failure (AHF) every year throughout the world. Despite tremendous advances in cardiovascular care, morbidity and mortality for AHF remain high, consuming billions of health care dollars. With the aging of the population, the incidence and prevalence of HF is projected to increase. Yet, initial treatment of AHF today is similar to 40 years ago. Multiple studies have yielded new insights regarding initial management, with regards to both treatment and strategies of care. These advances will be reviewed in the context of initial or early AHF management. There remains, however, an unmet need to improve outcomes for AHF patients.
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Affiliation(s)
- Peter S Pang
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario St, Suite 300, Chicago, IL 60611, USA
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Peck KY, Lim YZ, Hopper I, Krum H. Medical therapy versus implantable cardioverter -defibrillator in preventing sudden cardiac death in patients with left ventricular systolic dysfunction and heart failure: A meta-analysis of >35,000 patients. Int J Cardiol 2014; 173:197-203. [DOI: 10.1016/j.ijcard.2014.02.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 02/02/2014] [Accepted: 02/13/2014] [Indexed: 11/29/2022]
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Ferreira JP, Santos M, Almeida S, Marques I, Bettencourt P, Carvalho H. The role of albuminuria as a non-invasive marker for congestive acutely decompensated chronic heart failure and the spironolactone effect in elderly Portuguese: a non-randomized trial. Nephrology (Carlton) 2014; 19:149-56. [PMID: 24533733 DOI: 10.1111/nep.12188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND/OBJECTIVES Albuminuria is a robust, validated cardiovascular risk factor. It is a simple and widely available test that was shown to be a powerful and independent predictor of prognosis in chronic heart failure. Mineralocorticoid receptor antagonists may reduce the acute and chronic harmful effects of mineralocorticoid receptor activation on the kidney. The objectives of the trial were to compare the effect of spironolactone versus standard acutely decompensated heart failure (ADHF) therapy on albuminuria and to investigate the role of albuminuria as a prognostic marker in patients with ADHF. METHODS Secondary analysis of a prospective, interventional study including 100 patients with ADHF. Fifty patients were non-randomly assigned to spironolactone 100 mg/day plus standard ADHF therapy (intervention group) or standard ADHF therapy alone (control group). RESULTS Patients in control group were older, had higher creatinine and urea levels, and had higher proportion of microalbuminuria (all, P < 0.05). Paired comparison of baseline and day 3 log albuminuria within each group, showed a more pronounced decrease in the intervention group (1.79 ± 0.75 to 1.59 ± 0.67, P = 0.003 vs 1.89 ± 0.70 to 1.79 ± 0.74, P = 0.096). In addition, the proportion of patients with normoalbuminuria increased from baseline to day 3 in spironolactone group (20 (40%) to 27 (54%), P < 001), accordingly the number of patients in the micro and macroalbuminuria groups was reduced. Day 1 albuminuria was positively correlated with day 1 N-terminal pro-brain natriuretic peptide (0.260 [0.105-0.758], P = 0.009). CONCLUSIONS High-dose spironolactone added to standard ADHF therapy is likely to induce a more pronounced albuminuria decrease and a significant reduction in the proportion of micro and macroalbuminuria.
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Ferreira JP, Santos M, Almeida S, Marques I, Bettencourt P, Carvalho H. Mineralocorticoid receptor antagonism in acutely decompensated chronic heart failure. Eur J Intern Med 2014; 25:67-72. [PMID: 24070521 DOI: 10.1016/j.ejim.2013.08.711] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 08/14/2013] [Accepted: 08/14/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND/OBJECTIVES Mineralocorticoid receptor antagonist (MRA) use in acutely decompensated chronic heart failure (ADCHF) may improve congestion through diuretic effect and prevent neurohormonal activation. We aimed to evaluate the clinical effect and safety of spironolactone in ADCHF. METHODS Prospective, experimental, single-center, and single-blinded trial. Patients were treated with: standard ADCHF therapy or oral spironolactone 50-100mg/d plus standard ADCHF therapy. RESULTS During a 1year period, 100 patients were enrolled, 50 included in the treatment group. Mean (SD) spironolactone dose (mg) at day 1 was 94.5±23.3 and at day 3 was 62.7±24.3. Worsening renal function (increase in pCr≥0.3mg/dL from day 1 to day 3) was more likely to occur in control group (20% vs. 4%; p=0.038), serum potassium did not differ between groups, and plasma NTproBNP had a significant decrease in spironolactone group at day 3 (median [IQR], 2488 [4579] vs. 1555 [1832]; p=0.05). Furthermore, a greater proportion of patients in the treatment group were free of congestion at day 3: less edema, rales, jugular venous pressure (JVP) and orthopnea (all, p<0.05). In addition, a significantly higher proportion of patients were on oral furosemide at day 3 (44% vs. 82%; p<0.001). CONCLUSIONS Our study supports the safety of high dose spironolactone in ADCHF and suggests a positive impact in the resolution of congestion. The important findings of our pilot study need to be confirmed in larger trials.
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Affiliation(s)
| | | | - Sofia Almeida
- Climate Change Impacts, Adaptation and Mitigation Research Group (CC-IAM), Faculdade de Ciências, Universidade de Lisboa, Portugal
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Ferreira JP, Santos M, Almeida S, Marques I, Bettencourt P, Carvalho H. Tailoring diuretic therapy in acute heart failure: insight into early diuretic response predictors. Clin Res Cardiol 2013; 102:745-53. [DOI: 10.1007/s00392-013-0588-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 05/31/2013] [Indexed: 11/30/2022]
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Young MJ. Targeting the mineralocorticoid receptor in cardiovascular disease. Expert Opin Ther Targets 2013; 17:321-31. [DOI: 10.1517/14728222.2013.748750] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Rehospitalization for heart failure: problems and perspectives. J Am Coll Cardiol 2012; 61:391-403. [PMID: 23219302 DOI: 10.1016/j.jacc.2012.09.038] [Citation(s) in RCA: 505] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 08/27/2012] [Accepted: 09/11/2012] [Indexed: 12/12/2022]
Abstract
With a prevalence of 5.8 million in the United States alone, heart failure (HF) is associated with high morbidity, mortality, and healthcare expenditures. Close to 1 million hospitalizations for heart failure (HHF) occur annually, accounting for over 6.5 million hospital days and a substantial portion of the estimated $37.2 billion that is spent each year on HF in the United States. Although some progress has been made in reducing mortality in patients hospitalized with HF, rates of rehospitalization continue to rise, and approach 30% within 60 to 90 days of discharge. Approximately half of HHF patients have preserved or relatively preserved ejection fraction (EF). Their post-discharge event rate is similar to those with reduced EF. HF readmission is increasingly being used as a quality metric, a basis for hospital reimbursement, and an outcome measure in HF clinical trials. In order to effectively prevent HF readmissions and improve overall outcomes, it is important to have a complete and longitudinal characterization of HHF patients. This paper highlights management strategies that when properly implemented may help reduce HF rehospitalizations and include adopting a mechanistic approach to cardiac abnormalities, treating noncardiac comorbidities, increasing utilization of evidence-based therapies, and improving care transitions, monitoring, and disease management.
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Lazzarini V, Felker GM. Management of the cardiorenal syndrome in acute heart failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:342-55. [PMID: 22644350 DOI: 10.1007/s11936-012-0186-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OPINION STATEMENT Interactions between the heart and kidney in the setting of acute heart failure are complex and have a substantial impact on patient care and outcomes. Further research is needed to better distinguish the different causes of kidney injury, allow its early and accurate prediction and detection, and identify therapeutic targets. Novel renal biomarkers could potentially provide a useful tool for this purpose. Restoration of optimal fluid status and resolution of renal venous congestion are important goals of therapy. Changes in serum creatinine, although an important marker of renal function, may not be associated with adverse outcomes, especially if they are transient and a consequence of more aggressive decongestion, or the appropriate titration of drugs affecting the renin-angiotensin-aldosterone axis. In addition to loop diuretics, a variety of drugs and strategies have been investigated in acute heart failure. Use of mineralocorticoid receptor antagonists and vasopressin antagonists may have potential benefits and should be further investigated. Inotropic agents should be limited in those clinical settings suggesting hypoperfusion. Ultrafiltration seems to provide a safe and effective tool to overcome diuretic resistance and optimize fluid status avoiding detrimental effects of diuretic therapy.
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Talatinian A, Chow SL, Heywood JT. Expanding Role of Mineralocorticoid Receptor Antagonists in the Treatment of Heart Failure. Pharmacotherapy 2012; 32:827-37. [DOI: 10.1002/j.1875-9114.2012.01104.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Alidz Talatinian
- College of Pharmacy; Western University of Health Sciences; Pomona; California
| | - Sheryl L. Chow
- College of Pharmacy; Western University of Health Sciences; Pomona; California
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Pitt B, Filippatos G, Gheorghiade M, Kober L, Krum H, Ponikowski P, Nowack C, Kolkhof P, Kim SY, Zannad F. Rationale and design of ARTS: a randomized, double-blind study of BAY 94-8862 in patients with chronic heart failure and mild or moderate chronic kidney disease. Eur J Heart Fail 2012; 14:668-75. [PMID: 22562554 DOI: 10.1093/eurjhf/hfs061] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS BAY 94-8862 is a novel, non-steroidal, mineralocorticoid receptor antagonist with greater selectivity than spironolactone and stronger mineralocorticoid receptor binding affinity than eplerenone. The aims of the MinerAlocorticoid Receptor Antagonist Tolerability Study (ARTS; NCT01345656) are to evaluate the safety and tolerability of BAY 94-8862 in patients with heart failure associated with a reduced left ventricular ejection fraction (HFREF) and chronic kidney disease (CKD), and to examine the effects on biomarkers of cardiac and renal function. Methods ARTS is a multicentre, randomized, double-blind, placebo-controlled, parallel-group study divided into two parts. In part A, oral BAY 94-8862 [2.5, 5, or 10 mg once daily (o.d.)] is compared with placebo in ∼60 patients with HFREF and mild CKD. Outcome measures include serum potassium concentration, biomarkers of renal injury, estimated glomerular filtration rate (eGFR), and albuminuria. Part B compares BAY 94-8862 (2.5, 5, or 10 mg o.d., or 5 mg twice daily), placebo, and open-label spironolactone (25-50 mg o.d.) in ∼360 patients with HFREF and moderate CKD. Outcome measures include the change in serum potassium concentration with BAY 94-8862 vs. placebo (primary endpoint) and vs. spironolactone, safety and tolerability, biomarkers of cardiac and renal function or injury, eGFR, and albuminuria. BAY 94-8862 pharmacokinetics are also assessed. Perspectives ARTS is the first phase II clinical trial of BAY 94-8862 and is expected to provide a wealth of information on BAY 94-8862 in patients with HFREF and CKD, including the optimal dose range for further studies.
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Affiliation(s)
- Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, MI 48109-0366, USA.
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