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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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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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Xiangli S, Lan L, Libiya Z, Jun M, Shubin J. Effect of levosimendan combined with recombinant human brain natriuretic peptide on diuretic resistance. Libyan J Med 2021; 16:1973762. [PMID: 34493175 PMCID: PMC8439246 DOI: 10.1080/19932820.2021.1973762] [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] [Indexed: 10/27/2022] Open
Abstract
Levosimendan is a calcium sensitizer used for managing heart failure (HF) because of its inotropic and vasodilatory effects. As many patients do not respond to levosimendan as a monotherapy, it may be necessary to combine it with other diuretic agents such as recombinant human brain natriuretic peptide (rhBNc P). The aim of this study was to investigate efficacy of levosimendan when combined with rhBNP in patients with diuretic resistance and low ejection fraction (EF) rate.The study included HF patients with diuretic resistance and low EF. Before grouping, patients with a 24-hour urine volume of <0.5 mL/kg/h were administered with furosemide injection. Treatment group was administered levosimendan injection based on the original diuretic and rhBNP.One hundred twenty-eight patients were included, with 64 patients each in the control and treatment arms. 24-hour urine volume of the treatment group was significantly higher than that of the control group. Moreover, dyspnea score of the treatment group significantly improved compared with control group. In the treatment group, 12.5% of patients had no significant changes in the urine volume, weight, and dyspnea score before and after the treatment, indicating poor curative effect of the treatment, whereas in the control group, 23.4% of patients had poor curative effect (P < .05). No significant change was observed in the systolic blood pressure, heart rate, and serum creatinine level before and after treatment in both groups.Levosimendan in combination with rhBNP can effectively relieve diuretic resistance, reduce body weight, improve dyspnea, and ensure safety in the treatment process.
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Affiliation(s)
- Shen Xiangli
- Heart Center, Traditional Chinese Medicine Affiliated to Xinjiang Medical University, Urumqi, China
| | - Li Lan
- Heart Center, Traditional Chinese Medicine Affiliated to Xinjiang Medical University, Urumqi, China
| | - Zu Libiya
- Heart Center, Traditional Chinese Medicine Affiliated to Xinjiang Medical University, Urumqi, China
| | - Ma Jun
- Heart Center, Traditional Chinese Medicine Affiliated to Xinjiang Medical University, Urumqi, China
| | - Jiang Shubin
- Heart Center, Traditional Chinese Medicine Affiliated to Xinjiang Medical University, Urumqi, China
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Jardim SI, Ramos dos Santos L, Araújo I, Marques F, Branco P, Gaspar A, Fonseca C. A 2018 overview of diuretic resistance in heart failure. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Jardim SI, Ramos dos Santos L, Araújo I, Marques F, Branco P, Gaspar A, Fonseca C. A 2018 overview of diuretic resistance in heart failure. Rev Port Cardiol 2018; 37:935-945. [DOI: 10.1016/j.repc.2018.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/18/2018] [Accepted: 03/11/2018] [Indexed: 01/01/2023] Open
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Acute Right Ventricular Dysfunction in Intensive Care Unit. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8217105. [PMID: 29201914 PMCID: PMC5671685 DOI: 10.1155/2017/8217105] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/13/2017] [Accepted: 09/18/2017] [Indexed: 02/07/2023]
Abstract
The role of the left ventricle in ICU patients with circulatory shock has long been considered. However, acute right ventricle (RV) dysfunction causes and aggravates many common critical diseases (acute respiratory distress syndrome, pulmonary embolism, acute myocardial infarction, and postoperative cardiac surgery). Several supportive therapies, including mechanical ventilation and fluid management, can make RV dysfunction worse, potentially exacerbating shock. We briefly review the epidemiology, pathophysiology, diagnosis, and recommendations to guide management of acute RV dysfunction in ICU patients. Our aim is to clarify the complex effects of mechanical ventilation, fluid therapy, vasoactive drug infusions, and other therapies to resuscitate the critical patient optimally.
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Hyponatraemia and congestive heart failure refractory to diuretic treatment. Utility of tolvaptan. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2017.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Pose A, Almenar L, Manzano L, Gavira JJ, López Granados A, Delgado J, Aramburu O, Arévalo JC, Méndez M, Comín J, Manito N. Hyponatraemia and congestive heart failure refractory to diuretic treatment. Utility of tolvaptan. Rev Clin Esp 2017; 217:398-404. [PMID: 28372784 DOI: 10.1016/j.rce.2017.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/07/2017] [Accepted: 02/18/2017] [Indexed: 11/28/2022]
Abstract
Heart failure (HF) is currently one of the most significant healthcare problems in Spain and has a continuously increasing prevalence. Advances in our understanding of the various biological responses that promote cardiac remodelling and pulmonary venous congestion constitute the basis of current treatment. This article, prepared by members of the HF groups of the Spanish Society of Cardiology and the Spanish Society of Internal Medicine, discusses the current therapeutic strategies for patients with congestion refractory to diuretic treatment. The article includes our clinical experience with the use of tolvaptan as an additional treatment for congestion associated with hyponatraemia. To this end, we propose an algorithm for the use of tolvaptan in patients with congestive HF, natraemia <130mEq/l and poor response to conventional diuretic treatment.
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Affiliation(s)
- A Pose
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, España.
| | - L Almenar
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - L Manzano
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, España
| | - J J Gavira
- Servicio de Cardiología, Clínica Universitaria de Navarra, Pamplona, España
| | - A López Granados
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, España
| | - J Delgado
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, España
| | - O Aramburu
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Macarena, Sevilla, España
| | - J C Arévalo
- Servicio de Medicina Interna, Hospital Comarcal de Zafra, Zafra, Badajoz, España
| | - M Méndez
- Servicio de Medicina Interna, Hospital Universitario San Carlos, Madrid, España
| | - J Comín
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
| | - N Manito
- Servicio de Cardiología, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
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Pose A, Almenar L, Gavira JJ, López-Granados A, Blasco T, Delgado J, Aramburu O, Rodríguez A, Manzano L, Manito N. Benefit of tolvaptan in the management of hyponatraemia in patients with diuretic-refractory congestive heart failure: the SEMI-SEC project. ESC Heart Fail 2017; 4:130-137. [PMID: 28451449 PMCID: PMC5396041 DOI: 10.1002/ehf2.12124] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/14/2016] [Accepted: 11/02/2016] [Indexed: 12/18/2022] Open
Abstract
Aims Hyponatraemia is an electrolyte disorder that occurs in advanced congestive heart failure (HF) and worsens prognosis. We explored the usefulness of tolvaptan, which has shown promising results in the treatment of this condition. Methods and results This study is based on a retrospective national registry (2011–15) of patients hospitalized with refractory HF and hyponatraemia who agreed to receive tolvaptan when standard treatment was ineffective. The benefit of tolvaptan was analysed according to the following criteria: normalization ([Na+] ≥ 135 mmol/L) or increased sodium levels [Na+] ≥ 4 mEq/L on completion of treatment, and increase in urine output by 300 or 500 mL at 48 h. Factors associated with tolvaptan benefit were explored. A total of 241 patients were included, 53.9% of whom had ejection fraction <40%. All patients received concomitant loop diuretics. Initial tolvaptan dose was 17.2 ± 6.1 mg, and end dose was 26.4 ± 23.2 mg (duration 7.8 ± 8.6 days). Serum sodium concentrations increased significantly at 24–48 h, from 126.5 ± 6.2 mEq/L at baseline to 134.1 ± 6.1 mEq/L at the end of treatment (P < 0.0001). Weight fell by ~5 kg before discharge (P < 0.0001) and urine output increased 1.3‐fold (P < 0.0001). Normal sodium levels and/or increases of 500 mL in urine output were achieved by 90.8% of patients (35.7% achieved both) and 94.8% increased to [Na+] ≥ 4 mEq/L and/or +300 mL in urine output (54.4% both). Conclusions An increase in sodium levels and/or improvement in urine output was observed in patients admitted for HF and refractory hyponatraemia under tolvaptan treatment. Tolvaptan may be useful in this setting, in which no effective proven alternatives are available.
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Affiliation(s)
- Antonio Pose
- Department of Internal MedicineComplexo Hospitalario Universitario de Santiago de CompostelaLa CoruñaSpain
| | - Luis Almenar
- Cardiology DepartmentHospital Universitario y Politécnico La FeValenciaSpain
| | - Juan José Gavira
- Cardiology DepartmentClínica Universitaria de NavarraPamplonaSpain
| | | | - Teresa Blasco
- Cardiology DepartmentHospital Miguel ServetZaragozaSpain
| | - Juan Delgado
- Cardiology DepartmentHospital Universitario 12 de OctubreMadridSpain
| | - Oscar Aramburu
- Department of Internal MedicineHospital Universitario Virgen de la MacarenaSevilleSpain
| | - Avelino Rodríguez
- Department of Internal MedicineComplexo Hospitalario Universitario de VigoPontevedraSpain
| | - Luis Manzano
- Depatment of Internal MedicineHospital Universitario Ramón y CajalMadridSpain.,University of AlcaláAlcalá de HenaresSpain
| | - Nicolás Manito
- Cardiology DepartmentHospital Universitario de BellvitgeBarcelonaSpain
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Nwosu C, Mezue K, Bhagatwala K, Ezema N. A Practical Comprehensive Approach to Management of Acute Decompensated Heart Failure. Curr Cardiol Rev 2016; 12:311-317. [PMID: 26926295 PMCID: PMC5304255 DOI: 10.2174/1573403x12666160301120030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) has a high incidence and prevalence in the USA and worldwide. It is a very common cause of significant morbidity and mortality with serious cost implications on the US health sector. The primary focus of this review is to synthesize an effective comprehensive care plan for patients in acute decompensated heart failure (ADHF) based on the most current evidence available. It begins with a brief overview of the pathophysiology, clinical presentation and evaluation of patients in ADHF. It then reviews management goals and treatment guidelines, with emphasis on challenges presented by diuretic resistance and worsening renal function (WRF). It provides information on recognition of advanced HF even during acute presentation, estimation of prognosis and proactive identification of patients that will benefit from mechanical cardiac devices, transplantation and palliative care/hospice. In addition, it presents strategies to address the problem of readmissions, which is an ominous prognostic factor with enormous economic burden.
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Affiliation(s)
- Chukwunweike Nwosu
- Abington Memorial Hospital, 1200 Old York Road, Abington PA. 19001. USA.
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