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Kobayashi M, Yamashina A, Satomi K, Tezuka A, Ito S, Asakura M, Kitakaze M, Ferreira JP. Adverse events associated with early initiation of Eplerenone in patients hospitalized for acute heart failure. Int J Cardiol 2024; 415:132477. [PMID: 39181408 DOI: 10.1016/j.ijcard.2024.132477] [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: 03/08/2024] [Revised: 07/17/2024] [Accepted: 08/20/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND The guidelines recommend the initiation or up-titration of heart failure (HF) treatments following an HF hospitalization; however, concerns about adverse events may limit the use of mineralocorticoid receptor antagonists (MRAs). Patient profiles or disease severity might impact adverse events associated with MRA therapy in acute HF. METHODS The EARLIER trial included patients with acute HF who were randomized to eplerenone or placebo over 6 months. Adverse events (i.e., worsening renal function [WRF], hyperkalemia, hypotension, and volume depletion/dehydration) were assessed. HF-related outcome included a composite of all-cause mortality, HF re-hospitalization, investigator-reported worsening HF and out-of-hospital diuretic intensification. RESULTS In 297 patients (mean age: 67 ± 13 years; 73% males), adverse events were observed: 44.4% experienced WRF (>20% drop in estimated glomerular filtration rate[eGFR] and/or investigator-reported WRF), 8.4% had hyperkalemia (potassium >5.5 mmol/L and/or investigator-reported hyperkalemia), 27.9% experienced hypotension (systolic blood pressure[SBP] <90 mmHg and/or investigator-reported hypotension), and 16.8% had investigator-reported volume depletion/dehydration. Eplerenone vs. placebo did not elevate the incidence of these events (all-p-values>0.0 5). Multivariable analyses revealed that, irrespective of treatment allocation, older age (>7 5 years), prevalent diabetes, symptomatic congestion, and microalbuminuria were associated with increased risk of WRF. Baseline eGFR<60 ml/min/1.73m2 and SBP < 90 mmHg predicted hyperkalemia and hypotension, respectively, while older patients were more likely to experience volume depletion/dehydration. However, these patient profiles did not alter the benefit of eplerenone on outcomes (HR [9 5%CI] = 0.53 [0.29 to 0.97], P = 0.04; all-p-for-interaction>0.10). CONCLUSION Eplerenone did not increase adverse events compared with placebo in acute HF. Importantly, disease severity and comorbidity burden greatly influence adverse events, but not benefit from eplerenone.
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Affiliation(s)
| | | | - Kazuhiro Satomi
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Ayako Tezuka
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Shin Ito
- Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, Hyogo, Japan
| | - Masafumi Kitakaze
- Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Osaka, Japan; Hanwa Memorial Hospital, Osaka, Japan
| | - João Pedro Ferreira
- Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal; Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
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Chen D, Yun X, Lee D, DiCostanzo JR, Donini O, Shikuma CM, Thompson K, Lehrer AT, Shimoda L, Suk JS. Telmisartan Nanosuspension for Inhaled Therapy of COVID-19 Lung Disease and Other Respiratory Infections. Mol Pharm 2023; 20:750-757. [PMID: 36448927 PMCID: PMC9718101 DOI: 10.1021/acs.molpharmaceut.2c00448] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 12/03/2022]
Abstract
Vaccine hesitancy and the occurrence of elusive variants necessitate further treatment options for coronavirus disease 2019 (COVID-19). Accumulated evidence indicates that clinically used hypertensive drugs, angiotensin receptor blockers (ARBs), may benefit patients by mitigating disease severity and/or viral propagation. However, current clinical formulations administered orally pose systemic safety concerns and likely require a very high dose to achieve the desired therapeutic window in the lung. To address these limitations, we have developed a nanosuspension formulation of an ARB, entirely based on clinically approved materials, for inhaled treatment of COVID-19. We confirmed in vitro that our formulation exhibits physiological stability, inherent drug activity, and inhibitory effect against SARV-CoV-2 replication. Our formulation also demonstrates excellent lung pharmacokinetics and acceptable tolerability in rodents and/or nonhuman primates following direct administration into the lung. Thus, we are currently pursuing clinical development of our formulation for its uses in patients with COVID-19 or other respiratory infections.
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Affiliation(s)
- Daiqin Chen
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Xin Yun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Daiheon Lee
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | | | | | - Cecilia M. Shikuma
- Department of Medicine, John A. Burns School of Medicine, University of Hawaiʻi at Mānoa, Honolulu, HI 96813, USA
| | - Karen Thompson
- Department of Pathology, John A. Burns School of Medicine, University of Hawaiʻi at Mānoa, Honolulu, HI 96813, USA
| | - Axel T. Lehrer
- Department of Tropical Medicine, Medical Microbiology & Pharmacology, John A. Burns School of Medicine, University of Hawaiʻi at Mānoa, Honolulu, HI 96813, USA
| | - Larissa Shimoda
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jung Soo Suk
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
- Department of Chemical & Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
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Masarone D, Pacileo R, Pacileo G. Use of disease-modifying drugs in diabetic patients with heart failure with reduced ejection fraction. Heart Fail Rev 2021; 28:657-665. [PMID: 34734359 DOI: 10.1007/s10741-021-10189-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 12/11/2022]
Abstract
Type 2 diabetes mellitus and heart failure are closely related, patients with type 2 diabetes mellitus have a higher risk of developing heart failure, and those with heart failure are at increased risk of developing type 2 diabetes. Although no specific randomized clinical trials have been conducted to test the effect of cardiovascular therapies (drugs and/or devices) in diabetic patients with heart failure, a lot of evidence shows that all interventions effective in improving prognosis in patients with heart failure reduced ejection fraction are equally beneficial in patients with and without diabetes. However, the use of disease-modifying drugs in patients with diabetes and heart failure reduced ejection fraction is a clinical challenge due to the increased risk of adverse effects. For example, β-blockers are underutilized in diabetic patients due to the theoretical unfavorable effects on glucose metabolism as well as the use of drugs that interact with the renin-angiotensin system can be challenged in patients with diabetic nephropathy because of the risk of hyperkalemia. This review outlines the current use of disease-modifying drugs in diabetic patients with heart failure reduced ejection fraction. In addition, the role of novel pharmacologic agents as type 2 sodium-glucose co-transporter inhibitors (SGLT2ii) is discussed.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, Via Leonardo Bianchi 1, 80100, Naples, Italy.
| | - Roberta Pacileo
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, Via Leonardo Bianchi 1, 80100, Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, Via Leonardo Bianchi 1, 80100, Naples, Italy
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Farrero M, Bellumkonda L, Gómez Otero I, Díaz Molina B. Sex and Heart Failure Treatment Prescription and Adherence. Front Cardiovasc Med 2021; 8:630141. [PMID: 34026865 PMCID: PMC8137967 DOI: 10.3389/fcvm.2021.630141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/26/2021] [Indexed: 12/11/2022] Open
Abstract
Heart disease is the leading cause of death in both men and women in developed countries. Heart failure (HF) contributes to significant morbidity and mortality and continues to remain on the rise. While advances in pharmacological therapies have improved its prognosis, there remain a number of unanswered questions regarding the impact of these therapies in women. Current HF guidelines recommend up-titration of neurohormonal blockade, to the same target doses in both men and women but several factors may impair achieving this goal in women: more adverse drug reactions, reduced adherence and even lack of evidence on the optimal drug dose. Systematic under-representation of women in cardiovascular drug trials hinders the identification of sex differences in the efficacy and safety of cardiovascular medications. Women are also under-represented in device therapy trials and are 30% less likely to receive a device in clinical practice. Despite presenting with fewer ventricular arrythmias and having an increased risk of implant complications, women show better response to resynchronization therapy, with lower mortality and HF hospitalizations. Fewer women receive advanced HF therapies. They have a better post-heart transplant survival compared to men, but an increased immunological risk needs to be acknowledged. Technological advances in mechanical circulatory support, with smaller and more hemocompatible devices, will likely increase their implantation in women. This review outlines current evidence regarding sex-related differences in prescription, adherence, adverse events, and prognostic impact of the main management strategies for HF.
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Affiliation(s)
- Marta Farrero
- Heart Failure Unit, Cardiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Inés Gómez Otero
- Heart Failure Unit, Cardiology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red Enfermedades CardioVasculares (CIBERCV), Madrid, Spain.,Cardiology Group, Health Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Beatriz Díaz Molina
- Heart Failure Unit, Cardiology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Health Research Institute of Principado de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (IISPA), Oviedo, Spain
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Kobayashi M, Voors AA, Ouwerkerk W, Duarte K, Girerd N, Rossignol P, Metra M, Lang CC, Ng LL, Filippatos G, Dickstein K, van Veldhuisen DJ, Zannad F, Ferreira JP. Perceived risk profile and treatment optimization in heart failure: an analysis from BIOlogy Study to TAilored Treatment in chronic heart failure. Clin Cardiol 2021; 44:780-788. [PMID: 33960439 PMCID: PMC8207977 DOI: 10.1002/clc.23576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/07/2021] [Accepted: 02/08/2021] [Indexed: 12/21/2022] Open
Abstract
Background Achieving target doses of angiotensin‐converting‐enzyme inhibitor/angiotensin‐receptor blockers (ACEi/ARB) and beta‐blockers in heart failure with reduced ejection fraction (HFrEF) is often underperformed. In BIOlogy Study to TAilored Treatment in chronic heart failure (BIOSTAT‐CHF) study, many patients were not up‐titrated for which no clear reason was reported. Therefore, we hypothesized that perceived‐risk profile might influence treatment optimization. Methods We studied 2100 patients with HFrEF (LVEF≤40%) to compare the clinical characteristics and adverse events associated with treatment up‐titration (after a 3‐month titration protocol) between; a) patients not reaching target doses for unclear reason; b) patients not reaching target doses due to symptoms and/or side effects; c) patients reaching target doses. Results For ACEi/ARB, (a), (b) and (c) was observed in 51.3%, 25.9% and 22.7% of patients, respectively. For beta‐blockers, (a), (b) and (c) was observed in 67.5%, 20.2% and 12.3% of patients, respectively. By multinomial logistic regression analysis for ACEi/ARB, patients in group (a) and (b) had lower blood pressure and poorer renal function, and patients in group (a) were older and had lower ejection fraction. For beta‐blockers, patients in group (a) and (b) had more severe congestion and lower heart rate. At 9 months, adverse events (i.e., hypotension, bradycardia, renal impairment, and hyperkalemia) occurred similarly among the three groups. Conclusions Patients in whom clinicians did not give a reason why up‐titration was missed were older and had more co‐morbidities. Patients in whom up‐titration was achieved did not have excess adverse events. However, from these observational findings, the pattern of subsequent adverse events among patients in whom up‐titration was missed cannot be determined.
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Affiliation(s)
- Masatake Kobayashi
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Hospital Drive, Singapore.,Department of Dermatology, Amsterdam UMC, Amsterdam Infection & Immunity Institute, University of Amsterdam, Amsterdam, Netherlands
| | - Kevin Duarte
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Patrick Rossignol
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Marco Metra
- Cardiology. University and Civil hospitals of Brescia, Brescia, Italy
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | | | - Kenneth Dickstein
- Department of Internal Medicine, University of Bergen, Bergen, Norway.,Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
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Hyperkalemia and management of renin-angiotensin-aldosterone system inhibitors in chronic heart failure with reduced ejection fraction: A systematic review. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Fonseca C, Brito D, Branco P, Frazão JM, Silva-Cardoso J, Bettencourt P. Hyperkalemia and management of renin-angiotensin-aldosterone system inhibitors in chronic heart failure with reduced ejection fraction: A systematic review. Rev Port Cardiol 2020; 39:517-541. [PMID: 32868174 DOI: 10.1016/j.repc.2020.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 01/17/2020] [Accepted: 03/23/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Renin-angiotensin-aldosterone system inhibitors (RAASi) are the cornerstone of treatment of heart failure with reduced ejection fraction (HFrEF). RAASi optimization in real-life care is challenged by hyperkalemia, a potentially fatal adverse event, which can necessitate downtitration or discontinuation of RAASi and negatively impact survival in HFrEF. The literature on this problem is sparse. We performed a systematic review of studies on HFrEF to investigate the prevalence, incidence, and risk factors of hyperkalemia, RAASi prescription rates, frequency of RAASi downtitration or discontinuation due to hyperkalemia, and the potential negative effect of the latter on prognosis. METHODS We conducted a MEDLINE (PubMed) search including observational and interventional studies published between January 1987 and May 2018. RESULTS A total of 30 observational and 18 interventional studies were included in the review. The incidence of hyperkalemia reported was between 0% and 63% in observational studies and was between 0% and 30% in clinical trials. Risk factors for hyperkalemia included RAASi prescription, older age, diabetes, and chronic kidney disease. In real-life studies, RAASi were downtitrated or discontinued in 3-22% of HFrEF patients; hyperkalemia was the reported cause in 5% of cases. No reports were found on the impact on prognosis of RAASi downtitration or discontinuation due to hyperkalemia. CONCLUSIONS Hyperkalemia and RAASi downtitration or discontinuation are frequent, particularly in real-life HFrEF studies. Further research is needed to clarify the role of RAASi downtitration or discontinuation due to hyperkalemia and to assess its long-term prognostic impact in HFrEF patients.
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Affiliation(s)
- Cândida Fonseca
- Heart Failure Clinic, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisboa, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal.
| | - Dulce Brito
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte (CHLN), Lisboa, Portugal; CCUL, Faculty of Medicine, Universidade de Lisboa, Lisboa, Portugal
| | - Patrícia Branco
- Nephrology Department, Santa Cruz Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), Carnaxide, Portugal
| | - João Miguel Frazão
- Institute for Research and Innovation in Health Sciences (i3S) and Institute for Biomedical Engineering (INEB), Universidade do Porto, Porto, Portugal; Nephrology Department, Centro Hospitalar Universitário de São João (CHUSJ) and Faculty of Medicine, Universidade do Porto, Porto, Portugal
| | - José Silva-Cardoso
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal; Cardiology Department, Centro Hospitalar Universitário de São João (CHUSJ), Porto, Portugal
| | - Paulo Bettencourt
- Internal Medicine Department, CUF Porto Hospital, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
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Adverse Drug Reactions to Guideline-Recommended Heart Failure Drugs in Women: A Systematic Review of the Literature. JACC-HEART FAILURE 2020; 7:258-266. [PMID: 30819382 DOI: 10.1016/j.jchf.2019.01.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES This study sought to summarize all available evidence on sex differences in adverse drug reactions (ADRs) to heart failure (HF) medication. BACKGROUND Women are more likely to experience ADRs than men, and these reactions may negatively affect women's immediate and long-term health. HF in particular is associated with increased ADR risk because of the high number of comorbidities and older age. However, little is known about ADRs in women with HF who are treated with guideline-recommended drugs. METHODS A systematic search of PubMed and EMBASE was performed to collect all available information on ADRs to angiotensin-converting enzyme inhibitors, β-blockers, angiotensin II receptor blockers, mineralocorticoid receptor antagonists, ivabradine, and digoxin in both women and men with HF. RESULTS The search identified 155 eligible records, of which only 11 (7%) reported ADR data for women and men separately. Sex-stratified reporting of ADRs did not increase over the last decades. Six of the 11 studies did not report sex differences. Three studies reported a higher risk of angiotensin-converting enzyme inhibitor-related ADRs in women, 1 study showed higher digoxin-related mortality risk for women, and 1 study reported a higher risk of mineralocorticoid receptor antagonist-related ADRs in men. No sex differences in ADRs were reported for angiotensin II receptor blockers and β-blockers. Sex-stratified data were not available for ivabradine. CONCLUSIONS These results underline the scarcity of ADR data stratified by sex. The study investigators call for a change in standard scientific practice toward reporting of ADR data for women and men separately.
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GF, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Marinella Ruospo
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Patrizia Natale
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Robert R Quinn
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Paul E Ronksley
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical Center, Department of Medicine, 3459 Fifth Avenue, Pittsburgh, PA, USA, 15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of Otago, Department of Medicine, Nephrologist, Christchurch, New Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Giovanni Fm Strippoli
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
- The Children's Hospital at Westmead, Cochrane Kidney and Transplant, Centre for Kidney Research, Westmead, NSW, Australia, 2145
| | - Pietro Ravani
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
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Bashier A, Bin Hussain A, Abdelgadir E, Alawadi F, Sabbour H, Chilton R. Consensus recommendations for management of patients with type 2 diabetes mellitus and cardiovascular diseases. Diabetol Metab Syndr 2019; 11:80. [PMID: 31572499 PMCID: PMC6761728 DOI: 10.1186/s13098-019-0476-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/19/2019] [Indexed: 02/12/2023] Open
Abstract
The recent American Diabetes Association and the European Association for the Study of Diabetes guideline mentioned glycaemia management in type 2 diabetes mellitus (T2DM) patients with cardiovascular diseases (CVDs); however, it did not cover the treatment approaches for patients with T2DM having a high risk of CVD, and treatment and screening approaches for CVDs in patients with concomitant T2DM. This consensus guideline undertakes the data obtained from all the cardiovascular outcome trials (CVOTs) to propose approaches for the T2DM management in presence of CV comorbidities. For patients at high risk of CVD, metformin is the drug of choice to manage the T2DM to achieve a patient specific HbA1c target. In case of established CVD, a combination of glucagon-like peptide-1 receptor agonist with proven CV benefits is recommended along with metformin, while for chronic kidney disease or heart failure, a sodium-glucose transporter proteins-2 inhibitor with proven benefit is advised. This document also summarises various screening and investigational approaches for the major CV events with their accuracy and specificity along with the treatment guidance to assist the healthcare professionals in selecting the best management strategies for every individual. Since lifestyle modification and management plays an important role in maintaining the effectiveness of the pharmacological therapies, authors of this consensus recommendation have also briefed on the patient-centric non-pharmacological management of T2DM and CVD.
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Affiliation(s)
- Alaaeldin Bashier
- Department of Endocrinology, Dubai Health Authority, Dubai Hospital, P.O. Box 94132, Dubai, UAE
| | - Azza Bin Hussain
- Department of Endocrinology, Dubai Health Authority, Dubai Hospital, P.O. Box 94132, Dubai, UAE
| | - Elamin Abdelgadir
- Department of Endocrinology, Dubai Health Authority, Dubai Hospital, P.O. Box 94132, Dubai, UAE
| | - Fatheya Alawadi
- Department of Endocrinology, Dubai Health Authority, Dubai Hospital, P.O. Box 94132, Dubai, UAE
| | - Hani Sabbour
- Cleveland Clinic Abu Dhabi, Heart and Vascular Institute, Al Maryah Island, Abu Dhabi, UAE
| | - Robert Chilton
- Division of Cardiology, University of Texas Health Science Center, Audie L Murphy VA Hospital, San Antonio, TX USA
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Vardeny O, Claggett B, Kachadourian J, Pearson SM, Desai AS, Packer M, Rouleau J, Zile MR, Swedberg K, Lefkowitz M, Shi V, McMurray JJV, Solomon SD. Incidence, Predictors, and Outcomes Associated With Hypotensive Episodes Among Heart Failure Patients Receiving Sacubitril/Valsartan or Enalapril: The PARADIGM-HF Trial (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure). Circ Heart Fail 2019; 11:e004745. [PMID: 29643067 DOI: 10.1161/circheartfailure.117.004745] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 03/02/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND In PARADIGM-HF (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure), heart failure treatment with sacubitril/valsartan reduced the primary composite outcome of cardiovascular death or heart failure hospitalization compared with enalapril but resulted in more symptomatic hypotension. Concern on hypotension may be limiting use of sacubitril/valsartan in appropriate patients. METHODS AND RESULTS We characterized patients in PARADIGM-HF by whether they reported hypotension during study run-in periods (enalapril, followed by sacubitril/valsartan) and after randomization and assessed whether hypotension modified the efficacy of sacubitril/valsartan. Of the 10 513 patients entering the enalapril run-in, 136 (1.3%) experienced hypotension and 93 (68%) were unable to continue to the next phase; of 9419 patients entering the sacubitril/valsartan run-in period, 228 (2.4%) patients experienced hypotension and 51% were unable to successfully complete the run-in. After randomization, 388 (9.2%) participants had 501 hypotensive events with enalapril, and 588 (14.0%) participants had 803 hypotensive events with sacubitril/valsartan (P<0.001). There was no difference between randomized treatment groups in the number of participants who discontinued therapy because of hypotension. Individuals with a hypotensive event in either group were older, had lower blood pressure at randomization, and were more likely to have an implantable cardioverter defibrillator. Participants with hypotensive events during run-in who were ultimately randomized derived similar efficacy from sacubitril/valsartan compared with enalapril as those without hypotensive events (P interaction>0.90). CONCLUSIONS Hypotension was more common with sacubitril/valsartan relative to enalapril in PARADIGM-HF but did not differentially affect permanent discontinuations. Patients with hypotension during run-in derived similar benefit from sacubitril/valsartan compared with enalapril as those who did not experience hypotension.
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Affiliation(s)
- Orly Vardeny
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Brian Claggett
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Jessica Kachadourian
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Scott M Pearson
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Akshay S Desai
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Milton Packer
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Jean Rouleau
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Michael R Zile
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Karl Swedberg
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Martin Lefkowitz
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Victor Shi
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - John J V McMurray
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Scott D Solomon
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.).
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Abstract
Hyperkalaemia causes significant burden, and even mild hyperkalaemia has been independently associated with increased morbidity and mortality. Patients with chronic disease states, such as heart failure, hypertension, chronic kidney disease and diabetes mellitus, are increasingly susceptible to the development of hyperkalaemia. Options for management of hyperkalaemia had mainly been limited to short-term, temporizing methods with focus on rapid achievement of normokalaemia. Until recently, there was a lack of safe, efficacious and well-tolerated therapies for long-term management. Two novel potassium binders, patiromer and sodium zirconium cyclosilicate, have recently been approved by the US Food and Drug Administration for the management of hyperkalaemia. This review discusses these potassium binders with focus largely on the clinical implications of these agents in patients with chronic cardiovascular conditions.
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Affiliation(s)
- Shilpa Vijayakumar
- Department of Medicine, Stony Brook University, 101 Nicolls Road, Stony Brook, NY, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, 2500 North State Street, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin-Brandenburg Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany; and
- Department of Cardiology, Universityätsmedizin Göttingen (UMG), Göttingen, Germany
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The Utility of 5 Hypothetical Health States in Heart Failure Using Time Trade-Off (TTO) and EQ-5D-5L in Korea. Clin Drug Investig 2018; 38:727-736. [PMID: 29804184 DOI: 10.1007/s40261-018-0659-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Utility provides a preference for specific health state in economic evaluation, and they obtained from general population could be useful in respect of societal resource allocation. We aimed to investigate the utilities of health states for heart failure (HF), a major and growing public health problem, related to hospitalization and adverse drug effects by interrogating the general Korean population. METHODS Five health states for patients with HF were developed based on literature reviews: stable chronic heart failure (SCHF), hospitalization, SCHF + cough, SCHF + hypotension, and SCHF + hyperkalemia. We selected 100 individuals from the general population through quota sampling by age, sex, and region, and conducted face-to-face interviews. We measured utilities for 5 hypothetical health states of HF using both time trade-off (TTO) and EuroQol-5 dimensions-5 levels (EQ-5D-5L). Repeated-measures analysis of variance compared the utilities between all health states for each instrument. To identify the factors affecting the utility, a linear mixed model (LMM) analysis was performed. RESULTS The mean utility value for SCHF, SCHF + cough, SCHF + hypotension, SCHF + hyperkalemia, and hospitalization was calculated as 0.815, 0.732, 0.646, 0.548, and 0.360, respectively, by using TTO. The respective values using EQ-5D-5L were 0.871, 0.793, 0.710, 0.589, and 0.215. The utilities for HF significantly differed between all health states in each instrument (p < 0.001). In LMM analysis, hospitalization had a significantly negative effect on the utilities of both instruments. CONCLUSIONS The utilities decreased in order of SCHF, SCHF + cough, SCHF + hypotension, SCHF + hyperkalemia, and hospitalization. These results can be useful for decision making in resource allocation for HF interventions.
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14
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Stilhano RS, Samoto VY, Silva LM, Pereira GJ, Erustes AG, Smaili SS, Won Han S. Reduction in skeletal muscle fibrosis of spontaneously hypertensive rats after laceration by microRNA targeting angiotensin II receptor. PLoS One 2017; 12:e0186719. [PMID: 29059221 PMCID: PMC5653346 DOI: 10.1371/journal.pone.0186719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 10/08/2017] [Indexed: 12/23/2022] Open
Abstract
Regeneration of injured skeletal muscles is affected by fibrosis, which can be improved by the administration of angiotensin II (AngII) receptor (ATR) blockers in normotensive animals. However, the role of ATR in skeletal muscle fibrosis in hypertensive organisms has not been investigated yet. The tibialis anterior (TA) muscle of spontaneously hypertensive (SHR) and Wistar rats (WR) were lacerated and a lentivector encoding a microRNA targeting AngII receptor type 1 (At1) (Lv-mirAT1a) or control (Lv-mirCTL) was injected. The TA muscles were collected after 30 days to evaluate fibrosis by histology and gene expression by real-time quantitative PCR (RT-qPCR) and Western blot. SHR's myoblasts were analyzed by RT-qPCR, 48 h after transduction. In the SHR's TA, AT1 protein expression was 23.5-fold higher than in WR without injury, but no difference was observed in the angiotensin II receptor type 2 (AT2) protein expression. TA laceration followed by suture (LS) produced fibrosis in the SHR (23.3±8.5%) and WR (7.9±1.5%). Lv-mirAT1 treatment decreased At1 gene expression in 50% and reduced fibrosis to 7% 30 days after. RT-qPCR showed that reduction in At1 expression is due to downregulation of the At1a but not of the At1b. RT-qPCR of myoblasts from SHR transduced with Lv-mirAT1a showed downregulation of the Tgf-b1, Tgf-b2, Smad3, Col1a1, and Col3a1 genes by mirAT1a. In vivo and in vitro studies indicate that hypertension overproduces skeletal muscle fibrosis, and AngII-AT1a signaling is the main pathway of fibrosis in SHR. Moreover, muscle fibrosis can be treated specifically by in loco injection of Lv-mirAT1a without affecting other organs.
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Affiliation(s)
- Roberta Sessa Stilhano
- Department of Biophysics, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Vivian Yochiko Samoto
- Department of Biophysics, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Leonardo Martins Silva
- Department of Biophysics, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Gustavo José Pereira
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Adolfo Garcia Erustes
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Soraya Soubhi Smaili
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Sang Won Han
- Department of Biophysics, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
- * E-mail:
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15
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Abstract
Renal disease and cardiovascular disease are commonly encountered in the same patient. The dynamic interactions between renal disease and cardiovascular disease have an impact on perioperative management. Renal failure is an independent risk factor for cardiovascular disease and the link between the two disease states remains to be fully elucidated.
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Omae K, Ogawa T, Yoshikawa M, Sakura H, Nitta K. Impact of serum potassium on therapeutic prognosis of maintenance hemodialysis patients on angiotensin receptor antagonists. RENAL REPLACEMENT THERAPY 2016. [DOI: 10.1186/s41100-016-0026-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Pellicori P, Clark AL. Clinical trials update from the European Society of Cardiology-Heart Failure meeting 2015: AUGMENT-HF, TITRATION, STOP-HF, HARMONIZE, LION HEART, MOOD-HF, and renin-angiotensin inhibitors in patients with heart and renal failure. Eur J Heart Fail 2015; 17:979-83. [PMID: 26289928 DOI: 10.1002/ejhf.340] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 07/14/2015] [Accepted: 07/17/2015] [Indexed: 11/08/2022] Open
Abstract
This article provides an overview on the key trials relevant to the pathophysiology, prevention, and treatment of heart failure (HF) presented at the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) annual meeting held in Seville, Spain in May 2015. Trials reported include AUGMENT-AF (myocardial injections of calcium-alginate hydrogel), a propensity score-matched study of renin-angiotensin system antagonists in patients with HF and severe renal dysfunction, HARMONIZE (sodium zirconium cyclosilicate used to bind potassium), TITRATION, comparing two regimes for introducing LCZ696, STOP-HF, a trial of intramyocardial stromal cell-derived factor-1, MOOD-HF (escitalopram for patients with heart failure and depression), and LION HEART, a trial of intermittent levosimendan therapy. Unpublished reports should be considered as preliminary, since analyses may change in the final publication.
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Affiliation(s)
- Pierpaolo Pellicori
- Hull York Medical School, Castle Hill Hospital, Castle Road, Cottingham, Kingston upon Hull, UK
| | - Andrew L Clark
- Hull York Medical School, Castle Hill Hospital, Castle Road, Cottingham, Kingston upon Hull, UK
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Elgendy IY, Huo T, Chik V, Pepine CJ, Bavry AA. Efficacy and safety of angiotensin receptor blockers in older patients: a meta-analysis of randomized trials. Am J Hypertens 2015; 28:576-85. [PMID: 25391580 DOI: 10.1093/ajh/hpu209] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 09/29/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The efficacy and safety of angiotensin receptor blockers (ARBs) in the older population is unclear. OBJECTIVES To determine the efficacy and safety of ARBs in older patients. METHODS Randomized trials that compared ARBs to control and reported clinical outcomes in patients with a mean age of 65 years or older were included. Random-effects summary risk ratios (RRs) were constructed. RESULTS A total of 16 trials met our selection criteria, which yielded 113,386 patients. ARBs were associated with a marginal increased risk of all-cause mortality (RR: 1.03, 95% confidence interval (CI): 1.00-1.06, P = 0.05), a nonsignificant increased risk of myocardial infarction (RR: 1.04, 95% CI: 0.96-1.12, P = 0.36), a marginal reduction in heart failure hospitalization (RR: 0.86, 95% CI: 0.74-1.00, P = 0.06), and a significant reduction in the risk of stroke (RR: 0.93, 95% CI: 0.87-0.99, P = 0.03). ARBs were associated with an increased risk of acute kidney injury (RR: 1.48, 95% CI: 1.24-1.77, P < 0.001), hypotension (RR: 1.56, 95% CI: 1.24-1.97, P < 0.001), and hyperkalemia (RR: 1.57, 95% CI: 1.13-2.19, P = 0.008). On the sensitivity analysis including placebo-controlled trials, the risk of all-cause mortality was no longer significant (P = 0.2), while the remainder of the outcomes did not change. CONCLUSION In older patients, the benefit of ARBs compared with control was strongest for stroke reduction, with no (or weak) associations for all-cause mortality, myocardial infarction, and heart failure hospitalization. Benefit was offset by an increased risk of acute kidney injury, hypotension, and hyperkalemia. Thus, ARBs should be used with caution in older patients when clinically indicated.
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Affiliation(s)
- Islam Y Elgendy
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Tianyao Huo
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Veronica Chik
- North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Anthony A Bavry
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA; North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA.
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Kiernan MS, Gregory D, Sarnak MJ, Rossignol P, Massaro J, Kociol R, Zannad F, Konstam MA. Early and Late Effects of High- Versus Low-Dose Angiotensin Receptor Blockade on Renal Function and Outcomes in Patients With Chronic Heart Failure. JACC-HEART FAILURE 2015; 3:214-23. [DOI: 10.1016/j.jchf.2014.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 11/14/2014] [Indexed: 01/13/2023]
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Characterization and Prediction of Adverse Events From Intensive Chronic Heart Failure Management and Effect on Quality of Life: Results From the Pro-B-Type Natriuretic Peptide Outpatient-Tailored Chronic Heart Failure Therapy (PROTECT) Study. J Card Fail 2015; 21:9-15. [DOI: 10.1016/j.cardfail.2014.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 10/01/2014] [Accepted: 10/13/2014] [Indexed: 11/23/2022]
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Abstract
Angiotensin II (AII), an octapeptide member of the renin-angiotensin system (RAS), is formed by the enzyme angiotensin converting enzyme (ACE) and exerts adverse cellular effects through an interaction with its type 1 receptor (AT1R). Both ACE inhibitors and angiotensin receptor blockers (ARB) mitigate the vasoconstrictive, proliferative, proinflammatory, proapoptotic, and profibrotic effects of AII and are widely used as effective anti-remodeling agents in clinical practice. Prediction of individual response to these agents, however, remains problematic and is influenced by many factors including race, gender, and genotype. In addition, systemic and tissue RAS activity do not correlate closely. This report summarizes the results of on-going attempts to noninvasively determine tissue ACE activity and AT1R expression using novel nuclear tracers. It is hoped that the availability of such imaging techniques improve treatment of heart failure through more selective pharmacologic intervention and better dose titration of available drugs.
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22
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Abstract
Heart failure is one of the most prevalent cardiovascular diseases in the United States, and is associated with significant morbidity, mortality, and costs. Prompt diagnosis may help decrease mortality, hospital stay, and costs related to treatment. A complete heart failure evaluation comprises a comprehensive history and physical examination, echocardiogram, and diagnostic tools that provide information regarding the etiology of heart failure, related complications, and prognosis in order to prescribe appropriate therapy, monitor response to therapy, and transition expeditiously to advanced therapies when needed. Emerging technologies and biomarkers may provide better risk stratification and more accurate determination of cause and progression.
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Affiliation(s)
- Maria Patarroyo-Aponte
- Division of Cardiovascular Medicine, University of Minnesota Medical Center, Lillehei Heart Institute, University of Minnesota, 420 Delaware Street Southeast, MMC 508, Minneapolis, MN 55455, USA
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Zhang YY, Li JN, Xia HHX, Zhang SL, Zhong J, Wu YY, Miao SK, Zhou LM. Protective effects of losartan in mice with chronic viral myocarditis induced by coxsackievirus B3. Life Sci 2013; 92:1186-94. [PMID: 23702425 DOI: 10.1016/j.lfs.2013.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 04/14/2013] [Accepted: 05/08/2013] [Indexed: 02/07/2023]
Abstract
AIM To investigate whether losartan has protective effects in mice with chronic viral myocarditis induced by coxsackievirus B3 (CVB3). MAIN METHODS Thirty two male Balb/c mice were intraperitoneally injected with CVB3 (10×TCID50) to induce chronic viral myocarditis (CVM). Losartan at 12.5mg/kg (n=16) or normal saline (n=16) were orally administered daily for 28 days to these mice. Uninfected mice (n=6) were used as controls. On day 29, all mice underwent anesthesia and echocardiography prior to sacrifice. Serum IL-17, IL-4, IFN-γ and TNF-α levels were measured by enzyme-linked immunosorbent assay, and cardiac tissues were histologically examined after hematoxylin & eosin staining. In addition, the effect of losartan on the virus titers in primary cultured neonatal rat cardiomyocytes infected with CVB3 was measured on Hep-2 cells at 72 h post infection. KEY FINDINGS Mice infected with CBV3 had significantly increased mortality, heart/body weight ratios, necrosis and inflammatory scores and decreased cardiac ejection fractions, compared with the controls (all P<0.05). Losartan significantly decreased mortality from 40.0% to 12.5%, heart/body weight ratios from 7.08 ± 2.17 to 4.15 ± 0.99, and necrosis and inflammatory scores from 3.33 ± 0.50 to 2.50 ± 0.65 (all P<0.05), and increased ejection fractions from 55.80 ± 9.25 to 72.31 ± 12.15 (P<0.05). Losartan significantly enhanced IL-4, and decreased IFN-γ, TNF-α and IL-17 (all P<0.05). In the in vitro experiment, losartan had no influence on virus titers. SIGNIFICANCE Losartan protects mice against CVB3-induced CVM, most likely through upregulating Th2 responses, and down-regulating Th1 and Th17 responses.
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Affiliation(s)
- Yuan-Yuan Zhang
- Department of Pharmacology, West China School of Preclinical and Forensic Medicine, Sichuan University, Chengdu 610041, China
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Pitt B. Adverse events in HEAAL: when to hold and when to fold. Eur J Heart Fail 2012; 14:1319-21. [PMID: 23159580 DOI: 10.1093/eurjhf/hfs167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Moderate renal insufficiency does not attenuate the clinical benefit of aldosterone antagonists in heart failure. J Am Coll Cardiol 2012; 60:2090-1. [PMID: 23083776 DOI: 10.1016/j.jacc.2012.08.971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 08/09/2012] [Indexed: 12/22/2022]
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