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Biegus J, Cotter G, Metra M, Ponikowski P. Decongestion in acute heart failure: Is it time to change diuretic-centred paradigm? Eur J Heart Fail 2024. [PMID: 39169731 DOI: 10.1002/ejhf.3423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/18/2024] [Accepted: 07/25/2024] [Indexed: 08/23/2024] Open
Abstract
Congestion is a common cause of clinical deterioration and the most common clinical presentation at admission in acute heart failure (HF). Therefore, finding effective and sustainable ways to alleviate congestion has become a crucial goal for treating HF patients. Congestion is a result of complex underlying pathophysiology; therefore, it is not a direct cause of the disease but its consequence. Any therapy that directly promotes sodium/water removal only, thus targeting only clinical symptoms, neither modifies the natural course of the disease nor improves prognosis. This review aims to provide a comprehensive evaluation of the current decongestive therapies and propose a new (not diuretic-centred) paradigm of long-term congestion management in HF that attempts to correct the underlying pathophysiology, thus improving congestion, preventing its development, and favourably altering the natural course of the disease rather than merely treating its symptoms.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Gad Cotter
- Momentum Research, Inc., Chapel Hill, NC, USA
- U 942 Inserm MASCOT, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
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Cuthbert JJ, Clark AL. Diuretic Treatment in Patients with Heart Failure: Current Evidence and Future Directions - Part I: Loop Diuretics. Curr Heart Fail Rep 2024; 21:101-114. [PMID: 38240883 PMCID: PMC10924023 DOI: 10.1007/s11897-024-00643-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE OF REVIEW Fluid retention or congestion is a major cause of symptoms, poor quality of life, and adverse outcome in patients with heart failure (HF). Despite advances in disease-modifying therapy, the mainstay of treatment for congestion-loop diuretics-has remained largely unchanged for 50 years. In these two articles (part I: loop diuretics and part II: combination therapy), we will review the history of diuretic treatment and the current trial evidence for different diuretic strategies and explore potential future directions of research. RECENT FINDINGS We will assess recent trials including DOSE, TRANSFORM, ADVOR, CLOROTIC, OSPREY-AHF, and PUSH-AHF amongst others, and assess how these may influence current practice and future research. There are few data on which to base diuretic therapy in clinical practice. The most robust evidence is for high dose loop diuretic treatment over low-dose treatment for patients admitted to hospital with HF, yet this is not reflected in guidelines. There is an urgent need for more and better research on different diuretic strategies in patients with HF.
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Affiliation(s)
- Joseph James Cuthbert
- Clinical Sciences Centre, Hull York Medical School, University of Hull, Cottingham Road, Kingston-Upon-Hull, East Yorkshire, UK.
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals Trust, Castle Road, Cottingham, East Yorkshire, UK.
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals Trust, Castle Road, Cottingham, East Yorkshire, UK
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Mizobuchi S, Saito Y, Kitano D, Toyama K, Miyagawa M, Koyama Y, Fujito H, Kojima K, Murata N, Fukamachi D, Okumura Y. Sodium-glucose co-transporter 2 inhibitors in acute heart failure: real-world prescription trends and outcomes analysis. ESC Heart Fail 2024; 11:410-421. [PMID: 38017700 PMCID: PMC10804185 DOI: 10.1002/ehf2.14597] [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: 08/19/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/30/2023] Open
Abstract
AIMS Sodium-glucose co-transporter 2 (SGLT2) inhibitors have shown potential therapeutic benefits in heart failure (HF). However, data on their real-world usage and benefits in acute decompensated heart failure (ADHF) are limited. METHODS AND RESULTS We conducted a post hoc analysis of real-world data from 1108 patients with ADHF admitted to Nihon University Itabashi Hospital (Tokyo, Japan) between 2018 and 2022. Patients were divided into two groups based on the prescription of SGLT2 inhibitors during hospitalization: an SGLT2 inhibitor group (SGLT2i group) (n = 289) and a non-SGLT2i group (n = 819). The primary endpoints were death and rehospitalization for HF after discharge. The median age was 76 [interquartile range (IQR): 66, 83] years, and 732 patients (66%) were male. Data showed an increasing trend in the prescription of SGLT2 inhibitors since 2021. During a median follow-up period of 366 days (IQR: 116, 614), 458 (41.3%) patients reached the primary endpoint. The Kaplan-Meier analysis showed that the SGLT2i group had a significantly lower rate of composite events than the non-SGLT2i group, both overall (log-rank test, P < 0.001) and in the following left ventricular ejection fraction (LVEF) subgroups: HF with reduced ejection fraction (EF) (n = 413), HF with mildly reduced EF (n = 226), and HF with preserved EF (n = 466) (log-rank test; P = 0.044, P = 0.013, and P = 0.001, respectively). Furthermore, patients starting SGLT2 inhibitors during hospitalization had a significantly lower rate of composite events than those not using SGLT2 inhibitors (log-rank test, P < 0.001). This association was also significant in the LVEF subgroups (P = 0.005, P = 0.032, and P = 0.004, respectively). CONCLUSIONS The prescription and initiation of SGLT2 inhibitors during hospitalization are associated with improved post-discharge outcomes in patients with ADHF, irrespective of LVEF.
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Affiliation(s)
- Saki Mizobuchi
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
| | - Yuki Saito
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
| | - Daisuke Kitano
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
| | - Kazuto Toyama
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
| | - Masatsugu Miyagawa
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
| | - Yutaka Koyama
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
| | - Hidesato Fujito
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
| | - Keisuke Kojima
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
| | - Nobuhiro Murata
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
| | - Daisuke Fukamachi
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of MedicineNihon University School of Medicine30‐1 Ohyaguchi‐kamicho, Itabashi‐kuTokyo173‐8610Japan
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Bisht H, Tripathi A, Arya A, Konat A, Patel D, Godhani D, Kamaria R, Shah P, Chudasama G, Jain P, Sharma K. Ultrafiltration in Heart Failure: A Review. Cureus 2023; 15:e39933. [PMID: 37409214 PMCID: PMC10318566 DOI: 10.7759/cureus.39933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 07/07/2023] Open
Abstract
Ultrafiltration is an effective method to get rid of fluid retention and congestion in patients with acute decompensated heart failure (HF) without affecting the circulating volume. Although its efficacy in comparison to diuretics is debatable, the evaluation of our analysis is based on various studies that comprise published clinical trials on ultrafiltration and studies comparing the efficacy of diuretics and ultrafiltration. Apart from this, we also look at literature that provides shortcomings of the said procedure and its scope for future advancements. Heart failure ultimately leads to volume overload, which is a highly concerning complication. Diuretics have been used as a first-line treatment for fluid overload but are becoming inefficacious due to the development of resistance and renal dysfunction. Ultrafiltration, on the other hand, is an attractive alternative to counter volume overload and congestion, which are unresponsive to medical therapy. There is also evidence that it significantly decreases the probability of future episodes of decompensation. There are, however, disagreements about whether ultrafiltration is an effective method to improve mortality in these patients. There is a lack of conclusive studies demonstrating the superiority of one fluid removal method over another. Hence, it is imperative to continue searching for the most effective method to treat congestion. Priority should be given to more mechanistic studies regarding ultrafiltration.
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Affiliation(s)
- Himanshi Bisht
- Medicine, Byramjee Jeejeebhoy (BJ) Medical College, Ahmedabad, IND
| | - Apoorva Tripathi
- Medicine, Byramjee Jeejeebhoy (BJ) Medical College, Ahmedabad, IND
| | - Akshat Arya
- Internal Medicine, Byramjee Jeejeebhoy (BJ) Medical College, Ahmedabad, IND
| | - Ashwati Konat
- Department of Zoology, Biomedical Technology and Human Genetics, Gujarat University, Ahmedabad, IND
| | - Divya Patel
- Internal Medicine, Byramjee Jeejeebhoy (BJ) Medical College, Ahmedabad, IND
| | - Dhruvin Godhani
- Internal Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College, Gandhinagar, IND
| | - Rushi Kamaria
- Internal Medicine, Government Medical College, Surat, IND
| | - Parita Shah
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Gayatri Chudasama
- Internal Medicine, Byramjee Jeejeebhoy (BJ) Medical College, Ahmedabad, IND
| | - Pragya Jain
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Kamal Sharma
- Cardiology, Dr. Kamal Sharma Cardiology Clinic, Ahmedabad, IND
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Ghani U, Farooq O, Aziz S, Alam S, Khan MJ, Rahim O. The Spectrum of Heart Failure Management. Cureus 2023; 15:e40587. [PMID: 37469814 PMCID: PMC10353487 DOI: 10.7759/cureus.40587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/21/2023] Open
Abstract
Heart failure, a complex cardiovascular condition, is a huge burden on patients, caregivers, and healthcare systems and it is prevalent worldwide. Heart failure is caused by a wide variety of underlying conditions that include both cardiac and non-cardiac pathologies. Identifying the underlying cause enables us to apply etiology-based interventions. The spectrum of heart failure management ranges from classification to transplantation. In addition to its classification and monitoring, this article reviews various management strategies, including both conventional methods and the latest innovations. These include lifestyle interventions, pharmacotherapy, device therapy, transplantation, and regenerative medicine.
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Affiliation(s)
- Usman Ghani
- Cardiology, Northwest General Hospital and Research Center, Peshawar, PAK
| | - Omer Farooq
- Internal Medicine, Ascension Saint Francis Hospital, Evanston, USA
| | - Sundal Aziz
- Cardiology, Northwest General Hospital and Research Center, Peshawar, PAK
| | - Sundus Alam
- Acute Medicine, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, GBR
| | - Muhammad Junaid Khan
- Orthopaedic Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, GBR
| | - Omar Rahim
- Cardiology, Naseer Teaching Hospital, Peshawar, PAK
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Yaku H, Kato T, Morimoto T, Kaneda K, Nishikawa R, Kitai T, Inuzuka Y, Tamaki Y, Yamazaki T, Kitamura J, Ezaki H, Nagao K, Yamamoto H, Isotani A, Takeshi A, Izumi C, Sato Y, Nakagawa Y, Matoba S, Sakata Y, Kuwahara K, Kimura T. Rationale and study design of the GOREISAN for heart failure (GOREISAN-HF) trial: A randomized clinical trial. Am Heart J 2023; 260:18-25. [PMID: 36841318 DOI: 10.1016/j.ahj.2023.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/15/2023] [Accepted: 02/18/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND The decongestion strategy using loop diuretics is essential for improving signs and symptoms of heart failure (HF). However, chronic use of loop diuretics in HF has been linked to worsening renal function and adverse clinical outcomes in a dose-dependent manner. Goreisan, a traditional Japanese herbal medicine, has a long history of use in Japan for regulating body fluid homeostasis and has been recognized as causing less adverse outcomes such as dehydration in contrast to loop diuretics in clinical practice. Therefore, we designed the GOREISAN-HF trial to evaluate the long-term effects of a new decongestion strategy adding Goreisan to usual care in patients with HF and volume overload. METHODS The GOREISAN-HF trial is an investigator-initiated, multicenter, pragmatic, randomized, comparative effectiveness trial in which we will enroll 2,192 patients hospitalized for HF at 68 hospitals in Japan. All study participants will be randomly assigned to either a decongestion strategy that adds Goreisan at a dose of 7.5 g daily on top of usual care or usual care alone. Investigators have the flexibility to change the existing diuretic regimen in both groups. The primary end point is the improvement rate of cardiac edema at 12-month follow-up, and the co-primary end point is a composite of all-cause death or hospitalization up to the end of the planned follow-up period. Secondary end points include longitudinal changes in patient-reported outcomes, loop diuretics dose, and renal function. CONCLUSIONS The GOREISAN-HF is the first large-scale randomized pragmatic trial to assess the efficacy and safety of a new congestion control strategy adding Goreisan to usual care in patients with HF and volume overload. REGISTRATION NUMBER NCT04691700.
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Affiliation(s)
- Hidenori Yaku
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Morimoto
- Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazuhisa Kaneda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yasutaka Inuzuka
- Department of Cardiovascular Medicine, Shiga General Hospital, Moriyama, Japan
| | - Yodo Tamaki
- Division of Cardiology, Tenri Hospital, Nara, Japan
| | - Taketoshi Yamazaki
- Department of Internal Medicine, Rakuwakai Otowa Rehabilitation Hospital, Kyoto, Japan
| | - Jun Kitamura
- Department of Internal Medicine, Kobe Kaisei Hospital, Kobe, Japan
| | - Hirotaka Ezaki
- Department of Cardiology, Tokorozawa Heart Center, Tokorozawa, Japan
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hiromi Yamamoto
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Akihiro Isotani
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Arita Takeshi
- Division of Cardiovascular Medicine Heart & Neuro-Vascular Center, Fukuoka Wajiro, Fukuoka, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University Graduate School of Medicine, Nagano, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Kawanami S, Egami Y, Sugae H, Ukita K, Kawamura A, Nakamura H, Matsuhiro Y, Yasumoto K, Tsuda M, Okamoto N, Matsunaga‐Lee Y, Yano M, Nishino M, Tanouchi J. Predictors of bleeding events in acute decompensated heart failure patients with antithrombotic therapy: AURORA study. ESC Heart Fail 2023; 10:1114-1121. [PMID: 36585753 PMCID: PMC10053354 DOI: 10.1002/ehf2.14277] [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: 02/28/2022] [Revised: 10/18/2022] [Accepted: 12/15/2022] [Indexed: 01/01/2023] Open
Abstract
AIMS Heart failure (HF) is reported to be one of the major risks of bleeding events. On the other hand, HF patients frequently receive anticoagulants or antiplatelet therapy to manage various co-morbidities. However, predictors of bleeding events in patients with HF have rarely been reported. This study aimed to evaluate the predictors of bleeding events and relationship between bleeding events and HF re-hospitalizations. METHODS AND RESULTS We included 1660 acute decompensated heart failure (ADHF) patients from the AURORA registry between January 2015 and December 2020. A total of 1429 patients were excluded because of history of HF admission, missing echocardiographic data at discharge, lost to follow-up, haemodialysis and no antithrombotic drugs. Finally, we evaluated 231 patients from AURORA registry. The bleeding events were defined as Type 2 to 5 bleeding according to the Bleeding Academic Research Consortium definition. We divided our patients into the bleeding group and non-bleeding group. We compared the baseline characteristics, medications, laboratory data, and echocardiographic data between the two groups. Median age was 78 (IQR 71-82) years old and male accounted for 59%. Approximately half of the patients had an antiplatelet therapy and 70% had an anticoagulant therapy. During a median follow-up of 651 (IQR 357-1139) days, 32 patients (13.8%) suffered from bleeding events. The major driver of the registered events was gastrointestinal bleeding (n = 21, 65.6%), and the other events were cerebral bleeding (n = 4, 12.5%), intraarticular bleeding (n = 2, 6.3%), urogenital bleeding (n = 2, 6.3%), haemorrhagic pericardial effusions (n = 1, 3.1%), subcutaneous hematomas (n = 1, 3.1%), and haemothorax (n = 1, 3.1%). There was a significantly lower haemoglobin level (P < 0.01), higher proportion of inferior vena cava (IVC) diameter ≥21 mm (P < 0.01), and higher furosemide equivalent doses per kilogram (P < 0.01) in the bleeding group than non-bleeding group. A multivariate analysis revealed an equivalent dose of furosemide per kilogram ≥0.66 mg/kg (hazard ratios (HR) of 2.64, 95% confidence interval (CI) 1.26-5.68, P = 0.01), haemoglobin ≤10.3 g/dL (HR of 2.43, 95% CI 1.14-5.03, P = 0.02), and IVC diameter ≥21 mm (HR of 2.79, 95% CI 1.16-6.29, P = 0.02) were independently associated with bleeding events. The Kaplan-Meier analysis showed that HF re-hospitalization rates were higher in the bleeding group than non-bleeding group (P = 0.04). CONCLUSIONS High doses of oral loop diuretics, IVC dilatation, and anaemia were predictors of bleeding events in patients hospitalized with ADHF patients. In addition, bleeding events were associated with HF re-hospitalizations.
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Affiliation(s)
- Shodai Kawanami
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Yasuyuki Egami
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Hiroki Sugae
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Kohei Ukita
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Akito Kawamura
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Hitoshi Nakamura
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Yutaka Matsuhiro
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Koji Yasumoto
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Masaki Tsuda
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Naotaka Okamoto
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Yasuharu Matsunaga‐Lee
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Masamichi Yano
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Masami Nishino
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Jun Tanouchi
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
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Persistent Hypochloremia Is Associated with Adverse Prognosis in Patients Repeatedly Hospitalized for Heart Failure. J Clin Med 2023; 12:jcm12041257. [PMID: 36835793 PMCID: PMC9962161 DOI: 10.3390/jcm12041257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Hypochloremia reflects neuro-hormonal activation in patients with heart failure (HF). However, the prognostic impact of persistent hypochloremia in those patients remains unclear. METHODS We collected the data of patients who were hospitalized for HF at least twice between 2010 and 2021 (n = 348). Dialysis patients (n = 26) were excluded. The patients were divided into four groups based on the absence/presence of hypochloremia (<98 mmol/L) at discharge from their first and second hospitalizations: Group A (patients without hypochloremia at their first and second hospitalizations, n = 243); Group B (those with hypochloremia at their first hospitalization and without hypochloremia at their second hospitalization, n = 29); Group C (those without hypochloremia at their first hospitalization and with hypochloremia at their second hospitalization, n = 34); and Group D (those with hypochloremia at their first and second hospitalizations, n = 16). RESULTS a Kaplan-Meier analysis revealed that all-cause mortality and cardiac mortality were the highest in Group D compared to the other groups. A multivariable Cox proportional hazard analysis revealed that persistent hypochloremia was independently associated with both all-cause death (hazard ratio 3.490, p < 0.001) and cardiac death (hazard ratio 3.919, p < 0.001). CONCLUSIONS In patients with HF, prolonged hypochloremia over two hospitalizations is associated with an adverse prognosis.
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Stencel J, Rajapreyar I, Samson R, Le Jemtel T. Comprehensive and Safe Decongestion in Acutely Decompensated Heart Failure. Curr Heart Fail Rep 2022; 19:364-374. [PMID: 36045314 DOI: 10.1007/s11897-022-00573-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF THE REVIEW Progressive intravascular, interstitial, and alveolar fluid overload underlies the transition from compensated to acutely decompensated heart failure and loop diuretics are the mainstay of treatment. Adverse effects and resistance to loop diuretics received much attention while the contribution of a depressed cardiac output to diuretic resistance was downplayed. RECENT FINDINGS Analysis of experience with positive inotropic agents, especially dobutamine, indicates that enhancement of cardiac output is not consistently associated with increased renal blood flow. However, urinary output and renal sodium excretion increase likely due to dobutamine-mediated decrease in renal and systemic reduced activation of sympathetic nervous- and renin-angiotensin-aldosterone system. Mechanical circulatory support with left ventricular assist devices ascertained the contribution of low cardiac output to diuretic resistance and the pathogenesis and progression of kidney disease in acutely decompensated heart failure. Diuretic resistance commonly occurs in acutely decompensated heart failure. However, failure to resolve fluid overload despite high doses of loop diuretics should alert to the presence of a low cardiac output state.
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Affiliation(s)
- Jason Stencel
- Tulane University School of Medicine, New Orleans, LA, USA.
| | | | - Rohan Samson
- Rudd Heart and Lung Center, University of Louisville Health, Louisville, KY, USA
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10
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Kawai T, Nakatani D, Watanabe T, Yamada T, Morita T, Sakata Y, Hikoso S, Mizuno H, Suna S, Kitamura T, Okada K, Dohi T, Sotomi Y, Sunaga A, Kida H, Oeun B, Sato T, Sato H, Hori M, Komuro I, Fukunami M, Sakata Y. Loop Diuretic Use is Associated With Adverse Clinical Outcomes in Acute Myocardial Infarction Patients With Low Volume Status: Loop diuretics in AMI patient. Curr Probl Cardiol 2022; 47:101326. [PMID: 35870545 DOI: 10.1016/j.cpcardiol.2022.101326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/17/2022] [Accepted: 07/17/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Little information is available on the difference in the prognostic impact of loop diuretics in patients with acute myocardial infarction (AMI) based on plasma volume status. METHODS A total of 3,364 survivors of AMI who were registered in the large database of the Osaka Acute Coronary Insufficiency Study (OACIS) were studied. Plasma volume status was assessed by the estimated plasma volume status (ePVS) that was calculated based on a weight- and hematocrit-based formula at discharge. The endpoint was a composite endpoint of all-cause death and rehospitalization due to heart failure for 5 years. RESULTS During a median follow-up period of 1.9 years, 90 and 223 patients had events in the groups with low ePVS (<median value of 4.07%) and high ePVS (≥4.07%), respectively. Multivariable Cox regression analysis showed that loop diuretics use was independently associated with an increased risk of the composite endpoint in the low ePVS group (hazard ratio [HR], 2.572; 95% confidence interval [CI], 1.386-4.771; p=0.002), but not in the high ePVS group (HR, 1.028; 95% CI, 0.698-1.512; p=0.890). These results were unchanged even in the propensity-score matched cohorts. There was no heterogeneity in the increased risk of the primary endpoints between various patient characteristics and loop diuretic use in the matched cohorts. CONCLUSION Prescription of loop diuretics at discharge was associated with increased risk of poor long-term prognosis in patients with AMI without PV expansion, but not with PV expansion. Therefore, careful observation is needed when loop diuretics are prescribed for AMI patients without PV expansion.
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Affiliation(s)
- Tsutomu Kawai
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Tetsuya Watanabe
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Takashi Morita
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yasuhiko Sakata
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Suita, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroya Mizuno
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shinichiro Suna
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Bolrathanak Oeun
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Taiki Sato
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroshi Sato
- School of Human Welfare Studies, Kwansei Gakuin University, Nishinomiya, Japan
| | - Masatsugu Hori
- Osaka Prefectural Hospital Organization Osaka International Cancer Institute, Osaka, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | | | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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11
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Curtain JP, Campbell RT, Petrie MC, Jackson AM, Abraham WT, Desai AS, Dickstein K, Køber L, Rouleau JL, Swedberg K, Zile MR, Solomon SD, Jhund PS, McMurray JJV. Clinical Outcomes Related to Background Diuretic Use and New Diuretic Initiation in Patients With HFrEF. JACC. HEART FAILURE 2022; 10:415-427. [PMID: 35654526 DOI: 10.1016/j.jchf.2022.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Up to 20% of patients in heart failure with reduced ejection fraction (HFrEF) trials are not taking diuretic agents at baseline, but little is known about them. OBJECTIVES The aim of this study was to examine outcomes in patients with HFrEF not taking diuretic medications and after diuretic medications are started. METHODS Patient characteristics and outcomes were compared between patients taking or not taking diuretic drugs at baseline in the ATMOSPHERE (Aliskiren Trial of Minimizing Outcomes for Patients With Heart Failure) and PARADIGM-HF (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial) trials combined. Patients starting diuretic medications were also compared with those remaining off diuretic drugs during follow-up. Symptoms (Kansas City Cardiomyopathy Questionnaire Clinical Summary Score [KCCQ-CSS]), hospitalization for worsening heart failure (HF), mortality, and kidney function (estimated glomerular filtration rate slope) were examined. RESULTS At baseline, the 3,079 of 15,415 patients (20%) not taking diuretic medications had a less severe HF profile, less neurohumoral activation, and better kidney function. They were less likely to experience the primary outcome (hospitalization for HF or cardiovascular death) than patients taking diuretic agents (adjusted HR: 0.77; 95% CI: 0.74-0.80; P < 0.001) and death of any cause. Commencement of a diuretic drug was associated with higher subsequent risk for death (adjusted HR: 2.05; 95% CI: 1.99-2.11; P < 0.001) and greater decreases in KCCQ-CSS and estimated glomerular filtration rate. The 5 strongest predictors of initiation of diuretic medications were higher N-terminal pro-B-type natriuretic peptide, higher body mass index, older age, history of diabetes, and worse KCCQ-CSS. In PARADIGM-HF, fewer patients who were treated with sacubitril/valsartan commenced diuretic agents (OR: 0.72; 95% CI: 0.58-0.88; P = 0.002). CONCLUSIONS Patients with HFrEF not taking diuretic medications and those who remained off them had better outcomes than patients treated with diuretic agents or who commenced them.
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Affiliation(s)
- James P Curtain
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Ross T Campbell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Alice M Jackson
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - William T Abraham
- Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kenneth Dickstein
- Stavanger University Hospital, Stavanger, Norway; Institute of Internal Medicine, University of Bergen, Bergen, Norway
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Michael R Zile
- Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, South Carolina, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
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12
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Cooper LB, Bruce S, Psotka M, Mentz R, Bell R, Seliger SL, O'Connor C, deFilippi C. Proteomic differences among patients with heart failure taking furosemide or torsemide. Clin Cardiol 2022; 45:265-272. [PMID: 35014074 PMCID: PMC8922525 DOI: 10.1002/clc.23733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/13/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Loop diuretics are commonly used for patients with heart failure (HF) but it remains unknown if one loop diuretic is clinically superior. HYPOTHESIS Biomarkers and proteomics provide insight to how different loop diuretics may differentially affect outcomes. METHODS Blood and urine were collected from outpatients with HF who were taking torsemide or furosemide for >30 days. Differences were assessed in cardiac, renal, and inflammatory biomarkers and soluble protein panels using the Olink Cardiovascular III and inflammation panels. RESULTS Of 78 subjects, 55 (71%) were treated with furosemide and 23 (29%) with torsemide, and 25 provided a urine sample (15 treated with furosemide, 10 with torsemide). Patients taking torsemide were older (68 vs 64 years) with a lower mean eGFR (46 vs 54 ml/min/1.73 m2 ), a higher proportion were women (39% vs 24%) and Black (43% vs 27%). In plasma, levels of hs-cTnT, NT-proBNP, and hsCRP were not significantly different between groups. In urine, there were significant differences in urinary albumin, β-2M, and NGAL, with higher levels in the torsemide-treated patients. Of 184 proteins testing in Olink panels, in plasma, 156 (85%) were higher in patients taking torsemide but none were significantly different after correcting for false discovery. CONCLUSIONS We show differences in urinary biomarkers but few differences in plasma biomarkers among HF patients on different loop diuretics. Olink technology can detect differences in plasma protein levels from multiple biologic domains. These findings raise the importance of defining differences in mechanisms of action of each diuretic in an appropriately powered study.
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Affiliation(s)
- Lauren B Cooper
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA.,Inova Heart & Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Scott Bruce
- Department of Statistics, Volgenau School of Engineering, George Mason University, Fairfax, Virginia, USA
| | - Mitchell Psotka
- Inova Heart & Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Robert Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel Bell
- Inova Heart & Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Stephen L Seliger
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher O'Connor
- Inova Heart & Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Christopher deFilippi
- Inova Heart & Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia, USA
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13
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Ortmann L, Mauch TJ, Ballweg J. Enteral Sodium Chloride Supplementation and Fluid Balance in Children Receiving Diuretics. CHILDREN 2022; 9:children9010094. [PMID: 35053719 PMCID: PMC8774517 DOI: 10.3390/children9010094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 11/16/2022]
Abstract
The use of sodium chloride (NaCl) supplementation in children being prescribed diuretics is controversial due to concerns that supplementation could lead to fluid retention. This is a single-center retrospective study in which fluid balance and diuretic dosing was examined in children prescribed enteral NaCl supplements for hyponatremia while receiving loop diuretics. The aim of this study was to determine whether significant fluid retention occurred with the addition of NaCl. Fifty-five patients with 68 events were studied. The median age was 5.2 months, and 82% were hospitalized for cardiac disease. Daily fluid balance the seven days prior to NaCl supplementation was lower than the seven days after, with measurement of: median 17 mL/kg/day (7–26) vs. 22 mL/kg/day (13–35) (p = 0.0003). There was no change in patient weight after supplementation (p = 0.63). There was no difference in the median loop diuretic dose before and after supplementation, with the diuretic dose in furosemide equivalents of 3.2 mL/kg/day (2.3–4.4) vs. 3.2 mL/kg/day (2.2–4.7) (p = 0.50). There was no difference in the proportion of patients receiving thiazide diuretics after supplementation (56% before vs. 50% after (p = 0.10)). NaCl supplementation in children receiving loop diuretics increased calculated fluid balance, but weight was unchanged, and this was not associated with an increase in diuretic needs, suggesting clinicians did not consider the increase in fluid balance to be clinically significant.
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Affiliation(s)
- Laura Ortmann
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68198, USA; (T.J.M.); (J.B.)
- Children’s Hospital & Medical Center, Omaha, NE 68114, USA
- Correspondence:
| | - Teri J. Mauch
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68198, USA; (T.J.M.); (J.B.)
- Children’s Hospital & Medical Center, Omaha, NE 68114, USA
| | - Jean Ballweg
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68198, USA; (T.J.M.); (J.B.)
- Children’s Hospital & Medical Center, Omaha, NE 68114, USA
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14
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Peters AE, Mentz RJ, DeWald TA, Greene SJ. An evaluation of torsemide in patients with heart failure and renal disease. Expert Rev Cardiovasc Ther 2022; 20:5-11. [PMID: 34936522 PMCID: PMC8887994 DOI: 10.1080/14779072.2022.2022474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Torsemide is a loop diuretic that inhibits the Na+/K+/2Cl- cotransporter type 2 in the thick ascending loop of Henle, leading to increased excretion of urinary sodium and chloride and associated diuresis. While furosemide remains the dominant diuretic utilized in current practice, increasing evidence supports potential advantages of torsemide in heart failure (HF) and/or renal disease. AREAS COVERED This narrative review covers the evidence for use of torsemide in HF and renal disease. Comparative effectiveness with regards to clinical outcomes is reviewed, as well as the ongoing multicenter trial, TRANSFORM-HF, comparing the effect of torsemide versus furosemide among patients with HF. EXPERT OPINION Compared with furosemide, torsemide has favorable pharmacodynamics/pharmacokinetics including higher bioavailability, longer duration of effect, minor renal excretion, decreased kaliuresis, and enhanced natriuresis/diuresis. These properties may be further supported by differential effects on RAAS regulation and fibrosis modulation as compared with other diuretics. The limited current body of evidence indicates that torsemide may be superior to furosemide with respect to improving HF functional status and reducing HF hospitalization, and there are mixed data regarding effect on reducing overall cardiovascular hospitalizations/mortality. Further, randomized data are necessary to definitively determine if torsemide can reduce risk of mortality and hospitalization among patients with HF.
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Affiliation(s)
- Anthony E. Peters
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Tracy A. DeWald
- Division of Clinical Pharmacology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Stephen J. Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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15
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Yaku H, Kaneda K, Kitamura J, Kato T, Kimura T. Kampo medicine for the holistic approach to older adults with heart failure. J Cardiol 2021; 80:306-312. [PMID: 34974939 DOI: 10.1016/j.jjcc.2021.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/13/2022]
Abstract
Heart failure (HF) is a leading cause of hospitalization, morbidity, and mortality in older adults and represents a significant clinical and economic burden on the health care system. However, there are many challenges in assessing and managing HF in elderly patients, who often have coexisting multimorbidity, frailty, and malnutrition. Therefore, it is often difficult to solve these problems with Western medicine alone, and a holistic approach, including Kampo medicine, can be helpful. In particular, managing volume control and frailty by adding Kampo formulas may help improve health-related quality of life and substantially impact prognosis in HF. This review article summarizes the role of Kampo medicine for older patients with HF and frailty.
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Affiliation(s)
- Hidenori Yaku
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan; Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazuhisa Kaneda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Jun Kitamura
- Department of Internal Medicine, Kobe Kaisei Hospital, Kobe, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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16
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Nakao Y, Kawakami H, Saito M, Inoue K, Ikeda S, Yamaguchi O. Cost-Effectiveness of long-term tolvaptan administration for chronic heart failure treatment in Japan. J Cardiol 2021; 79:408-416. [PMID: 34799217 DOI: 10.1016/j.jjcc.2021.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/24/2021] [Accepted: 10/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Tolvaptan (TLV) is effective for acute heart failure (HF) with congestion, but its long-term administration in patients with chronic HF (CHF) remains controversial. Moreover, the cost-effectiveness of TLV for CHF treatment has not yet been investigated. Thus, we sought to validate the cost-effectiveness of TLV for CHF treatment in Japan. METHODS A Markov model was developed to compare total costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) between long-term TLV strategy and the standard strategy using furosemide for CHF. The target population included 75-year-old patients with CHF. The effectiveness of the TLV strategy for CHF treatment was determined based on a systematic review and meta-analysis. We used a 10-year horizon, with sensitivity analyses for significant variables and a scenario analysis for patients with CHF receiving high-dose furosemide (≥60 mg per day). RESULTS In the base case analysis, the total cost of the long-term TLV strategy was higher than that of the standard strategy (\3,243,779 vs. \1,179,964). The total QALYs of the long-term TLV strategy were lower than those of the standard strategy (4.52 vs 4.59). Thus, a standard TLV prescription for CHF treatment has no clinical or economic benefit. In the scenario analysis (i.e. in patients with CHF receiving high-dose furosemide), the long-term TLV strategy was more effective (total QALYs, 5.10 vs. 4.41) but more expensive (total costs, \3,540,558 vs. \1,272,208) than the standard strategy. The ICER of the TLV strategy against the standard strategy (¥3,289,579/QALY) was below the willingness-to-pay of \5,000,000, which suggests that the long-term TLV strategy is cost-effective relative to the standard strategy in patients with CHF receiving high-dose furosemide. CONCLUSIONS Long-term TLV administration did not provide a clear benefit for all patients with CHF. However, this treatment strategy may be a cost-effective therapeutic option for patients who require high-dose furosemide.
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Affiliation(s)
- Yasuhisa Nakao
- Department of Cardiology, Pulmonology, Nephrology and Hypertension, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Hiroshi Kawakami
- Department of Cardiology, Pulmonology, Nephrology and Hypertension, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan.
| | - Makoto Saito
- Department of Cardiology, Kitaishikai Hospital, Ozu, Japan
| | - Katsuji Inoue
- Department of Cardiology, Pulmonology, Nephrology and Hypertension, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Shuntaro Ikeda
- Department of Cardiology, Pulmonology, Nephrology and Hypertension, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Nephrology and Hypertension, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
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17
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Kuragaichi T, Sato Y. Temporal trends of a vasopressin V 2 receptor antagonist in heart failure using a nationwide database in Japan. ESC Heart Fail 2021; 8:527-538. [PMID: 33185011 PMCID: PMC7835557 DOI: 10.1002/ehf2.13111] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 10/21/2020] [Accepted: 10/29/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Real-world data on the use of tolvaptan, an oral selective vasopressin 2 receptor antagonist, for patients with heart failure (HF) are not available in Western countries because tolvaptan is not indicated in the Western countries for volume overload in HF. This study aimed to investigate the current status and recent trends of tolvaptan use for HF in Japan by analysing a nationwide Japanese Diagnosis Procedure Combination database. METHODS AND RESULTS We retrospectively identified 257 812 patients hospitalized because of HF between 1 April 2008 and 30 November 2018. The diagnosis of HF at admission was based on the International Classification of Diseases, Tenth Revision, and in-hospital treatment. We investigated patient characteristics, in-hospital diuretic treatment, and tolvaptan treatment after discharge. The proportion of patients who were prescribed with tolvaptan for HF increased from 3.2% in 2011 to 39% in 2018. Since 2015, tolvaptan was prescribed within 2 days of hospitalization in >50% of HF cases. At discharge of a patient who was prescribed with tolvaptan, the rate of oral loop diuretic prescription at a dose ≥80 mg decreased, while the rate of diuretic prescription at a dose <40 mg increased. After discharge, the rate of tolvaptan prescription gradually increased from 34.0% in 2011 to 69.7% in 2018; however, tolvaptan prescriptions lasting >14 days decreased after 2012. CONCLUSIONS This large-scale survey indicated an increased rate of tolvaptan prescription and an early shift to tolvaptan treatment in patients with HF in Japan. The prognostic effects of this change in HF treatment remain unclear.
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Affiliation(s)
- Takashi Kuragaichi
- Department of CardiologyHyogo Prefectural Amagasaki General Medical Center2‐17‐77, Higashinaniwa‐choAmagasakiHyogo660‐8550Japan
| | - Yukihito Sato
- Department of CardiologyHyogo Prefectural Amagasaki General Medical Center2‐17‐77, Higashinaniwa‐choAmagasakiHyogo660‐8550Japan
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18
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Angiotensin Receptor Neprilysin Inhibitors in HFrEF: Is This the First Disease Modifying Therapy Drug Class Leading to a Substantial Reduction in Diuretic Need? INTERNATIONAL JOURNAL OF HEART FAILURE 2021; 3:106-116. [PMID: 36262879 PMCID: PMC9536695 DOI: 10.36628/ijhf.2020.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/24/2021] [Accepted: 02/07/2021] [Indexed: 01/12/2023]
Abstract
Despite significant advances in disease modifying therapy in heart failure (HF), diuretics have remained the cornerstone of volume management in all HF phenotypes. Diuretics, alongside their definite acute haemodynamic and symptomatic benefits, also possess many possible deleterious side effects. Moreover, questions remain regarding the prognostic impact of chronic diuretic use. To date, few data exist pertaining to diuretic reduction as a result of individual traditional guideline directed medical therapy in HF with reduced ejection fraction (HFrEF). However, diuretic reduction has been demonstrated with sacubitril/valsartan (angiotensin receptor-neprilysin inhibitor [ARNi]) from the PARADIGM study, as well as, post-marketing reports from our own group and others. Whether the ARNi compound represents the dawn of a new era, where effective therapies will have a more noticeable reduction on diuretic need, remains to be seen. The emergence of sodium glucose transport 2 inhibitors and guanylate cyclase stimulators may further exemplify this issue and potentially extend this benefit to HF patients outside of the HFrEF phenotype. In conclusion, emerging new therapies in HFrEF could reduce the reliance on diuretics in the management of this phenotype of HF. These developments further highlight the clinical importance to continually assess an individual's diuretic requirements through careful volume assessment.
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Uchida Y, Inao M, Tsuji S, Uemura H, Kouyama JI, Naiki K, Sugawara K, Nakao M, Nakayama N, Imai Y, Tomiya T, Mochida S. Furosemide as a factor to deteriorate therapeutic efficacy of tolvaptan in patients with decompensated cirrhosis. Hepatol Res 2020; 50:1355-1364. [PMID: 32886950 DOI: 10.1111/hepr.13566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 12/13/2022]
Abstract
AIM To optimize the therapeutic strategy for patients with decompensated cirrhosis manifesting hepatic ascites and/or edema, factors affecting the outcome of patients receiving tolvaptan were evaluated. METHODS The subjects were 165 patients receiving tolvaptan including 116 patients (70%) also treated with furosemide. The therapeutic efficacy of tolvaptan was defined as "effective" when a body weight reduction of 1.5 kg or more was obtained within 1 week. The long-term outcome was defined as "favorable" when the ascites-related events-free duration was prolonged following tolvaptan treatment, compared with that before treatment, or ascites-related events were absent for at least 120 days during treatment based on the hazard function analysis. RESULTS Tolvaptan was effective in 115 patients (70%). Among them, the long-term outcome was evaluated in 99 patients and was favorable in 70 patients (71%). A multivariate analysis revealed that the serum blood urea nitrogen levels at baseline (odds ratio 0.960 per +1 mg/dL, P = 0.021) and the type of tolvaptan initiation (planned vs. emergent; 3.695, P < 0.001) were associated with therapeutic efficacy, while the furosemide dose (0.280 per +20 mg/day, P = 0.014) and previous ascites-related events (0.074, P < 0.001) were associated with the long-term outcome. Receiver operating curve analyses identified the optimal cut-off values for the furosemide dose as 15 mg/day (P < 0.001). Furthermore, the cumulative survival rates in patients receiving furosemide at 15 mg/day or less were significantly higher than those in the remaining patients (P = 0.048). CONCLUSION Furosemide given at baseline contributed to an unfavorable outcome in patients receiving tolvaptan; consequently, tolvaptan should be given before increasing the furosemide dose.
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Affiliation(s)
- Yoshihito Uchida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Mie Inao
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Shohei Tsuji
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Hayato Uemura
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Jun-Ichi Kouyama
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Kayoko Naiki
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Kayoko Sugawara
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Masamitsu Nakao
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Nobuaki Nakayama
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Yukinori Imai
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Tomoaki Tomiya
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Satoshi Mochida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
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20
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Takagi K, Sato N, Ishihara S, Iha H, Kobayashi N, Ito Y, Nohara T, Ohkuma S, Mitsuishi T, Ishizuka A, Shigihara S, Sone M, Nakama K, Tokuyama H, Omote T, Kikuchi A, Nakamura S, Yamamoto E, Ishikawa M, Amitani K, Takahashi N, Maruyama Y, Imura H, Shimizu W. Differences in pharmacological property between combined therapy of the vasopressin V2-receptor antagonist tolvaptan plus furosemide and monotherapy of furosemide in patients with hospitalized heart failure. J Cardiol 2020; 76:499-505. [PMID: 32665162 DOI: 10.1016/j.jjcc.2020.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/07/2020] [Accepted: 05/07/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tolvaptan has been shown to improve congestion in heart failure patients. The purpose of this study was to evaluate the pharmacology and clinical efficacy of combined tolvaptan and furosemide therapy. METHODS This study included 40 patients with systemic volume overload who were hospitalized for heart failure. Patients who showed no improvement in the condition after receiving 20 mg intravenous furosemide were included and were randomly selected to receive tolvaptan as an add-on to furosemide or to receive an increased dose of furosemide. We evaluated the bioelectrical impedance analyzer parameters, the parameters of the inferior vena cava using echocardiography, vital signs, body weight, urine output, and laboratory data for 5 days. RESULTS In the changes from baseline between intracellular water volume (ICW) and extracellular water volume (ECW) after additional use of tolvaptan or furosemide from Day 1 to Day 5, there were no significant differences observed between ICW and ECW over 5 days in the tolvaptan + furosemide group, although differences were found in the furosemide group from Day 2 onward. Changes in the respiratory collapse of inferior vena cava increased significantly, and systolic blood pressure decreased significantly only in the furosemide group. CONCLUSIONS The present study clearly demonstrates that combined therapy with tolvaptan and furosemide removed excess ICW and ECW to an equal extent, while furosemide alone primarily removed ECW, including intravascular water.
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Affiliation(s)
- Koji Takagi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Naoki Sato
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan.
| | - Shiro Ishihara
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Hayano Iha
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Noriyuki Kobayashi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Yusuke Ito
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Tsuyoshi Nohara
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Satoru Ohkuma
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Tatsuya Mitsuishi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Atsushi Ishizuka
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan
| | - Shota Shigihara
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Michiko Sone
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Kenji Nakama
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Hideo Tokuyama
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan
| | - Toshiya Omote
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Arifumi Kikuchi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Shunichi Nakamura
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Eisei Yamamoto
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Masahiro Ishikawa
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Kenichi Amitani
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Naoto Takahashi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Yuji Maruyama
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Hajime Imura
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
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21
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Kalogeropoulos AP, Thankachen J, Butler J, Fang JC. Diuretic and renal effects of spironolactone and heart failure hospitalizations: a
TOPCAT
Americas analysis. Eur J Heart Fail 2020; 22:1600-1610. [DOI: 10.1002/ejhf.1917] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/18/2020] [Accepted: 05/25/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
| | - Jincy Thankachen
- Division of Cardiology Department of Medicine, Stony Brook University Stony Brook NY USA
- Division of Cardiology Jacobi Medical Center Bronx NY USA
| | - Javed Butler
- Department of Medicine University of Mississippi Jackson MS USA
| | - James C. Fang
- Division of Cardiovascular Medicine University of Utah Salt Lake City UT USA
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22
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Association of loop diuretics use and dose with outcomes in outpatients with heart failure: a systematic review and meta-analysis of observational studies involving 96,959 patients. Heart Fail Rev 2020; 27:147-161. [DOI: 10.1007/s10741-020-09995-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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23
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Miyoshi A, Nishii N, Okamoto Y, Fujita S, Kawamoto K, Okawa K, Hiramatsu S, Nakamura K, Morita H, Ito H. Lifestyle Modification or Medication to Improve Condition of Patients With Asymptomatic Heart Failure ― Monitoring and Management of OptiVol Alert to Reduce Heart Failure Hospitalization II (MOMOTARO II) Study ―. Circ J 2020; 84:456-462. [DOI: 10.1253/circj.cj-19-0986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihito Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Nobuhiro Nishii
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Yoji Okamoto
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Shinpei Fujita
- Department of Cardiovascular Medicine, Fukuyama City Hospital
| | - Kenji Kawamoto
- Department of Cardiovascular Medicine, National Hospital Organization Iwakuni Clinical Center
| | - Keisuke Okawa
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital
| | - Shigeki Hiramatsu
- Department of Cardiovascular Medicine, Fukuyama Cardiovascular Hospital
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
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24
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Nakano I, Tsuda M, Kinugawa S, Fukushima A, Kakutani N, Takada S, Yokota T. Loop diuretic use is associated with skeletal muscle wasting in patients with heart failure. J Cardiol 2020; 76:109-114. [PMID: 32001074 DOI: 10.1016/j.jjcc.2020.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/13/2019] [Accepted: 01/04/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Loop diuretics are widely used for the management of fluid retention in patients with heart failure (HF). Sarcopenia, defined as decreased skeletal muscle mass, is frequently present in patients with HF and is associated with poor prognosis. The effects of loop diuretics on skeletal muscle in HF patients have not been fully elucidated. Here, we investigated the impact of loop diuretics on the skeletal muscle mass in patients with HF. METHODS We conducted a subanalysis of a cross-sectional study from 10 hospitals evaluating 155 patients with HF (age 67 ± 13 yrs, 69% men). RESULTS We compared the HF patients who were treated with loop diuretics (n = 120) with the patients who were not (n = 35). The thigh and arm circumferences were significantly small in the group treated with loop diuretics compared to those not so treated (39.9 ± 4.8 vs. 43.5 ± 6.9 cm, p < 0.001 and 26.7 ± 3.5 vs. 28.9 ± 6.2 cm, p < 0.001, respectively). In a univariate analysis, higher age, lower body mass index, lower hemoglobin, and loop diuretic use were significantly associated with smaller thigh circumference. In a multivariable analysis, the use of loop diuretics was independently associated with smaller thigh circumference (β = -0.51, 95% confidence interval -0.98 to -0.046, p = 0.032). CONCLUSION Loop diuretics are associated with decreased thigh and arm circumferences in patients with HF, independent of the severity of HF. Our findings revealed for the first time the adverse effects of loop diuretics on skeletal muscle wasting. These findings will have a significant impact in clinical practice regarding the frequent use of loop diuretics in HF patients.
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Affiliation(s)
- Ippei Nakano
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaya Tsuda
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Arata Fukushima
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoya Kakutani
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shingo Takada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takashi Yokota
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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25
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Potter BM, Ames MK, Hess A, Poglitsch M. Comparison between the effects of torsemide and furosemide on the renin-angiotensin-aldosterone system of normal dogs. J Vet Cardiol 2019; 26:51-62. [PMID: 31809955 DOI: 10.1016/j.jvc.2019.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 10/28/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION/OBJECTIVES We hypothesized that torsemide and furosemide, at approximately equipotent dosages (similar diuresis), would have comparable effects on the circulating renin-angiotensin-aldosterone system. ANIMALS, MATERIALS AND METHODS Six, healthy, middle-aged, male Beagles were randomized to receive torsemide (0.1 mg/kg PO q 12 h), furosemide (2.0 mg/kg PO q 12 h), or placebo for 10 days during three separate periods, separated by a 10-day washout period, in a crossover design. Blood was collected on days 1, 5, and 9 and 24-h urine collection ended on days 2, 6, and 10. After repeated measures analysis and Bonferonni correction, variables with an adjusted p<0.05 were investigated further, using Tukey's method. RESULTS Twenty-four-hour urine production differed significantly between the diuretics only on day 10, with torsemide causing a 38% greater diuresis than furosemide. There was, however, no significant difference in average 3-day diuresis. There were no significant differences between diuretics in the 24-h urinary excretion of sodium, chloride, or potassium, though furosemide caused less kaliuresis than torsemide. Serum renin, angiotensin II, and aldosterone and the urine aldosterone-to-creatinine ratio were significantly increased in the diuretic groups, as compared to placebo on days 5/6 and 9/10. There were no significant differences in these values between diuretics. Creatinine and blood urea nitrogen concentrations rose comparably in the diuretic groups, remaining within reference intervals in all dogs. CONCLUSIONS At approximately equipotent dosages (20:1), torsemide and furosemide produced comparable renin-angiotensin-aldosterone system activation. Torsemide's similar potassium excretion profile to furosemide decreases support for a hypothesized mineralocorticoid-receptor blocking capability.
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Affiliation(s)
- B M Potter
- Department of Clinical Sciences, Colorado State University, Campus Delivery 1678, Fort Collins, CO, 80523, USA
| | - M K Ames
- Department of Clinical Sciences, Colorado State University, Campus Delivery 1678, Fort Collins, CO, 80523, USA.
| | - A Hess
- Department of Statistics, Colorado State University, 102 Statistics Building, Fort Collins, CO, 80523, USA
| | - M Poglitsch
- Attoquant Diagnostics GmbH, Campus Vienna Biocenter 5, 1030 Vienna Austria
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26
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Alvarez CK, Cronin E, Baker WL, Kluger J. Heart failure as a substrate and trigger for ventricular tachycardia. J Interv Card Electrophysiol 2019; 56:229-247. [PMID: 31598875 DOI: 10.1007/s10840-019-00623-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 09/06/2019] [Indexed: 02/06/2023]
Abstract
Heart failure (HF) is a major cause of morbidity and mortality with more than 5.1 million individuals affected in the USA. Ventricular tachyarrhythmias (VAs) including ventricular tachycardia and ventricular fibrillation are common in patients with heart failure. The pathophysiology of these mechanisms as well as the contribution of heart failure to the genesis of these arrhythmias is complex and multifaceted. Myocardial hypertrophy and stretch with increased preload and afterload lead to shortening of the action potential at early repolarization and lengthening of the action potential at final repolarization which can result in re-entrant ventricular tachycardia. Myocardial fibrosis and scar can create the substrate for re-entrant ventricular tachycardia. Altered calcium handling in the failing heart can lead to the development of proarrhythmic early and delayed after depolarizations. Various medications used in the treatment of HF such as loop diuretics and angiotensin converting enzyme inhibitors have not demonstrated a reduction in sudden cardiac death (SCD); however, beta-blockers (BB) are effective in reducing mortality and SCD. Amongst patients who have HF with reduced ejection fraction, the angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan) has been shown to reduce cardiovascular mortality, specifically by reducing SCD, as well as death due to worsening HF. Implantable cardioverter-defibrillator (ICD) implantation in HF patients reduces the risk of SCD; however, subsequent mortality is increased in those who receive ICD shocks. Prophylactic ICD implantation reduces death from arrhythmia but does not reduce overall mortality during the acute post-myocardial infarction (MI) period (less than 40 days), for those with reduced ejection fraction and impaired autonomic dysfunction. Furthermore, although death from arrhythmias is reduced, this is offset by an increase in the mortality from non-arrhythmic causes. This article provides a review of the aforementioned mechanisms of arrhythmogenesis in heart failure; the role and impact of HF therapy such as cardiac resynchronization therapy (CRT), including the role, if any, of CRT-P and CRT-D in preventing VAs; the utility of both non-invasive parameters as well as multiple implant-based parameters for telemonitoring in HF; and the effect of left ventricular assist device implantation on VAs.
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Affiliation(s)
- Chikezie K Alvarez
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.
| | - Edmond Cronin
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - William L Baker
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Jeffrey Kluger
- Hartford Healthcare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
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27
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Packer M. Obesity-Associated Heart Failure as a Theoretical Target for Treatment With Mineralocorticoid Receptor Antagonists. JAMA Cardiol 2019; 3:883-887. [PMID: 30046826 DOI: 10.1001/jamacardio.2018.2090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Despite their clinical benefits, mineralocorticoid receptor antagonists are greatly underprescribed by most practitioners who treat patients with chronic heart failure. A novel approach to encouraging the use of these drugs is to enhance awareness about the intimate link between aldosterone and obesity. Observations There is a strong association between abdominal obesity and circulating levels of aldosterone, and markers of abdominal obesity identify patients most likely to benefit from mineralocorticoid receptor antagonism. In a trial of patients with heart failure and a reduced ejection fraction, patients with an increased waist circumference exhibited an approximately 50% reduction in the risk of a primary end point. The magnitude of benefit was more than twice as great in patients with abdominal obesity than in those with a normal waist circumference, and patients with abdominal obesity tolerated treatment better than nonobese patients. Similarly, in a trial of patients with heart failure and a preserved ejection fraction, those who were most likely to have abdominal obesity (identified by their level of natriuretic peptides) were most likely to demonstrate a benefit of treatment with spironolactone, exhibiting an approximately 80% reduction in the risk of a primary end point (based on a small number of events). Conclusions and Relevance Although these analyses are post hoc, their concordance and strong biological foundation suggests that abdominal obesity may identify patients who respond most favorably to mineralocorticoid receptor antagonism. Given the easy availability of its measurement, targeting patients with an increased waist circumference could enhance the adoption of these important drugs for the treatment of chronic heart failure in clinical practice.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
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28
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Weeda ER, Cassarly C, Brinton DL, Shirley DW, Simpson KN. Loop diuretic use among patients with heart failure and type 2 diabetes treated with sodium glucose cotransporter-2 inhibitors. J Diabetes Complications 2019; 33:567-571. [PMID: 31176543 PMCID: PMC6613996 DOI: 10.1016/j.jdiacomp.2019.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/19/2019] [Accepted: 05/05/2019] [Indexed: 01/14/2023]
Abstract
AIMS To compare loop diuretic use in patients with comorbid heart failure (HF) and type 2 diabetes (T2D) newly initiated on sodium glucose cotransporter-2 inhibitors (SGLT2Is) versus other oral anti-glycemic agents (AGAs). METHODS This analysis used 2013-2015 MarketScan Medicare Supplemental claims data. HF and T2D patients were identified and SGLT2I users were propensity score matched to other AGA users. The mean daily dose of loop diuretics in furosemide equivalents was ascertained. For those not on baseline loop diuretics, new use was compared between cohorts. For those on baseline loop diuretics, we assessed patterns of use (increased dose, decreased dose, stable dose, no longer using) at 12-months. RESULTS A total of 750 SGLT2I users were matched to 750 other AGA users. The distribution of loop diuretic use at mean doses of 0 mg (i.e., no use), ≤20 mg, >20 mg-40 mg, >40 mg-80 mg and >80 mg/day did not differ between cohorts at baseline or 12-months (p > 0.05 for both). SGLT2I use was associated with less new loop diuretic use (22.7% [79/348] vs. 34.0% [132/388]; p = 0.001). For those on loop diuretics at baseline (n = 764), patterns of use at 12-months did not differ between cohorts (p = 0.14). CONCLUSIONS New loop diuretic use was less frequent among SGLT2I users; however, patterns of loop diuretic use did not differ between cohorts in those on loop diuretics at baseline.
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Affiliation(s)
- Erin R Weeda
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, Medical University of South Carolina, Charleston, SC 29425, USA.
| | - Christy Cassarly
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA; Department of Healthcare Leadership & Management, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Daniel L Brinton
- Department of Healthcare Leadership & Management, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
| | - David W Shirley
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kit N Simpson
- Department of Healthcare Leadership & Management, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
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29
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Patients With CONgestive Heart Failure Benefit From Long-Term Treatment Effects With Novel Treatment Using Azosemide Compared With Furosemide Derived From Existing Retrospective Study Data: CONTENTED. J Cardiovasc Pharmacol 2019; 73:365-372. [PMID: 31162245 DOI: 10.1097/fjc.0000000000000669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A long-acting loop diuretic, azosemide, has been shown to improve long-term prognosis in patients with heart failure compared with a short-acting loop diuretic, furosemide. However, the therapeutic advantages of azosemide over furosemide have not been clearly established. In this study, we retrospectively analyzed clinical outcomes and laboratory data in patients with congestive heart failure treated with furosemide or azosemide, and the efficacy of these agents was compared. First, we screened 1900 patients and selected 124 (furosemide group: n = 40; azosemide group: n = 84) as the total study population. From these patients, we next selected 72 patients for the propensity score-matched analysis (furosemide group: n = 36; azosemide group: n = 36). The incidence of all-cause death and rehospitalization due to worsening heart failure during 24 months of follow-up was similar between the furosemide and azosemide groups in both the total study population and the propensity score-matched population. However, in the propensity score-matched analysis, the estimated glomerular filtration rate time-dependently decreased during 36 months of follow-up in the furosemide group (56.5 ± 19.5-43.2 ± 16.3 mL/min/1.73 m), whereas it did not change in the azosemide group (58.6 ± 22.0-50.3 ± 17.8 mL/min/1.73 m) (P = 0.032). Azosemide might have some potential advantage for renal protection over furosemide in patients with congestive heart failure.
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30
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Suzuki S, Motoki H, Kanzaki Y, Maruyama T, Hashizume N, Kozuka A, Yahikozawa K, Kuwahara K. Comparison of Long-Acting and Short-Acting Loop Diuretics in the Treatment of Heart Failure With Preserved Ejection Fraction. Circ Rep 2019; 1:137-141. [PMID: 33693128 PMCID: PMC7890284 DOI: 10.1253/circrep.cr-19-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background:
Clinical evidence of the effects of loop diuretics in patients with heart failure with preserved ejection fraction (HFpEF) is lacking. Thus, we compared the impact of azosemide and furosemide, long- and short-acting loop diuretics, in patients with HFpEF. Methods and Results:
A prospective multicenter cohort study was conducted between July 2014 and July 2018. We enrolled 301 consecutive patients with HFpEF (median age, 84 years; IQR, 79–88 years; 54.8% female). Azosemide was used in 127 patients (azosemide group), and furosemide in 174 (furosemide group). We constructed Cox models for a composite of cardiac death, non-fatal myocardial infarction, non-fatal stroke, and HF hospitalization (primary endpoints). During a median follow-up of 317 days (IQR, 174–734 days), the primary endpoint occurred in 112 patients (37.2%). On multivariate inverse probability of treatment weighted (IPTW) Cox modeling, the azosemide group had a significantly lower incidence of adverse events than the furosemide group (hazard ratio [HR], 0.46; 95% confidence interval [CI]: 0.27–0.80; P=0.006). Furthermore, on multivariate IPTW Cox modeling for the secondary endpoints, cardiac death (HR, 0.38; 95% CI: 0.17–0.89; P=0.025) and unplanned hospitalization for decompensated HF (HR, 0.50; 95% CI: 0.28–0.89; P=0.018) were also reduced in the azosemide group. Conclusions:
Azosemide significantly reduced the risk of adverse events compared with furosemide in HFpEF patients.
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Affiliation(s)
- Sho Suzuki
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Yusuke Kanzaki
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Takuya Maruyama
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Naoto Hashizume
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Ayako Kozuka
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Kumiko Yahikozawa
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
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31
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Li M, Zheng C, Kawada T, Inagaki M, Uemura K, Sugimachi M. Chronic vagal nerve stimulation exerts additional beneficial effects on the beta-blocker-treated failing heart. J Physiol Sci 2019; 69:295-303. [PMID: 30414045 PMCID: PMC10717668 DOI: 10.1007/s12576-018-0646-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/29/2018] [Indexed: 12/20/2022]
Abstract
Vagal nerve stimulation (VNS) induces bradycardia in chronic heart failure (CHF). We hypothesized that beta-blocker would cover the beneficial effects of VNS on CHF if the anti-beta-adrenergic effect was the main VNS effect. This study investigated the effects of VNS on cardiac remodeling in rats with CHF treated with metoprolol. Two weeks after myocardial infarction, surviving rats were randomly assigned to groups of sham stimulation (SS), sham stimulation with metoprolol (SSM), or VNS with metoprolol (VSM). Compared to the SS group, heart rate was significantly reduced in the SSM and VSM groups. Hemodynamic assessments showed that VSM rats maintained better cardiac pump function and presented higher cardiac index and lower heart weight than SSM rats. VSM was also associated with lower plasma brain natriuretic peptide and norepinephrine levels than SSM. VSM but not SSM improved the 50-day survival rate compared with the SS group. The results suggest that VNS may exert its beneficial effects on the failing heart independently of its anti-beta-adrenergic mechanism.
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Affiliation(s)
- Meihua Li
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan
| | - Can Zheng
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan.
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan
| | - Masashi Inagaki
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan
| | - Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan
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Ames MK, Atkins CE, Pitt B. The renin-angiotensin-aldosterone system and its suppression. J Vet Intern Med 2019; 33:363-382. [PMID: 30806496 PMCID: PMC6430926 DOI: 10.1111/jvim.15454] [Citation(s) in RCA: 222] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 01/30/2019] [Indexed: 12/11/2022] Open
Abstract
Chronic activation of the renin-angiotensin-aldosterone system (RAAS) promotes and perpetuates the syndromes of congestive heart failure, systemic hypertension, and chronic kidney disease. Excessive circulating and tissue angiotensin II (AngII) and aldosterone levels lead to a pro-fibrotic, -inflammatory, and -hypertrophic milieu that causes remodeling and dysfunction in cardiovascular and renal tissues. Understanding of the role of the RAAS in this abnormal pathologic remodeling has grown over the past few decades and numerous medical therapies aimed at suppressing the RAAS have been developed. Despite this, morbidity from these diseases remains high. Continued investigation into the complexities of the RAAS should help clinicians modulate (suppress or enhance) components of this system and improve quality of life and survival. This review focuses on updates in our understanding of the RAAS and the pathophysiology of AngII and aldosterone excess, reviewing what is known about its suppression in cardiovascular and renal diseases, especially in the cat and dog.
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Affiliation(s)
- Marisa K Ames
- Department of Clinical Sciences, College of Veterinary Medicine, Colorado State University, Fort Collins, Colorado
| | - Clarke E Atkins
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
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Ma X, Tannu S, Allocco J, Pan J, Dipiero J, Wong P. A mouse model of heart failure exhibiting pulmonary edema and pleural effusion: Useful for testing new drugs. J Pharmacol Toxicol Methods 2019; 96:78-86. [PMID: 30738210 DOI: 10.1016/j.vascn.2019.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/11/2019] [Accepted: 02/03/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Mouse models of chronic heart failure (HF) have been widely used in HF research. However, the current HF models most often use the C57BL/6 mouse strain and do not show the clinically relevant characteristics of pulmonary congestion. In this study, we developed a robust mouse model of HF in the BALB/c mouse strain, exhibiting pulmonary edema and pleural effusion, and we validated the model using the standard pharmacological therapies in patients with chronic HF and reduced ejection fraction (HFrEF) or acute decompensated HF. METHODS After induction of myocardial infarction (MI) by permanent ligation of the left coronary artery in BALB/c mice, the cardiac function, pulmonary congestion, disease biomarkers, and survival were evaluated using the angiotensin converting enzyme inhibitor enalapril or the loop diuretic furosemide. Enalapril was administered 4 weeks post-MI for 6 weeks or furosemide was given 10 weeks post-MI for 4 days, when pulmonary congestion was evident. RESULTS Compared to sham controls, MI mice developed systolic dysfunction, exhibited lung weight increase at 4 weeks, and progressively developed pleural effusion (60% of the animals) at 10 weeks. Compared to the vehicle, enalapril significantly reduced the lung weight and pleural effusion, preserved systolic function, and improved survival. Furthermore, furosemide completely abolished the pleural effusion. Enalapril or furosemide also reduced the plasma brain natriuretic peptide concentration. DISCUSSION The post-MI HF in BALB/c mice shows reproducible and robust pulmonary congestion and may be a clinically relevant model for novel drug testing for treatment in patients with HFrEF or acute decompensated HF.
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Affiliation(s)
- Xiuying Ma
- Cardiovascular & Fibrosis Discovery Biology, Research & Development, Bristol-Myers Squibb Company, 311 Pennington Rocky Hill Road, Pennington, NJ 08534, USA.
| | - Shahid Tannu
- Cardiovascular & Fibrosis Discovery Biology, Research & Development, Bristol-Myers Squibb Company, 311 Pennington Rocky Hill Road, Pennington, NJ 08534, USA.
| | - John Allocco
- Cardiovascular & Fibrosis Discovery Biology, Research & Development, Bristol-Myers Squibb Company, 311 Pennington Rocky Hill Road, Pennington, NJ 08534, USA.
| | - Jie Pan
- Cardiovascular & Fibrosis Discovery Biology, Research & Development, Bristol-Myers Squibb Company, 311 Pennington Rocky Hill Road, Pennington, NJ 08534, USA.
| | - Janet Dipiero
- Cardiovascular & Fibrosis Discovery Biology, Research & Development, Bristol-Myers Squibb Company, 311 Pennington Rocky Hill Road, Pennington, NJ 08534, USA.
| | - Pancras Wong
- Cardiovascular & Fibrosis Discovery Biology, Research & Development, Bristol-Myers Squibb Company, 311 Pennington Rocky Hill Road, Pennington, NJ 08534, USA.
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Onitsuka H, Koyama S, Ideguchi T, Ishikawa T, Kitamura K, Nagamachi S. Impact of short-acting loop diuretic doses and cardiac sympathetic nerve abnormalities on outcomes of patients with reduced left ventricular function. Medicine (Baltimore) 2019; 98:e14657. [PMID: 30813209 PMCID: PMC6407956 DOI: 10.1097/md.0000000000014657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Recent studies reported that high doses of short-acting loop diuretics are associated with poor outcomes in patients with heart failure (HF). Short-acting loop diuretics have been shown to activate the renin-angiotensin system (RAS) and have no favorable effects on cardiac sympathetic nervous system (SNS) activity. The goal of this study is to investigate the relationship between daily doses of furosemide and the outcomes of patients with left ventricular dysfunction (LVD) from the viewpoint of cardiac SNS abnormalities using iodine-123-labeled metaiodobenzylguanidine (l-MIBG) myocardial scintigraphy.We enrolled 137 hospitalized patients (62.5 ± 14.2 years old, 103 men) with LVEF < 45% who underwent l-MIBG myocardial scintigraphy. A delayed heart-to-mediastinum ratio (delayed HMR) was assessed using l-MIBG scintigraphy. Cardiac events were defined as cardiac death or re-hospitalization due to the deterioration of HF. Cox proportional hazard analysis was used to identify predictors of cardiac events.Cardiac events occurred in 57 patients in a follow-up period of 33.1 ± 30 months. In a multivariate Cox proportional hazard analysis, delayed HMR and furosemide doses were identified as independent predictors of cardiac events (P = .0042, P = .033, respectively). Inverse probability of treatment weighting Cox modeling showed that the use of furosemide (≥40 mg /day) was associated with cardiac events with a hazard ratio of 1.96 (P = .003). In the Kaplan-Mayer analysis, the cardiac event-free survival rate was significantly lower in patients treated with high doses of furosemide (≥60 mg/day vs 40-60 mg/day vs <40 mg/day, the Log-rank test P < .0001). In a receiver-operating characteristic (ROC) analysis, the cut-off value for cardiac events was 40 mg/day of furosemide. The cardiac event-free rate was significantly lower in patients with delayed HMR <1.8 (median value) and receiving furosemide ≥40 mg/day than in other patients (the Log-rank test P < .0001). Significant differences in cardiac event rates according to furosemide doses among patients with delayed HMR <1.8 were observed among patients without β-blocker therapy (P = .001), but not among those with β-blocker therapy (P = .127).The present results indicate that a relationship exists between higher doses of furosemide and poor outcomes. The prognosis of HF patients with severe cardiac SNS abnormalities receiving high-dose short-acting loop diuretics is poor.
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Imamura T, Kinugawa K. Update of acute and long-term tolvaptan therapy. J Cardiol 2019; 73:102-107. [DOI: 10.1016/j.jjcc.2018.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/09/2018] [Indexed: 01/19/2023]
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Fudim M, O'Connor CM, Mulder H, Coles A, Bhatt AS, Ambrosy AP, Kraus WE, Piña IL, Whellan DJ, Mentz RJ. Loop diuretic adjustments in patients with chronic heart failure: Insights from HF-ACTION. Am Heart J 2018; 205:133-141. [PMID: 30158057 DOI: 10.1016/j.ahj.2018.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The relationship between diuretic use or change in diuretic use and outcomes in chronic heart failure (HF) remains poorly defined. We evaluated the association between diuretic use and changes in health status, exercise capacity, and clinical events in a large randomized trial of subjects with HF. METHODS HF-ACTION randomized 2,331 outpatients with HF and ejection fraction ≤35% to aerobic exercise training versus usual care. We grouped patients according to loop diuretic use from baseline through 6 months: continued use, never use, initiated, and discontinued. The association between diuretic use and changes in health status, exercise capacity, and clinical outcomes (all-cause mortality/hospitalization, cardiovascular mortality, and HF hospitalization) through 12 months was assessed using Cox proportional hazards models and generalized linear regression models, respectively. RESULTS A total of 2,004 (86%) patients had complete data on diuretic use. There was no association between diuretic status and Kansas City Cardiomyopathy Questionnaire, 6-minute walk distance, or peak Vo2 in adjusted analyses (all P > .05). A dose increase was associated with decrease in 6-minute walk distance (-4.25 m, SE 1.12 m, P < .001) and change in Kansas City Cardiomyopathy Questionnaire overall score (-0.56 m, SE 0.24 m, P = .02). There were no between-group differences for all-cause death or hospitalization comparing continuous use versus never use (adjusted HR 0.91; 95% CI 0.72-1.15; P = .432). CONCLUSIONS The initiation or discontinuation of diuretics over a 6-month time frame was not associated with a difference in mortality, hospitalizations, exercise, or health status outcomes, but a dose increase in HF patients was associated with worse exercise and health status outcomes.
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Parén P, Dahlström U, Edner M, Lappas G, Rosengren A, Schaufelberger M. Association of diuretic treatment at hospital discharge in patients with heart failure with all-cause short- and long-term mortality: A propensity score-matched analysis from SwedeHF. Int J Cardiol 2018; 257:118-124. [PMID: 29506681 DOI: 10.1016/j.ijcard.2017.09.193] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/05/2017] [Accepted: 09/22/2017] [Indexed: 12/28/2022]
Abstract
AIMS Diuretics are recommended for treating congestive symptoms in heart failure (HF). The short- and long-term prognostic effects of diuretic treatment at hospital discharge have not been studied in randomized clinical trials or in a Western world population. We aimed to determine the association of diuretic treatment at discharge with the risk of short-and long-term all-cause mortality in real-life patients in Sweden with HF irrespective of EF. METHODS AND RESULTS From a Swedish nationwide HF register 26,218 patients discharged from hospital were included in the present study. A total of 87% of patients were treated with and 13% were not treated with diuretics at hospital discharge. In a 1:1 propensity score-matched cohort of 6564 patients, the association of diuretic treatment at hospital discharge with the risk of 90-day all-cause mortality was neutral (HR 0.89, 95% CI 0.74-1.07, p=0.21) whereas the risk of long-term all-cause mortality (median follow-up: 2.85years) was increased (HR 1.15, 95% CI 1.06-1.24, p<0.001). CONCLUSION Diuretic treatment at hospital discharge was not associated with short-term mortality whereas it was associated with increased long-term mortality. Although we accounted for a wide range of clinical features, measured or unmeasured factors could still explain this increase in risk. However, our results suggest that diuretic treatment at hospital discharge may be regarded as a marker of increased long-term mortality.
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Affiliation(s)
- Pär Parén
- Department of Internal Medicine, Sahlgrenska University Hospital/Mölndal, Mölndal, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.
| | - Ulf Dahlström
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Magnus Edner
- Karolinska Institute, Department of Medicine, Unit of Cardiology, N3:06, Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Lappas
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Maria Schaufelberger
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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Parén P, Rosengren A, Zverkova Sandström T, Schaufelberger M. Decrease in loop diuretic treatment from 2005 to 2014 in Swedish real-life patients with chronic heart failure. Eur J Clin Pharmacol 2018; 75:247-254. [PMID: 30318559 PMCID: PMC6348069 DOI: 10.1007/s00228-018-2574-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/01/2018] [Indexed: 11/06/2022]
Abstract
Purpose Loop diuretics are recommended to treat congestive symptoms in patients with heart failure. However, observational studies have indicated that loop diuretic treatment in heart failure is associated with increased mortality. Therefore, loop diuretic discontinuation or dose reduction, when clinically possible, is recommended. Our aim was to study nationwide temporal trends in loop diuretic treatment from 2005 to 2014 in real-life patients with chronic heart failure. Methods Data from the nationwide Swedish National Patient, Prescribed Drug and Cause of Death Registers were linked. The annual proportions of patients with chronic heart failure treated with loop diuretics from 2005 to 2014 were calculated. In addition, the annual median loop diuretic doses (DDD) in patients with chronic heart failure treated with loop diuretics from 2005 to 2014 were calculated. Results The proportion of real-life patients with chronic heart failure treated with loop diuretics decreased from 73.2% in 2005 to 65.7% in 2014 (p for trend < 0.001). The median loop diuretic DDD in real-life patients with chronic heart failure decreased from 2.13 (IQR 1.09–2.77) in 2005 to 1.63 (IQR 1.09–2.25) in 2014 (p = 0.001 for trend). Conclusions Loop diuretic treatment decreased from 2005 to 2014 in real-life patients with chronic heart failure. The prognostic impact of changes in loop diuretic treatment in patients with heart failure remains unclear. Electronic supplementary material The online version of this article (10.1007/s00228-018-2574-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pär Parén
- Department of Internal Medicine, Sahlgrenska University Hospital/Mölndal, S-431 80, Mölndal, Sweden. .,Department of Molecular & Clinical Medicine, Institute of Medicine, Sahlgrenska Academy/University of Gothenburg, Gothenburg, Sweden.
| | - Annika Rosengren
- Department of Molecular & Clinical Medicine, Institute of Medicine, Sahlgrenska Academy/University of Gothenburg, Gothenburg, Sweden.,Department of Internal Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Tatiana Zverkova Sandström
- Department of Molecular & Clinical Medicine, Institute of Medicine, Sahlgrenska Academy/University of Gothenburg, Gothenburg, Sweden
| | - Maria Schaufelberger
- Department of Molecular & Clinical Medicine, Institute of Medicine, Sahlgrenska Academy/University of Gothenburg, Gothenburg, Sweden.,Department of Internal Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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Yao Y, Zhang J, Zhang Y, Zhang R. Can Torsemide and Combination of Loop Diuretics Improve Mortality in Patients with Chronic Heart Failure After Discharge? Int Heart J 2018; 59:813-820. [DOI: 10.1536/ihj.17-522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Younan Yao
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center of Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Jian Zhang
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center of Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Yuhui Zhang
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center of Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Rongcheng Zhang
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center of Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
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Elucidation of the Strongest Predictors of Cardiovascular Events in Patients with Heart Failure. EBioMedicine 2018; 33:185-195. [PMID: 29936136 PMCID: PMC6085496 DOI: 10.1016/j.ebiom.2018.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In previous retrospective studies, we identified the 50 most influential clinical predictors of cardiovascular outcomes in patients with heart failure (HF). The present study aimed to use the novel limitless-arity multiple-testing procedure to filter these 50 clinical factors and thus yield combinations of no more than four factors that could potentially predict the onset of cardiovascular events. A Kaplan-Meier analysis was used to investigate the importance of the combinations. METHODS In a multi-centre observational trial, we prospectively enrolled 213 patients with HF who were hospitalized because of exacerbation, discharged according to HF treatment guidelines and observed to monitor cardiovascular events. After the observation period, we stratified patients according to whether they experienced cardiovascular events (rehospitalisation or cardiovascular death). FINDINGS Among 77,562 combinations of fewer than five clinical parameters, we identified 151 combinations that could potentially explain the occurrence of cardiovascular events. Of these, 145 combinations included the use of inotropic agents, whereas the remaining 6 included the use of diuretics without bradycardia or tachycardia, suggesting that the high probability of cardiovascular events is exclusively determined by these two clinical factors. Importantly, Kaplan-Meier curves demonstrated that the use of inotropes or of diuretics without bradycardia or tachycardia were independent predictors of a markedly worse cardiovascular prognosis. INTERPRETATION Patients treated with either inotropic agents or diuretics without bradycardia or tachycardia were at a higher risk of cardiovascular events. The uses of these drugs, regardless of heart rate, are the strongest clinical predictors of cardiovascular events in patients with HF.
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Increased dose of diuretics correlates with severity of heart failure and renal dysfunction and does not lead to reduction of mortality and rehospitalizations due to acute decompensation of heart failure; data from AHEAD registry. COR ET VASA 2018. [DOI: 10.1016/j.crvasa.2017.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Ragab D, Taema KM, Farouk W, Saad M. Continuous infusion of furosemide versus intermittent boluses in acute decompensated heart failure: Effect on thoracic fluid content. Egypt Heart J 2018; 70:65-70. [PMID: 30166884 PMCID: PMC6112354 DOI: 10.1016/j.ehj.2017.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 12/05/2017] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION The administration of loop diuretics in the management of acute decompensated heart failure (ADHF) whether IV boluses or continuous infusion is still controversial. We intended to evaluate differences between the two administration routes on the thoracic fluid content (TFC) and the renal functions. METHODS Sixty patients with ADHF admitted to the critical care medicine department (Cairo University, Egypt) were initially enrolled in the study. Twenty patients were excluded due to EF > 40%, myocardial infarction within 30 days, and baseline serum creatinine level > 4.0 mg/dL. Furosemide (120 mg/day) was given to the remaining 40 pts who continued the study after 1:1 randomization to either continuous infusion (group-I, 20 pts) or three equal intermittent daily doses (group-II, 20 pts). Subsequent dose titration was allowed after 24 h, but not earlier, according to patient's response. No other diuretic medications were allowed. All patients were daily evaluated for NYHA class, urine output, TFC, body weight, serum K+, and renal chemistry. RESULTS The median age (Q1-Q3) was 54.5 (43.8-63.8) years old with 24 (60%) males. Apart from TFC which was significantly higher in group-I, the admission demographic, clinical, laboratory and co-morbid conditions were similar in both groups. There was statistically insignificant tendency for increased urine output during the 1st and 2nd days in group-I compared to group-II (p = .08). The body weight was decreased during the 1st day by 2 (1.5-2.5) kg in group-I compared to 1.5 (1-2) kg in group-II, (p = .03). These changes became insignificant during the 2nd day (p = .4). The decrease of TFC was significantly higher in group-I than in group-II [10 (6.3-14.5) vs 7 (3.3-9.8) kΩ-1 during the first day and 8 (6-11) vs 6 (3.3-8.5) kΩ-1 during the second day in groups-I&II respectively, P = .02 for both]. There was similar NYHA class improvement in both groups (p = .7). The serum creatinine was increased by 0.2 (0.1-0.5) vs 0 (-0.1 to 0.2) mg% and the CrCl was decreased by 7.4 (4.5-12.3) vs 3.1 (0.2-8.8) ml/min in groups-I&II respectively (p = .009 and .02 respectively). CONCLUSIONS We concluded that continuous furosemide infusion in ADHF might cause greater weight loss and more decrease in TFC with no symptomatic improvement and possibly with more nephrotoxic effect.
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Pioli MR, Ritter AMV, Modolo R. Unsweetening the Heart: Possible Pleiotropic Effects of SGLT2 Inhibitors on Cardio and Cerebrovascular Alterations in Resistant Hypertensive Subjects. Am J Hypertens 2018; 31:274-280. [PMID: 29186300 DOI: 10.1093/ajh/hpx204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 11/22/2017] [Indexed: 01/08/2023] Open
Abstract
Resistant hypertension (RH) is a multifactorial disease associated with several target organ damage, such as microalbuminuria, left ventricular hypertrophy, and arterial stiffness. These subjects have high cardiovascular complications, especially when associated with diabetes condition. Sodium glucose cotransporter 2 (SGLT-2) inhibitors represent a new class of oral antidiabetic drugs that have shown positive effects in diabetics and even hypertensives subjects. Several studies demonstrated positive outcomes related to blood pressure levels, body weight, and glycemic control. Also found a reduction on microalbuminuria, cardiac and arterial remodeling process, and decrease in hospitalization care due heart failure. Despite these positive effects, the outcomes found for stroke were conflicted and tend neutral effect. Based on this, we sought to assess the pleiotropic effects of SGLT-2 inhibitors and the possible impact in RH subjects. In order to analyze the prospects of SGLT-2 inhibitors as a possible medication to complement the therapy manage of this high-risk class of patients.
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Affiliation(s)
- Mariana R Pioli
- Laboratory of Cardiovascular Pharmacology, Department of Pharmacology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
| | - Alessandra M V Ritter
- Laboratory of Cardiovascular Pharmacology, Department of Pharmacology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
| | - Rodrigo Modolo
- Laboratory of Cardiovascular Pharmacology, Department of Pharmacology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
- Department of Internal Medicine - Cardiology Division, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
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Imai S, Shinoda M, Obara H, Kitago M, Hibi T, Abe Y, Yagi H, Matsubara K, Higashi H, Itano O, Kitagawa Y. Tolvaptan for Fluid Management in Living Donor Liver Transplant Recipients. Ann Transplant 2018; 23:25-33. [PMID: 29311539 PMCID: PMC6248066 DOI: 10.12659/aot.905817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Tolvaptan, an antagonist of the vasopressin V2 receptor is a novel oral diuretic that promotes water excretion selectively. We have used furosemide as a primary diuretic and added human atrial natriuretic peptide (hANP) if necessary for fluid management postoperatively in living-donor liver transplantation (LDLT) recipients. Recently we introduced tolvaptan and used both tolvaptan and furosemide as primary diuretics. MATERIAL AND METHODS Clinical outcomes were compared between LDLT recipients whose postoperative fluid management was performed before (control group, n=10) and after (tolvaptan group, n=16) introduction of tolvaptan. RESULTS Preoperative and intraoperative demographic data did not differ significantly between the groups except for the period of post-surgical follow-up and total ischemic time. Urine volume was 1,242±692, 2,240±1307, and 2,268±1262 mL on postoperative day 1, 3, and 7, respectively, in the tolvaptan group. These volumes did not significantly differ from those in control group (1,027±462, 1,788±909, and 2,057±1216 mL on day 1, 3, and 7 postoperatively, respectively). Body weight gain and fluid volume from abdominal drainage tubes postoperatively did not differ significantly between groups. The time from hANP initiation to discontinuation and the time to removal of central vein catheters were significantly reduced in tolvaptan-treated patients. No severe side effects directly related to tolvaptan were observed. The survival rate at month 6 was 90.0% in control patients versus 93.8% in tolvaptan-treated patients. CONCLUSIONS The outcomes of this investigation indicate that tolvaptan in combination with furosemide provides an adequate diuretic for fluid management subsequent to LDLT without causing adverse effects.
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Affiliation(s)
- Shunichi Imai
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taizo Hibi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hisanobu Higashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Itano
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Nakano Y, Mizuno T, Niwa T, Mukai K, Wakabayashi H, Watanabe A, Ando H, Takashima H, Murotani K, Waseda K, Amano T. Impact of Continuous Administration of Tolvaptan on Preventing Medium-Term Worsening Renal Function and Long-Term Adverse Events in Heart Failure Patients with Chronic Kidney Disease. Int Heart J 2018; 59:105-111. [DOI: 10.1536/ihj.16-625] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | | | - Toru Niwa
- Department of Cardiology, Aichi Medical University
| | | | | | | | | | | | - Kenta Murotani
- Division of Biostatistics, Clinical Research Center, Aichi Medical University
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46
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Zheng C, Li M, Kawada T, Inagaki M, Uemura K, Sugimachi M. Frequent drinking of small volumes improves cardiac function and survival in rats with chronic heart failure. Physiol Rep 2017; 5:5/21/e13497. [PMID: 29122962 PMCID: PMC5688786 DOI: 10.14814/phy2.13497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 10/11/2017] [Indexed: 11/24/2022] Open
Abstract
Fluid retention is the main reason for the high hospitalization rate among patients with chronic heart failure (CHF). Given the lack of knowledge about fluid intake regulation and its consequences in patients with CHF, current guidelines do not provide clear direction for fluid management. Using a rat model of CHF, we investigated altering drinking behaviors and explored fluid management strategies. CHF was induced by ligating the left anterior descending coronary arteries in 8‐week‐old, male, Sprague‐Dawley rats. A custom‐designed drop counting and feedback control system was used to record and modulate drinking behaviors. During the first month after an induced myocardial infarction (MI), we observed that the spontaneous per drinking volume (PDV) was significantly increased in animals with prolonged intervals between drinking episodes. In addition, there was a significant inverse correlation between the early PDV and the post‐MI lifespan (r = −0.907; P < 0.001). Moreover, modulating the drinking behavior of rats with CHF to involve frequent drinking of small PDVs significantly enhanced hemodynamics and prevented cardiac remodeling, with a significant improvement in the 180‐day survival rate, compared with animals allowed to drink freely (50% vs. 36%; P < 0.01). The results of dynamic PDV changes, after MI, suggest that an impaired thirst mechanism is associated with the sensing and regulating of fluid balance in rats with CHF. These results suggest that increasing the drinking frequency, with small PDVs, may be beneficial to preventing progression of cardiac dysfunction in CHF.
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Affiliation(s)
- Can Zheng
- Department of Cardiovascular Dynamics; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Meihua Li
- Department of Cardiovascular Dynamics; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Masashi Inagaki
- Department of Cardiovascular Dynamics; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Kazunori Uemura
- Department of Cardiovascular Dynamics; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics; National Cerebral and Cardiovascular Center; Osaka Japan
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47
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Saitoh M, Dos Santos MR, Emami A, Ishida J, Ebner N, Valentova M, Bekfani T, Sandek A, Lainscak M, Doehner W, Anker SD, von Haehling S. Anorexia, functional capacity, and clinical outcome in patients with chronic heart failure: results from the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF). ESC Heart Fail 2017; 4:448-457. [PMID: 28960880 PMCID: PMC5695184 DOI: 10.1002/ehf2.12209] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/01/2017] [Accepted: 08/03/2017] [Indexed: 12/24/2022] Open
Abstract
Aims We aimed to assess determinants of anorexia, that is loss of appetite in patients with heart failure (HF) and aimed to further elucidate the association between anorexia, functional capacity, and outcomes in affected patients. Methods and results We assessed anorexia status among 166 patients with HF (25 female, 66 ± 12 years) who participated in the Studies Investigating Co‐morbidities Aggravating HF. Anorexia was assessed by a 6‐point Likert scale (ranging from 0 to 5), wherein values ≥1 indicate anorexia. Functional capacity was assessed as peak oxygen uptake (peak VO2), 6 min walk test, and short physical performance battery test. A total of 57 patients (34%) reported any anorexia, and these patients showed lower values of peak VO2, 6 min walk distance, and short physical performance battery score (all P < 0.05). Using multivariate analysis adjusting for clinically important factors, only high‐sensitivity C‐reactive protein [odds ratio (OR) 1.24, P = 0.04], use of loop diuretics (OR 5.76, P = 0.03), and the presence of cachexia (OR 2.53, P = 0.04) remained independent predictors of anorexia. A total of 22 patients (13%) died during a mean follow‐up of 22.5 ± 5.1 months. Kaplan‐Meier curves for cumulative survival showed that those patients with anorexia presented higher mortality (Log‐rank test P = 0.03). Conclusions Inflammation, use of loop diuretics, and cachexia are associated with an increased likelihood of anorexia in patients with HF, and patients with anorexia showed impaired functional capacity and poor outcomes.
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Affiliation(s)
- Masakazu Saitoh
- Department of Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), Göttingen, Germany
| | - Marcelo R Dos Santos
- Department of Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), Göttingen, Germany.,Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Amir Emami
- Department of Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), Göttingen, Germany
| | - Junichi Ishida
- Department of Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), Göttingen, Germany
| | - Nicole Ebner
- Department of Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), Göttingen, Germany
| | - Miroslava Valentova
- Department of Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), Göttingen, Germany
| | - Tarek Bekfani
- Department of Internal Medicine I, Division of Cardiology, Angiology, Pneumology and Intensive Medical Care, Friedrich-Schiller-University, Jena, Germany
| | - Anja Sandek
- Department of Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), Göttingen, Germany
| | - Mitja Lainscak
- Faculty of Medicine, Ljubljana, Slovenia; Departments of Cardiology and Research and Education, General Hospital Celje, Celje, Slovenia
| | - Wolfram Doehner
- Centre for Stroke Research Berlin and Department of Cardiology, Virchow Klinikum, Charité-Universitätsmedizin, Berlin, Germany
| | - Stefan D Anker
- Department of Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), Göttingen, Germany.,Division of Cardiology and Metabolism - Heart Failure, Cachexia and Sarcopenia; Department of Internal Medicine and Cardiology, Berlin-Brandenburg Center for Regenerative Therapies (BCRT) at Charité University Medicine, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), Göttingen, Germany
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48
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Romano G, Vitale G, Bellavia D, Agnese V, Clemenza F. Is diuretic withdrawal safe in patients with heart failure and reduced ejection fraction? A retrospective analysis of our outpatient cohort. Eur J Intern Med 2017; 42:e11-e13. [PMID: 28390780 DOI: 10.1016/j.ejim.2017.03.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 03/29/2017] [Accepted: 03/30/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Giuseppe Romano
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS - ISMETT, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione, via Tricomi 5, 90127 Palermo, Italy.
| | - Giuseppe Vitale
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS - ISMETT, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione, via Tricomi 5, 90127 Palermo, Italy
| | - Diego Bellavia
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS - ISMETT, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione, via Tricomi 5, 90127 Palermo, Italy
| | - Valentina Agnese
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS - ISMETT, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione, via Tricomi 5, 90127 Palermo, Italy
| | - Francesco Clemenza
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS - ISMETT, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione, via Tricomi 5, 90127 Palermo, Italy
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49
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Ames MK, Atkins CE, Eriksson A, Hess AM. Aldosterone breakthrough in dogs with naturally occurring myxomatous mitral valve disease. J Vet Cardiol 2017; 19:218-227. [PMID: 28576479 DOI: 10.1016/j.jvc.2017.03.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 03/18/2017] [Accepted: 03/27/2017] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Aldosterone breakthrough (ABT) is the condition in which angiotensin converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers fail to effectively suppress the activity of the renin angiotensin aldosterone system. The objective of this study was to determine if ABT occurs in dogs with naturally occurring myxomatous mitral valve disease receiving an ACEI, using the urine aldosterone to creatinine ratio (UAldo:C) as a measure of renin angiotensin aldosterone system activation. ANIMALS, MATERIALS AND METHODS This study includes 39 dogs with myxomatous mitral valve disease. A UAldo:C cut-off definition (derived from a normal population of healthy, adult, and client-owned dogs) was used to determine the prevalence of ABT in this population. Spearman analysis and univariate logistic regression were used to evaluate the relationship between UAldo:C and ABT (yes/no) and eight variables (age, serum K+ concentration, serum creatinine concentration, ACEI therapy duration and ACEI dosage, furosemide therapy duration and furosemide dosage, and urine sample storage time). Finally, the UAldo:C in dogs receiving spironolactone, as part congestive heart failure (CHF) therapy, was compared to dogs with CHF that were not receiving spironolactone. RESULTS The prevalence of ABT was 32% in dogs with CHF and 30% in dogs without CHF. There was no relationship between either the UAldo:C or the likelihood of ABT and the eight variables. Therapy with spironolactone lead to a significant elevation of the UAldo:C. DISCUSSION Using the UAldo:C and a relatively stringent definition of ABT, it appears that incomplete RAAS blockade is common in dogs with MMVD receiving an ACEI. The prevalence of ABT in this canine population mirrors that reported in humans. While the mechanism of ABT is likely multifactorial and still poorly understood, the proven existence of ABT in dogs offers the potential to improve the prognosis for MMVD with the addition of a mineralocorticoid receptor blocker to current therapeutic regimens. CONCLUSIONS Approximately 30% of dogs being treated for heart disease and CHF satisfied the definition of ABT. Identifying patient subpopulations experiencing ABT may help guide future study design and clinical decision-making.
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Affiliation(s)
- M K Ames
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Dr. Raleigh, NC, 27607, USA.
| | - C E Atkins
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Dr. Raleigh, NC, 27607, USA
| | - A Eriksson
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Dr. Raleigh, NC, 27607, USA
| | - A M Hess
- Department of Statistics, Colorado State University, Ft. Collins, CO, USA
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50
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Cardiac Dysfunction, Congestion and Loop Diuretics: their Relationship to Prognosis in Heart Failure. Cardiovasc Drugs Ther 2017; 30:599-609. [PMID: 27819111 DOI: 10.1007/s10557-016-6697-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Diuretics are the mainstay of treatment for congestion but concerns exist that they adversely affect prognosis. We explored whether the relationship between loop diuretic use and outcome is explained by the underlying severity of congestion amongst patients referred with suspected heart failure. METHOD AND RESULTS Of 1190 patients, 712 had a left ventricular ejection fraction (LVEF) ≤50 %, 267 had LVEF >50 % with raised plasma NTproBNP (>400 ng/L) and 211 had LVEF >50 % with NTproBNP ≤400 ng/L; respectively, 72 %, 68 % and 37 % of these groups were treated with loop diuretics including 28 %, 29 % and 10 % in doses ≥80 mg furosemide equivalent/day. Compared to patients with cardiac dysfunction (either LVEF ≤50 % or NT-proBNP >400 ng/L) but not taking a loop diuretic, those taking a loop diuretic were older and had more clinical evidence of congestion, renal dysfunction, anaemia and hyponatraemia. During a median follow-up of 934 (IQR: 513-1425) days, 450 patients were hospitalized for HF or died. Patients prescribed loop diuretics had a worse outcome. However, in multi-variable models, clinical, echocardiographic (inferior vena cava diameter), and biochemical (NTproBNP) measures of congestion were strongly associated with an adverse outcome but not the use, or dose, of loop diuretics. CONCLUSIONS Prescription of loop diuretics identifies patients with more advanced features of heart failure and congestion, which may account for their worse prognosis. Further research is needed to clarify the relationship between loop diuretic agents and outcome; imaging and biochemical measures of congestion might be better guides to diuretic dose than symptoms or clinical signs.
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