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Cobo Marcos M, Comín‐Colet J, de la Espriella R, Rubio Gracia J, Morales‐Rull JL, Zegrí I, Llacer P, Diez‐Villanueva P, Jiménez‐Marrero S, de Juan Bagudá J, Ortiz Cortés C, Goirigolzarri‐Artaza J, García‐Pinilla JM, Barrios E, del Prado Díaz S, Montero Hernández E, Sanchez‐Marteles M, Nuñez J. Design and baseline characteristics of SALT-HF trial: hypertonic saline therapy in ambulatory heart failure. ESC Heart Fail 2024; 11:1767-1776. [PMID: 38380837 PMCID: PMC11098644 DOI: 10.1002/ehf2.14720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/22/2024] [Accepted: 01/29/2024] [Indexed: 02/22/2024] Open
Abstract
AIMS Hypertonic saline solution (HSS) plus intravenous (IV) loop diuretic appears to enhance the diuretic response in patients hospitalized for heart failure (HF). The efficacy and safety of this therapy in the ambulatory setting have not been evaluated. We aimed to describe the design and baseline characteristics of the SALT-HF trial participants. METHODS AND RESULTS 'Efficacy of Saline Hypertonic Therapy in Ambulatory Patients with HF' (SALT-HF) trial was a multicenter, double-blinded, and randomized study involving ambulatory patients who experienced worsening heart failure (WHF) without criteria for hospitalization. Enrolled patients had to present at least two signs of volume overload, use ≥ 80 mg of oral furosemide daily, and have elevated natriuretic peptides. Patients were randomized 1:1 to treatment with a 1-h infusion of IV furosemide plus HSS (2.6-3.4% NaCl depending on plasmatic sodium levels) versus a 1-h infusion of IV furosemide at the same dose (125-250 mg, depending on basal loop diuretic dose). Clinical, laboratory, and imaging parameters were collected at baseline and after 7 days, and a telephone visit was planned after 30 days. The primary endpoint was 3-h diuresis after treatment started. Secondary endpoints included (a) 7-day changes in congestion data, (b) 7-day changes in kidney function and electrolytes, (c) 30-day clinical events (need of IV diuretic, HF hospitalization, cardiovascular mortality, all-cause mortality or HF-hospitalization). RESULTS A total of 167 participants [median age, 81 years; interquartile range (IQR), 73-87, 30.5% females] were randomized across 13 sites between December 2020 and March 2023. Half of the participants (n = 82) had an ejection fraction >50%. Most patients showed a high burden of comorbidities, with a median Charlson index of 3 (IQR: 2-4). Common co-morbidities included diabetes mellitus (41%, n = 69), atrial fibrillation (80%, n = 134), and chronic kidney disease (64%, n = 107). Patients exhibited a poor functional NYHA class (69% presenting NYHA III) and several signs of congestion. The mean composite congestion score was 4.3 (standard deviation: 1.7). Ninety per cent of the patients (n = 151) presented oedema and jugular engorgement, and 71% (n = 118) showed lung B lines assessed by ultrasound. Median inferior vena cava diameter was 23 mm, (IQR: 21-25), and plasmatic levels of N-terminal-pro-B-type natriuretic peptide (NTproBNP) and antigen carbohydrate 125 (CA125) were increased (median NT-proBNP 4969 pg/mL, IQR: 2508-9328; median CA125 46 U/L, IQR: 20-114). CONCLUSIONS SALT-HF trial randomized 167 ambulatory patients with WHF and will determine whether an infusion of hypertonic saline therapy plus furosemide increases diuresis and improves decongestion compared to equivalent furosemide administration alone.
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Affiliation(s)
- M. Cobo Marcos
- Department of CardiologyHospital Universitario Puerta de HierroMadridSpain
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular)MadridSpain
| | - J. Comín‐Colet
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular)MadridSpain
- Department of CardiologyHospital Universitario de Bellvitge, IDIBELLBarcelonaSpain
| | - R. de la Espriella
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA)University of ValenciaValenciaSpain
| | - J. Rubio Gracia
- Department of Internal Medicine, Hospital Universitario Lozano BlesaUniversity of Zaragoza, Aragon Health Research Institute (IIS Aragon)ZaragozaSpain
| | - J. L. Morales‐Rull
- Department of Internal MedicineHospital Universitario Arnau de VilanovaLleidaSpain
- Heart Failure Unit, Lleida Health RegionInstitut de Recerca Biomèdica de Lleida (IRBLleida)LleidaSpain
| | - I. Zegrí
- Department of CardiologyHospital de la Santa Creu i Sant PauBarcelonaSpain
| | - P. Llacer
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de AlcaláMadridSpain
| | - P. Diez‐Villanueva
- Department of CardiologyHospital Universitario de la PrincesaMadridSpain
| | - S. Jiménez‐Marrero
- Department of CardiologyHospital Universitario de Bellvitge, IDIBELLBarcelonaSpain
| | - J. de Juan Bagudá
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular)MadridSpain
- Department of CardiologyUniversity Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12)MadridSpain
- Instituto de Salud Carlos IIIMadridSpain
- Department of Medicine, Faculty of Biomedical and Health ScienceUniversidad Europea de MadridMadridSpain
| | - C. Ortiz Cortés
- Department of CardiologyHospital Universitario San Pedro de AlcántaraCáceresSpain
| | | | - J. M. García‐Pinilla
- Department of CardiologyHospital Universitario Virgen de la VictoriaMálagaSpain
- Instituto de Investigación Biomédica‐Plataforma BIONAND. Málaga Ciber‐CardiovascularMálagaSpain
- Insitituto de Salud Carlos III. Departamento de Medicina y DermatologíaUniversidad de MálagaMálagaSpain
| | - E. Barrios
- Department of CardiologyHospital Universitario Rey Juan Carlos MóstolesMadridSpain
| | - S. del Prado Díaz
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular)MadridSpain
- Department of CardiologyHospital Universitario Ramón y CajalMadridSpain
| | - E. Montero Hernández
- Department of Internal MedicineHospital Universitario Puerta de Hierro MajadahondaMadridSpain
| | - M. Sanchez‐Marteles
- Department of Internal Medicine, Hospital Universitario Lozano BlesaUniversity of Zaragoza, Aragon Health Research Institute (IIS Aragon)ZaragozaSpain
| | - J. Nuñez
- Centro de Investigación Biomédica en Red (CIBER Cardiovascular)MadridSpain
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA)University of ValenciaValenciaSpain
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2
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Van den Eynde J, Verbrugge FH. Renal Sodium Avidity in Heart Failure. Cardiorenal Med 2024; 14:270-280. [PMID: 38565080 DOI: 10.1159/000538601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Increased renal sodium avidity is a hallmark feature of the heart failure syndrome. SUMMARY Increased renal sodium avidity refers to the inability of the kidneys to elicit potent natriuresis in response to sodium loading. This eventually causes congestion, which is a major contributor to hospital admissions and mortality in heart failure. KEY MESSAGES Important novel concepts such as the renal tamponade hypothesis, accelerated nephron loss, and the role of hypochloremia, the sympathetic nervous system, inflammation, the lymphatic system, and interstitial sodium buffers are involved in the pathophysiology of renal sodium avidity. A good understanding of these concepts is crucially important with respect to treatment recommendations regarding dietary sodium restriction, fluid restriction, rapid up-titration of guideline-directed medical therapies, combination diuretic therapy, natriuresis-guided diuretic therapy, use of hypertonic saline, and ultrafiltration.
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Affiliation(s)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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3
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Mullens W, Damman K, Dhont S, Banerjee D, Bayes-Genis A, Cannata A, Chioncel O, Cikes M, Ezekowitz J, Flammer AJ, Martens P, Mebazaa A, Mentz RJ, Miró Ò, Moura B, Nunez J, Ter Maaten JM, Testani J, van Kimmenade R, Verbrugge FH, Metra M, Rosano GMC, Filippatos G. Dietary sodium and fluid intake in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024; 26:730-741. [PMID: 38606657 DOI: 10.1002/ejhf.3244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
Sodium and fluid restriction has traditionally been advocated in patients with heart failure (HF) due to their sodium and water avid state. However, most evidence regarding the altered sodium handling, fluid homeostasis and congestion-related signs and symptoms in patients with HF originates from untreated patient cohorts and physiological investigations. Recent data challenge the beneficial role of dietary sodium and fluid restriction in HF. Consequently, the European Society of Cardiology HF guidelines have gradually downgraded these recommendations over time, now advising for the limitation of salt intake to no more than 5 g/day in patients with HF, while contemplating fluid restriction of 1.5-2 L/day only in selected patients. Therefore, the objective of this clinical consensus statement is to provide advice on fluid and sodium intake in patients with acute and chronic HF, based on contemporary evidence and expert opinion.
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Affiliation(s)
- Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Hasselt University, Hasselt, Belgium
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sebastiaan Dhont
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Hasselt University, Hasselt, Belgium
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals National Health Service Foundation Trust, London, UK
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, CIBERCV, Barcelona, Spain
| | - Antonio Cannata
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases, University of Medicine Carol Davila, Bucharest, Romania
| | - Maja Cikes
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine & University Hospital Center Zagreb, Zagreb, Croatia
| | - Justin Ezekowitz
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - Andreas J Flammer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Òscar Miró
- Department of Emergency, Hospital Clínic, 'Processes and Pathologies, Emergencies Research Group' IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Brenda Moura
- Hospital das Forças Armadas and Cintesis - Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Julio Nunez
- Cardiology Department and Heart Failure Unit, Hospital Clínico Universitario de Valencia, University of Valencia, INCLIVA, Valencia, Spain
| | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jeffrey Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Roland van Kimmenade
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Marco Metra
- Cardiology, ASST Spedali Civili, and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe M C Rosano
- Cardiology Clinical Academic Group, Molecular and Clinical Research Institute, St Georges University of London, London, UK
- Cardiology, San Raffaele Cassino, Rome, Italy
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Diaz‐Arocutipa C, Denegri‐Galvan J, Vicent L, Pariona M, Mamas MA, Hernandez AV. The added value of hypertonic saline solution to furosemide monotherapy in patients with acute decompensated heart failure: A meta-analysis and trial sequential analysis. Clin Cardiol 2023; 46:853-865. [PMID: 37340592 PMCID: PMC10436795 DOI: 10.1002/clc.24033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/20/2023] [Accepted: 05/08/2023] [Indexed: 06/22/2023] Open
Abstract
We assessed the effects of hypertonic saline solution (HSS) plus furosemide versus furosemide alone in patients with acute decompensated heart failure (ADHF). We searched four electronic databases for randomized controlled trials (RCTs) until June 30, 2022. The quality of evidence (QoE) was assessed using the GRADE approach. All meta-analyses were performed using a random-effects model. A trial sequential analysis (TSA) was also conducted for intermediate and biomarker outcomes. Ten RCTs involving 3013 patients were included. HSS plus furosemide significantly reduced the length of hospital stay (mean difference [MD]: -3.60 days; 95% confidence interval [CI]: -4.56 to -2.64; QoE: moderate), weight (MD: -2.34 kg; 95% CI: -3.15 to -1.53; QoE: moderate), serum creatinine (MD: -0.41 mg/dL; 95% CI: -0.49 to -0.33; QoE: low), and type-B natriuretic peptide (MD: -124.26 pg/mL; 95% CI: -207.97 to -40.54; QoE: low) compared to furosemide alone. HSS plus furosemide significantly increased urine output (MD: 528.57 mL/24 h; 95% CI: 431.90 to 625.23; QoE: moderate), serum Na+ (MD: 6.80 mmol/L; 95% CI: 4.92 to 8.69; QoE: low), and urine Na+ (MD: 54.85 mmol/24 h; 95% CI: 46.31 to 63.38; QoE: moderate) compared to furosemide alone. TSA confirmed the benefit of HSS plus furosemide. Due to the heterogeneity in mortality and heart failure readmission, meta-analysis was not performed. Our study shows that HSS plus furosemide, compared to furosemide alone, improved surrogated outcomes in ADHF patients with low or intermediate QoE. Adequately powered RCTs are still needed to assess the benefit on heart failure readmission and mortality.
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Affiliation(s)
| | | | - Lourdes Vicent
- Cardiology DepartmentHospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12)MadridSpain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV)MadridSpain
| | - Marcos Pariona
- Department of CardiologyHospital Nacional Edgardo Rebagliati MartinsLimaPeru
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis ResearchKeele UniversityKeeleUK
| | - Adrian V. Hernandez
- Vicerrectorado de InvestigaciónUniversidad San Ignacio de LoyolaLimaPeru
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) GroupUniversity of Connecticut/Hartford Hospital Evidence‐Based Practice CenterHartfordCTUSA
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5
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Montgomery RA, Mauch J, Sankar P, Martyn T, Engelman T, Martens P, Faulkenberg K, Menon V, Estep JD, Tang WHW. Oral Sodium to Preserve Renal Efficiency in Acute Heart Failure: A Randomized, Placebo-Controlled, Double-Blind Study. J Card Fail 2023; 29:986-996. [PMID: 37044281 DOI: 10.1016/j.cardfail.2023.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/18/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Evidence for modulating the sodium chloride (NaCl) intake of patients hospitalized with acute heart failure (AHF) is inconclusive. Salt restriction may not benefit; hypertonic saline may aid diuresis. OBJECTIVE To compare the safety and efficacy of oral NaCl during intravenous (IV) diuretic therapy in renal function and weight. METHODS Seventy hospitalized patients with AHF who were being treated with IV furosemide infusion consented to receive, randomly, 2 grams of oral NaCl or placebo 3 times a day in a double-blind manner during diuresis. Treatment efficacy (bivariate primary endpoints of change in serum creatinine levels and change in weight) was measured at 96 hours, and adverse safety events were tracked for 90 days. RESULTS Sixty-five patients (34 NaCl, 31 placebo) were included for analysis after 5 withdrew. A median of 13 grams of NaCl was given compared to placebo. At 96 hours, there was no significant difference between treatment groups with respect to the primary endpoint (P = 0.33); however, the trial was underpowered, and there was greater than expected standard deviation in weight change. The mean change in creatinine levels and weight was 0.15 ± 0.44 mg/dL and 4.6 ± 4.2 kg in the placebo group compared with 0.04 ± 0.40 mg/dL and 4.0 ± 4.3 kg in the NaCl group (P = 0.30 and 0.57, respectively). Across efficacy and safety endpoints, we observed no significant difference between the 2 groups other than changes in serum sodium levels (-2.6 ± 2.7 in the placebo group and -0.3 ± 3.3 mEq/L in the NaCl group; P < 0.001) and in serum blood urea nitrogen levels (11 ± 15 in the placebo group; 3.1 ± 13 mEq/L in the NaCl group; P = 0.025). CONCLUSIONS In this single-center study, liberal vs restrictive oral sodium chloride intake strategies did not impact the safety and efficacy of intravenous diuretic therapy in patients with AHF. (ClinicalTrials.gov registration NCT04334668.).
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Affiliation(s)
- Robert A Montgomery
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Joseph Mauch
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | | | - Trejeeve Martyn
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Tim Engelman
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Pieter Martens
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Kathleen Faulkenberg
- Department of Pharmacy Practice & Science, University of Kentucky, Lexington, KY
| | - Venu Menon
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jerry D Estep
- Department of Cardiology, Cleveland Clinic Weston, Weston. FL
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH.
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6
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Martens P, Tang WHW. Role of Sodium and Sodium Restriction in Heart Failure. Curr Heart Fail Rep 2023; 20:230-236. [PMID: 37227668 DOI: 10.1007/s11897-023-00607-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE OF REVIEW Sodium plays an essential role in the regulation of extracellular volume. The current review discusses the physiologic handling of sodium in the body, underscores pathophysiologic alterations in sodium handling in heart failure and assesses the evidence and rational for sodium restriction in heart failure. RECENT FINDINGS Recent trials such as the SODIUM-HF trial have failed to demonstrate a benefit of sodium restriction in heart failure. The current review re-evaluates physiologic elements in sodium handling and discusses how the intrinsic renal sodium avidity, which drives the renal propensity towards retaining sodium, differs amongst patients. The sodium intake in heart failure patients is often above the threshold set by guidelines. This review gives an overview of the pathophysiology of sodium retention in heart failure and the rational for sodium restriction and potential of individualizing sodium restriction recommendations based on renal sodium avidity profiles.
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Affiliation(s)
- Pieter Martens
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, 44195, USA.
| | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, 44195, USA
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7
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Arora N. Serum Chloride and Heart Failure. Kidney Med 2023; 5:100614. [PMID: 36911181 PMCID: PMC9995484 DOI: 10.1016/j.xkme.2023.100614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Despite significant advances in management, heart failure continues to impose a significant epidemiologic burden with high prevalence and mortality rates. For decades, sodium has been the serum electrolyte most commonly associated with outcomes; however, challenging the conventional paradigm of sodium's influence, recent studies have identified a more prominent role in serum chloride in the pathophysiology of heart failure. More specifically, hypochloremia is associated with neurohumoral activation, diuretic resistance, and a worse prognosis in patients with heart failure. This review examines basic science, translational research, and clinical studies to better characterize the role of chloride in patients with heart failure and additionally discusses potential new therapies targeting chloride homeostasis that may impact the future of heart failure care.
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Affiliation(s)
- Nayan Arora
- University of Washington, Seattle, Washington
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8
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Koirala A, Pourafshar N, Daneshmand A, Wilcox CS, Mannemuddhu SS, Arora N. Etiology and Management of Edema: A Review. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:110-123. [PMID: 36868727 DOI: 10.1053/j.akdh.2022.12.002] [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: 06/21/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 04/18/2023]
Abstract
The development of peripheral edema can often pose a significant diagnostic and therapeutic challenge for practitioners due to its association with a wide variety of underlying disorders ranging in severity. Updates to the original Starling's principle have provided new mechanistic insights into edema formation. Additionally, contemporary data highlighting the role of hypochloremia in the development of diuretic resistance provide a possible new therapeutic target. This article reviews the pathophysiology of edema formation and discusses implications for treatment.
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Affiliation(s)
- Abbal Koirala
- Division of Nephrology, University of Washington, Seattle, WA
| | - Negiin Pourafshar
- Division of Nephrology, MedStar Georgetown University Hospital, Washington DC
| | - Arvin Daneshmand
- Division of Nephrology, MedStar Georgetown University Hospital, Washington DC
| | | | | | - Nayan Arora
- Division of Nephrology, University of Washington, Seattle, WA.
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McCallum W, Sarnak MJ. Cardiorenal Syndrome in the Hospital. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00026. [PMID: 36787124 PMCID: PMC10356127 DOI: 10.2215/cjn.0000000000000064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/22/2022] [Indexed: 01/22/2023]
Abstract
The cardiorenal syndrome refers to a group of complex, bidirectional pathophysiological pathways involving dysfunction in both the heart and kidney. Upward of 60% of patients admitted for acute decompensated heart failure have CKD, as defined by an eGFR of <60 ml/min per 1.73 m2. CKD, in turn, is one of the strongest risk factors for mortality and cardiovascular events in acute decompensated heart failure. Although not well understood, the mechanisms in the cardiorenal syndrome include venous congestion, arterial underfilling, neurohormonal activation, inflammation, and endothelial dysfunction. Arterial underfilling may lead to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, leading to sodium reabsorption and vasoconstriction. Venous congestion likely also mediates and perpetuates these maladaptive pathways. To rule out intrinsic kidney disease that is distinct from the cardiorenal syndrome, one should obtain a careful history, review longitudinal eGFR trends, assess albuminuria and proteinuria, and review the urine sediment and kidney imaging. The hallmark of the cardiorenal syndrome is intense sodium avidity and diuretic resistance, often requiring a combination of diuretics with varying pharmacological targets, and monitoring of urinary response to guide escalations in therapy. Invasive means of decongestion may be required including ultrafiltration or kidney RRT such as peritoneal dialysis, which is often better tolerated from a hemodynamic perspective than intermittent hemodialysis. Strategies for increasing forward perfusion in states of low cardiac output and cardiogenic shock may include afterload reduction and inotropes and, in the most severe cases, mechanical circulatory support devices, many of which have kidney-specific considerations.
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Affiliation(s)
- Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Şorodoc V, Asaftei A, Puha G, Ceasovschih A, Lionte C, Sîrbu O, Bologa C, Haliga RE, Constantin M, Coman AE, Petriș OR, Stoica A, Şorodoc L. Management of Hyponatremia in Heart Failure: Practical Considerations. J Pers Med 2023; 13:jpm13010140. [PMID: 36675801 PMCID: PMC9865833 DOI: 10.3390/jpm13010140] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 01/12/2023] Open
Abstract
Hyponatremia is commonly encountered in the setting of heart failure, especially in decompensated, fluid-overloaded patients. The pathophysiology of hyponatremia in patients with heart failure is complex, including numerous mechanisms: increased activity of the sympathetic nervous system and the renin-angiotensin-aldosterone system, high levels of arginine vasopressin and diuretic use. Symptoms are usually mild but hyponatremic encephalopathy can occur if there is an acute decrease in serum sodium levels. It is crucial to differentiate between dilutional hyponatremia, where free water excretion should be promoted, and depletional hyponatremia, where administration of saline is needed. An inappropriate correction of hyponatremia may lead to osmotic demyelination syndrome which can cause severe neurological symptoms. Treatment options for hyponatremia in heart failure, such as water restriction or the use of hypertonic saline with loop diuretics, have limited efficacy. The aim of this review is to summarize the principal mechanisms involved in the occurrence of hyponatremia, to present the main guidelines for the treatment of hyponatremia, and to collect and analyze data from studies which target new treatment options, such as vaptans.
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Affiliation(s)
- Victoriţa Şorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Andreea Asaftei
- 2nd Rheumatology Department, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
- Correspondence: (A.A.); (A.C.); (C.L.)
| | - Gabriela Puha
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Alexandr Ceasovschih
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
- Correspondence: (A.A.); (A.C.); (C.L.)
| | - Cătălina Lionte
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (A.A.); (A.C.); (C.L.)
| | - Oana Sîrbu
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cristina Bologa
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Raluca Ecaterina Haliga
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihai Constantin
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Adorata Elena Coman
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Ovidiu Rusalim Petriș
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Alexandra Stoica
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Laurenţiu Şorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
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11
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Colin-Ramirez E, Sepehrvand N, Rathwell S, Ross H, Escobedo J, Macdonald P, Troughton R, Saldarriaga C, Lanas F, Doughty R, McAlister FA, Ezekowitz JA. Sodium Restriction in Patients With Heart Failure: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Circ Heart Fail 2023; 16:e009879. [PMID: 36373551 DOI: 10.1161/circheartfailure.122.009879] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sodium restriction is a nonpharmacologic treatment suggested by practice guidelines for the management of patients with heart failure (HF). In this study, we synthesized the data from randomized controlled trials (RCTs) evaluating the effects of sodium restriction on clinical outcomes in patients with HF. METHODS In this aggregate data meta-analysis, Cochrane Central, MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase Ovid, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus databases were searched up to April 2, 2022. RCTs were included if they investigated the effects of sodium/salt restriction as compared to no restriction on clinical outcomes in patients with HF. Outcomes of interest included mortality, hospitalization, change in New York Heart Association functional class, and quality of life (QoL). RESULTS Seventeen RCTs were identified (834 and 871 patients in intervention and control groups, respectively). Sodium restriction did not reduce the risk of all-cause death (odds ratio, 0.95 [95% CI, 0.58-1.58]), hospitalization (odds ratio, 0.84 [95% CI, 0.62-1.13]), or the composite of death/hospitalization (odds ratio, 0.88 [95% CI, 0.63-1.23]). The results were similar in different subgroups, except for the numerically lower risk of death with reduced sodium intake reported in RCTs with dietary sodium at the 2000 to 3000 mg/d range as opposed to <2000 mg/d (and in RCTs with versus without fluid restriction as a co-intervention). Among RCTs reporting New York Heart Association change, 2 RCTs (which accounted for two-thirds of the data) showed improvement in New York Heart Association class with sodium restriction. Substantial heterogeneity existed for QoL: 6 RCTs showed improvement of QoL and 4 RCTs showed no improvement of sodium restriction on QoL. CONCLUSIONS In a meta-analysis of RCTs, sodium restriction was not associated with fewer deaths or hospitalizations in patients with HF. Dietary sodium restriction may be associated with improvements in symptoms and QoL.
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Affiliation(s)
| | - Nariman Sepehrvand
- Canadian VIGOUR Centre, Department of Medicine (N.S., S.R., F.A.M., J.A.E.), University of Alberta, Edmonton, Canada
| | - Sarah Rathwell
- Canadian VIGOUR Centre, Department of Medicine (N.S., S.R., F.A.M., J.A.E.), University of Alberta, Edmonton, Canada
| | - Heather Ross
- Division of Cardiology, Peter Munk Cardiac Center, University of Toronto, Ontario, Canada (H.R.)
| | - Jorge Escobedo
- Canadian VIGOUR Centre, Department of Medicine (N.S., S.R., F.A.M., J.A.E.), University of Alberta, Edmonton, Canada
| | - Peter Macdonald
- Heart Failure and Transplant Unit, Cardiology Department, St. Vincent's Hospital, Sydney, Darlinghurst, New South Wales, Australia (P.M.)
| | - Richard Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago, New Zealand (R.T.)
| | - Clara Saldarriaga
- Centro Cardiovascular Colombiano Clinica Santa Maria (Clinica Cardio VID), Antioquia, Columbia (C.S.)
| | - Fernando Lanas
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de la Frontera Temuco, Chile (F.L.)
| | | | - Finlay A McAlister
- Canadian VIGOUR Centre, Department of Medicine (N.S., S.R., F.A.M., J.A.E.), University of Alberta, Edmonton, Canada.,Division of General Internal Medicine, Department of Medicine (F.A.M.), University of Alberta, Edmonton, Canada
| | - Justin A Ezekowitz
- Division of Cardiology, Department of Medicine (J.A.E.), University of Alberta, Edmonton, Canada.,Instituto Mexicano del Seguro Social, Mexico City, Mexico (J.A.E.)
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12
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Effect of Hypertonic Saline Solution Combined with Furosemide on Acute Heart Failure: A Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5728967. [PMID: 36188107 PMCID: PMC9519297 DOI: 10.1155/2022/5728967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Background The efficacy of hypertonic saline solution (HSS) combined with furosemide in treating acute heart failure is controversial. This meta-analysis explores the efficacy of HSS combined with furosemide for the treatment of acute heart failure. Methods Literature were searched from databases, including PubMed, Web of Knowledge, Embase, Central, CMKI, Wanfang, and VIP. The inclusion criteria were as follows: (1) subjects: patients with acute heart failure; (2) the experimental group and the control group were properly set up; (3) intervention measures: patients in the experimental group were treated with HSS + furosemide, and patients in the control group were treated with furosemide; (4) the outcomes included at least one of the following indicators: readmission rate, mortality, 24 h urine volume, weight loss, and serum creatinine; and (5) randomized controlled trial (RCT). The method recommended by Cochrane Collaboration Network was used to evaluate the risk bias. The heterogeneity among the studies was evaluated through the chi-square test, and the publication bias was assessed by the Egger test. The results were described using risk ratio (RR), mean difference (MD), and 95% confidence interval (CI). Results The readmission rate in the HSS + furosemide group was lower than that in the furosemide group (RR = 0.53, 95% CI [0.46, 0.60], P < 0.00001), with no heterogeneity among the literature (P = 0.21, I2 = 29%). Patients in the HSS + furosemide group had a lower mortality rate than that in the furosemide group (RR = 0.55, 95% CI [0.46, 0.65], P < 0.00001). The chi-square test result indicated no heterogeneity among the literature (P = 0.25, I2 = 23%). Furthermore, the 24 h urine volume of patients in the HSS + furosemide group was higher than that in the furosemide group (MD = 497.29, 95% CI [457.61, 536.96], P < 0.00001). There was no heterogeneity among the literature (P = 0.58, I2 = 0%). In contrast, patients in the HSS + furosemide group demonstrated a lower serum creatinine level than those in the furosemide group (MD = −0.45, 95% CI [-0.51, -0.39], P < 0.00001). However, heterogeneity was observed among the literature (P < 0.00001, I2 = 81%). The weight loss in the HSS + furosemide group was higher than that in the furosemide group (MD = 1.83, 95% CI [1.51, 2.15], P < 0.00001). There was no heterogeneity among the literature (P = 0.42, I2 = 2%). Egger test showed no publication bias among the literature (P > 0.05). Conclusion Despite the heterogeneity and bias in our study, the combination of HSS with furosemide is promising in patients with acute heart failure. However, further research is still needed to confirm.
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13
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Rodríguez-Espinosa D, Guzman-Bofarull J, De La Fuente-Mancera JC, Maduell F, Broseta JJ, Farrero M. Multimodal Strategies for the Diagnosis and Management of Refractory Congestion. An Integrated Cardiorenal Approach. Front Physiol 2022; 13:913580. [PMID: 35874534 PMCID: PMC9304751 DOI: 10.3389/fphys.2022.913580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/20/2022] [Indexed: 01/12/2023] Open
Abstract
Refractory congestion is common in acute and chronic heart failure, and it significantly impacts functional class, renal function, hospital admissions, and survival. In this paper, the pathophysiological mechanisms involved in cardiorenal syndrome and the interplay between heart failure and chronic kidney disease are reviewed. Although the physical exam remains key in identifying congestion, new tools such as biomarkers or lung, vascular, and renal ultrasound are currently being used to detect subclinical forms and can potentially impact its management. Thus, an integrated multimodal diagnostic algorithm is proposed. There are several strategies for treating congestion, although data on their efficacy are scarce and have not been validated. Herein, we review the optimal use and monitorization of different diuretic types, administration route, dose titration using urinary volume and natriuresis, and a sequential diuretic scheme to achieve a multitargeted nephron blockade, common adverse events, and how to manage them. In addition, we discuss alternative strategies such as subcutaneous furosemide, hypertonic saline, and albumin infusions and the available evidence of their role in congestion management. We also discuss the use of extracorporeal therapies, such as ultrafiltration, peritoneal dialysis, or conventional hemodialysis, in patients with normal or impaired renal function. This review results from a multidisciplinary view involving both nephrologists and cardiologists.
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Affiliation(s)
- Diana Rodríguez-Espinosa
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | | | - Francisco Maduell
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | - José Jesús Broseta
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic of Barcelona, Barcelona, Spain
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14
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Escudero VJ, Mercadal J, Molina-Andújar A, Piñeiro GJ, Cucchiari D, Jacas A, Carramiñana A, Poch E. New Insights Into Diuretic Use to Treat Congestion in the ICU: Beyond Furosemide. FRONTIERS IN NEPHROLOGY 2022; 2:879766. [PMID: 37675009 PMCID: PMC10479653 DOI: 10.3389/fneph.2022.879766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/30/2022] [Indexed: 09/08/2023]
Abstract
Diuretics are commonly used in critically ill patients with acute kidney injury (AKI) and fluid overload in intensive care units (ICU), furosemide being the diuretic of choice in more than 90% of the cases. Current evidence shows that other diuretics with distinct mechanisms of action could be used with good results in patients with selected profiles. From acetazolamide to tolvaptan, we will discuss recent studies and highlight how specific diuretic mechanisms could help to manage different ICU problems, such as loop diuretic resistance, hypernatremia, hyponatremia, or metabolic alkalosis. The current review tries to shed some light on the potential use of non-loop diuretics based on patient profile and give recommendations for loop diuretic treatment performance focused on what the intensivist and critical care nephrologist need to know based on the current evidence.
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Affiliation(s)
- Victor Joaquin Escudero
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Jordi Mercadal
- Surgical Intensive Care Unit, Anesthesiology Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Univesitat de Barcelona, Barcelona, Spain
| | - Alícia Molina-Andújar
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Gaston J. Piñeiro
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - David Cucchiari
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Adriana Jacas
- Surgical Intensive Care Unit, Anesthesiology Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Univesitat de Barcelona, Barcelona, Spain
| | - Albert Carramiñana
- Surgical Intensive Care Unit, Anesthesiology Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Univesitat de Barcelona, Barcelona, Spain
| | - Esteban Poch
- Nephrology and Kidney Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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15
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Stein C, Helal L, Migliavaca CB, Sangalli CN, Colpani V, Raupp da Rosa P, Beck-da-Silva L, Rohde LE, Polanczyk CA, Falavigna M. Are the recommendation of sodium and fluid restriction in heart failure patients changing over the past years? A systematic review and meta-analysis. Clin Nutr ESPEN 2022; 49:129-137. [DOI: 10.1016/j.clnesp.2022.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/18/2022] [Accepted: 03/19/2022] [Indexed: 12/15/2022]
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16
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Kitajima N, Yamada H, Minami T, Ohtsuru S. Optimal Evidence Grading of Simultaneous Use of Hypertonic Saline and Furosemide for Fluid Overload. Crit Care Med 2022; 50:e405-e406. [PMID: 35311790 DOI: 10.1097/ccm.0000000000005419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Naoki Kitajima
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroyuki Yamada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takuma Minami
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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17
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Effects of Sodium Intake on Health and Performance in Endurance and Ultra-Endurance Sports. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063651. [PMID: 35329337 PMCID: PMC8955583 DOI: 10.3390/ijerph19063651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022]
Abstract
The majority of reviews on sports nutrition issues focus on macronutrients, often omitting or paying less attention to substances such as sodium. Through the literature, it is clear that there are no reviews that focus entirely on the effects of sodium and in particular on endurance sports. Sodium intake, both at high and low doses, has been found to be associated with health and performance issues in athletes. Besides, there have been theories that an electrolyte imbalance, specifically sodium, contributes to the development of muscle cramps (EAMC) and hyponatremia (EAH). For this reason, it is necessary to create this systematic review, in order to report extensively on the role of sodium consumption in the population and more specifically in endurance and ultra-endurance athletes, the relationship between the amount consumed and the occurrence of pathological disorders, the usefulness of simultaneous hydration and whether a disturbance of this substance leads to EAH and EAMC. As a method of data collection, this study focused on exploring literature from 2000–2021. The search was conducted through the research engines PubMed and Scopus. In order to reduce the health and performance effects in endurance athletes, simultaneous emphasis should be placed on both sodium and fluid intake.
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18
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de la Espriella R, Santas E, Zegri Reiriz I, Górriz JL, Cobo Marcos M, Núñez J. Quantification and treatment of congestion in heart failure: A clinical and pathophysiological overview. Nefrologia 2022; 42:145-162. [PMID: 36153911 DOI: 10.1016/j.nefroe.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/06/2021] [Indexed: 06/16/2023] Open
Abstract
Renal sodium and water retention with resulting extracellular volume expansion and redistribution are hallmark features of heart failure syndromes. However, congestion assessment, monitoring, and treatment represent a real challenge in daily clinical practice. This document reviewed historical and contemporary evidence of available methods for determining volume status and discuss pharmacological aspects and pathophysiological principles that underlie diuretic use.
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Affiliation(s)
- Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain
| | - Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain
| | - Isabel Zegri Reiriz
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain; Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jose Luis Górriz
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain; Servicio de Nefrología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; Departamento de Medicina, Universidad de Valencia, Spain
| | - Marta Cobo Marcos
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; CIBER Cardiovascular, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Spain.
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19
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20
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Abstract
Despite recent advances in the treatment of chronic heart failure, therapeutic options for acute heart failure (AHF) remain limited. AHF admissions are associated with significant multi-organ dysfunction, especially worsening renal failure, which results in significant morbidity and mortality. There are several aspects of AHF management: diagnosis, decongestion, vasoactive therapy, goal-directed medical therapy initiation and safe transition of care. Effective diagnosis and prognostication could be very helpful in an acute setting and rely upon biomarker evaluation with noninvasive assessment of fluid status. Decongestive strategies could be tailored to include pharmaceutical options along with consideration of utilizing ultrafiltration for refractory hypervolemia. Vasoactive agents to augment cardiac function have been evaluated in patients with AHF but have shown to only have limited efficacy. Post stabilization, initiation of quadruple goal-directed medical therapy—angiotensin receptor-neprilysin inhibitors, mineral receptor antagonists, sodium glucose type 2 (SGLT-2) inhibitors, and beta blockers—to prevent myocardial remodeling is being advocated as a standard of care. Safe transition of care is needed prior to discharge to prevent heart failure rehospitalization and mortality. Post-discharge close ambulatory monitoring (including remote hemodynamic monitoring), virtual visits, and rehabilitation are some of the strategies to consider. We hereby review the contemporary approach in AHF diagnosis and management.
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Affiliation(s)
- Hayaan Kamran
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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21
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Kapłon-Cieślicka A, Soloveva A, Mareev Y, Cabac-Pogorevici I, Verbrugge FH, Vardas P. Hyponatraemia in heart failure: time for new solutions? Heart 2021; 108:1179-1185. [PMID: 34903584 DOI: 10.1136/heartjnl-2021-320277] [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] [Received: 09/03/2021] [Accepted: 11/18/2021] [Indexed: 11/04/2022] Open
Abstract
Hyponatraemia is very common in heart failure (HF), especially in decompensated patients. It is associated with increased mortality and morbidity and considered a marker of advanced disease. Recognition of hyponatraemia and its causes may help guide treatment strategy. Historically, therapy has primarily focused on water restriction, decongestion with loop diuretics in case of volume overload (dilutional hyponatraemia) and sodium repletion in case of depletion. In this review, we summarise the potential benefits of established and emerging HF therapies on sodium homeostasis, with a focus on dual vasopressin antagonists, angiotensin receptor-neprilysin inhibitors, sodium-glucose cotransporter 2 inhibitors and hypertonic saline, and propose a potential therapeutic approach for hyponatraemia in HF.
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Affiliation(s)
| | - Anzhela Soloveva
- Department of Cardiology, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Yura Mareev
- Department of Cardiology, National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russian Federation.,Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Irina Cabac-Pogorevici
- Department of Cardiology, State University of Medicine and Pharmacy 'Nicolae Testemitanu', Chisinau, Moldova (the Republic of)
| | - Frederik Hendrik Verbrugge
- Department of Cardiology, Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Panagiotis Vardas
- Heart Sector, Hygeia Hospitals Groups, Athens, Greece.,Medical School, Cardiology Department, University of Crete, Heraclion, Greece
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22
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Inpatient Diuretic Management of Acute Heart Failure: A Practical Review. Am J Cardiovasc Drugs 2021; 21:595-608. [PMID: 33709346 DOI: 10.1007/s40256-020-00463-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 02/08/2023]
Abstract
The inpatient treatment of acute heart failure (AHF) is aimed at achieving euvolemia, relieving symptoms, and reducing rehospitalization. Adequate treatment of AHF is rooted in understanding the pharmacokinetics and pharmacodynamics of select diuretic agents used to achieve decongestion. While loop diuretics remain the primary treatment of AHF, the dosing strategies of loop diuretics and the use of adjunct diuretic classes to augment clinical response can be complex. This review examines the latest strategies for diuretic management in patients with AHF, including dosing and monitoring strategies, interaction of diuretics with other medication classes, use adjunctive therapies, and assessing endpoints for diuretic. The goal of the review is to guide the reader through commonly encountered clinical scenarios and pitfalls in the diuretic management of patients with AHF.
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23
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Orozco Burbano JD, Saldarriaga Giraldo CI, Echeverri Marín DA. [Hypertonic saline solution and high dose of diuretic, ¿what do we know and how can we use them in persistent congestion?]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2021; 2:247-253. [PMID: 37727671 PMCID: PMC10506575 DOI: 10.47487/apcyccv.v2i4.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 11/20/2021] [Indexed: 09/21/2023]
Abstract
The presence of decompensated heart failure continues to be a condition with high rates of hospitalization, impact on the health system, and quality of life for those who suffer it. The mainstay of treatment in these cases are diuretics. However, the resistance to this pharmacological group may occasionally occur, generating an inadequate negative fluid balance and persistence of congestion with negative clinical outcomes. Hypertonic saline solution with high doses of diuretic emerges as a therapeutic option for this group of patients with probable physiological, and clinical benefits on hospitalization and re-admission rates due to heart failure decompensation. A review of the most relevant aspects and benefits of this combination is discussed in this article.
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Affiliation(s)
- Juan D Orozco Burbano
- Departamento de Medicina Interna, Universidad del Cauca. Cauca, Colombia.Universidad del CaucaDepartamento de Medicina InternaUniversidad del CaucaCaucaColombia
- Hospital Universitario San José. Popayán, Colombia Hospital Universitario San JoséPopayánColombia
| | - Clara I Saldarriaga Giraldo
- Departamento de Cardiología, Universidad Pontificia Bolivariana. Medellín, Colombia.Universidad Pontificia BolivarianaDepartamento de CardiologíaUniversidad Pontificia BolivarianaMedellínColombia
- Clínica CardioVID. Medellín, Colombia.Clínica CardioVIDMedellínColombia
- Universidad de Antioquia. Medellín, Colombia. Universidad de AntioquiaUniversidad de AntioquiaMedellínColombia
| | - Diego A Echeverri Marín
- Departamento de Cardiología, Universidad Pontificia Bolivariana. Medellín, Colombia.Universidad Pontificia BolivarianaDepartamento de CardiologíaUniversidad Pontificia BolivarianaMedellínColombia
- Clínica CardioVID. Medellín, Colombia.Clínica CardioVIDMedellínColombia
- Universidad de Antioquia. Medellín, Colombia. Universidad de AntioquiaUniversidad de AntioquiaMedellínColombia
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24
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de la Espriella R, Santas E, Zegri Reiriz I, Górriz JL, Cobo Marcos M, Núñez J. Quantification and Treatment of Congestion in Heart Failure: A Clinical and Pathophysiological Overview. Nefrologia 2021; 42:S0211-6995(21)00114-4. [PMID: 34289940 DOI: 10.1016/j.nefro.2021.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/27/2021] [Accepted: 04/06/2021] [Indexed: 01/12/2023] Open
Abstract
Renal sodium and water retention with resulting extracellular volume expansion and redistribution are hallmark features of heart failure syndromes. However, congestion assessment, monitoring, and treatment represent a real challenge in daily clinical practice. This document reviewed historical and contemporary evidence of available methods for determining volume status and discuss pharmacological aspects and pathophysiological principles that underlie diuretic use.
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Affiliation(s)
- Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España
| | - Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España
| | - Isabel Zegri Reiriz
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España; Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - José Luis Górriz
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España; Servicio de Nefrología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España; Departamento de Medicina, Universidad de Valencia, España
| | - Marta Cobo Marcos
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España; Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España; CIBER Cardiovascular, España
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España; Departamento de Medicina, Universidad de Valencia, España; CIBER Cardiovascular, España.
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Simultaneous Use of Hypertonic Saline and IV Furosemide for Fluid Overload: A Systematic Review and Meta-Analysis. Crit Care Med 2021; 49:e1163-e1175. [PMID: 34166286 DOI: 10.1097/ccm.0000000000005174] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the efficacy of the simultaneous hypertonic saline solution and IV furosemide (HSS+Fx) for patients with fluid overload compared with IV furosemide alone (Fx). DATA SOURCES Electronic databases (MEDLINE, EMBASE, CENTRAL, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, and WOS) were searched from inception to March 2020. STUDY SELECTION Randomized controlled trials on the use of HSS+Fx in adult patients with fluid overload versus Fx were included. DATA EXTRACTION Data were collected on all-cause mortality, hospital length of stay, heart failure-related readmission, along with inpatient weight loss, change of daily diuresis, serum creatinine, and 24-hour urine sodium excretion from prior to post intervention. Pooled analysis with random effects models yielded relative risk or mean difference with 95% CIs. DATA SYNTHESIS Eleven randomized controlled trials comprising 2,987 acute decompensated heart failure patients were included. Meta-analysis demonstrated that HSS+Fx was associated with lower all-cause mortality (relative risk, 0.55; 95% CI, 0.46-0.67; p < 0.05; I2 = 12%) and heart failure-related readmissions (relative risk, 0.50; 95% CI, 0.33-0.76; p < 0.05; I2 = 61%), shorter hospital length of stay (mean difference, -3.28 d; 95% CI, -4.14 to -2.43; p < 0.05; I2 = 93%), increased daily diuresis (mean difference, 583.87 mL; 95% CI, 504.92-662.81; p < 0.05; I2 = 76%), weight loss (mean difference, -1.76 kg; 95% CI, -2.52 to -1.00; p < 0.05; I2 = 57%), serum sodium change (mean difference, 6.89 mEq/L; 95% CI, 4.98-8.79; p < 0.05; I2 = 95%), and higher 24-hour urine sodium excretion (mean difference, 61.10 mEq; 95% CI, 51.47-70.73; p < 0.05; I2 = 95%), along with decreased serum creatinine (mean difference, -0.46 mg/dL; 95% CI, -0.51 to -0.41; p < 0.05; I2 = 89%) when compared with Fx. The Grading of Recommendation, Assessment, Development, and Evaluation certainty of evidence ranged from low to moderate. CONCLUSIONS Benefits of the HSS+Fx over Fx were observed across all examined outcomes in acute decompensated heart failure patients with fluid overload. There is at least moderate certainty that HSS+Fx is associated with a reduction in mortality in patients with acute decompensated heart failure. Factors associated with a successful HSS+Fx utilization are still unknown. Current evidence cannot be extrapolated to other than fluid overload states in acute decompensated heart failure.
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Gatzoflias S, Hao S, Ferreri NR. Induction of renal tumor necrosis factor-α and other autacoids and the beneficial effects of hypertonic saline in acute decompensated heart failure. Am J Physiol Renal Physiol 2021; 320:F1159-F1164. [PMID: 33969695 DOI: 10.1152/ajprenal.00686.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Although administration of hypertonic saline (HSS) in combination with diuretics has yielded improved weight loss, preservation of renal function, and reduction in hospitalization time in the clinical setting of patients with acute decompensated heart failure (ADHF), the mechanisms that underlie these beneficial effects remain unclear and additional studies are needed before this approach can be adopted on a more consistent basis. As high salt conditions stimulate the production of several renal autacoids that exhibit natriuretic effects, renal physiologists can contribute to the understanding of mechanisms by which HSS leads to increased diuresis both as an individual therapy as well as in combination with loop diuretics. For instance, since HSS increases TNF-α production by proximal tubule and thick ascending limb of Henle's loop epithelial cells, this article is aimed at highlighting how the effects of TNF-α produced by these cell types may contribute to the beneficial effects of HSS in patients with ADHF. Although TNF-α produced by infiltrating macrophages and T cells exacerbates and attenuates renal damage, respectively, production of this cytokine within the tubular compartment of the kidney functions as an intrinsic regulator of blood pressure and Na+ homeostasis via mechanisms along the nephron related to inhibition of Na+-K+-2Cl- cotransporter isoform 2 activity and angiotensinogen expression. Thus, in the clinical setting of ADHF and hyponatremia, induction of TNF-α production along the nephron by administration of HSS may attenuate Na+-K+-2Cl- cotransporter isoform 2 activity and angiotensinogen expression as part of a mechanism that prevents excessive Na+ reabsorption in the thick ascending limb of Henle's loop, thereby mitigating volume overload.
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Affiliation(s)
| | - Shoujin Hao
- Department of Pharmacology, New York Medical College, Valhalla, New York
| | - Nicholas R Ferreri
- Department of Pharmacology, New York Medical College, Valhalla, New York
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Covic A, Copur S, Tapoi L, Afsar B, Ureche C, Siriopol D, Nistor I, Kanbay M. Efficiency of Hypertonic Saline in the Management of Decompensated Heart Failure: A Systematic Review and Meta-Analysis of Clinical Studies. Am J Cardiovasc Drugs 2021; 21:331-347. [PMID: 33210263 DOI: 10.1007/s40256-020-00453-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Acute decompensated heart failure (ADHF), with an incidence of 1-2%, is a clinical syndrome with significant morbidity and mortality despite therapeutic advancements and ongoing clinical trials. A recent therapeutic approach to patients with ADHF includes combination therapy with hypertonic saline solution (HSS) and furosemide, based on the hypothesis that resistance to loop diuretics occurs because of achievement of plateau in water and sodium excretion in patients receiving long-term loop diuretic therapy. OBJECTIVE Our aim was to conduct a meta-analysis to evaluate the efficiency of combination HSS plus furosemide therapy in patients with ADHF in terms of mortality, readmissions, length of hospital stay, kidney function, urine output, body weight, and B-type natriuretic peptide (BNP). METHODS A total of 14 studies-four observational and ten randomized studies (total 3398 patients)-were included in the meta-analysis. RESULTS Our results demonstrate the superiority of combination HSS plus furosemide therapy over furosemide alone in terms of kidney function preservation (mean creatinine difference - 0.33 mg/dL; P < 0.00001), improved diuresis (mean difference [MD] 581.94 mL/24 h; P < 0.00001) and natriuresis (MD 57.19; P < 0.00001), weight loss (MD 0.99 kg; P < 0.00001), duration of hospital stay (MD - 2.72 days; P < 0.00001), readmissions (relative risk 0.63; P = 0.01), and mortality (relative risk 0.55; P < 0.00001). However, no difference in BNP levels was detected (MD 19.88 pg/mL; P = 0.50). CONCLUSION Despite the heterogeneity and possible risk of bias among the studies, results appear promising on multiple aspects. A clear need exists for future randomized controlled trials investigating the role of combination HSS plus furosemide therapy to clarify these effects and their possible mechanisms.
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Affiliation(s)
- Adrian Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine and Pharmacy, Iasi, Romania
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Laura Tapoi
- Cardiovascular Diseases Institute, Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Baris Afsar
- Department of Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Carina Ureche
- Cardiovascular Diseases Institute, Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Dimitrie Siriopol
- Department of Nephrology, Grigore T. Popa' University of Medicine and Pharmacy, Iasi, Romania
| | - Ionut Nistor
- Department of Nephrology, Grigore T. Popa' University of Medicine and Pharmacy, Iasi, Romania
- Nephrology Clinic, Dialysis and Renal Transplant Centre, "Dr C. I. Parhon" Hospital, Iasi, Romania
- Evidence Based Medicine and Research Methodology Center, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, 34010, Istanbul, Turkey.
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Narasimhan B, Aravinthkumar R, Correa A, Aronow WS. Pharmacotherapeutic principles of fluid management in heart failure. Expert Opin Pharmacother 2021; 22:595-610. [PMID: 33560159 DOI: 10.1080/14656566.2020.1850694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Heart failure is a major public health concern that is expected to increase over the decades to come. Despite significant advances, fluid overload and congestion remain a major therapeutic challenge. Vascular congestion and neurohormonal activation are intricately linked and the goal of therapy fundamentally aims to reduce both.Areas covered: The authors briefly review a number of core concepts that elucidate the link between fluid overload and neuro-hormonal activation. This is followed by a review of heart-kidney interactions and the impact of diuresis in this setting. Following an in-depth review of currently available pharmacological agents, the rationale and evidence behind their use, the authors end with a brief note on novel agents/approaches to aid volume management in HF.Expert opinion: A number of non-pharmacological advances in the management of volume overload in heart failure, though promising - are associated with a number of shortcomings. Pharmacological therapy remains the cornerstone of volume management. A number of novel approaches, utilizing existing therapies as well as the emergence of new agents over the past decade bode well for the vulnerable HF population.
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Affiliation(s)
- Bharat Narasimhan
- Department of Medicine, Mount Sinai Morningside, Mount Sinai West, New York, NY
| | | | - Ashish Correa
- Department of Cardiology, Mount Sinai Morningside, Mount Sinai West, Icahn School of Medicine at Mount Sinai
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical center/New York Medical College, Valhalla, NY
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Patel Y, Joseph J. Sodium Intake and Heart Failure. Int J Mol Sci 2020; 21:ijms21249474. [PMID: 33322108 PMCID: PMC7763082 DOI: 10.3390/ijms21249474] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/05/2020] [Accepted: 12/10/2020] [Indexed: 12/27/2022] Open
Abstract
Sodium is an essential mineral and nutrient used in dietary practices across the world and is important to maintain proper blood volume and blood pressure. A high sodium diet is associated with increased expression of β—myosin heavy chain, decreased expression of α/β—myosin heavy chain, increased myocyte enhancer factor 2/nuclear factor of activated T cell transcriptional activity, and increased salt-inducible kinase 1 expression, which leads to alteration in myocardial mechanical performance. A high sodium diet is also associated with alterations in various proteins responsible for calcium homeostasis and myocardial contractility. Excessive sodium intake is associated with the development of a variety of comorbidities including hypertension, chronic kidney disease, stroke, and cardiovascular diseases. While the American College of Cardiology/American Heart Association/Heart Failure Society of America guidelines recommend limiting sodium intake to both prevent and manage heart failure, the evidence behind such recommendations is unclear. Our review article highlights evidence and underlying mechanisms favoring and contradicting limiting sodium intake in heart failure.
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Affiliation(s)
- Yash Patel
- Lifespan Cardiovascular Institute, Warren Alpert Medical School at Brown University, Providence, RI 02914, USA;
| | - Jacob Joseph
- Department of Medicine, Veterans Affairs Boston Healthcare System, Boston, MA 02132, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-857-203-6841
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Otero TMN, Aljure OD, Yu S. Postoperative resuscitation with hypertonic saline or hyperoncotic albumin in patients following cardiac surgery: A review of the literature. J Card Surg 2020; 36:1040-1049. [PMID: 33283332 DOI: 10.1111/jocs.15233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/12/2020] [Accepted: 11/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Over-resuscitation in postcardiac surgery patients is associated with significant morbidity and mortality. Accordingly, there is a growing interest in hyperoncotic albumin and hypertonic saline for resuscitation in patients following cardiac surgery. In this article, we will review the use of hyperosmolar fluid therapies for resuscitation in postcardiac surgical patients from the current literature. METHODS A literature search was conducted in MEDLINE (PubMed) utilizing keywords, narrowing publications from 2009 to 2020. RESULTS Patients receiving concentrated albumin after cardiac surgery required less fluid bolus therapy, less time on vasopressors, and had a lower positive fluid balance compared with patients receiving crystalloids. There was no difference in mortality in those given 20% albumin compared with crystalloids postcardiac surgery. Patients administered hypertonic saline following cardiac surgery had increased urinary output but its effect on total fluid and body weight was not significantly different compared with crystalloids. CONCLUSIONS In this analysis, publications on resuscitation with hyperoncotic albumin and hypertonic saline in patients following cardiac surgery were reviewed. While there is data supporting the use of alternative fluid therapies in other critically ill populations, the limited literature focused on concentrated albumin and hypertonic saline for resuscitation following cardiac surgery is equivocal.
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Affiliation(s)
- Tiffany M N Otero
- Department of Anesthesiology, Banner University Medical Center, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Oscar D Aljure
- Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Soojie Yu
- Department of Anesthesiology, Banner University Medical Center, University of Arizona College of Medicine, Tucson, Arizona, USA
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Bilgen F, Chen P, Poggi A, Wells J, Trumble E, Helmke S, Teruya S, Catalan T, Rosenblum HR, Cornellier ML, Karmally W, Maurer MS, Hummel SL. Insufficient Calorie Intake Worsens Post-Discharge Quality of Life and Increases Readmission Burden in Heart Failure. JACC-HEART FAILURE 2020; 8:756-764. [PMID: 32653445 DOI: 10.1016/j.jchf.2020.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the relationship between calorie intake and post-discharge outcomes in hospitalized patients with heart failure (HF). BACKGROUND Malnutrition increases adverse outcomes in HF, and dietary sodium restriction may inadvertently worsen nutritional intake. METHODS In a dietary intervention trial, baseline nutritional intake in HF inpatients was estimated using the Block Food Frequency Questionnaire (FFQ), and the Nutritional Risk Index (NRI) was calculated. Insufficient calorie intake was defined as <90% of metabolic needs, and a 15-point micronutrient deficiency score was created. Adjusted linear, logistic, and negative binomial regression were used to evaluate associations between insufficient calorie intake and quality of life (using the Kansas City Cardiomyopathy Questionnaire Clinical Summary [KCCQ-CS]), readmission risk, and days rehospitalized over 12 weeks. RESULTS Among 57 participants (70 ± 8 years of age; 31% female; mean body mass index 32 ± 8 kg/m2); median sodium and calorie intake amounts were 2,987 mg/day (interquartile range [IQR]: 2,160 to 3,540 mg/day) and 1,602 kcal/day (IQR: 1,201 to 2,142 kcal/day), respectively; 11% of these patients were screened as malnourished by the NRI. All patients consuming <2,000 mg/day sodium had insufficient calorie intake; this group also more frequently had dietary micronutrient and protein deficiencies. At 12 weeks, patients with insufficient calorie intake had less improvement in the KCCQ-CS score (β = -14.6; 95% confidence interval [CI]: -27.3 to -1.9), higher odds of readmission (odds ratio: 14.5; 95% CI: 2.2 to 94.4), and more days rehospitalized (incident rate ratio: 31.3; 95% CI: 4.3 to 229.3). CONCLUSIONS Despite a high prevalence for obesity and rare overt malnutrition, insufficient calorie intake was associated with poorer post-discharge quality of life and increased burden of readmission in patients with HF. Inpatient dietary assessment could improve readmission risk stratification and identify patients for nutritional intervention. (Geriatric Out of Hospital Randomized Meal Trial in Heart Failure [GOURMET-HF] NCT02148679).
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Affiliation(s)
| | - Peiyu Chen
- University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Stephen Helmke
- Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan
| | - Sergio Teruya
- Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan
| | | | | | | | - Wahida Karmally
- Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan
| | - Mathew S Maurer
- Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan
| | - Scott L Hummel
- University of Michigan, Ann Arbor, Michigan; Columbia University, New York, New York.
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Hypertonic saline for fluid resuscitation in ICU patients post-cardiac surgery (HERACLES): a double-blind randomized controlled clinical trial. Intensive Care Med 2020; 46:1683-1695. [PMID: 32519005 DOI: 10.1007/s00134-020-06132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Recent evidence questions a liberal approach to fluid resuscitation in intensive care unit (ICU) patients. Here, we assess whether use of hypertonic saline applied as single infusion at ICU admission after cardiac surgery can reduce cumulative perioperative fluid volume. METHODS Prospective randomized double-blind single-center clinical trial investigates effects of a single infusion of hypertonic saline (HS) versus normal saline (comparator). Primary endpoint was the cumulative amount of fluid administered in patients in the hypertonic saline versus the 0.9% saline groups (during ICU stay). Upon ICU admission, patients received a single infusion of 5 ml/kg body weight of 7.3% NaCl (or 0.9% NaCl) over 60 min. Patients undergoing cardiac surgery for elective valvular and/or coronary heart disease were included. Patients with advanced organ dysfunction, infection, and/or patients on chronic steroid medication were excluded. RESULTS A total of 101 patients were randomized to receive the study intervention (HS n = 53, NS n = 48). Cumulative fluid intake on the ICU (primary endpoint) did not differ between the HS and the NS groups [median 3193 ml (IQR 2052-4333 ml) vs. 3345 ml (IQR 2332-5043 ml)]. Postoperative urinary output until ICU discharge was increased in HS-treated patients [median 2250 ml (IQR 1640-2690 ml) vs. 1545 ml (IQR 1087-1976 ml)], and ICU fluid balance was lower in the HS group when compared to the NS group [296 ml (IQR - 441 to 1412 ml) vs. 1137 ml (IQR 322-2660 ml)]. CONCLUSION In a monocentric prospective double-blind randomized clinical trial, we observed that hypertonic saline did not reduce the total fluid volume administered on the ICU in critically ill cardiac surgery patients. Hypertonic saline infusion was associated with timely increase in urinary output. Variations in electrolyte and acid-base homeostasis were transient, but substantial in all patients.
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Nutrition intervention in heart failure: should consumption of the DASH eating pattern be recommended to improve outcomes? Heart Fail Rev 2020; 24:565-573. [PMID: 30923990 DOI: 10.1007/s10741-019-09781-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Heart failure (HF) is a chronic, systemic disorder that presents a serious and growing public health problem due to its high prevalence, mortality, and cost of care. Due to the aging of the population and medical advances that prolong the life of HF patients, more effective, widespread strategies for improved HF management in this rapidly growing patient population are needed. While the prevalence of malnutrition in HF patients has been well characterized, evidence is limited regarding the effects of specific macro- and micronutrient deficiencies on HF outcomes and their interaction with other aspects of HF management, including pharmacotherapy. There is a mounting appreciation for the effects of nutritional intervention on pathophysiology, treatment, and outcomes in patients with HF. Heart-healthy dietary patterns, such as the Dietary Approaches to Stop Hypertension (DASH), carry importance for the prevention and treatment of hypertension. While preliminary evidence looks promising regarding effects of DASH eating pattern consumption on ventricular function and 30-day hospitalizations in HF patients, more research is needed to confirm its effects on short-term and long-term HF outcomes while better understand underlying mechanisms in the context of HF pharmacotherapy.
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Abstract
Decompensated heart failure accounts for approximately 1 million hospitalizations in the United States annually, and this number is expected to increase significantly in the near future. Diuretics provide the initial management in most patients with fluid overload. However, the development of diuretic resistance remains a significant challenge in the treatment of heart failure. Due to the lack of a standard definition, the prevalence of this phenomenon remains difficult to determine, with some estimates suggesting that 25-30% of patients with heart failure have diuretic resistance. Certain characteristics, including low systolic blood pressures, renal impairment, and atherosclerotic disease, help predict the development of diuretic resistance. The underlying pathophysiology is likely multifactorial, with pharmacokinetic alterations, hormonal dysregulation, and the cardiorenal syndrome having significant roles. The therapeutic approach to this common problem typically involves increases in the diuretic dose and/or frequency, sequential nephron blockade, and mechanical fluid movement removal with ultrafiltration or peritoneal dialysis. Paracentesis is potentially useful in patients with intra-abdominal hypertension.
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Abstract
This article reviews treatment and management of common cardiovascular emergencies in critically ill patients, focusing on acute decompensated heart failure, cardiogenic shock, pulmonary embolism, and hypertensive crisis management with inotropes, vasopressors, diuretics, and antiarrhythmic drugs. Clinicians frequently come across challenging clinical scenarios, and there is a gap between evidence-based medicine and clinical practice. Inotropic and vasopressor agents are useful in the acute setting but must be weaned off or used as a bridge for mechanical circulation support devices. Clinicians should aim to lower complications by choosing medications with respect to comorbidities and close the gap between evidence-based medicine and clinical practice.
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Affiliation(s)
- Yogamaya Mantha
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA
| | - Rakushumimarika Harada
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA
| | - Michinari Hieda
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, 7232 Greenville Avenue, Dallas, TX 75231, USA.
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Kalogeropoulos A, Papadimitriou L, Georgiopoulou VV, Dunbar SB, Skopicki H, Butler J. Low- Versus Moderate-Sodium Diet in Patients With Recent Hospitalization for Heart Failure: The PROHIBIT (Prevent Adverse Outcomes in Heart Failure by Limiting Sodium) Pilot Study. Circ Heart Fail 2020; 13:e006389. [PMID: 31959014 DOI: 10.1161/circheartfailure.119.006389] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND We conducted a pilot study to assess feasibility, on-study retention, trends in natriuretic peptide levels, quality of life, and safety of a 12-week feeding trial with 1500- versus 3000-mg daily sodium meals in high-risk patients with heart failure. METHODS Of 196 patients with recent (≤2 weeks) hospitalization for heart failure, ejection fraction ≤40%, on optimal medical therapy, functionally independent, and able to communicate, 83 (47%) consented to participate. Of these, 27 (age, 62±11 years; 22 men; 20 white; ejection fraction, 26±8%) had 24-hour urine sodium ≥3000 mg and agreed to randomly receive either 1500-mg (N=12) or 3000-mg (N=15) sodium meals. RESULTS On-study retention at 12 weeks was 77% (82% versus 73%; P=0.53); 6 patients (2 in 1500-mg, 4 in 3000-mg arm) withdrew before study completion. Food satisfaction questionnaires indicated that both diets were well tolerated. Quality of life improved in the 1500-mg arm at 12 weeks but did not change in the 3000-mg arm. Average compliance with meals was 52% (based on urinary sodium) and was not significantly different between arms (42% versus 60%; P=0.25). Study meals reduced 24-hour urinary sodium by 137±21 mmol (1500-mg arm) and 82±16 mmol (3000-mg arm), both P<0.001; between-arms difference was 55 mmol (95% CI, 3-107; P=0.037). NT-proBNP (N-terminal pro-B-type natriuretic peptide) was not affected. Hospitalizations and low blood pressure events did not differ significantly between arms. Serum creatinine decreased more (by 0.17 mg/dL [95% CI, 0.06-0.28]; P=0.003) in the 1500-mg arm. Creatinine increases >0.5 mg/dL over baseline only occurred in 1 patient in the 3000-mg arm. CONCLUSIONS Even with prepared meals, investigating optimal dietary sodium in heart failure comes with challenges, including need for extensive screening, reluctance to participate, and compliance issues. Because both diets reduced urinary sodium without adverse safety or quality of life signals, a larger trial, with modifications to improve participation and compliance, would be ethical and feasible. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02467296.
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Affiliation(s)
- Andreas Kalogeropoulos
- Division of Cardiology, Department of Medicine, Stony Brook University, NY (A.K., L.P., H.S.)
| | - Lampros Papadimitriou
- Division of Cardiology, Department of Medicine, Stony Brook University, NY (A.K., L.P., H.S.).,Department of Medicine, University of Mississippi, Jackson (L.P., J.B.)
| | | | | | - Hal Skopicki
- Division of Cardiology, Department of Medicine, Stony Brook University, NY (A.K., L.P., H.S.)
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson (L.P., J.B.)
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Khan MS, Jones DW, Butler J. Salt, No Salt, or Less Salt for Patients With Heart Failure? Am J Med 2020; 133:32-38. [PMID: 31419422 DOI: 10.1016/j.amjmed.2019.07.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 01/11/2023]
Abstract
Restricting dietary sodium is a common recommendation given by clinicians to patients with heart failure and is one supported by current guidelines. However, the quality of evidence for this recommendation is suboptimal, and there is no consensus on the optimal level of sodium intake. Though excessive sodium intake is associated with left ventricular hypertrophy and hypertension, recent data have suggested that very low sodium intake is paradoxically associated with worse outcomes for patients with heart failure. This is possibly explained by the association between low sodium intake and activation of the sympathetic and renin-angiotensin-aldosterone systems. Nevertheless, sodium restriction is routinely recommended and remains a cornerstone of heart failure and blood pressure therapy. In this review we discuss the pros and cons of sodium restriction for patients with heart failure from the current literature.
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Affiliation(s)
| | - Daniel W Jones
- Department of Medicine, University of Mississippi, Jackson
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson.
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Sodium restriction, water intake, and diuretic regimen in patients with congestive heart failure. Heart Lung 2019; 48:467-468. [PMID: 31375276 DOI: 10.1016/j.hrtlng.2019.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022]
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Pfortmueller CA, Messmer AS, Hess B, Reineke D, Jakob L, Wenger S, Waskowski J, Zuercher P, Stoehr F, Erdoes G, Luedi MM, Jakob SM, Englberger L, Schefold JC. Hypertonic saline for fluid resuscitation after cardiac surgery (HERACLES): study protocol for a preliminary randomised controlled clinical trial. Trials 2019; 20:357. [PMID: 31200756 PMCID: PMC6570959 DOI: 10.1186/s13063-019-3420-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/09/2019] [Indexed: 01/15/2023] Open
Abstract
Background Intraoperative and postoperative management of cardiac surgery patients is complex, involving the application of differential vasopressors and volume therapy. It has been shown that a positive fluid balance has a major impact on postoperative outcome. Today, the advantages and disadvantages of buffered crystalloid solutes are a topic of controversy, with no consensus being reached so far. The use of hypertonic saline (HS) has shown promising results with respect to lower total fluid balance and postoperative weight gain in critically ill patients in preliminary studies. However, collection of more data on HS in critically ill patients seems warranted. This preliminary study aims to investigate whether fluid resuscitation using HS in patients following cardiac surgery results in less total fluid volume being administered. Methods In a prospective double-blind randomised controlled clinical trial, we aim to recruit 96 patients undergoing elective cardiac surgery for ischaemic and/or valvular heart disease. After postoperative admission to the intensive care unit (ICU), patients will be randomly assigned to receive 5 ml/kg ideal body weight HS (7.3% NaCl) or normal saline (NS, 0.9% NaCl) infused within 60 min. Blood and urine samples will be collected preoperatively and postoperatively up to day 6 to assess changes in renal, cardiac, inflammatory, acid-base, and electrolyte parameters. Additionally, we will perform renal ultrasonography studies to assess renal blood flow before, during, and after infusion, and we will measure total body water using preoperative and postoperative body composition analysis (bioimpedance). Patients will be followed up for 90 days. Discussion The key objective of this study is to assess the cumulative amount of fluid administered in the intervention (HS) group versus control (NS) group during the ICU stay. In this preliminary, prospective, randomised controlled clinical trial we will test the hypothesis that use of HS results in less total fluids infused and less postoperative weight gain when compared to the standard of intensive care in cardiac surgery patients. Trial registration ClinicalTrials.gov, NCT03280745. Registered on 12 September 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3420-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carmen A Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland.
| | - Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - Benjamin Hess
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - David Reineke
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laura Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - Stefanie Wenger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - Jan Waskowski
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - Patrick Zuercher
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - Frederik Stoehr
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - Lars Englberger
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
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Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, Testani JM, Tang WHW, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic PM, Ruschitzka F, Coats AJ. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019; 21:137-155. [PMID: 30600580 DOI: 10.1002/ejhf.1369] [Citation(s) in RCA: 529] [Impact Index Per Article: 105.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/14/2018] [Accepted: 10/27/2018] [Indexed: 12/11/2022] Open
Abstract
The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of diuretic therapy. The appropriate use of diuretics however remains challenging, especially when worsening renal function, diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic diuretic strategies, based upon diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Alexandre Mebazaa
- University of Paris Diderot, Hôpitaux Universitaires Saint Louis Lariboisière, APHP, U 942 Inserm, F-CRIN INI-CRCT, Paris, France
| | | | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | | | | | | | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d'Investigations Clinique 1433 and Inserm U1116; CHRU Nancy; F-CRIN INI-CRCT, Nancy, France
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, Athens, Greece.,University of Cyprus, Nicosia, Cyprus
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Hummel SL, Karmally W, Gillespie BW, Helmke S, Teruya S, Wells J, Trumble E, Jimenez O, Marolt C, Wessler JD, Cornellier M, Maurer MS. Home-Delivered Meals Postdischarge From Heart Failure Hospitalization. Circ Heart Fail 2018; 11:e004886. [PMID: 30354562 PMCID: PMC6205816 DOI: 10.1161/circheartfailure.117.004886] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background In patients with heart failure (HF), malnutrition and dietary sodium excess are common and may worsen outcomes. No prior studies have provided low-sodium, nutritionally complete meals following HF hospitalization. Methods and Results The GOURMET-HF study (Geriatric Out-of-Hospital Randomized Meal Trial in Heart Failure) randomized patients discharged from HF hospitalization to 4 weeks of home-delivered sodium-restricted Dietary Approaches to Stop Hypertension meals (DASH/SRD; 1500 mg sodium/d) versus usual care. The primary outcome was the between-group change in the Kansas City Cardiomyopathy Questionnaire summary score from discharge to 4 weeks postdischarge. Additional outcomes included changes in the Kansas City Cardiomyopathy Questionnaire clinical summary score and cardiac biomarkers. All patients were followed 12 weeks for death/all-cause readmission and potential diet-related adverse events (symptomatic hypotension, hyperkalemia, acute kidney injury). Sixty-six patients were randomized 1:1 at discharge to DASH/SRD versus usual care (age, 71±8 years; 30% female; ejection fraction, 39±18%). The Kansas City Cardiomyopathy Questionnaire summary score increased similarly between groups (DASH/SRD 46±23-59±20 versus usual care 43±19-53±24; P=0.38), but the Kansas City Cardiomyopathy Questionnaire clinical summary score increase tended to be greater in DASH/SRD participants (47±22-65±19 versus 45±20-55±26; P=0.053). Potentially diet-related adverse events were uncommon; 30-day HF readmissions (11% versus 27%; P=0.06) and days rehospitalized within that timeframe (17 versus 55; P=0.055) trended lower in DASH/SRD participants. Conclusions Home-delivered DASH/SRD after HF hospitalization appeared safe in selected patients and had directionally favorable effects on HF clinical status and 30-day readmissions. Larger studies are warranted to clarify the effects of postdischarge nutritional support in patients with HF. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02148679.
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Affiliation(s)
- Scott L. Hummel
- University of Michigan, Ann Arbor, MI
- Ann Arbor Veterans Affairs Health System, Ann Arbor, MI
| | | | | | | | | | | | - Erika Trumble
- Ann Arbor Veterans Affairs Health System, Ann Arbor, MI
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Kuehneman T, Gregory M, de Waal D, Davidson P, Frickel R, King C, Gradwell E, Handu D. Academy of Nutrition and Dietetics Evidence-Based Practice Guideline for the Management of Heart Failure in Adults. J Acad Nutr Diet 2018; 118:2331-2345. [PMID: 29759644 DOI: 10.1016/j.jand.2018.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Indexed: 02/03/2023]
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45
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Nutritional Assessment and Dietary Interventions in Older Patients with Heart Failure. CURRENT CARDIOVASCULAR RISK REPORTS 2018. [DOI: 10.1007/s12170-018-0580-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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46
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Gorodeski EZ, Goyal P, Hummel SL, Krishnaswami A, Goodlin SJ, Hart LL, Forman DE, Wenger NK, Kirkpatrick JN, Alexander KP. Domain Management Approach to Heart Failure in the Geriatric Patient: Present and Future. J Am Coll Cardiol 2018; 71:1921-1936. [PMID: 29699619 PMCID: PMC7304050 DOI: 10.1016/j.jacc.2018.02.059] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/22/2018] [Accepted: 02/25/2018] [Indexed: 02/07/2023]
Abstract
Heart failure (HF) is a quintessential geriatric cardiovascular condition, with more than 50% of hospitalizations occurring in adults age 75 years or older. In older patients, HF is closely linked to processes inherent to aging, which include cellular and structural changes to the myocardium, vasculature, and skeletal muscle. In addition, HF cannot be considered in isolation of physical functioning, or without the social, psychological, and behavioral dimensions of illness. The role of frailty, depression, cognitive impairment, nutrition, and goals of care are each uniquely relevant to the implementation and success of medical therapy. In this paper, we discuss a model of caring for older adults with HF through a 4-domain framework that can address the unique multidimensional needs and vulnerabilities of this population. We believe that clinicians who embrace this approach can improve health outcomes for older adults with HF.
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Affiliation(s)
- Eiran Z Gorodeski
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Parag Goyal
- Division of Cardiology and Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Scott L Hummel
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan
| | - Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California
| | - Sarah J Goodlin
- Geriatrics Section, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Medicine, Oregon Health & Sciences University, Portland, Oregon
| | - Linda L Hart
- Bon Secours Heart and Vascular Institute, Richmond, Virginia
| | - Daniel E Forman
- Section of Geriatric Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare Center, Pittsburgh, Pennsylvania; University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nanette K Wenger
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - James N Kirkpatrick
- Cardiovascular Division, Department of Medicine, Department of Bioethics and Humanities, University of Washington Medical Center, Seattle, Washington
| | - Karen P Alexander
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Lee YW, Huang LH, Ku CH. Use of dietary sodium intervention effect on neurohormonal and fluid overload in heart failure patients: Review of select research based literature. Appl Nurs Res 2018; 42:17-21. [PMID: 30029710 DOI: 10.1016/j.apnr.2018.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 04/14/2018] [Accepted: 04/18/2018] [Indexed: 11/15/2022]
Abstract
AIM This literature review analyzed ten articles investigating the effects of low dietary sodium intake on neurohormonal and fluid overload on heart failure (HF). BACKGROUND Recommendations for low dietary sodium to HF patients has been debated in the past one to two decades. METHODS This report presents a literature review of interventional studies from 2006 to 2015 investigating adult HF patients. RESULTS The results of the neurohormonal outcome variables seem to be the primary consideration for recommending a low sodium diet to patients with HF. Most of articles in this review reported that 2.6-3 g/day of dietary sodium is effective for decreased BNP, renin, and aldosterone (neurohormonal) plasma levels in patients with HF. CONCLUSIONS We have to provide the reason, effect, and amount of dietary sodium when providing dietary sodium recommendations to patients.
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Affiliation(s)
- Yi-Wen Lee
- College of Nursing, Chang Gung University of Science and Technology, 261, Wen-Hwa 1st Rd., Kwei-Shan, Taoyuan City 33303, Taiwan.
| | - Lian-Hua Huang
- Nursing Department, China Medical University Health Care System, 2, Yude Road, North District, Taichung, 40447, Taiwan.
| | - Chieh-Hsio Ku
- College of Nursing, Chang Gung University of Science and Technology, 261, Wen-Hwa 1st Rd., Kwei-Shan, Taoyuan City 33303, Taiwan.
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Aronow WS, Shamliyan TA. Dietary Sodium Interventions to Prevent Hospitalization and Readmission in Adults with Congestive Heart Failure. Am J Med 2018; 131:365-370.e1. [PMID: 29307539 DOI: 10.1016/j.amjmed.2017.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/08/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Wilbert S Aronow
- Westchester Medical Center, New York Medical College, Valhalla, NY
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Urinary composition predicts diuretic efficiency of hypertonic saline solution with furosemide therapy and heart failure prognosis. Heart Vessels 2018; 33:1029-1036. [PMID: 29556693 DOI: 10.1007/s00380-018-1156-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 03/16/2018] [Indexed: 10/17/2022]
Abstract
Recently, we and other group have reported that furosemide administration along with hypertonic saline solution enhanced diuretic efficiency of furosemide. However, little is known about factors which associated with high diuretic efficiency by hypertonic saline solution with furosemide therapy. To identify predictors of diuretic efficiency in the hypertonic saline solution with furosemide therapy, we recruited 30 consecutive hospitalized heart failure (HF) patients with volume overload (77 ± 10 years, systolic blood pressure > 90 mmHg, and estimated glomerular filtration rate > 15 ml/min/1.73 m2). Hypertonic saline with furosemide solution, consisting of 500 ml of 1.7% hypertonic saline solution with 40 mg of furosemide, was administered continuously over 24 h. The patients were divided into two groups on the basis of 24-h urine volume (UV) after initiation of diuretic treatment ≥ 2000 ml (high urine volume: HUV) and < 2000 ml (low urine volume: LUV). The basal clinical characteristics of both groups were analyzed and the predictors of HUV after receiving the treatment were identified. There were not significant differences between two groups in baseline clinical characteristics and medication. Univariate logistic analysis revealed that blood urea nitrogen/creatinine ratio, urine urea nitrogen/creatinine ratio (UUN/UCre), fractional excretion of sodium, and tricuspid annular plane systolic excursion positively associated with HUV. Multivariate logistic regression analysis revealed that UUN/UCre at baseline was independently associated with HUV, and UUN/UCre best predicts HUV by the therapy with a cut-off value of 6.16 g/dl/g Cre (AUC 0.910, 95% CI 0.696-0.999, sensitivity 80%, specificity 87%). The Kaplan-Meier curves revealed significant difference for HF rehospitalization and death rate at 180 days between patients with UUN/UCre ≥ 6.16 g/dl/g Cre and those with UUN/UCre < 6.16 g/dl/g Cre (log-rank P = 0.0489). UUN/UCre at baseline strongly predicted of diuretic efficiency in the hypertonic saline solution with furosemide therapy, and was associated with HF prognosis.
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50
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Lafrenière G, Béliveau P, Bégin JY, Simonyan D, Côté S, Gaudreault V, Israeli Z, Lavi S, Bagur R. Effects of hypertonic saline solution on body weight and serum creatinine in patients with acute decompensated heart failure. World J Cardiol 2017; 9:685-692. [PMID: 28932357 PMCID: PMC5583541 DOI: 10.4330/wjc.v9.i8.685] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 02/20/2017] [Accepted: 06/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To test the safety and effectiveness of hypertonic saline solution (HSS + F) as a strategy for weight loss and prevention of further deterioration of renal function.
METHODS Patients admitted with acute decompensated heart failure (ADHF) who received HSS + F were included in the study. After a period of a standard ADHF treatment, our patients received an intravenous infusion of furosemide (250 mg) combined with HSS (150 mL of 3% NaCl) twice a day for a mean duration of 2.3 d. Our primary outcomes were weight loss and a change in serum creatinine per day of treatment. The parameters of the period prior to treatment with HSS + F were compared with those of the period with HSS + F.
RESULTS A total of 47 patients were included. The mean creatinine on admission was 155 μmol/L ± 65 μmol/L, the ejection fraction was 40% ± 17%. The experimental treatment (HSS + F) resulted in greater weight loss per day of treatment than the standard treatment (-1.4 kg/d ± 1.4 kg/d vs -0.4 kg/d ± 1.0 kg/d, P = 0.0168). Importantly, the change in creatinine was not significantly different.
CONCLUSION This study supports the effectiveness of HSS + F on weight loss in patients with ADHF. The safety profile, particularly with regard to renal function, leads us to believe that HSS + F may be a valuable option for those patients presenting with ADHF who do not respond to conventional treatment with intravenous furosemide alone.
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Affiliation(s)
- Gabrielle Lafrenière
- Division of Cardiology, Department of Medicine, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC G1R 2J6, Canada
| | - Patrick Béliveau
- Division of Cardiology, Department of Medicine, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC G1R 2J6, Canada
| | - Jean-Yves Bégin
- Department of Psychoeducation, Université du Québec à Trois-Rivières, Trois-Rivières, QC G9A 5H7, Canada
| | - David Simonyan
- Clinical Research Platform, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC G1R 2J6, Canada
| | - Sylvain Côté
- Department of Pharmacy, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC G1R 2J6, Canada
| | - Valérie Gaudreault
- Division of Cardiology, Department of Medicine, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC G1R 2J6, Canada
| | - Zeev Israeli
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, London, ON N6A5A5, Canada
| | - Shahar Lavi
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, London, ON N6A5A5, Canada
| | - Rodrigo Bagur
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, London, ON N6A5A5, Canada
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