Diuretic Strategies in Acute Decompensated Heart Failure

The Effect of Early Administration of Hypertonic Saline Solution İn Acute Decompensated Heart Failure

BACKGROUND

There was no scientific evidence about the initial treatment of hypertonic saline solution (HSS) in acutely decompensated heart failure (ADHF).

OBJECTIVES

This study assessed the impact of using HSS along with a loop diuretic (LD) as the first diuretic treatment for ADHF, focusing on renal function, electrolyte levels, and clinical outcomes.

METHODS

In this retrospective case-control study, 171 adult patients (93 females/78 males) with ADHF were included between January 1, 2022, and December 31, 2022. Patients were allocated into two groups: upfront combo HSS+LD and standardized LD. The primary endpoint was worsening renal function (WRF). Hospitalization for HF and all-cause mortality were evaluated during 6 months of follow-up. The significance level adopted in the statistical analysis was 5%.

RESULTS

The groups exhibited similarities in baseline characteristics.A significantly higher diuresis on the 1st day (3975 [3000-5150] vs. 2583 [2000-3250], p=0.001) and natriuresis on the 2nd hour (116.00 [82.75-126.00] vs. 68.50 [54.00-89.75], p=0.001) in the initial upfront combo HSS+LD were found in comparison with the standardized LD.When compared to the standardized LD, the utilization of HSS led to an increase in serum Na+ (137.00 [131.75-140.00] vs. 140.00 [136.00-142.25], p=0.001 for upfront combo HSS, 139.00 [137.00-141.00] vs. 139.00 [136.00-140.00], p=.0470 for standardized LD), while chloride (99.00 [94.00-103.25] vs. 99.00[96.00-103.00], p=0.295), GFR (48.50 [29.75-72.50 vs. 50.00 [35.50-63.50, p=0.616), and creatinine (1.20 [0.90-1.70] vs. 1.20 [1.00-1.50], p=0.218) remained stable in the upfront combo HSS group when compared to standardized LD group (Cl-: 102.00 [99.00-106.00] vs. 98.00 [95.00-103.00], p=0.001, eGFR: 56.00 [41.00-71.00] vs. 55.00 [35.00-71.00], p=0.050, creatinine:1.10 [0.90-1.40] vs. 1.20 [0.90-1.70], p=0.009). Worsening renal function (16.1% vs 35.5%, p=0.007), and length of stay in the hospital (4 days [3-7] vs. 5 days [4-7], p=0.004) were lower in the upfront combo HSS+LD in comparison with the standardized LD. In-hospital mortality, hospitalization for HF, and all-cause mortality were similar between the two groups.

CONCLUSION

HSS as an initial therapy, when combined with LD, may provide a safe and effective diuresis without impairing renal function in ADHF. Therefore, HSS may lead to a shorter length of stay in the hospital for these patients.

The role of tolvaptan add-on therapy in patients with acute heart failure: a systematic review and network meta-analysis

Background

Several conflicting reviews have concluded that the use of loop diuretics is associated with poorer clinical and safety outcomes. Therefore, this study aimed to investigate the efficacy and safety of tolvaptan as an adjunct to conventional diuretic therapy in patients with acute heart failure (AHF).

Methods

A comprehensive search was conducted on PubMed, Embase, ProQuest, EBSCO, and Cochrane Library until 24 May 2023 to identify randomized controlled trials that compared the effects of tolvaptan with conventional therapy and placebo in patients with AHF. The quality assessment of the included trials was conducted using the Cochrane risk of bias. A network meta-analysis (NMA) was conducted to examine the dosage effect of tolvaptan.

Result

A total of 17 studies with 18 reports, involving 10,039 patients, were selected. The tolvaptan add-on therapy significantly alleviated dyspnea [24 h: RR 1.16 (1.04, 1.29), 48 h: RR 1.18 (1.04, 1.33)], reduced body weight within 48 h [Asian group, MD -0.93 (-1.48, -0.38); non-Asian group, MD -2.76 (-2.88, -2.65)], reduced edema [RR 1.08 (1.02, 1.15)], increased serum sodium [non-Asian group, MD 3.40 (3.02, 3.78)], and resulted in a change in serum creatinine [MD -0.10 (-0.18, -0.01)]. No significant differences were observed in mortality and rehospitalization. The NMA suggested that an intermediate dosage (15 mg/day) might offer the best efficacy in reducing dyspnea within 24 h, reducing edema, increasing serum sodium, and lowering the incidence of worsening renal function (WRF).

Conclusion

In conclusion, the meta-analysis showed that tolvaptan contributed to the short-term alleviation of congestive symptoms, elevated sodium levels, and a lower incidence of WRF. However, no significant benefits were observed in long-term symptoms, rehospitalization rates, and mortality. An intermediate dosage of tolvaptan might be considered the optimal choice for various clinical outcomes.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42023420288).

Clinical phenotypes according to diuretic combination in acute heart failure

BACKGROUND

The treatment of congestion in heart failure (HF) is a challenge despite the therapeutic arsenal available. The aim of this study was to analyze different combinations of diuretics used to resolve congestion in patients admitted for decompensated HF and to define clinical profiles according to these treatments.

METHODS

Single-center study of 1,559 patients admitted for decompensated HF was done between 2016 and 2020. Patients were grouped according to the diuretic combination that led to clinical stabilization and discharge from the hospital: (1) Loop diuretic. (2) Loop diuretic + distal tubule (antialdosterone ± thiazides). (3) Loop diuretic + distal + proximal tubule (acetazolamide ± SGLT2 inhibitor). (4) Loop diuretic + distal tubule + collecting duct (tolvaptan). (5) Loop diuretic + distal + proximal + collecting duct. Based on these diuretic combinations, profiles with clinical, analytical, and echocardiographic differences were established.

RESULTS

There were more previous hospitalizations in groups 4 and 5 (p = 0.001) with a predominance of pulmonary congestion in profiles 1 and 2 and systemic congestion in 3, 4, and 5. Creatinine and CA125 were higher in profiles 4 and 5 (p = 0.01 and p = 0.0001), with no differences in NT-proBNP. Profiles 4 and 5 had a higher proportion of dilatation and depression of right ventricular (p = 0.0001) and left ventricular (p = 0.003) function. Diuretic therapy-defined groups showed difference in clinical characteristics.

CONCLUSIONS

The diuretic treatment used identifies five clinical profiles according to the degree of congestion, renal function, CA125, and right ventricular functionality. These profiles would guide the best diuretic treatment on admission.

Role of medical management of cardiogenic shock in the era of mechanical circulatory support

PURPOSE OF REVIEW

The goal of this review is to summarize the current knowledge on the role of medical management of cardiogenic shock in the era of mechanical circulatory support based on important lessons from clinical trials and routine clinical practice, with a focus on providing practical recommendations that can improve contemporary in-hospital management.

RECENT FINDINGS

Despite an increasing number of invasive therapies being used to manage cardiogenic shock, evidence-based treatment regimens known to improve outcomes are limited. Medical management of cardiogenic shock includes pharmacological interventions aimed at optimizing determinants of cardiac output-contractility, preload, afterload, and heart rate. In this regard, inotropes and vasopressors remain cornerstone therapies for the management of cardiogenic shock. Norepinephrine has shown potential vasopressor advantage with compared with dopamine, and although milrinone and dobutamine are both considered appropriate first-line inotropes, there is limited data to guide selection, and a recent randomized clinical trial found no significant differences in the treatment of cardiogenic shock.

SUMMARY

In the absence of an evidence-based management approach to cardiogenic shock, clinical guidelines are based on expert opinion and routine clinical practice patterns. Further studies focusing on clinical outcomes among specific cardiogenic shock phenotypes are needed to better assess the clinical efficacy of these agents.

Risk factors for renal failure and short-term prognosis in patients with spontaneous intracerebral haemorrhage complicated by acute kidney injury

Background

Although acute kidney injury (AKI) is a known risk factor for adverse clinical outcomes in patients with spontaneous intracerebral haemorrhage (SICH), little is known about the predisposing factors that contribute to renal failure and short-term prognosis in the setting of SICH already complicated by AKI. In this study, we aimed to identify the renal failure factors in SICH patents with AKI.

Methods

Five hundred forty-three patients with SICH complicated by differential severities of AKI who were admitted to the First Affiliated Hospital of Fujian Medical University from January 2016 to December 2018 were retrospectively studied. Logistic regression and receiver operator characteristic (ROC) curve analysis were performed to determine the best predictive and discriminative variables. Multivariate Cox regression analysis was performed to identify prognostic factors for renal recovery.

Results

In the multivariable adjusted model, we found that hypernatremia, metabolic acidosis, elevated serum creatine kinase, hyperuricaemia, proteinuria, and the use of colloids and diuretics were all independent risk factors for the occurrence of stage 3 AKI in SICH patients. The area under the curve analysis indicated that hypernatremia and hyperuricaemia were predictive factors for stage 3 AKI, and the combination of these two parameters increased their predictability for stage 3 AKI. Kaplan-Meier survival curves revealed that the renal recovery rate in SICH patients with stages 1 and 2 AKI was significantly higher than that in SICH patients with stage 3 AKI. Multivariate Cox regression analysis suggested that hypernatremia and the occurrence of stage 3 AKI are predictors for poor short-term renal recovery.

Conclusions

These findings illustrate that hypernatremia and hyperuricaemia represent potential risk factors for the occurrence of stage 3 AKI in SICH patients. Those patients with hypernatremia and stage 3 AKI were associated with a poor short-term prognosis in renal recovery.

Effects of tolvaptan add-on therapy in patients with acute heart failure: meta-analysis on randomised controlled trials

OBJECTIVES

Treating acute decompensated heartfailure (ADHF) for improving congestion with diuretics may cause worsening renal function (WRF), but the clinical efficacy of tolvaptan add-on therapy on reducing WRF in ADHF patients is inconsistent. This analysis is to evaluate the effects of tolvaptan add-on therapy on reducing WRF in ADHF patients.

METHODS

Meta-analysis of randomised trials of tolvaptan add-on therapy on reducing WRF in ADHF patients. The MEDLINE, Embase and Cochrane Central Register of Controlled Trials databases were searched for relevant articles from their inception to 31 October, 2017. Two reviewers filtrated the documents on WRF, short-term all-cause mortality, body weight decreased, elevated sodium level for calculating pooled relatives risks, weighted mean difference and associated 95% CIs. We used fixed-effects or random-effects models according to I² statistics.

ACHIEVEMENTS

Seven random controlled trials with 937 patients were included for analysis. Compared with the control, tolvaptan add-on therapy did not improve incidence of worsening renal function (RR 0.78, 95% CI 0.48 to 1.26, p=0.31, I²=66%) and short-term all-cause mortality (RR 0.85, 95% CI 0.47 to 1.56, p=0.61, I²=0%). On subgroup analyses, there was a suggestion of possible effect modification by dose of tolvaptan, in which benefit was observed in low-dose (≤15 mg/day) group (RR 0.48, 95% CI 0.23 to 1.02, p=0.05, I²=54%), but not with high-dose (30 mg) group (RR 1.33, 95% CI 0.99 to 1.78, p=0.05, I²=0%). However, tolvaptan add-on therapy reduced body weight in 2 days (standardised mean difference -0.49, 95% CI -0.64 to -0.34, p<0.00001, I²=0%), increased sodium level (mean difference 1.56, 95% CI 0.04 to 3.07, p=0.04, I²=0%).

CONCLUSION

The result suggests that comparing with the standard diuretic therapy, tolvaptan add-on therapy did not reduce the incidence of WRF and short-term mortality, however, it can decrease body weight and increase the sodium level in patients who are with ADHF. Further researches are still required for confirmation.

Diuretics in the Management of Cardiorenal Syndrome

The leading cause of death worldwide is cardiovascular disease. The heart and the kidneys are functionally interdependent, such that dysfunction in one organ may cause dysfunction in the other. By one estimate, more than 60% of patients with congestive heart failure develop chronic kidney disease. Volume overload and congestion are hallmarks of heart failure, and these findings are associated with severe symptoms and poor outcomes. Given the importance of congestion, diuretics remain a cornerstone of heart failure management. However, diuretic treatment remains largely empirical, with little evidence currently available to guide decisions. In this review, we discuss the pathophysiology of cardiorenal syndrome, the pharmacology of loop diuretics, mechanisms of diuretic resistance, and evidence-based treatment paradigms.

Heart Failure: Optimizing Recognition and Management in Outpatient Settings

Heart failure represents a growing chronic medical condition with major implications on patient morbidity, mortality, and cost to health care systems. In this article, the heart failure syndrome is reviewed from a perspective of diagnosis and management, with updated therapeutic options reflected in major guidelines published since this topic was last reviewed in Primary Care Clinics in Office Practice in 2013. An emphasis is placed on the use of the American Heart Association/American College of Cardiology's staging system as a framework to improve early identification and treatment of patients at risk of symptomatic heart failure.

L'insuffisance cardiaque aiguë aux urgences : présentations cliniques, diagnostic et prise en charge thérapeutique

L’insuffisance cardiaque (IC) est une maladie fréquente dont l'incidence croît dans tous les pays développés et dont la morbimortalité est effroyable. Devant une dyspnée aiguë, maître symptôme de la décompensation, le diagnostic d’insuffisance cardiaque aiguë (ICA) reste difficile aux urgences. En effet, les connaissances ayant permis de comprendre les mécanismes physiopathologiques, le concept nosologique d’une seule entité clinique a évolué vers la notion de syndromes d’ICA (SICA) intégrant plusieurs cadres nosographiques de la décompensation d’une IC chronique au tableau de détresse respiratoire aiguë dans l’œdème aigu du poumon cardiogénique, voire au choc cardiogénique. Afin de poser le diagnostic devant ces différentes formes de décompensations aiguës, l'urgentiste a recours à des examens complémentaires qui permettent de déterminer l'étiologie de l'épisode d'IC. Si la réalisation de l'électrocardiogramme et celle de la radiographie thoracique restent indispensables, l’utilisation de biomarqueurs cardiaques, au premier rang desquels les peptides natriurétiques se sont imposés, fait aujourd'hui partie intégrante des outils nécessaires à l'élaboration de la démarche diagnostique. Par ailleurs, la généralisation progressive de l'échographie clinique au sein des services d'urgences permet aujourd'hui d'améliorer la démarche diagnostique et de proposer une approche thérapeutique plus rapide. Ainsi, le concept moderne de « Time-to-therapy » prend-il tout son sens aux urgences où l'utilisation optimisée des différents traitements médicamenteux doit s'associer aux supports d'oxygénothérapie souvent nécessaires à la prise en charge de la dyspnée aiguë. Cet article se propose de faire une revue de la littérature et des recommandations actuelles afin d'assurer une prise en charge optimale des SICA aux urgences et en extrahospitalier.

Interaction Between the Sodium-Glucose-Linked Transporter 2 Inhibitor Dapagliflozin and the Loop Diuretic Bumetanide in Normal Human Subjects

Background

Dapagliflozin inhibits the sodium‐glucose–linked transporter 2 in the renal proximal tubule, thereby promoting glycosuria to reduce hyperglycemia in type 2 diabetes mellitus. Because these patients may require loop diuretics, and sodium‐glucose–linked transporter 2 inhibition causes an osmotic diuresis, we evaluated the diuretic interaction between dapagliflozin and bumetanide.

Methods and Results

Healthy subjects (n=42) receiving a fixed diet with ≈110 mmol·d⁻¹ of Na⁺ were randomized to bumetanide (1 mg·d⁻¹), dapagliflozin (10 mg·d⁻¹), or both for 7 days, followed by 7 days of both. There were no meaningful pharmacokinetic interactions. Na⁺ excretion increased modestly with the first dose of dapagliflozin (22±6 mmol·d⁻¹; P<0.005) but by more (P<0.005) with the first dose of bumetanide (74±7 mmol·d⁻¹; P<0.005), which was not significantly different from both diuretics together (80±5 mmol·d⁻¹; P<0.005). However, Na⁺ excretion with dapagliflozin was 190% greater (P<0.005) when added after 1 week of bumetanide (64±6 mmol·d⁻¹), and Na⁺ excretion with bumetanide was 36% greater (P<0.005) when added after 1 week of dapagliflozin (101±8 mmol·d⁻¹). Serum urate was increased 4% by bumetanide but reduced 40% by dapagliflozin or 20% by combined therapy (P<0.05).

Conclusions

First‐dose Na⁺ excretion with bumetanide and dapagliflozin is not additive, but the weekly administration of one diuretic enhances the initial Na⁺ excretion with the other, thereby demonstrating mutual adaptive natriuretic synergy. Combined therapy reverses bumetanide‐induced hyperuricemia. This requires further study in diabetic patients with hyperglycemia who have enhanced glycosuria and natriuresis with dapagliflozin.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00930865.