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Fernandez Hazim C, Duarte G, Urena AP, Jain S, Mishra R, Vittorio TJ, Rodriguez-Guerra M. Diuretic resistance and the role of albumin in congestive heart failure. Drugs Context 2023; 12:2023-6-5. [PMID: 38188263 PMCID: PMC10768781 DOI: 10.7573/dic.2023-6-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Diuresis with loop diuretics is the mainstay treatment for volume optimization in patients with congestive heart failure, in which perfusion and volume expansion play a crucial role. There are robust guidelines with extensive evidence for the management of heart failure; however, clear guidance is needed for patients who do not respond to standard diuretic treatment. Diuretic resistance (DR) can be defined as an insufficient quantity of natriuresis with proper diuretic therapy. A combination of diuretic regimens is used to overcome DR and, more recently, SGLT2 inhibitors have been shown to improve diuresis. Despite DR being relatively common, it is challenging to treat and there remains a notable lack of substantial data guiding its management. Moreover, DR has been linked with poor prognosis. This review aims to expose the multiple approaches for treatment of patients with DR and the importance of intravascular volume expansion in the response to therapy.
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Affiliation(s)
| | | | - Ana P Urena
- Medicina Cardiovascular Asociada, Santo Domingo, Dominican Republic
| | - Swati Jain
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rishabh Mishra
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy J Vittorio
- BronxCare Health System, Icahn School of Medicine at Mt. Sinai, Bronx, NY, USA
| | - Miguel Rodriguez-Guerra
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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2
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Bekele AT. Natriuretic Peptide Receptors (NPRs) as a Potential Target for the Treatment of Heart Failure. Curr Heart Fail Rep 2023; 20:429-440. [PMID: 37710133 DOI: 10.1007/s11897-023-00628-8] [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: 08/22/2023] [Indexed: 09/16/2023]
Abstract
PURPOSE OF REVIEW Heart failure is defined as a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. The natriuretic peptide is known to exert its biological action on the kidney, heart, blood vessels, renin-angiotensin system, autonomous nervous system, and central nervous system. The natriuretic peptide-natriuretic receptor system plays an important role in the regulation of blood pressure and body fluid volume through its pleiotropic effects. RECENT FINDINGS The clinical and animal studies suggest that natriuretic peptide-natriuretic receptors are important targets for the treatment of heart failure and other cardiovascular diseases. Even though attempts targeting natriuretic peptide receptors are underway for heart failure treatment, they seem insufficient despite the receptor systems' potential. This review summarizes natriuretic peptide-natriuretic receptor system's physiological actions and potential target for the treatment of heart failure. Natriuretic peptides play multiple roles in different parts of the body, almost all of the activities related to this receptor system appear to have the potential to be harnessed to treat heart failure or symptoms associated with heart failure.
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Affiliation(s)
- Adamu T Bekele
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia.
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3
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Gomes da Silva F, Calça R, Rita Martins A, Araújo I, Aguiar C, Fonseca C, Branco P. Diuretic-resistant heart failure and the role of ultrafiltration: A proposed protocol. Rev Port Cardiol 2023; 42:797-803. [PMID: 36948455 DOI: 10.1016/j.repc.2022.05.012] [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: 10/23/2021] [Revised: 02/13/2022] [Accepted: 05/09/2022] [Indexed: 03/24/2023] Open
Abstract
Acute heart failure (HF) decompensation generally manifests with signs and symptoms of congestion that strongly predict poor poor patient outcome. Loop diuretics are the cornerstone of therapy to counteract fluid overload and are widely used for acute management and chronic stabilization of HF. However, a diminished response to loop diuretics is a common problem, affecting the patient's clinical course and potentially prolonging hospitalization. Diuretic resistance is defined as failure to decongest despite appropriate and escalating loop diuretic therapy. We propose a protocol for the management of diuretic resistance. The initial approach should include an assessment of causes of pseudo-diuretic resistance. Adjustments to loop diuretic therapy, such as increasing doses and frequency of administration and sequential nephron blockade, may be successful. For hospitalized patients with progressive disease there are more invasive methods for fluid removal. Switching from oral to intravenous loop diuretics is essential to avoid variable absorption and for symptomatic relief. Extracorporeal ultrafiltration is also an option since this technique is highly effective at removing plasma fluid from blood. While extracorporeal ultrafiltration is an invasive solution, peritoneal dialysis is a home-based, intermittent therapeutic option that can enable efficient management of fluid overload, preventing HF-related hospital admission, and improving quality of life. As a last resort for fluid removal, a peritoneal dialysis regimen should fully exploit its decongestive properties and should be tailored to the patient's characteristics and clinical needs.
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Affiliation(s)
| | - Rita Calça
- Serviço de Nefrologia, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Ana Rita Martins
- Serviço de Nefrologia, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Inês Araújo
- Serviço de Medicina Interna, Hospital de São Francisco Xavier, Lisboa, Portugal
| | - Carlos Aguiar
- Serviço de Cardiologia, Hospital de Santa Cruz, Lisboa, Portugal
| | - Cândida Fonseca
- Serviço de Medicina Interna, Hospital de São Francisco Xavier, Lisboa, Portugal
| | - Patrícia Branco
- Serviço de Nefrologia, Hospital de Santa Cruz, Carnaxide, Portugal
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4
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Oyama MA, Adin D. Toward quantification of loop diuretic responsiveness for congestive heart failure. J Vet Intern Med 2022; 37:12-21. [PMID: 36408832 PMCID: PMC9889629 DOI: 10.1111/jvim.16590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 11/11/2022] [Indexed: 11/22/2022] Open
Abstract
Diuretics, such as furosemide, are routinely administered to dogs with congestive heart failure (CHF). Traditionally, dose and determination of efficacy primarily are based on clinical signs rather than quantitative measures of drug action. Treatment of human CHF patients increasingly is guided by quantification of urine sodium concentration (uNa) and urine volume after diuretic administration. Use of these and other measures of diuretic responsiveness is associated with decreased duration of hospitalization, complication rates, future rehospitalization, and mortality. At their core, loop diuretics act through natriuresis, and attention to body sodium (Na) stores and handling offers insight into the pathophysiology of CHF and pharmacology of diuretics beyond what is achievable from clinical signs alone. Human patients with low diuretic responsiveness or diuretic resistance are at risk for difficult or incomplete decongestion that requires diuretic intensification or other remedial strategies. Identification of the specific etiology of resistance in a patient can help tailor personalized interventions. In this review, we advance the concept of loop diuretic responsiveness by highlighting Na and natriuresis. Specifically, we review body water homeostasis and congestion in light of the increasingly recognized role of interstitial Na, propose definitions for diuretic responsiveness and resistance in veterinary subjects, review relevant findings of recent studies, explain how the particular cause of resistance can guide treatment, and identify current knowledge gaps. We believe that a quantitative approach to loop diuretic usage primarily involving natriuresis will advance our understanding and care of dogs with CHF.
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Affiliation(s)
- Mark A. Oyama
- Clinical Sciences and Advanced MedicineUniversity of Pennsylvania, MJR‐VHUP‐CardiologyPhiladelphiaPennsylvaniaUSA
| | - Darcy Adin
- Large Animal Clinical SciencesUniversity of FloridaGainesvilleFloridaUSA
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5
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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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6
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Dahiya G, Bensimhon D, Goodwin MM, Mohr JF, Alexy T. From Oral to Subcutaneous Furosemide: The Road to Novel Opportunities to Manage Congestion. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100076. [PMID: 37288336 PMCID: PMC10242578 DOI: 10.1016/j.shj.2022.100076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 06/09/2023]
Abstract
The steadily rising prevalence of heart failure (HF) and the associated increase in health care expenditures represent a significant burden for patients, caregivers, and society. Ambulatory management of worsening congestion is a complex undertaking that requires diuretic escalation, yet clinical success is often hindered by the progressively declining bioavailability of oral agents. Once beyond a threshold, patients with acute on chronic HF often require hospital admission for intravenous diuresis. A novel, pH neutral formulation of furosemide that is administered by a biphasic drug delivery profile (80 mg total over 5 hours) via an automated, on-body infusor was designed to overcome these limitations. Early studies have shown that it has equivalent bioavailability with comparable diuresis and natriuresis to the intravenous formulation, leads to significant decongestion, and improvement in quality of life. It was shown to be safe and is well tolerated by patients. Although there is one ongoing clinical trial, available data have demonstrated the potential to shift hospital-administered, intravenous diuresis to the outpatient setting. Reduction in the need for recurrent hospital admissions would be highly desirable by most patients with chronic HF and would lead to a significant reduction in health care expenditures. In this article, we describe the rationale and evolution of this novel PH neutral formulation of furosemide administered subcutaneously, summarize its pharmacokinetic and pharmacodynamic profiles, and review emerging clinical trials demonstrating its clinical safety, efficacy, and potential to reduce health care expenditures.
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Affiliation(s)
- Garima Dahiya
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Daniel Bensimhon
- Division of Cardiovascular Medicine, Cone Health, Greensboro, North Carolina, USA
| | - Matthew M. Goodwin
- Clinical Development and Medical Affairs, scPharmaceuticals, Burlington, Massachusetts, USA
| | - John F. Mohr
- Clinical Development and Medical Affairs, scPharmaceuticals, Burlington, Massachusetts, USA
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Godino C, Scotti A, Marengo A, Battini I, Brambilla P, Stucchi S, Slavich M, Salerno A, Fragasso G, Margonato A. Effectiveness and cost-efficacy of diuretics home administration via peripherally inserted central venous catheter in patients with end-stage heart failure. Int J Cardiol 2022; 365:69-77. [PMID: 35853499 DOI: 10.1016/j.ijcard.2022.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/21/2022] [Accepted: 07/14/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND End-stage heart failure (ESHF) is characterized by severe cardiac dysfunction with persistent disabling symptoms and recurrent acute decompensated heart failure (ADHF), despite guideline-directed medical therapy. The aim of this study was to evaluate the efficacy and safety of intravenous diuretics administration at home through a peripherally inserted central venous catheter (PICC) in ESHF patients. METHODS AND RESULTS Forty-one ESHF patients received PICC implantation for intravenous diuretic administration at home. The primary efficacy endpoint was the patient-level number of HF hospitalizations in the short (1-3 months), medium (six months), and long term (1 year), before and after PICC implantation. Pre- and post-PICC ADHF-free days were also evaluated as co-primary endpoint. Secondary endpoints comprised changes in clinical, laboratory and echocardiographic parameters, and device safety. A cost-effectiveness analysis was performed to estimate the economic impact of using PICC. For each time frame analyzed, a significant reduction in the number of hospitalizations due to ADHF was observed, resulting in a significant increase in ADHF-free days (71 ± 44 vs. 163 ± 136, p = 0.003). In matched patients' analysis, significant decrease in body weight (68 ± 16 kg vs. 63 ± 10 kg, p = 0.041) and mitral regurgitation grade 3/4 (55% vs. 18%, p < 0.001) were also observed. Freedom from PICC-related complications was observed in 61% of patients. A significant reduction in overall ADHF-hospitalizations cost was observed. CONCLUSIONS This proof-of-concept study demonstrates the effectiveness and safety of home administration of intravenous diuretic therapy via PICC in ESHF patients. This palliative cost-effective strategy can be taken in consideration for selected end-stage patients no longer responsive to conventional therapies.
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Affiliation(s)
- Cosmo Godino
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Andrea Scotti
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America; Cardiovascular Research Foundation, NY, New York, United States of America
| | - Alessandra Marengo
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | | | - Massimo Slavich
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Salerno
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Fragasso
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Margonato
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
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8
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Oya T, Sato J, Maezawa K, Shiba N, Takeda M, Momose Y. Efficacy and safety of tolvaptan in chronic heart failure. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tomonori Oya
- Graduate School of Pharmaceutical Sciences International University of Health and Welfare Graduate School Tochigi Japan
- Department of Pharmacy International University of Health and Welfare Hospital Tochigi Japan
| | - Junya Sato
- Graduate School of Pharmaceutical Sciences International University of Health and Welfare Graduate School Tochigi Japan
- Department of Pharmacy International University of Health and Welfare Hospital Tochigi Japan
| | - Kayoko Maezawa
- Graduate School of Pharmaceutical Sciences International University of Health and Welfare Graduate School Tochigi Japan
- Department of Pharmacy International University of Health and Welfare Hospital Tochigi Japan
- Department of Pharmaceutical Sciences International University of Health and Welfare Tochigi Japan
| | - Nobuyuki Shiba
- Department of Cardiovascular Medicine International University of Health and Welfare Hospital Tochigi Japan
| | - Morihiko Takeda
- Department of Cardiovascular Medicine International University of Health and Welfare Hospital Tochigi Japan
| | - Yasuyuki Momose
- Graduate School of Pharmaceutical Sciences International University of Health and Welfare Graduate School Tochigi Japan
- Department of Pharmacy International University of Health and Welfare Hospital Tochigi Japan
- Department of Pharmaceutical Sciences International University of Health and Welfare Tochigi Japan
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Kennelly P, Sapkota R, Azhar M, Cheema FH, Conway C, Hameed A. Diuretic therapy in congestive heart failure. Acta Cardiol 2022; 77:97-104. [PMID: 33653227 DOI: 10.1080/00015385.2021.1878423] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In heart failure, fluid overload is a major pathological mechanism leading to vascular congestion, pulmonary congestion and elevated jugular venous pressures. Diuretics play a significant role in the management of patients with congestive heart failure. It is used to relieve the congestive symptoms of heart failure. However, the appropriate use of diuretics remains challenging due to various complications like electrolyte abnormalities, worsening renal function and diuretic resistance. This has prompted towards the search of safer and effective alternatives. This review evaluates the use of diuretics in congestive heart failure and discusses the complications of different types of diuretics, which is essential for successful management of congestion in patients with heart failure and hence to optimise the outcome for the patients.
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Affiliation(s)
- Patrick Kennelly
- Graduate Entry Medicine, School of Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Rajju Sapkota
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Maimoona Azhar
- Graduate Entry Medicine, School of Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Department of Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Faisal Habib Cheema
- HCA Healthcare Gulf Coast Division, Houston, TX, USA
- College of Medicine, University of Houston, Houston, TX, USA
| | - Claire Conway
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Aamir Hameed
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Trinity Centre for Biomedical Engineering (TCBE), Trinity College Dublin (TCD), Dublin, Ireland
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10
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Effect of sampling time on urinary electrolytes following oral furosemide administration in dogs with myxomatous mitral valve disease. J Vet Cardiol 2022; 41:57-69. [DOI: 10.1016/j.jvc.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 11/23/2022]
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Shams E, Bonnice S, Mayrovitz HN. Diuretic Resistance Associated With Heart Failure. Cureus 2022; 14:e21369. [PMID: 35198282 PMCID: PMC8852330 DOI: 10.7759/cureus.21369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/18/2022] [Indexed: 11/05/2022] Open
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12
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Impact of Outpatient Diuretic Infusion Therapy on Healthcare Cost and Readmissions. INTERNATIONAL JOURNAL OF HEART FAILURE 2022; 4:29-41. [PMID: 36262194 PMCID: PMC9383339 DOI: 10.36628/ijhf.2021.0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 12/22/2021] [Accepted: 12/25/2021] [Indexed: 01/10/2023]
Abstract
Background and Objectives Heart failure (HF) is a complex syndrome with multiple etiologies resulting in impaired ventricular filling or pumping of blood. HF is as a major public health concern that leads to significant morbidity and mortality resulting in an enormous financial burden on the healthcare system. The study objectives were to assess the 30-day hospital readmission rates and its financial impact on the hospital. Methods The study was a retrospective single-center analysis of decoded data of all HF patients admitted to an outpatient diuretic infusion program. Adult patients who were readmitted to the hospital within 30 days despite guideline derive medical therapy were included if they were enrolled in the outpatient diuretic infusion clinic. Adult patients who were included in this study received a furosemide dose of 40 mg intravenously (infusion over 3 hours) at the clinic visit. Patients whose clinical signs/symptoms improved and remained stable in consequent visits were eventually discharged from the clinic. Financial impact was assessed using data obtained from the hospital administration on cost of HF readmissions. Results The results show a 30-day hospital readmission rate at 6–9% in the years analyzed (n=56) with a net savings of $562,815 to $736,560 per year. Conclusions This treatment strategy has no detrimental effects in addition to generating substantial financial savings. It appears to be a useful addition to the existing medical treatment regimens chronic HF patients.
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13
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Orozco Burbano JD, Saldarriaga Giraldo CI, Echeverri Marín DA. [Hypertonic saline solution and high dose of diuretic, ¿what do we know and how can we use them in persistent congestion?]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2021; 2:247-253. [PMID: 37727671 PMCID: PMC10506575 DOI: 10.47487/apcyccv.v2i4.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 11/20/2021] [Indexed: 09/21/2023]
Abstract
The presence of decompensated heart failure continues to be a condition with high rates of hospitalization, impact on the health system, and quality of life for those who suffer it. The mainstay of treatment in these cases are diuretics. However, the resistance to this pharmacological group may occasionally occur, generating an inadequate negative fluid balance and persistence of congestion with negative clinical outcomes. Hypertonic saline solution with high doses of diuretic emerges as a therapeutic option for this group of patients with probable physiological, and clinical benefits on hospitalization and re-admission rates due to heart failure decompensation. A review of the most relevant aspects and benefits of this combination is discussed in this article.
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Affiliation(s)
- Juan D Orozco Burbano
- Departamento de Medicina Interna, Universidad del Cauca. Cauca, Colombia.Universidad del CaucaDepartamento de Medicina InternaUniversidad del CaucaCaucaColombia
- Hospital Universitario San José. Popayán, Colombia Hospital Universitario San JoséPopayánColombia
| | - Clara I Saldarriaga Giraldo
- Departamento de Cardiología, Universidad Pontificia Bolivariana. Medellín, Colombia.Universidad Pontificia BolivarianaDepartamento de CardiologíaUniversidad Pontificia BolivarianaMedellínColombia
- Clínica CardioVID. Medellín, Colombia.Clínica CardioVIDMedellínColombia
- Universidad de Antioquia. Medellín, Colombia. Universidad de AntioquiaUniversidad de AntioquiaMedellínColombia
| | - Diego A Echeverri Marín
- Departamento de Cardiología, Universidad Pontificia Bolivariana. Medellín, Colombia.Universidad Pontificia BolivarianaDepartamento de CardiologíaUniversidad Pontificia BolivarianaMedellínColombia
- Clínica CardioVID. Medellín, Colombia.Clínica CardioVIDMedellínColombia
- Universidad de Antioquia. Medellín, Colombia. Universidad de AntioquiaUniversidad de AntioquiaMedellínColombia
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14
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Kenig A, Kolben Y, Asleh R, Amir O, Ilan Y. Improving Diuretic Response in Heart Failure by Implementing a Patient-Tailored Variability and Chronotherapy-Guided Algorithm. Front Cardiovasc Med 2021; 8:695547. [PMID: 34458334 PMCID: PMC8385752 DOI: 10.3389/fcvm.2021.695547] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/21/2021] [Indexed: 01/12/2023] Open
Abstract
Heart failure is a major public health problem, which is associated with significant mortality, morbidity, and healthcare expenditures. A substantial amount of the morbidity is attributed to volume overload, for which loop diuretics are a mandatory treatment. However, the variability in response to diuretics and development of diuretic resistance adversely affect the clinical outcomes. Morevoer, there exists a marked intra- and inter-patient variability in response to diuretics that affects the clinical course and related adverse outcomes. In the present article, we review the mechanisms underlying the development of diuretic resistance. The role of the autonomic nervous system and chronobiology in the pathogenesis of congestive heart failure and response to therapy are also discussed. Establishing a novel model for overcoming diuretic resistance is presented based on a patient-tailored variability and chronotherapy-guided machine learning algorithm that comprises clinical, laboratory, and sensor-derived inputs, including inputs from pulmonary artery measurements. Inter- and intra-patient signatures of variabilities, alterations of biological clock, and autonomic nervous system responses are embedded into the algorithm; thus, it may enable a tailored dose regimen in a continuous manner that accommodates the highly dynamic complex system.
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Affiliation(s)
- Ariel Kenig
- Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Yotam Kolben
- Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Rabea Asleh
- Department of Cardiology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Offer Amir
- Department of Cardiology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Yaron Ilan
- Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
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15
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Margonato D, Ancona F, Ingallina G, Melillo F, Stella S, Biondi F, Boccellino A, Godino C, Margonato A, Agricola E. Tricuspid Regurgitation in Left Ventricular Systolic Dysfunction: Marker or Target? Front Cardiovasc Med 2021; 8:702589. [PMID: 34262955 PMCID: PMC8273168 DOI: 10.3389/fcvm.2021.702589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/02/2021] [Indexed: 12/28/2022] Open
Abstract
Far from being historically considered a primary healthcare problem, tricuspid regurgitation (TR) has recently gained much attention from the scientific community. In fact, in the last years, robust evidence has emerged regarding the epidemiological impact of TR, whose prevalence seems to be similar to that of other valvulopathies, such as aortic stenosis, with an estimated up to 4% of people >75 years affected by at least moderate TR in the United States, and up to 23% among patients suffering from heart failure with reduced ejection fraction. This recurrent coexistence of left ventricular systolic dysfunction (LVSD) and TR is not surprising, considered the multiple etiologies of tricuspid valve disease. TR can complicate heart failure mostly as a functional disease, because of pulmonary hypertension (PH), subsequent to elevated left ventricular end-diastolic pressure, leading to right ventricular dilatation, and valve tethering. Moreover, the so-called "functional isolated" TR can occur, in the absence of PH, as a result of right atrial dilatation associated with atrial fibrillation, a common finding in patients with LVSD. Finally, TR can result as a iatrogenic consequence of transvalvular lead insertion, another frequent scenario in this cohort of patients. Nonetheless, despite the significant coincidence of these two conditions, their mutual relation, and the independent prognostic role of TR is still a matter of debate. Whether significant TR is just a marker for advanced left-heart disease, or a crucial potential therapeutical target, remains unclear. Aim of the authors in this review is to present an update concerning the epidemiological features and the clinical burden of TR in the context of LVSD, its prognostic value, and the potential benefit for early tricuspid intervention in patients affected by contemporary TR and LVSD.
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Affiliation(s)
- Davide Margonato
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy.,Cardiology Department, University of Pavia, Pavia, Italy
| | - Francesco Ancona
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Melillo
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Stella
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Federico Biondi
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Boccellino
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Cosmo Godino
- Department of Clinical Cardiology, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Margonato
- Department of Clinical Cardiology, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
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16
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An Y, Wang Q, Wang H, Zhang N, Zhang F. Clinical significance of sFRP5, RBP-4 and NT-proBNP in patients with chronic heart failure. Am J Transl Res 2021; 13:6305-6311. [PMID: 34306370 PMCID: PMC8290780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/08/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE This study was designed to investigate the levels and clinical significance of secretory frizzled-related protein 5 (sFRP5), retinol binding protein 4 (RBP-4) and N-terminal (NT)-pro hormone BNP (NT-proBNP) in patients with chronic heart failure (CHF). METHODS Eighty-nine patients with CHF treated in our hospital were included as the observation group. Seventy-five healthy volunteers who underwent physical examination in our hospital during the same period were selected as the control group. The subjects in the observation group were divided into NYHA class II (n=23), NYHA class III (n=34) and NYHA class IV (n=32) according to NYHA classification, and the levels of sFRP5, RBP-4 and NT-proBNP as well as left ventricular end-diastolic diameter (LVEDD) and left ventricular ejection fraction (LVEF) were compared in the three groups. Spearman correlation was used to analyze the relationship between sFRP5, RBP-4, NT-proBNP and LVEDD, LVEF. The ROC curves of sFRP5, RBP-4 and NT-proBNP for the diagnosis of CHF were plotted. Patients in the observation group were divided into a death group (n=30) and a survival group (n=59) according to the 1-year follow-up outcome, and the levels of sFRP5, RBP-4, and NT-proBNP were compared between the two groups. RESULTS The observation group showed significantly higher levels of sFRP5, RBP-4, NT-proBNP and LVEDD, and a significantly lower level of LVEF than the control group. Spearman's correlation analysis showed that sFRP5, RBP-4, NT-proBNP were correlated with LVEDD and LVEF in CHF patients (P < 0.05). The ROC curve showed that the AUC of sFRP5, RBP-4 and NT-proBNP for CHF diagnosis were 0.9378, 0.9133, and 0.9375, respectively. sFRP5, RBP-4, and NT-proBNP in the death group were all higher than those in the survival group (P < 0.05). CONCLUSION sFRP5, RBP-4, and NT-proBNP showed a close correlation with CHF. It is worthy of using this method as a clinical index for the diagnosis and prognosis of CHF.
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Affiliation(s)
- Yu An
- Department of Cardiology, Affiliated Hospital of Chengde Medical CollegeChengde, Hebei Province, China
| | - Qingsong Wang
- Department of Cardiology, Affiliated Hospital of Chengde Medical CollegeChengde, Hebei Province, China
| | - Hong Wang
- Department of Cardiology, Affiliated Hospital of Chengde Medical CollegeChengde, Hebei Province, China
| | - Na Zhang
- Department of Cardiology, Affiliated Hospital of Chengde Medical CollegeChengde, Hebei Province, China
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17
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Gatzoflias S, Hao S, Ferreri NR. Induction of renal tumor necrosis factor-α and other autacoids and the beneficial effects of hypertonic saline in acute decompensated heart failure. Am J Physiol Renal Physiol 2021; 320:F1159-F1164. [PMID: 33969695 DOI: 10.1152/ajprenal.00686.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Although administration of hypertonic saline (HSS) in combination with diuretics has yielded improved weight loss, preservation of renal function, and reduction in hospitalization time in the clinical setting of patients with acute decompensated heart failure (ADHF), the mechanisms that underlie these beneficial effects remain unclear and additional studies are needed before this approach can be adopted on a more consistent basis. As high salt conditions stimulate the production of several renal autacoids that exhibit natriuretic effects, renal physiologists can contribute to the understanding of mechanisms by which HSS leads to increased diuresis both as an individual therapy as well as in combination with loop diuretics. For instance, since HSS increases TNF-α production by proximal tubule and thick ascending limb of Henle's loop epithelial cells, this article is aimed at highlighting how the effects of TNF-α produced by these cell types may contribute to the beneficial effects of HSS in patients with ADHF. Although TNF-α produced by infiltrating macrophages and T cells exacerbates and attenuates renal damage, respectively, production of this cytokine within the tubular compartment of the kidney functions as an intrinsic regulator of blood pressure and Na+ homeostasis via mechanisms along the nephron related to inhibition of Na+-K+-2Cl- cotransporter isoform 2 activity and angiotensinogen expression. Thus, in the clinical setting of ADHF and hyponatremia, induction of TNF-α production along the nephron by administration of HSS may attenuate Na+-K+-2Cl- cotransporter isoform 2 activity and angiotensinogen expression as part of a mechanism that prevents excessive Na+ reabsorption in the thick ascending limb of Henle's loop, thereby mitigating volume overload.
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Affiliation(s)
| | - Shoujin Hao
- Department of Pharmacology, New York Medical College, Valhalla, New York
| | - Nicholas R Ferreri
- Department of Pharmacology, New York Medical College, Valhalla, New York
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18
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Cui Y, Hou Y, Zhang H, Liu Y, Mao K, Nie H, Ding Y. Regulation of Electrolyte Permeability by Herbal Monomers in Edematous Disorders. Curr Pharm Des 2021; 27:833-839. [PMID: 32940173 DOI: 10.2174/1381612826666200917144655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/10/2020] [Indexed: 11/22/2022]
Abstract
Edema is a gradual accumulation of fluid in the interstitial tissues or luminal cavities, which is regulated by ion transport pathways and reflects dysfunction of fluid and salt homeostasis. Increasing evidence suggests that some herbal monomers significantly reduce organ/tissue edema. In this review, we briefly summarized the electrolyte permeability involved in pathomechanisms of organ edema, and the benefits of herbal monomers on ionic transport machinery, including Na+-K+-ATPase, Na+ and Cl- channels, Na+-K+-2Cl- co-transporter, etc. Pharmaceutical relevance is implicated in developing advanced strategies to mitigate edematous disorders. In conclusion, the natural herbal monomers regulate electrolyte permeability in many edematous disorders, and further basic and clinical studies are needed.
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Affiliation(s)
- Yong Cui
- Department of Anesthesiology, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yapeng Hou
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang, China
| | - Honglei Zhang
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang, China
| | - Yanhong Liu
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang, China
| | - Kejun Mao
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang, China
| | - Hongguang Nie
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang, China
| | - Yan Ding
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang, China
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19
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Chrysant SG, Chrysant GS. The pathophysiology and management of diuretic resistance in patients with heart failure. Hosp Pract (1995) 2021; 50:93-101. [PMID: 33596757 DOI: 10.1080/21548331.2021.1893065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The objectives of the study are to investigate the causes of diuretic resistance in patients with advanced congestive heart failure (CHF), since diuretics are the cornerstone of treatment of these patients. Several studies have shown that diuretic resistance in patients with advanced CHF is common, ranging from 25% to 50% in hospitalized patients. METHODS In order to get a current perspective as to the magnitude of diuretic resistance in such patients, a focused Medline search of the English language literature was conducted between 2015 and 2020 using the search terms, CHF, diuretics, treatment, resistance, frequency, and 30 papers with pertinent information were selected. RESULTS The analysis of data from the selected papers demonstrated that diuretic resistance is common in hospitalized patients with advanced CHF and frequently associated with renal failure, which is secondary to CHF. CONCLUSIONS Diuretic resistance appears to be common in patients with advanced CHF and it is mostly due to decreased cardiac output, low blood pressure, decreased glomerular filtration rate, decreased filtration of sodium, and increased tubular reabsorption of sodium. Diuretic resistance in such patients can be overcome with the combination of loop diuretics with thiazide and thiazide-like diuretics, aldosterone antagonists, as well as other agents. The data from these studies in combination with collateral literature will be discussed in this review.
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Affiliation(s)
- Steven G Chrysant
- Department of cardiology, University of Oklahoma Health Sciences Center, Oklahoma, United States.,Department of cardiology, INTEGRIS Baptist Medical Center, Oklahoma, United States
| | - George S Chrysant
- Department of cardiology, University of Oklahoma Health Sciences Center, Oklahoma, United States.,Department of cardiology, INTEGRIS Baptist Medical Center, Oklahoma, United States
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20
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Raffaello WM, Henrina J, Huang I, Lim MA, Suciadi LP, Siswanto BB, Pranata R. Clinical Characteristics of De Novo Heart Failure and Acute Decompensated Chronic Heart Failure: Are They Distinctive Phenotypes That Contribute to Different Outcomes? Card Fail Rev 2021; 7:e02. [PMID: 33708417 PMCID: PMC7919682 DOI: 10.15420/cfr.2020.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/23/2020] [Indexed: 12/11/2022] Open
Abstract
Heart failure is currently one of the leading causes of morbidity and mortality. Patients with heart failure often present with acute symptoms and may have a poor prognosis. Recent evidence shows differences in clinical characteristics and outcomes between de novo heart failure (DNHF) and acute decompensated chronic heart failure (ADCHF). Based on a better understanding of the distinct pathophysiology of these two conditions, new strategies may be considered to treat heart failure patients and improve outcomes. In this review, the authors elaborate distinctions regarding the clinical characteristics and outcomes of DNHF and ADCHF and their respective pathophysiology. Future clinical trials of therapies should address the potentially different phenotypes between DNHF and ADCHF if meaningful discoveries are to be made.
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Affiliation(s)
| | - Joshua Henrina
- Siloam Heart Institute, Siloam Hospitals Kebon Jeruk Jakarta, Indonesia
| | - Ian Huang
- Faculty of Medicine, Universitas Pelita Harapan Tangerang, Indonesia.,Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital Bandung, Indonesia
| | | | | | - Bambang Budi Siswanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia, National Cardiovascular Center Harapan Kita Jakarta, Indonesia
| | - Raymond Pranata
- Faculty of Medicine, Universitas Pelita Harapan Tangerang, Indonesia
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21
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Asai Y, Sato T, Kito D, Yamamoto T, Hioki I, Urata Y, Abe Y. Combination therapy of midodrine and droxidopa for refractory hypotension in heart failure with preserved ejection fraction per a pharmacist's proposal: a case report. J Pharm Health Care Sci 2021; 7:10. [PMID: 33653416 PMCID: PMC7927230 DOI: 10.1186/s40780-021-00193-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 02/11/2021] [Indexed: 11/30/2022] Open
Abstract
Background Patients with chronic heart failure (CHF) are often treated using many diuretics for symptom relief; however, diuretic use may have to continue despite hypotension development in these patients. Here, we present a case of heart failure with preserved ejection fraction (HFpEF), which is defined as ejection fraction ≥50% in CHF, and refractory hypotension, which was treated with midodrine and droxidopa to normalize blood pressure. Case presentation The patient was a 62-year-old man with a history of HFpEF due to mitral regurgitation and complaints of dyspnea on exertion. He had been prescribed multiple medications at an outpatient clinic for CHF management, including azosemide 60 mg/day, bisoprolol 2.5 mg/day, enalapril 2.5 mg/day, spironolactone 50 mg/day, and tolvaptan 15 mg/day. The systolic blood pressure (SBP) of the patient remained at 70–80 mmHg because the use of the diuretic could not be reduced or discontinued owing to edema and weight gain. He was hospitalized for the exacerbation of CHF. Although midodrine 8 mg/day was administered to improve hypotension, the SBP of the patient increased only up to 90 mmHg. On the 35th day after hospitalization, the urine volume decreased significantly (< 100 mL/day) due to hypotension. When droxidopa 200 mg/day replaced intravenous noradrenaline on the 47th day, the SBP remained at 100–120 mmHg and the urine volume increased. Conclusions Oral combination treatment with midodrine and droxidopa might contribute to the maintenance of blood pressure and diuretic activity in HFpEF patients with refractory hypotension. However, further long-term studies evaluating the safety and efficacy of this combination therapy for patients with HFpEF are needed.
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Affiliation(s)
- Yuki Asai
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojincho, Tsu, Mie, 514-1101, Japan.
| | - Tomoaki Sato
- Department of Cardiovascular Surgery, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojincho, Tsu, Mie, 514-1101, Japan
| | - Daisuke Kito
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojincho, Tsu, Mie, 514-1101, Japan
| | - Takanori Yamamoto
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojincho, Tsu, Mie, 514-1101, Japan
| | - Iwao Hioki
- Department of Cardiovascular Surgery, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojincho, Tsu, Mie, 514-1101, Japan
| | - Yasuhisa Urata
- Department of Cardiovascular Surgery, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojincho, Tsu, Mie, 514-1101, Japan
| | - Yasuharu Abe
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojincho, Tsu, Mie, 514-1101, Japan
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22
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Simonavičius J, Maeder MT, Eurlings CGMJ, Aizpurua AB, Čelutkienė J, Barysienė J, Toggweiler S, Kaufmann BA, Brunner-La Rocca HP. Intensification of pharmacological decongestion but not the actual daily loop diuretic dose predicts worse chronic heart failure outcome: insights from TIME-CHF. Clin Res Cardiol 2020; 110:1221-1233. [PMID: 33216179 DOI: 10.1007/s00392-020-01779-7] [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: 03/19/2020] [Accepted: 11/02/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Both loop diuretics (LDs) and congestion have been related to worse heart failure (HF) outcome. The relationship between the cause and effect is unknown. The aim of this study was to investigate the interaction between congestion, diuretic use and HF outcome. METHODS Six hundred and twenty-two chronic HF patients from TIME-CHF were studied. Congestion was measured by means of a clinical congestion index (CCI). Loop diuretic dose was considered at baseline and month 6. Treatment intensification was defined as the increase in LD dose over 6 months or loop diuretic and thiazide or thiazide-like diuretic co-administration. The end-points were survival and HF hospitalisation-free survival. RESULTS High-LD dose at baseline and month 6 (≥ 80 mg of furosemide per day) was not identified as an independent predictor of outcome. CCI at baseline remained independently associated with impaired survival [hazard ratio (HR) 1.34, (95% confidence interval) (95% CI) (1.20-1.50), p < 0.001] and HF hospitalisation-free survival [HR 1.09, 95% CI (1.02-1.17), p = 0.015]. CCI at month 6 was independently associated with HF hospitalisation-free survival [HR 1.24, 95% CI (1.11-1.38), p < 0.001]. Treatment intensification was independently associated with survival [HR 1.75, 95% CI (1.19-1.38), p = 0.004] and HF hospitalisation-free survival [HR 1.69, 95% CI (1.22-2.35), p = 0.002]. Patients undergoing treatment intensification resulting in decongestion had better outcome than patients with persistent (worsening) congestion despite LD dose up-titration (p < 0.001). CONCLUSION Intensification of pharmacological decongestion but not the actual LD dose was related to poor outcome in chronic HF. If treatment intensification translated into clinical decongestion, outcome was better than in case of persistent or worsening congestion.
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Affiliation(s)
- Justas Simonavičius
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands. .,Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariskiu str. 2, 08406, Vilnius, Lithuania. .,The Faculty of Medicine of Vilnius University, Vilnius, Lithuania.
| | - Micha T Maeder
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Casper G M J Eurlings
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Jelena Čelutkienė
- Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Jūratė Barysienė
- Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Stefan Toggweiler
- Division of Cardiology, Heart Centre Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Beat A Kaufmann
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
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23
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Goldsmith SR, Burkhoff D, Gustafsson F, Voors A, Zannad F, Kolkhof P, Staedtler G, Colorado P, Dinh W, Udelson JE. Dual Vasopressin Receptor Antagonism to Improve Congestion in Patients With Acute Heart Failure: Design of the AVANTI Trial. J Card Fail 2020; 27:233-241. [PMID: 33188886 DOI: 10.1016/j.cardfail.2020.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/07/2020] [Accepted: 10/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Loop diuretics are the main treatment for patients with acute heart failure, but are associated with neurohormonal stimulation and worsening renal function and do not improve long-term outcomes. Antagonists to arginine vasopressin may provide an alternative strategy to avoid these effects. The AVANTI study will investigate the efficacy and safety of pecavaptan, a novel, balanced dual-acting V1a/V2 vasopressin antagonist, both as adjunctive therapy to loop diuretics after admission for acute heart failure, and later as monotherapy. METHODS AND RESULTS AVANTI is a double-blind, randomized phase II study in 571 patients hospitalized with acute heart failure and signs of persistent congestion before discharge. In part A, patients will receive either pecavaptan 30 mg/d or placebo with standard of care for 30 days. In part B, eligible patients will continue treatment or receive pecavaptan or diuretics as monotherapy for another 30 days. The primary end points for part A are changes in body weight and serum creatinine; for part B, changes in body weight and blood urea nitrogen/creatinine ratio. CONCLUSIONS This study will provide the first evidence that a balanced V1a/V2 antagonist may safely enhance decongestion, both as an adjunct to loop diuretics and as an alternative strategy. TRIAL REGISTRATION NUMBER NCT03901729.
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Affiliation(s)
- Steven R Goldsmith
- Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Adriaan Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Faiez Zannad
- University of Lorraine, Inserm CIC-P 1433, CHRU de Nancy, Inserm U1116, French Clinical Research Infrastructure Network Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Peter Kolkhof
- Bayer AG, Research and Development, Preclinical Research, Heart and Vascular Disease, Wuppertal, Germany
| | - Gerald Staedtler
- Bayer AG, Research and Development, Pharmaceuticals, TA Statistics 1 CNTH, Berlin, Germany
| | | | - Wilfried Dinh
- Bayer AG, Research and Development, Pharmaceuticals, Translational Sciences, Translational Medicine, Experimental Medicine CV, Wuppertal, Germany; Centre for Clinical Medicine, University Faculty of Health, University of Witten Herdecke, Witten, Germany
| | - James E Udelson
- Division of Cardiology and the CardioVascular Centre, Tufts Medical Center, Boston, Massachusetts, USA.
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24
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Abstract
Decompensated heart failure accounts for approximately 1 million hospitalizations in the United States annually, and this number is expected to increase significantly in the near future. Diuretics provide the initial management in most patients with fluid overload. However, the development of diuretic resistance remains a significant challenge in the treatment of heart failure. Due to the lack of a standard definition, the prevalence of this phenomenon remains difficult to determine, with some estimates suggesting that 25-30% of patients with heart failure have diuretic resistance. Certain characteristics, including low systolic blood pressures, renal impairment, and atherosclerotic disease, help predict the development of diuretic resistance. The underlying pathophysiology is likely multifactorial, with pharmacokinetic alterations, hormonal dysregulation, and the cardiorenal syndrome having significant roles. The therapeutic approach to this common problem typically involves increases in the diuretic dose and/or frequency, sequential nephron blockade, and mechanical fluid movement removal with ultrafiltration or peritoneal dialysis. Paracentesis is potentially useful in patients with intra-abdominal hypertension.
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25
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Abstract
RATIONALE Refractory edema is characterized by persistent swelling which does not react to diuretic use and sodium restriction. Traditional herbal medicine, Gwack Rhyung Tang and Chunggan extract effectively treated refractory lower limb edema caused by cirrhosis and improved liver function. PATIENT CONCERNS A 64-year-old male patient with a history of hypertension, diabetes mellitus, hepatic encephalopathy, and cellulitis presented lower limb edema which did not react to diuretics for more than 7 months. DIAGNOSES Refractory edema caused by cirrhosis. INTERVENTIONS The patient was treated for 25 days using Gwack Rhyung Tang and Chunggan extract. OUTCOMES Loss of body weight, decrease in circumferences of both lower limb and improvement of liver function biochemistry results are checked. There was no recurrence or aggravation of the condition up to 3 weeks of follow-up periods. LESSONS Traditional herbal medicine can be an effective alternative for refractory edema due to cirrhosis with improving liver function.
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Affiliation(s)
- Gayoung Lee
- Department of Internal Medicine, Cheonan Korean Medicine Hospital of Daejeon University
- Liver and Immunology Research Center, Dunsan Korean Medicine Hospital of Daejeon University
- Department of Internal Medicine, Graduated School of Korean Medicine, University of Daejeon, Daejeon-si, Republic of Korea
| | - Jung-Hyo Cho
- Liver and Immunology Research Center, Dunsan Korean Medicine Hospital of Daejeon University
- Department of Internal Medicine, Graduated School of Korean Medicine, University of Daejeon, Daejeon-si, Republic of Korea
| | - Chang-Gue Son
- Liver and Immunology Research Center, Dunsan Korean Medicine Hospital of Daejeon University
- Department of Internal Medicine, Graduated School of Korean Medicine, University of Daejeon, Daejeon-si, Republic of Korea
| | - Namhun Lee
- Department of Internal Medicine, Cheonan Korean Medicine Hospital of Daejeon University
- Liver and Immunology Research Center, Dunsan Korean Medicine Hospital of Daejeon University
- Department of Internal Medicine, Graduated School of Korean Medicine, University of Daejeon, Daejeon-si, Republic of Korea
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26
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Simonavičius J, Sanders van-Wijk S, Rickenbacher P, Maeder MT, Pfister O, Kaufmann BA, Pfisterer M, Čelutkienė J, Puronaitė R, Knackstedt C, van Empel V, Brunner-La Rocca HP. Prognostic Significance of Longitudinal Clinical Congestion Pattern in Chronic Heart Failure: Insights From TIME-CHF Trial. Am J Med 2019; 132:e679-e692. [PMID: 31051151 DOI: 10.1016/j.amjmed.2019.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relationship between longitudinal clinical congestion pattern and heart failure outcome is uncertain. This study was designed to assess the prevalence of congestion over time and to investigate its impact on outcome in chronic heart failure. METHODS A total of 588 patients with chronic heart failure older than 60 years of age with New York Heart Association (NYHA) functional class ≥II from the TIME-CHF study were included. The endpoints for this study were survival and hospitalization-free heart failure survival. Orthopnea, NYHA ≥III, paroxysmal nocturnal dyspnea, hepatomegaly, peripheral pitting edema, jugular venous distension, and rales were repeatedly investigated and related to outcomes. These congestion-related signs and symptoms were used to design a 7-item Clinical Congestion Index. RESULTS Sixty-one percent of patients had a Clinical Congestion Index ≥3 at baseline, which decreased to 18% at month 18. During the median [interquartile range] follow-up of 27.2 [14.3-39.8] months, 17%, 27%, and 47% of patients with baseline Clinical Congestion Index of 0, 1-2, and ≥3 at inclusion, respectively, died (P <.001). Clinical Congestion Index was identified as an independent predictor of mortality at all visits (P <.05) except month 6 and reduced hospitalization-free heart failure survival (P <.05). Successful decongestion was related to better outcome as compared to persistent congestion or partial decongestion (log-rank P <0.001). CONCLUSIONS The extent of congestion as assessed by means of clinical signs and symptoms decreased over time with intensified treatment, but it remained present or relapsed in a substantial number of patients with heart failure and was associated with poor outcome. This highlights the importance of appropriate decongestion in chronic heart failure.
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Affiliation(s)
- Justas Simonavičius
- Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | | | - Peter Rickenbacher
- Department of Cardiology, University Hospital Bruderholz, Bruderholz, Switzerland
| | - Micha T Maeder
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Otmar Pfister
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Beat A Kaufmann
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | | | - Jelena Čelutkienė
- Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Roma Puronaitė
- Department of Information Systems, Centre of Informatics and Development, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Clinic of Cardiac and Vascular diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; Institute of Data Science and Digital Technologies, Faculty of Mathematics and Informatics, Vilnius University, Vilnius, Lithuania
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Cardiology, University Hospital Basel, Basel, Switzerland
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Masella C, Viggiano D, Molfino I, Zacchia M, Capolongo G, Anastasio P, Simeoni M. Diuretic Resistance in Cardio-Nephrology: Role of Pharmacokinetics, Hypochloremia, and Kidney Remodeling. Kidney Blood Press Res 2019; 44:915-927. [DOI: 10.1159/000502648] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/10/2019] [Indexed: 11/19/2022] Open
Abstract
Background: Diuretic resistance is among the most challenging problems that the cardio-nephrologist must address in daily clinical practice, with a considerable burden on hospital admissions and health care costs. Indeed, loop diuretics are the first-line therapy to overcome fluid overload in heart failure patients. The pathophysiological mechanisms of fluid and sodium retention are complex and depend on several neuro-hormonal signals mainly acting on sodium reabsorption along the renal tubule. Consequently, doses and administration modalities of diuretics must be carefully tailored to patients in order to overcome under- or overtreatment. The frequent and tricky development of diuretic resistance depends in part on post-diuretic sodium retention, reduced tubular secretion of the drug, and reduced sodium/chloride sensing. Sodium and chloride depletions have been recently shown to be major factors mediating these processes. Aquaretics and high-saline infusions have been recently suggested in cases of hyponatremic conditions. This review discusses the limitations and strengths of these approaches. Summary: Long-term diuretic use may lead to diuretic resistance in cardio-renal syndromes. To overcome this complication intravenous administration of loop diuretics and a combination of different diuretic classes have been proposed. In the presence of hyponatremia, high-saline solutions in addition to loop diuretics might be beneficial, whereas aquaretics require caution to avoid overcorrection. Key Messages: Diuretic resistance is a central theme for cardio-renal syndromes. Hyponatremia and hypochloremia may be part of the mechanisms for diuretic resistance. Aquaretics and high-saline solutions have been proposed as possible new therapeutic solutions.
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28
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Simonavičius J, Knackstedt C, Brunner-La Rocca HP. Loop diuretics in chronic heart failure: how to manage congestion? Heart Fail Rev 2018; 24:17-30. [DOI: 10.1007/s10741-018-9735-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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29
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Ukrainets IV, Sidorenko LV, Golik MY, Chernenok IM, Grinevich LA, Davidenko AA. N-Aryl-7-hydroxy-5-oxo-2,3-dihydro-1H,5H-pyrido-[3,2,1-ij]quinoline-6-carboxamides. The Synthesis and Effects on Urinary Output. Sci Pharm 2018; 86:E12. [PMID: 29642551 PMCID: PMC6027687 DOI: 10.3390/scipharm86020012] [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: 01/31/2018] [Revised: 03/27/2018] [Accepted: 02/04/2018] [Indexed: 12/11/2022] Open
Abstract
Continuing a targeted search for new leading structures with diuretic action among tricyclic derivatives of hydroxyquinolines, which are of interest as potential inhibitors of aldosterone synthase, the synthesis of a series of the corresponding pyrido[3,2,1-ij]quinoline-6-carboxanilides was carried out by amidation of ethyl-7-hydroxy-5-oxo-2,3-dihydro-1H,5H-pyrido[3,2,1-ij]quinoline-6-carboxylate with aniline, aminophenols and O-alkylsubstituted analogs with high yields and purity. The optimal conditions of this reaction are proposed; they make it possible to prevent partial destruction of the original heterocyclic ester and thereby avoid formation of specific impurities of 7-hydroxy-2,3-dihydro-1H,5H-pyrido[3,2,1-ij]quinolin-5-one. To confirm the structure of all substances obtained, elemental analysis, nuclear magnetic resonance (NMR) spectroscopy, and mass spectrometry were used. Moreover, the peculiarities of their ¹H and 13C-NMR spectra, as well as their mass spectrometric behavior under conditions of electron impact ionization, were discussed. The effect of pyrido[3,2,1-ij]quinoline-6-carboxanilides on the urinary function of the kidneys was studied in white rats of both genders by the standard method of oral administration at a dose of 10 mg/kg. Testing was conducted in comparison with hydrochlorothiazide, as well as with structurally close pyrrolo[3,2,1-ij] quinoline-5-carboxanilides studied earlier with the same substituents in the anilide fragments. It was found that addition of one methylene unit to the heterocycle partially hydrogenated and annelated with the quinolone core has a positive impact on biological properties-most of the substances studied exhibit a statistically significant diuretic effect exceeding the activity of not only hydrochlorothiazide, in some cases, but also the action of the structural analogs. The important structural and biological regularities, which are common with pyrroloquinolines and introduced by a chemical modification, were revealed. The importance of the presence in the structure of terminal amide fragments of tricyclic quinoline-3-carboxamides of a 4-methoxy-substituted aromatic ring was particularly marked. The expediency of further study of pyridoquinolines as promising diuretic agents has been shown.
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Affiliation(s)
- Igor V Ukrainets
- Department of Pharmaceutical Chemistry, National University of Pharmacy, 53 Pushkinska St., 61002 Kharkiv, Ukraine.
| | - Lyudmila V Sidorenko
- Department of Pharmaceutical Chemistry, National University of Pharmacy, 53 Pushkinska St., 61002 Kharkiv, Ukraine.
| | - Mykola Y Golik
- Department of Analytical Chemistry, National University of Pharmacy, 4 Valentynivska St., 61168 Kharkiv, Ukraine.
| | - Igor M Chernenok
- Department of Pharmaceutical Chemistry, National University of Pharmacy, 53 Pushkinska St., 61002 Kharkiv, Ukraine.
| | - Lina A Grinevich
- Department of Medical Chemistry, National University of Pharmacy, 4 Valentynivska St., 61168 Kharkiv, Ukraine.
| | - Alexandra A Davidenko
- Department of Pharmaceutical Chemistry, N. I. Pirogov Vinnitsa National Medical University, 56 Pirogov St., 21018 Vinnitsa, Ukraine.
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