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Patel RN, Sharma A, Prasad A, Bansal S. Heart Failure With Preserved Ejection Fraction With CKD: A Narrative Review of a Multispecialty Disorder. Kidney Med 2023; 5:100705. [PMID: 38046909 PMCID: PMC10692714 DOI: 10.1016/j.xkme.2023.100705] [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: 12/05/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a heterogenous syndrome with varying phenotypic expression. The phenotype chronic kidney disease (CKD) associated HFpEF is increasing in prevalence globally and is associated with increased morbidity and mortality compared to other HFpEF variants. These 2 conditions share common risk factors, including obesity, diabetes, and metabolic syndrome, as well as similar pathophysiology, including systemic inflammation, oxidative stress, elevated neurohormones, mineralocorticoid-receptor activation, and venous congestion. Given the coexistence of CKD and HFpEF, the diagnosis of HFpEF can be difficult. Moreover, treatment options for HFpEF have remained limited despite the success seen in its counterpart, heart failure with reduced ejection fraction. HFpEF encompasses complex multisystem pathophysiological perturbations beyond neurohormones, it is unlikely that a single agent can have significant benefit in this population. Recent data on sodium-glucose cotransporter 2 (SGLT2) inhibitors in HFpEF and CKD, and on glucagon-like peptide-1 (GLP-1) agonists and mineralocorticoid-receptor antagonists in metabolic syndrome, which target multiple pathways simultaneously, have led to promising therapeutics for HFpEF and CKD. In this perspective, our goal is to increase awareness of HFpEF as a multisystem disorder that shares the same disease processes seen in CKD and to emphasize that its management in individuals with CKD warrants a collective and multidisciplinary approach.
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Affiliation(s)
- Rahul N. Patel
- Transplant Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Akash Sharma
- The University of Texas Health Science Center at San Antonio Joe R and Teresa Lozano Long School of Medicine, San Antonio, TX, USA
| | - Anand Prasad
- Division of Cardiology, The University of Texas Health at San Antonio, San Antonio, Texas, USA
| | - Shweta Bansal
- Division of Nephrology, The University of Texas Health at San Antonio, San Antonio, Texas, USA
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2
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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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3
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Ajibowo AO, Okobi OE, Emore E, Soladoye E, Sike CG, Odoma VA, Bakare IO, Kolawole OA, Afolayan A, Okobi E, Chukwu C. Cardiorenal Syndrome: A Literature Review. Cureus 2023; 15:e41252. [PMID: 37529809 PMCID: PMC10389294 DOI: 10.7759/cureus.41252] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2023] [Indexed: 08/03/2023] Open
Abstract
Cardiorenal syndrome (CRS) is a condition characterized by the intricate two-way relationship between the heart and kidneys, which can lead to acute or chronic dysfunction in these organs. The interplay between cardiorenal connectors and both hemodynamic and non-hemodynamic factors is crucial to understanding this syndrome. The clinical importance of these interactions is evident in the changes observed in hemodynamic factors, neurohormonal markers, and inflammatory processes. Identifying and understanding biomarkers associated with CRS is valuable for early detection and enabling intervention before significant organ dysfunction occurs. This comprehensive review focuses on the clinical significance of biomarkers in the diagnosis, prognosis, and management of CRS. Finally, it highlights the necessity for further advancements in managing this condition.
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Affiliation(s)
| | - Okelue E Okobi
- Family Medicine, Medficient Health Systems, Laurel, USA
- Family Medicine, Lakeside Medical Center, Belle Glade, USA
| | | | | | - Cherechi G Sike
- General Practice, Windsor University School of Medicine, Cayon, KNA
| | - Victor A Odoma
- Cardiology/Oncology, Indiana University (IU) Health, Bloomington, USA
| | - Ibrahim O Bakare
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | | | - Adebola Afolayan
- Internal Medicine, Triboro Center for Nursing and Rehabilitation, New York City, USA
| | - Emeka Okobi
- Dentistry, Ahmadu Bello University Teaching Hospital Zaria, Abuja, NGA
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4
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Amatruda JG, Scherzer R, Rao VS, Ivey-Miranda JB, Shlipak MG, Estrella MM, Testani JM. Renin-Angiotensin-Aldosterone System Activation and Diuretic Response in Ambulatory Patients With Heart Failure. Kidney Med 2022; 4:100465. [PMID: 35620081 PMCID: PMC9127684 DOI: 10.1016/j.xkme.2022.100465] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Rationale & Objective Heart failure treatment relies on loop diuretics to induce natriuresis and decongestion, but the therapy is often limited by diuretic resistance. We explored the association of renin-angiotensin-aldosterone system (RAAS) activation with diuretic response. Study Design Observational cohort. Setting & Population Euvolemic ambulatory adults with chronic heart failure were administered torsemide in a monitored environment. Predictors Plasma total renin, active renin, angiotensinogen, and aldosterone levels. Urine total renin and angiotensinogen levels. Outcomes Sodium output per doubling of diuretic dose and fractional excretion of sodium per doubling of diuretic dose. Analytical Approach Robust linear regression models estimated the associations of each RAAS intermediate with outcomes. Results The analysis included 56 participants, and the median age was 65 years; 50% were women, and 41% were Black. The median home diuretic dose was 80-mg furosemide equivalents. In unadjusted and multivariable-adjusted models, higher levels of RAAS measures were generally associated with lower diuretic efficiency. Higher plasma total renin remained significantly associated with lower sodium output per doubling of diuretic dose (β = -0.41 [-0.76, -0.059] per SD change) with adjustment; higher plasma total and active renin were significantly associated with lower fractional excretion of sodium per doubling of diuretic dose (β = -0.48 [-0.83, -0.14] and β = -0.51 [-0.95, -0.08], respectively) in adjusted models. Stratification by RAAS inhibitor use did not substantially alter these associations. Limitations Small sample size; highly selected participants; associations may not be causal. Conclusions Among multiple measures of RAAS activation, higher plasma total and active renin levels were consistently associated with lower diuretic response. These findings highlight the potential drivers of diuretic resistance and underscore the need for high-quality trials of decongestive therapy enhanced by RAAS blockade.
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Affiliation(s)
- Jonathan G. Amatruda
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System & University of California, San Francisco, San Francisco, CA
| | - Rebecca Scherzer
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System & University of California, San Francisco, San Francisco, CA
| | - Veena S. Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Juan B. Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
- Hospital de Cardiología, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Michael G. Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System & University of California, San Francisco, San Francisco, CA
- Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, CA
| | - Michelle M. Estrella
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System & University of California, San Francisco, San Francisco, CA
- Division of Nephrology, Department of Medicine, San Francisco VA Health Care System, San Francisco, CA
- Address for Correspondence: Michelle M. Estrella, MD, MHS, 4150 Clement St, Building 2, Room 145, San Francisco, CA 94121.
| | - Jeffrey M. Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
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5
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de la Espriella R, Santas E, Zegri Reiriz I, Górriz JL, Cobo Marcos M, Núñez J. Quantification and treatment of congestion in heart failure: A clinical and pathophysiological overview. Nefrologia 2022; 42:145-162. [PMID: 36153911 DOI: 10.1016/j.nefroe.2021.04.007] [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: 01/11/2021] [Accepted: 04/06/2021] [Indexed: 06/16/2023] Open
Abstract
Renal sodium and water retention with resulting extracellular volume expansion and redistribution are hallmark features of heart failure syndromes. However, congestion assessment, monitoring, and treatment represent a real challenge in daily clinical practice. This document reviewed historical and contemporary evidence of available methods for determining volume status and discuss pharmacological aspects and pathophysiological principles that underlie diuretic use.
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Affiliation(s)
- Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain
| | - Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain
| | - Isabel Zegri Reiriz
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain; Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jose Luis Górriz
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain; Servicio de Nefrología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; Departamento de Medicina, Universidad de Valencia, Spain
| | - Marta Cobo Marcos
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; CIBER Cardiovascular, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Spain.
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6
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de la Espriella R, Santas E, Zegri Reiriz I, Górriz JL, Cobo Marcos M, Núñez J. Quantification and Treatment of Congestion in Heart Failure: A Clinical and Pathophysiological Overview. Nefrologia 2021; 42:S0211-6995(21)00114-4. [PMID: 34289940 DOI: 10.1016/j.nefro.2021.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/27/2021] [Accepted: 04/06/2021] [Indexed: 01/12/2023] Open
Abstract
Renal sodium and water retention with resulting extracellular volume expansion and redistribution are hallmark features of heart failure syndromes. However, congestion assessment, monitoring, and treatment represent a real challenge in daily clinical practice. This document reviewed historical and contemporary evidence of available methods for determining volume status and discuss pharmacological aspects and pathophysiological principles that underlie diuretic use.
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Affiliation(s)
- Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España
| | - Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España
| | - Isabel Zegri Reiriz
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España; Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - José Luis Górriz
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España; Servicio de Nefrología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España; Departamento de Medicina, Universidad de Valencia, España
| | - Marta Cobo Marcos
- Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España; Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España; CIBER Cardiovascular, España
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, España; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, España; Departamento de Medicina, Universidad de Valencia, España; CIBER Cardiovascular, España.
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7
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de Denus S, Leclair G, Dubé MP, St-Jean I, Zada YF, Oussaïd E, Jutras M, Givertz MM, Mentz RJ, Tang WHW, Ferreira JP, Rouleau J, Butler J, Kalogeropoulos AP. Spironolactone metabolite concentrations in decompensated heart failure: insights from the ATHENA-HF trial. Eur J Heart Fail 2020; 22:1451-1461. [PMID: 32237012 DOI: 10.1002/ejhf.1802] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/21/2020] [Accepted: 03/06/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS In Aldosterone Targeted Neurohormonal Combined with Natriuresis Therapy in Heart Failure (ATHENA-HF), high-dose spironolactone (100 mg daily) did not improve efficacy endpoints over usual care [placebo or continued low-dose spironolactone (25 mg daily) in patients already receiving spironolactone] in the treatment of acute heart failure (HF). We hypothesized that low concentrations of the long-acting active metabolites of spironolactone [canrenone and 7α-thiomethylspironolactone (7α-TMS)] in the high-dose group could have contributed to these neutral results. METHODS AND RESULTS In patients randomized to high-dose spironolactone not previously treated with spironolactone (high-dose-naïve, n = 112), concentrations of canrenone and 7α-TMS increased at 48 and 96 h compared to baseline, and between 48 and 96 h (all P < 0.005), indicating that steady-state concentrations had not been reached by 48 h. In patients previously on low-dose, high-dose spironolactone (high-dose-previous, n = 37), concentrations of canrenone increased at 48 and 96 h compared to baseline (both P < 0.0005), with a marginal increase between 48 and 96 h (P = 0.0507). At 48 h, both high-dose groups had higher concentrations of both metabolites than the low-dose spironolactone group (P < 0.0001). Moreover, concentrations of both metabolites were higher in high-dose-previous vs. high-dose-naïve patients (P < 0.01), indicating that previous spironolactone use was significant, and that steady-state has not been reached in high-dose-naïve patients at 48 h. We found limited and inconsistent evidence of correlation between metabolite concentrations and endpoints. CONCLUSIONS Lower-than-anticipated concentrations of spironolactone active metabolites were observed for at least 48 h in the high-dose spironolactone group and may have contributed to the absence of pharmacological effects of spironolactone in the ATHENA-HF trial.
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Affiliation(s)
- Simon de Denus
- Faculty of Pharmacy, Montreal, Canada.,Montreal Heart Institute, Montreal, Canada.,Université de Montreal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | | | - Marie-Pierre Dubé
- Montreal Heart Institute, Montreal, Canada.,Université de Montreal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada.,Medicine, Université de Montréal, Montreal, Canada
| | | | - Yassamin Feroz Zada
- Montreal Heart Institute, Montreal, Canada.,Université de Montreal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | - Essaïd Oussaïd
- Montreal Heart Institute, Montreal, Canada.,Université de Montreal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | | | - Michael M Givertz
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert J Mentz
- Department of Medicine, Duke University, Durham, NC, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Jean Rouleau
- Montreal Heart Institute, Montreal, Canada.,Medicine, Université de Montréal, Montreal, Canada
| | - Javed Butler
- Department of Medicine, Stony Brook University, Stony Brook, NY, USA
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8
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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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9
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Butler J, Anstrom KJ, Felker GM, Givertz MM, Kalogeropoulos AP, Konstam MA, Mann DL, Margulies KB, McNulty SE, Mentz RJ, Redfield MM, Tang WHW, Whellan DJ, Shah M, Desvigne-Nickens P, Hernandez AF, Braunwald E. Efficacy and Safety of Spironolactone in Acute Heart Failure: The ATHENA-HF Randomized Clinical Trial. JAMA Cardiol 2019; 2:950-958. [PMID: 28700781 DOI: 10.1001/jamacardio.2017.2198] [Citation(s) in RCA: 170] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance Persistent congestion is associated with worse outcomes in acute heart failure (AHF). Mineralocorticoid receptor antagonists administered at high doses may relieve congestion, overcome diuretic resistance, and mitigate the effects of adverse neurohormonal activation in AHF. Objective To assess the effect of high-dose spironolactone and usual care on N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels compared with usual care alone. Design, Setting, and Participants This double-blind and placebo (or low-dose)-controlled randomized clinical trial was conducted in 22 US acute care hospitals among patients with AHF who were previously receiving no or low-dose (12.5 mg or 25 mg daily) spironolactone and had NT-proBNP levels of 1000 pg/mL or more or B-type natriuretic peptide levels of 250 pg/mL or more, regardless of ejection fraction. Interventions High-dose spironolactone (100 mg) vs placebo or 25 mg spironolactone (usual care) daily for 96 hours. Main Outcomes and Measures The primary end point was the change in NT-proBNP levels from baseline to 96 hours. Secondary end points included the clinical congestion score, dyspnea assessment, net urine output, and net weight change. Safety end points included hyperkalemia and changes in renal function. Results A total of 360 patients were randomized, of whom the median age was 65 years, 129 (36%) were women, 200 (55.5%) were white, 151 (42%) were black, 8 (2%) were Hispanic or Latino, 9 (2.5%) were of other race/ethnicity, and the median left ventricular ejection fraction was 34%. Baseline median (interquartile range) NT-proBNP levels were 4601 (2697-9596) pg/mL among the group treated with high-dose spironolactone and 3753 (1968-7633) pg/mL among the group who received usual care. There was no significant difference in the log NT-proBNP reduction between the 2 groups (-0.55 [95% CI, -0.92 to -0.18] with high-dose spironolactone and -0.49 [95% CI, -0.98 to -0.14] with usual care, P = .57). None of the secondary end point or day-30 all-cause mortality or heart failure hospitalization rate differed between the 2 groups. The changes in serum potassium and estimated glomerular filtration rate at 24, 48, 72, and 96 hours. were similar between the 2 groups. Conclusions and Relevance Adding treatment with high-dose spironolactone to usual care for patients with AHF for 96 hours was well tolerated but did not improve the primary or secondary efficacy end points. Trial Registration clinicaltrials.gov Identifier: NCT02235077.
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Affiliation(s)
- Javed Butler
- Department of Medicine, Stony Brook University, Stony Brook, New York
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University, Durham, North Caroline
| | | | - Michael M Givertz
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Marvin A Konstam
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Douglas L Mann
- Department of Medicine, Washington University, St Louis, Missouri
| | | | - Steven E McNulty
- Duke Clinical Research Institute, Duke University, Durham, North Caroline
| | - Robert J Mentz
- Department of Medicine, Duke University, Durham, North Carolina
| | | | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - David J Whellan
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Monica Shah
- National Center for Advancing Translational Sciences, National Institutes of Health, Baltimore, Maryland
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Baltimore, Maryland
| | - Adrian F Hernandez
- Department of Medicine, Duke University, Durham, North Carolina.,Associate Editor
| | - Eugene Braunwald
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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10
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Verbrugge FH, Martens P, Ameloot K, Haemels V, Penders J, Dupont M, Tang WHW, Droogné W, Mullens W. Spironolactone to increase natriuresis in congestive heart failure with cardiorenal syndrome. Acta Cardiol 2019; 74:100-107. [PMID: 29587582 DOI: 10.1080/00015385.2018.1455947] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Signs and symptoms of volume overload are the most frequent reason for hospital admission in acute heart failure (AHF). Diuretics are mainstay treatment, but their optimal type and dose regimen remain unclear, especially in patients with cardiorenal syndrome. METHODS This prospective study aimed to include 80 AHF patients with volume overload and cardiorenal syndrome. Through a 2 × 2 factorial design, patients were randomised towards (1) combinational treatment with acetazolamide and low-dose loop diuretics versus high-dose loop diuretics; and (2) open-label oral spironolactone 25 mg OD given upfront versus at discharge. Here reported are the results of the spironolactone treatment arm after complete follow-up of 34/80 patients (since the study was stopped because of slow recruitment). The primary study end-point was incident hypokalaemia (<3.5 mmol/L) or hyperkalaemia (>5.5 mmol/L). RESULTS Serum potassium derangements were numerically less frequent in the upfront versus discharge spironolactone group, yet this result was underpowered due to incomplete study recruitment (hyperkalaemia: 6% vs. 11%; hypokalaemia: 13% vs. 28%, respectively; p-value = .270). Natriuresis after 24 h was higher in the upfront vs. discharge spironolactone group (314 ± 142 vs. 200 ± 91 mmol/L, respectively; p-value = .010). Relative change in plasma NT-proBNP level after 72 h was similar among both groups (-16 ± 29% vs. -5 ± 45%, respectively; p value = .393), with no difference in all-cause mortality (p-value = .682) or the combination of all-cause mortality and heart failure readmission (p-value = .799). DISCUSSION Spironolactone use upfront in AHF patients at high risk for cardiorenal syndrome is safe and increases natriuresis.
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Affiliation(s)
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Veerle Haemels
- Department of Cardiovascular Medicine, UZ Leuven, Leuven, Belgium
| | - Joris Penders
- Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - W. H. Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Walter Droogné
- Department of Cardiovascular Medicine, UZ Leuven, Leuven, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
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11
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Practical management of concomitant acute heart failure and worsening renal function in the emergency department. Eur J Emerg Med 2018; 25:229-236. [PMID: 28984663 DOI: 10.1097/mej.0000000000000505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Worsening renal function (i.e. any increase in creatinine or decrease in the estimated glomerular filtration rate) is common in patients admitted for acute heart failure in the emergency department. Although worsening renal function (WRF) has been associated with the occurrence of dismal outcomes, this only appears to be the case when associated with clinical deterioration. However, if the clinical status of the patient is improving, a certain increase in serum creatinine may be acceptable. This WRF, which is not associated with clinical deterioration or adverse outcomes (e.g. during treatment up-titration), has been referred to as 'pseudo-WRF' and should not detract clinicians from targeting 'guideline-recommended' therapies. This is an important message for emergency physicians to pursue diuretics as long as signs of pulmonary congestion persist to improve the clinical status of the patient. In the present review, we aim to provide clinicians in acute settings with an integrative and comprehensive approach to cardiorenal interactions in acute heart failure.
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Kapelios CJ, Bonou M, Vogiatzi P, Tzanis G, Mantzouratou P, Lund LH, Barbetseas J. Association Between High-Dose Spironolactone and Decongestion in Patients with Acute Heart Failure: An Observational Retrospective Study. Am J Cardiovasc Drugs 2018; 18:415-422. [PMID: 29971596 DOI: 10.1007/s40256-018-0290-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Acute congestive heart failure (ACHF) is a state of severe, secondary hyperaldosteronism. Relief of congestion has prognostic implications. Our aim was to assess associations between high-dose spironolactone and (1) decongestion and (2) safety in patients with ACHF. METHODS The charts of 20 patients who were hospitalized with ACHF and received high doses of spironolactone (75-300 mg daily, group A) on top of standard of care (SOC) treatment were retrospectively studied and compared with the ones of 20 matched patients who received SOC treatment alone (group B). RESULTS The two groups were similar as per their baseline characteristics. Mean daily spironolactone dose was 143 ± 56 in group A vs. 25 ± 25 mg in group B (P < 0.001). Patients of group A demonstrated significantly greater daily urine output (median [25th, 75th percentile] 2.9 [2.3, 3.9] vs. 2.2 [1.9, 2.5] L/day, P = 0.009), daily weight loss (1.1 [0.9, 1.7] vs. 0.4 [0.2, 1.2] kg/day, P = 0.005) and total body weight loss (10.5 [7.3, 13.8] vs. 3.8 [3.0, 6.0] kg, P < 0.001) compared with patients of group B. There were no differences in incidence of renal dysfunction, hypokalemia and hyperkalemia. CONCLUSION In patients with ACHF, administration of high doses of spironolactone on top of SOC treatment appears safe and is associated with greater decongestion than SOC alone.
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Verbrugge FH. Editor's Choice-Diuretic resistance in acute heart failure. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 7:379-389. [PMID: 29897275 DOI: 10.1177/2048872618768488] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diuretic resistance is a powerful predictor of adverse outcome in acute heart failure (AHF), irrespectively of underlying glomerular filtration rate. Metrics of diuretic efficacy such as natriuresis, urine output, weight loss, net fluid balance, or fractional sodium excretion, differ in their risk for measurement error, convenience, and biological plausibility, which should be taken into account when interpreting their results. Loop diuretic resistance in AHF has multiple causes including altered drug pharmacokinetics, impaired renal perfusion and effective circulatory volume, neurohumoral activation, post-diuretic sodium retention, the braking phenomenon and functional as well as structural adaptations in the nephron. Ideally, these mechanisms should guide specific treatment decisions with the goal of achieving complete decongestion. Therefore, volume overload needs to be identified correctly to avoid poor diuretic response due to electrolyte depletion or dehydration. Next, renal perfusion should be optimised if possible and loop diuretics should be prescribed above their threshold dose. Addition of thiazide-type diuretics should be considered when a progressive decrease in loop diuretic efficacy is observed with prolonged use (i.e., the braking phenomenon). Furthermore, thiazide-type diuretics are a useful addition in patients with low glomerular filtration rate. However, they limit free water excretion and are relatively contraindicated in cases of hypotonic hyponatremia, where acetazolamide is the better option. Finally, ultrafiltration should be considered in patients with refractory diuretic resistance as persistent volume overload after decongestive treatment is associated with worse outcomes. Whether more upfront use of any of these individually tailored decongestion strategies is superior to monotherapy with loop diuretics remains to be shown by adequately powered randomised clinical trials.
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Abstract
PURPOSE OF REVIEW The burden of heart failure in the United States is growing rapidly to epic proportions with serious clinical implications for patients and economic strain for healthcare systems. One of the most common reasons for hospitalization in acute decompensated heart failure (ADHF) is excess volume accumulation which leads to untoward symptoms including dyspnea,orthopnea, and edema. RECENT FINDINGS Over the past several decades, there has been great interest in exploring various decongestive strategies in order to achieve symptomatic improvement and favorable clinical outcomes. These include different modalities of loop diuretic administration, the adjunctive use of non-loop diuretics, and other diuretic sparing strategies. Herein, we provide an appraisal of these decongestive strategies and discuss novel concepts predicting clinical outcomes based on diuretic response and decongestive adequacy while discussing commonly encountered problems such as worsening renal function in ADHF.
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Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, Giannetti N, Grzeslo A, Hamilton PG, Heckman GA, Howlett JG, Koshman SL, Lepage S, McKelvie RS, Moe GW, Rajda M, Swiggum E, Virani SA, Zieroth S, Al-Hesayen A, Cohen-Solal A, D'Astous M, De S, Estrella-Holder E, Fremes S, Green L, Haddad H, Harkness K, Hernandez AF, Kouz S, LeBlanc MH, Masoudi FA, Ross HJ, Roussin A, Sussex B. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017; 33:1342-1433. [PMID: 29111106 DOI: 10.1016/j.cjca.2017.08.022] [Citation(s) in RCA: 433] [Impact Index Per Article: 61.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 02/06/2023] Open
Abstract
Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.
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Affiliation(s)
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | - Michael Chan
- Edmonton Cardiology Consultants, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Adam Grzeslo
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Serge Lepage
- Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | | | - Miroslaw Rajda
- QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Sean A Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Sabe De
- London Health Sciences, Western University, London, Ontario, Canada
| | | | - Stephen Fremes
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Green
- University of Alberta, Edmonton, Alberta, Canada
| | - Haissam Haddad
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, Québec, Canada
| | | | | | | | - Andre Roussin
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bruce Sussex
- Memorial University, St John's, Newfoundland, Canada
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Shah N, Madanieh R, Alkan M, Dogar MU, Kosmas CE, Vittorio TJ. A perspective on diuretic resistance in chronic congestive heart failure. Ther Adv Cardiovasc Dis 2017; 11:271-278. [PMID: 28728476 DOI: 10.1177/1753944717718717] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Chronic congestive heart failure (CHF) is a complex disorder characterized by inability of the heart to keep up the demands on it, followed by the progressive pump failure and fluid accumulation. Although the loop diuretics are widely used in heart failure (HF) patients, both pharmacodynamic and pharmacokinetic alterations are thought to be responsible for diuretic resistance in these patients. Strategies to overcome diuretic resistance include sodium intake restriction, changes in diuretic dose and route of administration and sequential nephron diuretic therapy. In this review, we discuss the definition, prevalence, mechanism of development and management strategies of diuretic resistance in HF patients.
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Affiliation(s)
- Niel Shah
- St. Francis Hospital, The Heart Center ®, Center for Advanced Cardiac Therapeutics, Roslyn, NY, USA
| | - Raef Madanieh
- St. Francis Hospital, The Heart Center ®, Center for Advanced Cardiac Therapeutics, Roslyn, NY, USA
| | - Mehmet Alkan
- Brown University, College of Arts and Sciences, Providence, RI, USA
| | - Muhammad U Dogar
- St. Francis Hospital, The Heart Center ®, Center for Advanced Cardiac Therapeutics, Roslyn, NY, USA
| | | | - Timothy J Vittorio
- St. Francis Hospital, The Heart Center®, Center for Advanced Cardiac Therapeutics, 100 Port Washington Boulevard, Roslyn, NY 11576-1348, USA
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18
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Sica DA, Gehr TW, Frishman WH. Use of Diuretics in the Treatment of Heart Failure in Older Adults. Heart Fail Clin 2017; 13:503-512. [DOI: 10.1016/j.hfc.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
Loop diuretics are central to the management of fluid overload in acute decompensated heart failure. However, a variance in the response to loop diuretics can alter a patient's clinical course and has an adverse effect on clinical outcomes. Thus, a diminished response to loop diuretics is an important clinical issue. Factors thought to contribute to diuretic resistance include erratic oral absorption in congested states and postdiuretic sodium retention. Further contributing to diuretic resistance in patients with advanced heart failure are decreases in renal perfusion and alterations in sodium handling that occur in an attempt to maintain circulatory homeostasis. Several pharmacologic interventions have been used to improve diuretic response. Intravenous diuretic administration, increasing diuretic doses, or changing diuretic agents can potentially overcome pharmacokinetic obstacles which contribute to drug resistance. Combination diuretic therapy may be useful to overcome increased sodium retention, dopamine may improve renal perfusion, and hypertonic saline may transiently increase intravascular volume and improve sodium delivery to the tubules of the nephron. Despite the prevalence of diuretic resistance, there remains a paucity of clinical trial evidence to help guide therapy in these patients.
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20
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Pham D, Grodin JL. Dilemmas in the Dosing of Heart Failure Drugs: Titrating Diuretics in Chronic Heart Failure. Card Fail Rev 2017; 3:108-112. [PMID: 29387462 DOI: 10.15420/cfr.2017:10:1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Despite advances in medical therapy over the past few decades, the incidence of heart failure hospitalisation continues to rise. Diuretics are the most common therapy used to treat heart failure as they relieve congestion. However, there is a lack of guidance on how to best use these medications. Guidelines support the use of diuretics at the lowest clinically effective dose but do not specify a diuretic strategy beyond that. Here we review the diuretics available for treatment, potential mechanisms of diuretic resistance and ways to address this in the ambulatory setting, and review tools that have been developed to help guide diuretic use in the treatment of chronic heart failure.
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Affiliation(s)
- David Pham
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center,Dallas, Texas, USA
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center,Dallas, Texas, USA
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21
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Sica DA. Mineralocorticoid Receptor Antagonists for Treatment of Hypertension and Heart Failure. Methodist Debakey Cardiovasc J 2016; 11:235-9. [PMID: 27057293 DOI: 10.14797/mdcj-11-4-235] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Spironolactone and eplerenone are both mineralocorticoid-receptor antagonists. These compounds block both the epithelial and nonepithelial actions of aldosterone, with the latter assuming increasing clinical relevance. Spironolactone and eplerenone both affect reductions in blood pressure either as mono- or add-on therapy; moreover, they each afford survival benefits in diverse circumstances of heart failure and the probability of renal protection in proteinuric chronic kidney disease. However, as use of mineralocorticoid-blocking agents has expanded, the hazards inherent in taking such drugs have become more apparent. Whereas the endocrine side effects of spironolactone are in most cases little more than a cosmetic annoyance, the potassium-sparing effects of both spironolactone and eplerenone can prove disastrous, even fatal, if sufficient degrees of hyperkalemia emerge. For most patients, however, the risk of developing hyperkalemia in and of itself should not discourage the sensible clinician from bringing these compounds into play. Hyperkalemia should always be considered a possibility in patients receiving either of these medications; therefore, anticipatory steps should be taken to minimize the likelihood of its occurrence if long-term therapy of these agents is being considered.
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Affiliation(s)
- Domenic A Sica
- Virginia Commonwealth University Health System, Richmond, Virginia
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22
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Abstract
We present the case of a patient with heart failure and severe congestion who was responding poorly to diuretic therapy. We discuss the key problems concerning the pathophysiology and bedside therapeutic approach to congestion and fluid overload in this clinical setting, and we give practical suggestions to overcome congestion, especially in the setting of diuretic resistance and worsening renal function. We conclude that the application of key pharmacokinetic and pharmacodynamic principles of diuretic therapy, along with in-depth knowledge of the pathophysiology of heart failure, still represent the cornerstones for a correct approach to decongestive therapy in these patients.
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Abstract
Cardio-renal syndrome is a commonly encountered problem in clinical practice. Its pathogenesis is not fully understood. The purpose of this article is to highlight the interaction between the cardiovascular system and the renal system and how their interaction results in the complex syndrome of cardio-renal dysfunction. Additionally, we outline the available therapeutic strategies to manage this complex syndrome.
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Affiliation(s)
- Joseph Gnanaraj
- Department of Cardiology, Bridgeport Hospital, Bridgeport, CT, USA
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24
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Butler J, Hernandez AF, Anstrom KJ, Kalogeropoulos A, Redfield MM, Konstam MA, Tang WHW, Felker GM, Shah MR, Braunwald E. Rationale and Design of the ATHENA-HF Trial: Aldosterone Targeted Neurohormonal Combined With Natriuresis Therapy in Heart Failure. JACC-HEART FAILURE 2016; 4:726-35. [PMID: 27522631 DOI: 10.1016/j.jchf.2016.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/06/2016] [Accepted: 06/14/2016] [Indexed: 10/21/2022]
Abstract
Although therapy with mineralocorticoid receptor antagonists (MRAs) is recommended for patients with chronic heart failure (HF) with reduced ejection fraction and in post-infarction HF, it has not been studied well in acute HF (AHF) despite being commonly used in this setting. At high doses, MRA therapy in AHF may relieve congestion through its natriuretic properties and mitigate the effects of adverse neurohormonal activation associated with intravenous loop diuretics. The ATHENA-HF (Aldosterone Targeted Neurohormonal Combined with Natriuresis Therapy in Heart Failure) trial is a randomized, double-blind, placebo-controlled study of the safety and efficacy of 100 mg/day spironolactone versus placebo (or continued low-dose spironolactone use in participants who are already receiving spironolactone at baseline) in 360 patients hospitalized for AHF. Patients are randomized within 24 h of receiving the first dose of intravenous diuretics. The primary objective is to determine if high-dose spironolactone, compared with standard care, will lead to greater reductions in N-terminal pro-B-type natriuretic peptide levels from randomization to 96 h. The secondary endpoints include changes in the clinical congestion score, dyspnea relief, urine output, weight change, loop diuretic dose, and in-hospital worsening HF. Index hospital length of stay and 30-day clinical outcomes will be assessed. Safety endpoints include risk of hyperkalemia and renal function. Differences among patients with reduced versus preserved ejection fraction will be determined. (Study of High-dose Spironolactone vs. Placebo Therapy in Acute Heart Failure [ATHENA-HF]; NCT02235077).
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Affiliation(s)
- Javed Butler
- Department of Medicine, Stony Brook University, Stony Brook, New York.
| | | | - Kevin J Anstrom
- Department of Medicine, Duke University, Durham, North Carolina
| | | | | | | | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - Monica R Shah
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Baltimore, Maryland
| | - Eugene Braunwald
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Pitt B, Pedro Ferreira J, Zannad F. Mineralocorticoid receptor antagonists in patients with heart failure: current experience and future perspectives. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2016; 3:48-57. [DOI: 10.1093/ehjcvp/pvw016] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 01/14/2023]
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Pitt B, Stier CT, Rajagopalan S. Mineralocorticoid receptor blockade: new insights into the mechanism of action in patients with cardiovascular disease. J Renin Angiotensin Aldosterone Syst 2016; 4:164-8. [PMID: 14608520 DOI: 10.3317/jraas.2003.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Mineralocorticoid receptor (MR) blockade is effective in reducing total mortality and the incidence of heart failure in patients with systolic left ventricular dysfunction (SLVD) associated with chronic heart failure or post myocardial infarction. Pre-clinical and clinical studies in SLVD have shown that MR blockade reduces sudden cardiac death, left ventricular remodelling, left ventricular hypertrophy, endothelial dysfunction, autonomic imbalance, renal dysfunction and improves fibrinolysis. While MR blockade promotes sodium excretion and the combination of an angiotensin-converting enzyme inhibitor and a MR blocker have been shown to be more effective than either alone in causing natriuresis, it is unlikely that their beneficial effects can be explained solely on this basis. Aldosterone has been shown to have a number of adverse effects, including activation of other neurohumeral mediators, stimulation of active reactive oxygen species (ROS), activation of the NF-κβ and AP-1 signalling pathways, vascular inflammation and fibrosis, myocardial hypertrophy, autonomic imbalance, and a decrease in fibrinolysis. MR blockade is, however, effective both in situations with and without an increase in serum aldosterone level, since the MR can be occupied and activated by cortisol as well as by aldosterone. In view of these mechanisms, MR blockade may play an important role not only on SLVD, but also in essential hypertension with normal systolic function, diastolic heart failure, valvular heart disease, vascular stiffening with ageing, progression of renal disease, and diabetes mellitus. This hypothesis will, however, require further prospective evaluation.
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Affiliation(s)
- Bertram Pitt
- Division of Cardiology, University of Michigan, USA.
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27
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Vaduganathan M, Mentz RJ, Greene SJ, Senni M, Sato N, Nodari S, Butler J, Gheorghiade M. Combination decongestion therapy in hospitalized heart failure: loop diuretics, mineralocorticoid receptor antagonists and vasopressin antagonists. Expert Rev Cardiovasc Ther 2016; 13:799-809. [PMID: 26106934 DOI: 10.1586/14779072.2015.1053872] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Congestion is the most common reason for admissions and readmissions for heart failure (HF). The vast majority of hospitalized HF patients appear to respond readily to loop diuretics, but available data suggest that a significant proportion are being discharged with persistent evidence of congestion. Although novel therapies targeting congestion should continue to be developed, currently available agents may be utilized more optimally to facilitate complete decongestion. The combination of loop diuretics, natriuretic doses of mineralocorticoid receptor antagonists and vasopressin antagonists represents a regimen of currently available therapies that affects early and persistent decongestion, while limiting the associated risks of electrolyte disturbances, hemodynamic fluctuations, renal dysfunction and mortality.
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Affiliation(s)
- Muthiah Vaduganathan
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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28
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Verbrugge FH, Mullens W, Tang WHW. Management of Cardio-Renal Syndrome and Diuretic Resistance. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:11. [PMID: 26803318 DOI: 10.1007/s11936-015-0436-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OPINION STATEMENT Diuretic resistance in acute heart failure has emerged as a powerful predictor of adverse outcome, which is often independent of underlying glomerular filtration rate (GFR). Metrics of diuretic efficacy differ in their accuracy, convenience, and biological plausibility, which should be taken into account when interpreting their results. Loop diuretic efficacy depends on adequate delivery of both the pharmacological agent itself and its substrate (i.e., sodium chloride) to the loop diuretic site of action at the luminal side of the thick ascending limb of Henle's loop. This requires an adequate dosing strategy, with higher doses needed when GFR is low. Importantly, the kidneys are able only to regulate the effective circulatory volume. Thus, specific problems of intravascular volume depletion and poor cardiac output with impaired renal perfusion should be addressed. Addition of thiazide-type diuretics should be considered when a progressive decrease in loop diuretic efficacy is observed with prolonged use (i.e., the braking phenomenon). Furthermore, thiazide-type diuretics are a useful addition in patients with low GFR to maximally boost fractional sodium excretion when nephron perfusion is poor. However, thiazide-type diuretics limit free water excretion and should be withheld in cases of hypotonic hyponatremia. Mineralocorticoid receptor antagonists (MRA) and acetazolamide are interesting options to increase loop diuretic efficacy, but further study is needed to assess whether improved diuretic efficacy also translates into clinical outcome benefits. Finally, ultrafiltration should be considered in patients with refractory diuretic resistance as persistent volume overload after decongestive treatment is associated with worse outcomes. Whether more upfront use of individually tailored ultrafiltration is superior to pharmacological therapy remains to be shown by adequately powered randomized clinical trials.
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Affiliation(s)
- Frederik H Verbrugge
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland Clinic Main Campus J3-4, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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29
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Masoumi A, Ortiz F, Radhakrishnan J, Schrier RW, Colombo PC. Mineralocorticoid receptor antagonists as diuretics: Can congestive heart failure learn from liver failure? Heart Fail Rev 2015; 20:283-90. [PMID: 25447845 DOI: 10.1007/s10741-014-9467-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite significant improvements in diagnosis, understanding the pathophysiology and management of the patients with acute decompensated heart failure (ADHF), diuretic resistance, yet to be clearly defined, is a major hurdle. Secondary hyperaldosteronism is a pivotal factor in pathogenesis of sodium retention, refractory congestion in heart failure (HF) as well as diuretic resistance. In patients with decompensated cirrhosis who suffer from ascites, similar pathophysiological complications have been recognized. Administration of natriuretic doses of mineralocorticoid receptor antagonists (MRAs) has been well established in management of cirrhotic patients. However, this strategy in patients with ADHF has not been well studied. This article will discuss the potential use of natriuretic doses of MRAs to overcome the secondary hyperaldosteronism as an alternative diuretic regimen in patients with HF.
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Affiliation(s)
- Amirali Masoumi
- Division of Cardiology, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, NY, USA,
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30
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Spot urine sodium excretion as prognostic marker in acutely decompensated heart failure: the spironolactone effect. Clin Res Cardiol 2015; 105:489-507. [PMID: 26615605 DOI: 10.1007/s00392-015-0945-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Loop diuretic resistance characterized by inefficient sodium excretion complicates many patients with acutely decompensated heart failure (ADHF). Mineralocorticoid receptor antagonists (MRAs) in natriuretic doses may improve spot urine sodium excretion and outcomes. OBJECTIVE Our primary aim was to assess the association of high-dose spironolactone with short-term spot urine sodium excretion, and our secondary aim was to determine if this higher short-term spot urine sodium excretion is associated with reduction in the composite clinical outcome (of cardiovascular mortality and/or ADHF hospitalization) event rate at 180 days. METHODS Single-centre, non-randomized, open-label study enrolling 100 patients with ADHF. Patients were treated with standard ADHF therapy alone (n = 50) or oral spironolactone 100 mg/day plus standard ADHF therapy (n = 50). Spot urine samples were collected at day 1 and day 3 of hospitalization. RESULTS Spironolactone group had significantly higher spot urine sodium levels compared to standard care group at day 3 (84.13 ± 28.71 mmol/L vs 70.74 ± 34.43 mmol/L, p = 0.04). The proportion of patients with spot urinary sodium <60 mmol/L was lower in spironolactone group at day 3 (18.8 vs 45.7, p = 0.01). In multivariate analysis, spironolactone was independently associated with increased spot urinary sodium and urinary sodium/potassium ratio of >2 at day 3 (both, p < 0.05). Higher spot urine sodium levels were associated with a lower event rate [HR for urinary sodium >100 mmol/L = 0.16 (0.06-0.42), p < 0.01, compared to <60], and provided a significant prognostic gain measured by net reclassification indexes. CONCLUSION Spot urinary sodium levels >60 mmol/L and urinary sodium/potassium ratio >2 measured at day 3 of hospitalization for ADHF are associated with improved mid-term outcomes. Spironolactone is associated with increased spot urinary sodium and sodium/potassium ratio >2.
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Houston BA, Kalathiya RJ, Kim DA, Zakaria S. Volume Overload in Heart Failure: An Evidence-Based Review of Strategies for Treatment and Prevention. Mayo Clin Proc 2015; 90:1247-61. [PMID: 26189443 DOI: 10.1016/j.mayocp.2015.05.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 04/20/2015] [Accepted: 05/04/2015] [Indexed: 01/11/2023]
Abstract
Acute decompensated heart failure is the leading cause of hospital admission in the United States, with a high risk of readmission within 30 days. Most acute decompensated heart failure admissions are driven by congestive signs and symptoms resulting from fluid and sodium overload. We reviewed the evidence base addressing the management and prevention of fluid overload in heart failure, focusing on recent clinical trials. All the references in this review were obtained through PubMed and had at least 1 of the following key words: heart failure and volume overload, congestion, loop diuretics, thiazide diuretics, aldosterone antagonists, dopamine, cardiorenal syndrome, nesiritide, vasopressin antagonists, ultrafiltration, sodium restriction, fluid restriction, telemonitoring, and invasive hemodynamic monitoring. We also reviewed relevant references cited in the obtained articles, especially articles addressing methods of treating or preventing volume overload in patients with heart failure.
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Affiliation(s)
- Brian A Houston
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rohan J Kalathiya
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel A Kim
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sammy Zakaria
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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Salah K, Pinto YM, Eurlings LW, Metra M, Stienen S, Lombardi C, Tijssen JG, Kok WE. Serum potassium decline during hospitalization for acute decompensated heart failure is a predictor of 6-month mortality, independent of N-terminal pro-B-type natriuretic peptide levels: An individual patient data analysis. Am Heart J 2015; 170:531-42.e1. [PMID: 26385037 DOI: 10.1016/j.ahj.2015.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 06/06/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Limited data exist for the role of serum potassium changes during hospitalization for acute decompensated heart failure (ADHF). The present study investigated the long-term prognostic value of potassium changes during hospitalization in patients admitted for ADHF. METHODS Our study is a pooled individual patient data analysis assembled from 3 prospective cohorts comprising 754 patients hospitalized for ADHF. The endpoint was all-cause mortality within 180 days after discharge. Serum potassium levels and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured at admission and at discharge. RESULTS A percentage decrease >15% in serum potassium levels occurred in 96 (13%) patients, and an absolute decrease of >0.7 mmol/L in serum potassium levels occurred in 85 (12%) patients; and both were predictors of poor outcome independent of admission or discharge serum potassium. After the addition of other strong predictors of mortality-a 30% change in NT-proBNP during hospitalization, discharge levels of NT-proBNP, renal markers, and other relevant clinical variables-the multivariate hazard ratio of serum potassium percentage reduction of >15% remained an independent predictor of 180-day mortality (hazard ratio 2.06, 95% CI 1.14-3.73). CONCLUSIONS A percentage serum potassium decline of >15% is an independent predictor of 180-day all-cause mortality on top of baseline potassium levels, NT-proBNP levels, renal variables, and other relevant clinical variables. This suggest that patients hospitalized for ADHF with a decline of >15% in serum potassium levels are at risk and thus monitoring and regulating of serum potassium level during hospitalization are needed in these patients.
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Affiliation(s)
- Khibar Salah
- Academic Medical Center, University of Amsterdam, Heart failure Research Center & Department of Cardiology, Amsterdam, the Netherlands.
| | - Yigal M Pinto
- Academic Medical Center, University of Amsterdam, Heart failure Research Center & Department of Cardiology, Amsterdam, the Netherlands
| | - Luc W Eurlings
- University Hospital Maastricht, Department of Cardiology, Maastricht, the Netherlands
| | - Marco Metra
- University of Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Cardiology, Brescia, Italy
| | - Susan Stienen
- Academic Medical Center, University of Amsterdam, Heart failure Research Center & Department of Cardiology, Amsterdam, the Netherlands
| | - Carlo Lombardi
- University of Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Cardiology, Brescia, Italy
| | - Jan G Tijssen
- Academic Medical Center, University of Amsterdam, Heart failure Research Center & Department of Cardiology, Amsterdam, the Netherlands
| | - Wouter E Kok
- Academic Medical Center, University of Amsterdam, Heart failure Research Center & Department of Cardiology, Amsterdam, the Netherlands
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ter Maaten JM, Valente MAE, Metra M, Bruno N, O'Connor CM, Ponikowski P, Teerlink JR, Cotter G, Davison B, Cleland JG, Givertz MM, Bloomfield DM, Dittrich HC, van Veldhuisen DJ, Hillege HL, Damman K, Voors AA. A combined clinical and biomarker approach to predict diuretic response in acute heart failure. Clin Res Cardiol 2015; 105:145-53. [PMID: 26280875 PMCID: PMC4735256 DOI: 10.1007/s00392-015-0896-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/20/2015] [Indexed: 11/29/2022]
Abstract
Background Poor diuretic response in acute heart failure is related to poor clinical outcome. The underlying mechanisms and pathophysiology behind diuretic resistance are incompletely understood. We evaluated a combined approach using clinical characteristics and biomarkers to predict diuretic response in acute heart failure (AHF). Methods and results We investigated explanatory and predictive models for diuretic response—weight loss at day 4 per 40 mg of furosemide—in 974 patients with AHF included in the PROTECT trial. Biomarkers, addressing multiple pathophysiological pathways, were determined at baseline and after 24 h. An explanatory baseline biomarker model of a poor diuretic response included low potassium, chloride, hemoglobin, myeloperoxidase, and high blood urea nitrogen, albumin, triglycerides, ST2 and neutrophil gelatinase-associated lipocalin (r2 = 0.086). Diuretic response after 24 h (early diuretic response) was a strong predictor of diuretic response (β = 0.467, P < 0.001; r2 = 0.523). Addition of diuretic response after 24 h to biomarkers and clinical characteristics significantly improved the predictive model (r2 = 0.586, P < 0.001). Conclusions Biomarkers indicate that diuretic unresponsiveness is associated with an atherosclerotic profile with abnormal renal function and electrolytes. However, predicting diuretic response is difficult and biomarkers have limited additive value. Patients at risk of poor diuretic response can be identified by measuring early diuretic response after 24 h. Electronic supplementary material The online version of this article (doi:10.1007/s00392-015-0896-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jozine M ter Maaten
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Mattia A E Valente
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | | | - Noemi Bruno
- Department of Cardiovascular Sciences, "Sapienza" University of Rome, Rome, Italy
| | | | | | - John R Teerlink
- University of California at San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | | | | | | | | | | | - Howard C Dittrich
- University of Iowa Carver College of Medicine Cardiovascular Research Center, Iowa City, IA, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Hans L Hillege
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,University Medical Center Groningen, Department of Epidemiology, University of Groningen, Groningen, The Netherlands
| | - Kevin Damman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
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Di Somma S, Magrini L. Drug Therapy for Acute Heart Failure. ACTA ACUST UNITED AC 2015; 68:706-13. [PMID: 26088867 DOI: 10.1016/j.rec.2015.02.019] [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: 01/15/2015] [Accepted: 02/10/2015] [Indexed: 01/11/2023]
Abstract
Acute heart failure is globally one of most frequent reasons for hospitalization and still represents a challenge for the choice of the best treatment to improve patient outcome. According to current international guidelines, as soon as patients with acute heart failure arrive at the emergency department, the common therapeutic approach aims to improve their signs and symptoms, correct volume overload, and ameliorate cardiac hemodynamics by increasing vital organ perfusion. Recommended treatment for the early management of acute heart failure is characterized by the use of intravenous diuretics, oxygen, and vasodilators. Although these measures ameliorate the patient's symptoms, they do not favorably impact on short- and long-term mortality. Consequently, there is a pressing need for novel agents in acute heart failure treatment with the result that research in this field is increasing worldwide.
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Affiliation(s)
- Salvatore Di Somma
- Emergency Department Sant'Andrea Hospital, Medical-Surgery Sciences and Translational Medicine, University La Sapienza, Rome, Italy.
| | - Laura Magrini
- Emergency Department Sant'Andrea Hospital, Medical-Surgery Sciences and Translational Medicine, University La Sapienza, Rome, Italy
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Kırat T, Köse N. Response to the letter by Akinori Sairaku et al.: Different mechanisms=synergic effect. Int J Cardiol 2015; 186:148. [DOI: 10.1016/j.ijcard.2015.03.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/17/2015] [Indexed: 11/17/2022]
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Abstract
The administration of loop diuretics to achieve decongestion is the cornerstone of therapy for acute heart failure. Unfortunately, impaired response to diuretics is common in these patients and associated with adverse outcomes. Diuretic resistance is thought to result from a complex interplay between cardiac and renal dysfunction, and specific renal adaptation and escape mechanisms, such as neurohormonal activation and the braking phenomenon. However, our understanding of diuretic response in patients with acute heart failure is still limited and a uniform definition is lacking. Three objective methods to evaluate diuretic response have been introduced, which all suggest that diuretic response should be determined based on the effect of diuretic dose administered. Several strategies have been proposed to overcome diuretic resistance, including combination therapy and ultrafiltration, but prospective studies in patients who are truly unresponsive to diuretics are lacking. An enhanced understanding of diuretic response should ultimately lead to an improved, individualized approach to treating patients with acute heart failure.
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Cox ZL, Lenihan DJ. Loop Diuretic Resistance in Heart Failure: Resistance Etiology–Based Strategies to Restoring Diuretic Efficacy. J Card Fail 2014; 20:611-22. [DOI: 10.1016/j.cardfail.2014.05.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 05/17/2014] [Accepted: 05/22/2014] [Indexed: 02/08/2023]
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Shakar SF, Lindenfeld J. Treatment Approaches to Congestion Relief in Acute Decompensated HF: Insights After DOSE-AHF and CARRESS-HF. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:330. [DOI: 10.1007/s11936-014-0330-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Mentz RJ, Kjeldsen K, Rossi GP, Voors AA, Cleland JGF, Anker SD, Gheorghiade M, Fiuzat M, Rossignol P, Zannad F, Pitt B, O'Connor C, Felker GM. Decongestion in acute heart failure. Eur J Heart Fail 2014; 16:471-82. [PMID: 24599738 DOI: 10.1002/ejhf.74] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 01/24/2014] [Accepted: 01/31/2014] [Indexed: 12/20/2022] Open
Abstract
Congestion is a major reason for hospitalization in acute heart failure (HF). Therapeutic strategies to manage congestion include diuretics, vasodilators, ultrafiltration, vasopressin antagonists, mineralocorticoid receptor antagonists, and potentially also novel therapies such as gut sequesterants and serelaxin. Uncertainty exists with respect to the appropriate decongestion strategy for an individual patient. In this review, we summarize the benefit and risk profiles for these decongestion strategies and provide guidance on selecting an appropriate approach for different patients. An evidence-based initial approach to congestion management involves high-dose i.v. diuretics with addition of vasodilators for dyspnoea relief if blood pressure allows. To enhance diuresis or overcome diuretic resistance, options include dual nephron blockade with thiazide diuretics or natriuretic doses of mineralocorticoid receptor antagonists. Vasopressin antagonists may improve aquaresis and relieve dyspnoea. If diuretic strategies are unsuccessful, then ultrafiltration may be considered. Ultrafiltration should be used with caution in the setting of worsening renal function. This review is based on discussions among scientists, clinical trialists, and regulatory representatives at the 9th Global Cardio Vascular Clinical Trialists Forum in Paris, France, from 30 November to 1 December 2012.
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Pitt B, Gheorghiade M. Vasopressin V1 receptor-mediated aldosterone production as a result of selective V2 receptor antagonism: a potential explanation for the failure of tolvaptan to reduce cardiovascular outcomes in the EVEREST trial. Eur J Heart Fail 2014; 13:1261-3. [DOI: 10.1093/eurjhf/hfr150] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bertram Pitt
- University of Michigan School of Medicine, Cardiovascular Center; 1500 E. Medical Center Dr.; Ann Arbor MI 48109 USA
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation; Northwestern University Feinberg School of Medicine; 645 North Michigan Ave., Suite 1006 Chicago IL 60611 USA
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Ferreira JP, Santos M, Almeida S, Marques I, Bettencourt P, Carvalho H. Mineralocorticoid receptor antagonism in acutely decompensated chronic heart failure. Eur J Intern Med 2014; 25:67-72. [PMID: 24070521 DOI: 10.1016/j.ejim.2013.08.711] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 08/14/2013] [Accepted: 08/14/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND/OBJECTIVES Mineralocorticoid receptor antagonist (MRA) use in acutely decompensated chronic heart failure (ADCHF) may improve congestion through diuretic effect and prevent neurohormonal activation. We aimed to evaluate the clinical effect and safety of spironolactone in ADCHF. METHODS Prospective, experimental, single-center, and single-blinded trial. Patients were treated with: standard ADCHF therapy or oral spironolactone 50-100mg/d plus standard ADCHF therapy. RESULTS During a 1year period, 100 patients were enrolled, 50 included in the treatment group. Mean (SD) spironolactone dose (mg) at day 1 was 94.5±23.3 and at day 3 was 62.7±24.3. Worsening renal function (increase in pCr≥0.3mg/dL from day 1 to day 3) was more likely to occur in control group (20% vs. 4%; p=0.038), serum potassium did not differ between groups, and plasma NTproBNP had a significant decrease in spironolactone group at day 3 (median [IQR], 2488 [4579] vs. 1555 [1832]; p=0.05). Furthermore, a greater proportion of patients in the treatment group were free of congestion at day 3: less edema, rales, jugular venous pressure (JVP) and orthopnea (all, p<0.05). In addition, a significantly higher proportion of patients were on oral furosemide at day 3 (44% vs. 82%; p<0.001). CONCLUSIONS Our study supports the safety of high dose spironolactone in ADCHF and suggests a positive impact in the resolution of congestion. The important findings of our pilot study need to be confirmed in larger trials.
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Affiliation(s)
| | | | - Sofia Almeida
- Climate Change Impacts, Adaptation and Mitigation Research Group (CC-IAM), Faculdade de Ciências, Universidade de Lisboa, Portugal
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Trullàs JC, Morales-Rull JL, Formiga F. [Diuretic therapy in heart failure]. Med Clin (Barc) 2013; 142:163-70. [PMID: 23768854 DOI: 10.1016/j.medcli.2013.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 04/05/2013] [Accepted: 04/11/2013] [Indexed: 01/11/2023]
Abstract
Many of the primary clinical manifestations of heart failure (HF) are due to fluid retention, and treatments targeting congestion play a central role in HF management. Diuretic therapy remains the cornerstone of congestion treatment, and diuretics are prescribed to the majority of HF patients. Despite this ubiquitous use, there is limited evidence from prospective randomized studies to guide the use of diuretics. With the chronic use of diuretic and usually in advanced stages of HF, diuretics may fail to control salt and water retention. This review describes the mechanism of action of available diuretic classes, reviews their clinical use based on scientific evidence and discusses strategies to overcome diuretic resistance.
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Affiliation(s)
- Joan Carles Trullàs
- Servicio de Medicina Interna, Hospital Sant Jaume d'Olot, Universitat de Girona, Girona, España.
| | | | - Francesc Formiga
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España
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Shchekochikhin D, Lindenfeld J, Schrier R. Increased Spironolactone in Advanced Heart Failure: Effect of Doses Greater than 25 mg/Day on Plasma Potassium Concentration. Cardiorenal Med 2013; 3:1-6. [PMID: 23801997 PMCID: PMC3678142 DOI: 10.1159/000346447] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 12/07/2012] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Daily doses of spironolactone higher than 25 mg are rarely used in heart failure (HF) patients, presumably due to the concern for hyperkalemia. However, in advanced HF, doses ≥50 mg have been found to be necessary to produce natriuresis. The aim of the present study was to examine the safety of natriuretic doses of spironolactone (50-200 mg) on serum potassium concentration in New York Heart Association (NYHA) class III/IV HF patients over several weeks. METHODS 18 patients with advanced HF received 50-200 mg of spironolactone in addition to standard treatment. Serum electrolytes, BUN and serum creatinine were assessed at baseline, during increased doses of spironolactone and at the 1-month follow-up. RESULTS During a total of 738 patient-weeks, there was no significant increase in mean serum potassium (4.0 vs. 4.2 mEq/l) or serum creatinine (1.3 vs. 1.4 mg/dl). However, in 3 patients, spironolactone treatment was stopped due to a mean increase in serum creatinine (1.9 vs. 2.6 mg/dl) and in one of them, an increase in serum potassium (4.4 vs. 5.2 mEq/l) was noted. CONCLUSION Increased doses of spironolactone are generally safe during outpatient follow-up in selected patients with advanced HF, who are receiving treatment with ACE inhibitors, beta-blockers, and loop diuretics.
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Affiliation(s)
- Dmitry Shchekochikhin
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colo., USA
| | - JoAnn Lindenfeld
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colo., USA
| | - Robert Schrier
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colo., USA
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Abstract
Worsening renal function (WRF) during the treatment of acute decompensated heart failure (ADHF) occurs in up to a third of patients and is associated with worse survival. Venous congestion is increasingly being recognized as a key player associated with WRF in ADHF. Understanding the hemodynamic effects of venous congestion and the interplay between venous congestion and other pathophysiological factors such as raised abdominal pressure, endothelial cell activation, anemia/ iron deficiency, sympathetic overactivity, and stimulation of the renin-angiotensin-aldosterone system will help in devising effective management strategies. Early recognition of venous congestion through novel techniques such as bioimpedance measurements and remote monitoring of volume status combined with customized diuretic regimens may prevent venous congestion and perhaps avoid significant WRF.
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The 2012 Canadian Cardiovascular Society heart failure management guidelines update: focus on acute and chronic heart failure. Can J Cardiol 2012. [PMID: 23201056 DOI: 10.1016/j.cjca.2012.10.007] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The 2012 Canadian Cardiovascular Society Heart Failure (HF) Guidelines Update provides management recommendations for acute and chronic HF. In 2006, the Canadian Cardiovascular Society HF Guidelines committee first published an overview of HF management. Since then, significant additions to and changes in many of these recommendations have become apparent. With this in mind and in response to stakeholder feedback, the Guidelines Committee in 2012 has updated the overview of both acute and chronic heart failure diagnosis and management. The 2012 Update also includes recommendations, values and preferences, and practical tips to assist the medical practitioner manage their patients with HF.
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Lazzarini V, Felker GM. Management of the cardiorenal syndrome in acute heart failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:342-55. [PMID: 22644350 DOI: 10.1007/s11936-012-0186-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OPINION STATEMENT Interactions between the heart and kidney in the setting of acute heart failure are complex and have a substantial impact on patient care and outcomes. Further research is needed to better distinguish the different causes of kidney injury, allow its early and accurate prediction and detection, and identify therapeutic targets. Novel renal biomarkers could potentially provide a useful tool for this purpose. Restoration of optimal fluid status and resolution of renal venous congestion are important goals of therapy. Changes in serum creatinine, although an important marker of renal function, may not be associated with adverse outcomes, especially if they are transient and a consequence of more aggressive decongestion, or the appropriate titration of drugs affecting the renin-angiotensin-aldosterone axis. In addition to loop diuretics, a variety of drugs and strategies have been investigated in acute heart failure. Use of mineralocorticoid receptor antagonists and vasopressin antagonists may have potential benefits and should be further investigated. Inotropic agents should be limited in those clinical settings suggesting hypoperfusion. Ultrafiltration seems to provide a safe and effective tool to overcome diuretic resistance and optimize fluid status avoiding detrimental effects of diuretic therapy.
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Talatinian A, Chow SL, Heywood JT. Expanding Role of Mineralocorticoid Receptor Antagonists in the Treatment of Heart Failure. Pharmacotherapy 2012; 32:827-37. [DOI: 10.1002/j.1875-9114.2012.01104.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Alidz Talatinian
- College of Pharmacy; Western University of Health Sciences; Pomona; California
| | - Sheryl L. Chow
- College of Pharmacy; Western University of Health Sciences; Pomona; California
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Abstract
All diuretics except spironolactone exert their effects from the lumen of the nephron. Thus, to exert an effect, they must reach the urine. Pharmacokinetics (PK) describes this access. Different edematous disorders can affect access to this site of action and therein affect response to a diuretic. In addition, once a diuretic reaches the site of action, a response ensues. The characteristics of this response that can be affected by a patient's clinical condition are described by the pharmacodynamics (PD) of a diuretic. To understand the mechanisms of abnormal response to a diuretic one must dissect its PK and PD in different edematous disorders. For example, in patients with renal insufficiency, the mechanism of poor diuretic response is PK. In contrast, in patients with cirrhosis or in those with congestive heart failure, it is PD. In patients with nephrotic syndrome, both PK and PD are operative. These different mechanisms mandate differences in therapeutic strategy, as explained in this article.
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Affiliation(s)
- D Craig Brater
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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