Update of treatment of heart failure with reduction of left ventricular ejection fraction

Preparation, Characterization, and Selection of Optimal Forms of (S)-Carvedilol Salts for the Development of Extended-Release Formulation

(S)-carvedilol (S-CAR) is the dominant pharmacodynamic conformation of carvedilol, but its further development for extended-release formulation is restricted by its poor solubility. This study aimed to prepare and screen S-CAR salts that could be used to improve solubility and allow extended release. Five salts of S-CAR with well-known acid counterions (i.e., phosphate, hydrochloride, sulfate, fumarate, and tartrate) were produced using similar processes. However, these salts were obtained with water contents of 1.60-12.28%, and their physicochemical properties differed. The melting points of phosphate, hydrochloride, and tartrate were 1.1-1.5 times higher than that of the free base. The solubility of S-CAR salts was promoted to approximately 3-32 times higher than that of the free base at pH 5.0-8.0. Typical pH-dependent solubilities were evidently observed in S-CAR salts, but considerable differences in solubility properties among these salts were observed. S-CAR phosphate and hydrochloride possessed high melting points, considerable solubility, and excellent chemical and crystallographic stabilities. Accordingly, S-CAR phosphate and hydrochloride were chosen for further pharmacokinetic experiments and pharmaceutical study. S-CAR phosphate and hydrochloride extended-release capsules were prepared using HPMC K15 as the matrix and presented extended release in in vitro and in vivo evaluations. Results implied that water molecules in the hydrated salt were a potential threat to the achievement of crystal stability and thermostability. S-CAR phosphate and hydrochloride are suitable for further development of the extended-release formulation.

Determination and Comparison of the Solubility, Oil-Water Partition Coefficient, Intestinal Absorption, and Biliary Excretion of Carvedilol Enantiomers

Carvedilol is administered as a racemic mixture for the therapy of hypertension and heart failure. S-enantiomer is the dominant conformation of pharmacodynamics, but its further development was obstructed by its poor bioavailability. In this study, carvedilol and its enantiomers were compared in terms of solubility, permeability, and biliary excretion, and reasons for the poor bioavailability were discussed. Equilibrium solubility and log P were measured by a shake flask method at a wide pH range (1.2-8.0), and intestinal absorption and biliary excretion were evaluated using a single-pass rat intestinal perfusion model. According to BCS guidance, carvedilol and its R/S enantiomers are considered highly soluble at pH value less than 5.0 and low soluble at neutral or weak alkaline conditions. RS-carvedilol showed significantly lower solubilities at pH 1.2-5.0 and higher solubilities at pH 6.0-8.0 than its enantiomers. In addition, carvedilol and its enantiomers possessed similar log P values at pH 1.2-8.0. High intestinal permeabilities of carvedilol and its enantiomers were observed, and S-carvedilol showed higher absorption than R-carvedilol and RS-carvedilol. The biliary excretion about two major metabolites, 1-hydroxycarvedilol O-glucuronide and 8-hydroxycarvedilol O-glucuronide, of RS-carvedilol, S-carvedilol, and R-carvedilol were 66.4%, 73.5%, and 54.3%, respectively. In conclusion, there are significant differences amongst carvedilol and its R/S enantiomers in terms of solubility, intestine absorption, and biliary excretion abilities. The first pass effect is the primary reasons for the low bioavailability of S-carvedilol. Therefore, pharmaceutical strategies or parenteral routes should be considered to avoid the first pass metabolism.

Length of stay and readmission in older adults hospitalized for heart failure

INTRODUCTION

Hospital length of stay (LoS) and hospital readmissions are metrics of healthcare performance. We examined the association between these two metrics in older patients hospitalized with decompensated heart failure (HF).

MATERIAL AND METHODS

Eight thousand and forty-nine patients hospitalized for HF in 106 U.S. hospitals had a median LoS of 5 days; among them, 3777 had a LoS > 5 days. Using propensity scores for LoS > 5 days, we assembled 2723 pairs of patients with LoS 1-5 vs. > 5 days. The matched cohort of 5446 patients was balanced on 40 baseline characteristics. We repeated the above process in 7045 patients after excluding those with LoS > 10 days, thus assembling a second matched cohort of 2399 pairs of patients with LoS 1-5 vs. 6-10 days. Hazard ratios (HR) and 95% confidence intervals (CI) for outcomes associated with longer LoS were estimated in matched cohorts.

RESULTS

In the primary matched cohort (n = 5446), LoS > 5 days was associated with a higher risk of all-cause readmission at 30 days (HR = 1.16; 95% CI: 1.04-1.31; p = 0.010), but not during longer follow-up. A longer LoS was also associated with a higher risk of mortality during 8.8 years of follow-up (HR = 1.13; 95% CI: 1.06-1.21; p < 0.001). LoS had no association with HF readmission. Similar associations were observed among the matched sensitivity cohort (n = 4798) that excluded patients with LoS > 10 days.

CONCLUSIONS

In propensity score-matched balanced cohorts of patients with HF, a longer LoS was independently associated with poor outcomes, which persisted when LoS > 10 days were excluded.

Plasma renin activity, serum aldosterone concentration and selected organ damage indices in essential arterial hypertension

INTRODUCTION

The aim of this study was to assess the relations between plasma renin activity (PRA), serum aldosterone concentration (ALDO) and selected asymptomatic organ damage (AOD) indices in mild primary arterial hypertension (AH).

MATERIAL AND METHODS

We measured PRA, ALDO, and selected AOD indices (carotid-femoral pulse wave velocity (cfPWV), central aortic pulse pressure (cPP), estimated glomerular filtration rate (eGFR)) in 122 patients with untreated AH.

RESULTS

Patients with high PRA (≥ 0.65 ng/ml/h) were characterized by lower plasma sodium and aldosterone to renin ratio (ARR), higher ALDO, but a similar level of AOD indices compared to patients with low PRA. cfPWV (p = 0.04) and cPP (p = 0.019) increased with ARR, while eGFR decreased with ALDO (p = 0.008). Only eGFR was independently correlated with ALDO. In subjects with simultaneously high PRA and ARR values, we found significantly higher cfPWV (p = 0.02) and cPP (p = 0.04) and lower eGFR (p = 0.02) than in those with high PRA but low ARR values.

CONCLUSIONS

Assessment of the influence of the renin-angiotensin-aldosterone system (RAAS) on AOD should include the relationship between renin and aldosterone. The PRA itself has no predictive value for AOD. More advanced arterial stiffness and renal impairment are associated with increased PRA and ARR. The RAAS activity might be useful in AOD prediction and hypertension severity assessment.

Aldosterone nongenomically induces angiotensin II receptor dimerization in rat kidney: role of mineralocorticoid receptor and NADPH oxidase

INTRODUCTION

Previous in vitro studies demonstrated that aldosterone nongenomically induces transglutaminase (TG) and reactive oxygen species (ROS), which enhanced angiotensin II receptor (ATR) dimerization. There are no in vivo data in the kidney.

MATERIAL AND METHODS

Male Wistar rats were intraperitoneally injected with normal saline solution, or aldosterone (Aldo: 150 μg/kg BW); or received pretreatment with eplerenone (mineralocorticoid receptor (MR) blocker, Ep. + Aldo), or with apocynin (nicotinamide adenine dinucleotide phosphate (NADPH) oxidase inhibitor, Apo. + Aldo) 30 min before aldosterone. Thirty minutes after aldosterone injection, protein abundances of dimeric and monomeric forms of AT₁R and AT₂R, and protein abundances and localizations of TG2 and p47phox, a cytosolic subunit of NADPH oxidase, were determined by Western blot analysis and immunohistochemistry, respectively.

RESULTS

Protein abundances of dimeric forms of AT₁R and AT₂R were enhanced by 170% and 70%, respectively. Apocynin could block dimeric forms of both receptors while eplerenone inhibited only AT₂R. Monomeric protein levels of both receptors were maintained. Aldosterone significantly enhanced TG2 and p47phox protein abundances, which were blunted by eplerenone or apocynin. Aldosterone stimulated p47phox protein expression in both the cortex and the medulla while TG2 was induced mostly in the medulla. Eplerenone or apocynin normalized the immunoreactivity of both TG2 and p47phox.

CONCLUSIONS

This is the first in vivo study demonstrating that aldosterone nongenomically increases renal TG2 and p47phox protein expression and then activates AT₁R and AT₂R dimerizations. Aldosterone-stimulated AT₁R and AT₂R dimerizations are mediated through activation of NADPH oxidase. Aldosterone-induced AT₁R dimer formation is an MR-independent pathway, whereas the formation of AT₂R dimer is modulated in an MR-dependent manner.

Fatigue in heart failure outpatients: levels, associated factors, and the impact on quality of life

Introduction

Heart failure (HF) patients experience various psychosocial issues and physical symptoms such as fatigue, which adversely affect their quality of life (QoL). The aim of the study was to assess levels of fatigue in HF outpatients and the associated factors, as well as to explore the correlation between fatigue and QoL.

Material and methods

One hundred and thirty patients were enrolled in the study. Data collection was performed by the completion of “Minnesota Living With Heart Failure” questionnaire (MLHFQ) and the Greek version of the Modified Fatigue Impact Scale (MFIS-Greek). Data also included self-reported patients’ characteristics.

Results

Of the 130 HF outpatients, 50% scored above 69 (median) in total fatigue and above 41 and 29 (median) in physical and mental fatigue, respectively. Furthermore, 50% scored above 66 (median) in total QoL and above 32.5 and 13 (median) in the physical and mental state, respectively. These values indicate moderate to high impact of HF on fatigue and on patients’ QoL. Total fatigue was statistically significantly associated with NYHA stage (p = 0.001), confidence to acknowledge health deteriorations (p = 0.004), decrease in appetite (p = 0.001), dyspnoea at night (p = 0.001), oedema in lower limbs (p = 0.023), relation with health professionals (p = 0.031), and whether patients had limited daily activities (p = 0.002), social contacts (p = 0.014), and if they had financial worries (p = 0.003). Finally, as the score of fatigue increased, so the QoL score also increased.

Conclusions

A broader understanding of this distressing symptom in HF may contribute to the development of suitable interventions with the ultimate goal of improving QoL.

Discharge home health services referral and 30-day all-cause readmission in older adults with heart failure

INTRODUCTION

Heart failure (HF) is the leading cause of hospital readmission. Medicare home health services provide intermittent skilled nursing care to homebound Medicare beneficiaries. We examined whether discharge home health referral is associated with a lower risk of 30-day all-cause readmission in HF.

MATERIAL AND METHODS

Of the 8049 Medicare beneficiaries hospitalized for acute HF and discharged alive from 106 Alabama hospitals, 6406 (76%) patients were not admitted from nursing homes and were discharged home without discharge hospice referrals. Of these, 1369 (21%) received a discharge home health referral. Using propensity scores for home health referral, we assembled a matched cohort of 1253 pairs of patients receiving and not receiving home health referrals, balanced on 33 baseline characteristics.

RESULTS

The 2506 matched patients had a mean age of 78 years, 61% were women, and 27% were African American. Thirty-day all-cause readmission occurred in 28% and 19% of matched patients receiving and not receiving home health referrals, respectively (hazard ratio (HR) = 1.52; 95% confidence interval (CI): 1.29-1.80; p < 0.001). Home health referral was also associated with a higher risk of 30-day all-cause mortality (HR = 2.32; 95% CI: 1.58-3.41; p < 0.001) but not with 30-day HF readmission (HR = 1.28; 95% CI: 0.99-1.64; p = 0.056). HRs (95% CIs) for 1-year all-cause readmission, all-cause mortality, and HF readmission are 1.24 (1.13-1.36; p < 0.001), 1.37 (1.20-1.57; p < 0.001) and 1.09 (0.95-1.24; p = 0.216), respectively.

CONCLUSIONS

Hospitalized HF patients who received discharge home health services referral had a higher risk of 30-day and 1-year all-cause readmission and all-cause mortality, but not of HF readmission.