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de Sequera P, Bover R, Ivanova-Markova Y, Ivanova A, González-Domínguez A, Valls M, Campos V. Economic impact of the use of patiromer in chronic kidney disease or heart failure for the treatment of chronic hyperkalemia in Spain. Nefrologia 2023; 43:721-730. [PMID: 38228463 DOI: 10.1016/j.nefroe.2024.01.002] [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: 04/22/2022] [Accepted: 08/25/2022] [Indexed: 01/18/2024] Open
Abstract
INTRODUCTION Chronic hyperkalemia has negative consequences in the medium and long term, and determines the suspension of nephro and cardioprotective drugs, such as renin-angiotensin-aldosterone system inhibitors (RAASi). There is an alternative to the suspension or dose reduction of these treatments: the administration of potassium chelators. The aim of this study is to estimate the economic impact of the use of patiromer in patients with chronic kidney disease (CKD) or heart failure (HF) and hyperkalemia in Spain. MATERIALS AND METHOD The annual economic impact of the use of patiromer has been estimated from the perspective of the Spanish society. Two scenarios were compared: patients with CKD or HF and hyperkalemia treated with and without patiromer. The costs have been updated to 2020 euros, using the Health Consumer Price Index. Direct healthcare costs related to the use of resources (treatment with RAASi, CKD progression, cardiovascular events and hospitalization due to hyperkalemia), direct non-healthcare costs (informal care: costs derived from time dedicated by patient's relatives), the indirect costs (productivity loss), as well as an intangible cost (due to premature mortality) were considered. A deterministic sensitivity analysis was performed to validate the robustness of the study results. RESULTS The mean annual cost per patient in the scenario without patiromer is €9,834.09 and €10,739.37 in CKD and HF, respectively. The use of patiromer would lead to cost savings of over 30% in both diseases. The greatest savings in CKD come from the delay in the progression of CKD. While in the case of HF, 80.1% of these savings come from premature mortality reduction. The sensitivity analyses carried out show the robustness of the results, obtaining savings in all cases. CONCLUSIONS The incorporation of patiromer allows better control of hyperkalemia and, as a consequence, maintain treatment with RAASi in patients with CKD or HF. This would generate a 32% of annual savings in Spain (€3,127 in CKD; €3,466 in HF). The results support the positive contribution of patiromer to health cost in patients with only CKD or in patients with only HF.
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Affiliation(s)
- Patricia de Sequera
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ramón Bover
- Servicio de Cardiología, Hospital Universitario Clínico San Carlos, Madrid, Spain
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Scicchitano P, Iacoviello M, Massari F, De Palo M, Caldarola P, Mannarini A, Passantino A, Ciccone MM, Magnesa M. Optimizing Therapies in Heart Failure: The Role of Potassium Binders. Biomedicines 2022; 10:biomedicines10071721. [PMID: 35885026 PMCID: PMC9313061 DOI: 10.3390/biomedicines10071721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 11/21/2022] Open
Abstract
Heart failure (HF) is a worrisome cardiac pandemic with a negative prognostic impact on the overall survival of individuals. International guidelines recommend up-titration of standardized therapies in order to reduce symptoms, hospitalization rates, and cardiac death. Hyperkalemia (HK) has been identified in 3–18% of HF patients from randomized controlled trials and over 25% of HF patients in the “real world” setting. Pharmacological treatments and/or cardio-renal syndrome, as well as chronic kidney disease may be responsible for HK in HF patients. These conditions can prevent the upgrade of pharmacological treatments, thus, negatively impacting on the overall prognosis of patients. Potassium binders may be the best option in patients with HK in order to reduce serum concentrations of K+ and to promote correct upgrades of therapies. In addition to the well-established use of sodium polystyrene sulfonate (SPS), two novel drugs have been recently introduced: sodium zirconium cyclosilicate (SZC) and patiromer. SZC and patiromer are gaining a central role for the treatment of chronic HK. SZC has been shown to reduce K+ levels within 48 h, with guaranteed maintenance of normokalemia for up to12 months. Patiromer has resulted in a statistically significant decrease in serum potassium for up to 52 weeks. Therefore, long-term results seemed to positively promote the implementation of these compounds in clinical practice due to their low rate side effects. The aim of this narrative review is to delineate the impact of new potassium binders in the treatment of patients with HF by providing a critical reappraisal for daily application of novel therapies for hyperkalemia in the HF setting.
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Affiliation(s)
- Pietro Scicchitano
- Cardiology Section, Hospital “F. Perinei” Altamura (BA), 70022 Altamura, Italy;
- Correspondence: ; Tel.: +39-0803108286
| | - Massimo Iacoviello
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (M.I.); (M.M.)
| | - Francesco Massari
- Cardiology Section, Hospital “F. Perinei” Altamura (BA), 70022 Altamura, Italy;
| | - Micaela De Palo
- Cardiac Surgery Unit, Azienda Ospedaliero-Universitaria Policlinico Bari, 70124 Bari, Italy;
| | | | - Antonia Mannarini
- Division of University Cardiology, Cardiothoracic Department, Policlinic University Hospital, 70124 Bari, Italy;
| | - Andrea Passantino
- Division of Cardiology and Cardiac Rehabilitation, Scientific Clinical Institutes Maugeri, IRCCS Institute of Bari, 70124 Bari, Italy;
| | - Marco Matteo Ciccone
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy;
| | - Michele Magnesa
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (M.I.); (M.M.)
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Esteban-Fernández A, Ortiz Cortés C, López-Fernández S, Recio Mayoral A, Camacho Jurado FJ, Gómez Otero I, Molina M, Almenar Bonet L, López-Vilella R. Experience with the potassium binder patiromer in hyperkalaemia management in heart failure patients in real life. ESC Heart Fail 2022; 9:3071-3078. [PMID: 35748119 DOI: 10.1002/ehf2.13976] [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: 10/02/2021] [Revised: 04/06/2022] [Accepted: 05/08/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS Hyperkalaemia (HK) is common in heart failure (HF) patients, related to renal dysfunction and medical treatment. It limits medical therapy optimization, which impacts prognosis. New potassium (K) binders help control HK, allowing better medical management of HF. METHODS AND RESULTS A retrospective multicentre register included all outpatients with HF and HK (K ≥ 5.1 mEq/L) treated with patiromer according to current recommendations. We evaluated analytic and clinical parameters before starting the treatment and at 7, 30 and 90 days, as well as adverse events related to patiromer and treatment optimization. We included 74 patients (71.6% male) with a mean age of 70.8 years (SD 9.2). Sixty-seven patients (90.5%) presented HK in the previous year. Forty patients (54.1%) underwent down-titration of a renin-angiotensin-aldosterone inhibitor (RAASi) or a mineralocorticoid receptor antagonist (MRA), and 27 (36.5%) stopped any of them due to HK. Initial K was 5.5 mEq/L (SD 0.6), with a significantly reduction at 7 days (4.9 mEq/L (SD 0.8); P < 0.001), maintained at 90 days (4.9 mEq/L (SD 0.8); P < 0.001). There were no other electrolyte disturbances, with a slight improvement in renal function [glomerular filtration rate 39.6 mL/min (SD 20.4) to 42.7 mL/min (SD 23.2); P = 0.005]. Adverse events were reported in 33.9% of patients, the most common being hypomagnesaemia (16.3%), gastrointestinal disturbances (14.9%) and HK (2.8%). Withdrawal of patiromer was uncommon (12.2%) due to gastrointestinal disturbances in 66.7% of cases. Nine patients (12.2%) started on a RAASi, and 15 patients (20.3%) on an MRA during the follow-up. Forty-five patients (60.8%) increased the dose of RAASi or MRA, increasing to target doses in 5.4 and 10.8% of patients, respectively. At 90 days, NTproBNP values were reduced from 2509.5 pg/mL [IQR 1311-4,249] to 1396.0 pg/mL [IQR 804-4263]; P = 0.003, but the reduction was only observed in those who optimized HF medical treatment [NTproBNP from 1950.5 pg/mL (IQR 1208-3403) to 1349.0 pg/mL (IQR 804-2609); P < 0.01]. NYHA functional class only improved in 7.5% of patients, corresponding with those who optimized HF medical treatment. Compared with the previous 3 months before patiromer treatment, the rate of hospitalization was reduced from 28.4 to 10.9% (P < 0.01), and the emergency room visits from 18.9 to 5.4% (P < 0.01). CONCLUSIONS In a real-life cohort of patients with HF, patiromer reduced and maintained K levels during 3 months of follow-up. The most common adverse events were hypomagnesaemia and gastrointestinal disturbances. Patiromer helps optimize medical treatment, increasing the percentage of patients treated with RAASi and MRA at target doses. At the end of follow-up, natriuretic peptides values and hospital visits were reduced, suggesting the benefit of optimizing HF medical treatment.
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Affiliation(s)
- Alberto Esteban-Fernández
- Faculty of Health Sciences, Universidad Alfonso X el Sabio (UAX), Villanueva de la Cañada, Spain
- Cardiology Service, Hospital Universitario Severo Ochoa, Leganés, Spain
| | | | - Silvia López-Fernández
- Heart Failure Unit, Cardiology Service, Hospital Universitario Virgen de las Nieves, Granada, Spain
- IDIBELL, Instituto de Investigación Biosanitaria ibs, Granada, Spain
| | | | | | - Inés Gómez Otero
- Cardiology Service, Hospital Universitario de Santiago, A Coruña, Spain
| | - María Molina
- Faculty of Health Sciences, Universidad Alfonso X el Sabio (UAX), Villanueva de la Cañada, Spain
- Cardiology Service, Hospital Universitario Severo Ochoa, Leganés, Spain
| | - Luis Almenar Bonet
- Heart Failure and Transplant Unit, Cardiology Service, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- CIBERCV, Valencia, Spain
| | - Raquel López-Vilella
- Heart Failure and Transplant Unit, Cardiology Service, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- CIBERCV, Valencia, Spain
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Delgado-Jiménez JF, Segovia-Cubero J, Almenar-Bonet L, de Juan-Bagudá J, Lara-Padrón A, García-Pinilla JM, Bonilla-Palomas JL, López-Fernández S, Mirabet-Pérez S, Gómez-Otero I, Castro-Fernández A, Díaz-Molina B, Goirigolzarri-Artaza J, Rincón-Díaz LM, Pascual-Figal DA, Anguita-Sánchez M, Muñiz J, Crespo-Leiro MG. Prevalence, Incidence, and Outcomes of Hyperkalaemia in Patients with Chronic Heart Failure and Reduced Ejection Fraction from a Spanish Multicentre Study: SPANIK-HF Design and Baseline Characteristics. J Clin Med 2022; 11:jcm11051170. [PMID: 35268260 PMCID: PMC8910891 DOI: 10.3390/jcm11051170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 02/01/2023] Open
Abstract
Hyperkalaemia is a growing concern in the treatment of patients with heart failure and reduced ejection fraction (HFrEF) as it limits the use of some prognostic-modifying drugs and has a negative impact on prognosis. The objective of the present study was to estimate the prevalence of hyperkalaemia in outpatients with HFrEF and its impact on achieving optimal medical treatment. For this purpose, a multicentre, prospective, and observational study was carried out on consecutive HFrEF patients who were monitored as outpatients in heart failure (HF) units and who, in the opinion of their doctor, received optimal medical treatment. A total of 565 HFrEF patients were included from 16 specialised HF units. The mean age was 66 ± 12 years, 78% were male, 45% had an ischemic cause, 39% had atrial fibrillation, 43% were diabetic, 42% had a glomerular filtration rate < 60 mL/min/1.7 m2, and the mean left ventricular ejection fraction was 31 ± 7%. Treatment at the study entry included: 76% on diuretics, 13% on ivabradine, 7% on digoxin, 18.9% on angiotensin-conversing enzyme inhibitors (ACEi), 11.3% on angiotensin receptors blockers (ARBs), 63.8% on angiotensin-neprilysin inhibitors (ARNi), 78.5% on mineralocorticoid receptor antagonists (MRAs), and 92.9% on beta-blockers. Potassium levels in the baseline analysis were: ≤5 mEq/L = 80.5%, 5.1−5.4 mEq/L = 13.8%, 5.5−5.9 mEq/L = 4.6%, and ≥6 mEq/L = 1.06%. Hyperkalaemia was the reason for not prescribing or reaching the target dose of an MRAs in 34.8% and 12.5% of patients, respectively. The impact of hyperkalaemia on not prescribing or dropping below the target dose in relation to ACEi, ARBs, and ARNi was significantly less. In conclusion, hyperkalaemia is a frequent problem in the management of patients with HFrEF and a limiting factor in the optimisation of medical treatment.
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Affiliation(s)
- Juan F. Delgado-Jiménez
- Instituto de Investigación y Servicio de Cardiología del Hospital Universitario 12 de Octubre, 28041 Madrid, Spain;
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Correspondence:
| | - Javier Segovia-Cubero
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, 28222 Madrid, Spain
| | - Luis Almenar-Bonet
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Servicio de Cardiología, Hospital Universitario La Fe, 46026 Valencia, Spain
| | - Javier de Juan-Bagudá
- Instituto de Investigación y Servicio de Cardiología del Hospital Universitario 12 de Octubre, 28041 Madrid, Spain;
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
| | - Antonio Lara-Padrón
- Servicio de Cardiología, Hospital Universitario de Canarias, 38320 Santa Cruz de Tenerife, Spain;
| | - José Manuel García-Pinilla
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Servicio de Cardiología, International Business Information Management Association, Hospital Universitario Virgen de la Victoria, 29010 Malaga, Spain
| | | | - Silvia López-Fernández
- Servicio de Cardiología, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
| | - Sonia Mirabet-Pérez
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain
| | - Inés Gómez-Otero
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Servicio de Cardiología, Complexo Hospitalario Universitario de Santiago de Compostela, 15706 A Coruña, Spain
| | | | - Beatriz Díaz-Molina
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Servicio de Cardiología, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Josebe Goirigolzarri-Artaza
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Servicio de Cardiología, Hospital Universitario Clínico de San Carlos, 28040 Madrid, Spain
| | - Luis Miguel Rincón-Díaz
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Servicio de Cardiología, Hospital Ramón y Cajal, 28034 Madrid, Spain
| | - Domingo Andrés Pascual-Figal
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | | | - Javier Muñiz
- Instituto de Investigación Biomédica de A Coruña, Universidade da Coruña (UDC), 15006 A Coruña, Spain;
| | - María G. Crespo-Leiro
- Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), 28029 Madrid, Spain; (J.S.-C.); (L.A.-B.); (J.M.G.-P.); (S.M.-P.); (I.G.-O.); (B.D.-M.); (J.G.-A.); (L.M.R.-D.); (D.A.P.-F.); (M.G.C.-L.)
- Servicio de Cardiología, Complexo Hospitalario Universitario, 15006 A Coruña, Spain
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Olry de Labry Lima A, Díaz Castro Ó, Romero-Requena JM, García Díaz-Guerra MDLR, Arroyo Pineda V, de la Hija Díaz MB, Ascanio M, Darbà J, Cruzado JM. Hyperkalaemia management and related costs in chronic kidney disease patients with comorbidities in Spain. Clin Kidney J 2021; 14:2391-2400. [PMID: 34754435 PMCID: PMC8573009 DOI: 10.1093/ckj/sfab076] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Hyperkalaemia (HK) is a common electrolyte disorder in patients with chronic kidney disease (CKD) and/or treated with renin-angiotensin-aldosterone system inhibitors (RAASis). The aim of this study is to determine the severity, current management and cost of chronic HK. METHODS We performed a retrospective cohort study of patients with chronic HK and CKD, heart failure or diabetes mellitus between 2011 and 2018. The study follow-up was 36 months. RESULTS A total of 1499 patients with chronic HK were analysed: 66.2% presented with mild HK, 23.4% with moderate HK and 10.4% with severe HK. The severity was associated with CKD stage. Most patients (70.4%) were on RAASi therapies, which were frequently discontinued (discontinuation rate was 39.8, 49.8 and 51.8% in mild, moderate and severe HK, respectively). This RAASi discontinuation was similar with or without resin prescription. Overall, ion-exchange resins were prescribed to 42.5% of patients with HK and prescriptions were related to the severity of HK, being 90% for severe HK. Adherence to resin treatment was very low (36.8% in the first year and 17.5% in the third year) and potassium remained elevated in most patients with severe HK. The annual healthcare cost per patient with HK was €5929, reaching €12 705 in severe HK. Costs related to HK represent 31.9% of the annual cost per HK patient and 58.8% of the specialized care cost. CONCLUSIONS HK was usually managed by RAASi discontinuation and ion-exchange resin treatment. Most patients with HK were non-adherent to resins and those with severe HK remained with high potassium levels, despite bearing elevated healthcare expenditures.
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Affiliation(s)
- Antonio Olry de Labry Lima
- Escuela Andaluza de Salud Pública, Granada, Spain
- CIBER en Epidemiología y Salud Pública, Madrid, Spain
- Instituto de Investigación Biosanitaria, Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
| | - Óscar Díaz Castro
- Servizo de Cardioloxía, Complejo Hospitalario Universitario de Vigo, Servizo Galego de Saúde, Vigo, Pontevedra, Spain
| | | | | | - Virginia Arroyo Pineda
- Servicio de Farmacia de Atención Primaria, Hospital Nuestra Señora del Prado, Talavera de la Reina (Toledo), Spain
| | - M Belén de la Hija Díaz
- Servicio de Farmacia de Atención Primaria, Hospital Nuestra Señora del Prado, Talavera de la Reina (Toledo), Spain
| | | | - Josep Darbà
- Department of Economics, Universitat de Barcelona, Barcelona, Spain
| | - Josep M Cruzado
- Department of Nephrology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
- Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain
- Spanish Network for Renal Research, ISCIII, Madrid, Spain
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Laymito-Quispe RDP, López-Vilella R, Sánchez-Lázaro I, Donoso-Trenado V, Lozano-Edo S, Martínez-Dolz L, Almenar-Bonet L. Prognostic implications of hypo and hyperkalaemia in acute heart failure with reduced ejection fraction. Analysis of cardiovascular mortality and hospital readmissions. Med Clin (Barc) 2021; 158:211-217. [PMID: 34229884 DOI: 10.1016/j.medcli.2021.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/14/2021] [Accepted: 03/18/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Potassium alterations constitute a major clinical problem in decompensated heart failure (HF). This study aims to assess the prognostic implications of hypo and hyperkalaemia on admission for acute HF in cardiovascular mortality and hospital readmissions. MATERIAL AND METHOD From January 2016 to June 2020, 1,397 cases with a diagnosis of acute HF were admitted. Admission programmed for study, elective therapies, and patients with LVEF> 40% were excluded. The study was carried out on 689 patients, 45 with K+ <3.5 mmol/L, 49K +>5.0 mmol/L and 595K+3.5-5.0 mmol/L. Medical history, baseline clinical profile, drug therapy, and potassium levels obtained upon admission were analysed. RESULTS Annual mortality due to hypokalaemia (K+<3.5mmol/L) was 37.8% (HR 2.4; 95% CI: 1.3-4.7; P<.007); for hyperkalaemia 40.8% (HR: 1.9; 95% CI: 0.98-3.51; P<.055). Creatinine level and age were variables associated with mortality in both the hyperkalaemic and hypokalaemic cohorts. Hospital readmissions did not show statistical association with these electrolyte disorders. CONCLUSIONS In patients admitted for decompensated HF, both hyperkalaemia and hypokalaemia determined at admission have a negative prognostic impact on survival. Creatinine and age are other independent factors associated with mortality. The effect on the probability of hospital readmission at one year is not demonstrated in this study.
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Affiliation(s)
- Rocío Del Pilar Laymito-Quispe
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España.
| | - Raquel López-Vilella
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España
| | - Ignacio Sánchez-Lázaro
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Valencia, España
| | - Víctor Donoso-Trenado
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España
| | - Silvia Lozano-Edo
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España
| | - Luis Martínez-Dolz
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España; Facultad de Medicina, Universidad de Valencia, Valencia, España
| | - Luis Almenar-Bonet
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Servicio de Cardiología, Hospital Universitari i Politècnic La Fe. Valencia, España; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Valencia, España; Facultad de Medicina, Universidad de Valencia, Valencia, España
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Rosano GMC, Moura B, Metra M, Böhm M, Bauersachs J, Ben Gal T, Adamopoulos S, Abdelhamid M, Bistola V, Čelutkienė J, Chioncel O, Farmakis D, Ferrari R, Filippatos G, Hill L, Jankowska EA, Jaarsma T, Jhund P, Lainscak M, Lopatin Y, Lund LH, Milicic D, Mullens W, Pinto F, Ponikowski P, Savarese G, Thum T, Volterrani M, Anker SD, Seferovic PM, Coats AJS. Patient profiling in heart failure for tailoring medical therapy. A consensus document of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2021; 23:872-881. [PMID: 33932268 DOI: 10.1002/ejhf.2206] [Citation(s) in RCA: 129] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/17/2021] [Accepted: 04/29/2021] [Indexed: 12/22/2022] Open
Abstract
Despite guideline recommendations and available evidence, implementation of treatment in heart failure (HF) is poor. The majority of patients are not prescribed drugs at target doses that have been proven to positively impact morbidity and mortality. Among others, tolerability issues related to low blood pressure, heart rate, impaired renal function or hyperkalaemia are responsible. Chronic kidney disease plays an important role as it affects up to 50% of patients with HF. Also, dynamic changes in estimated glomerular filtration rate may occur during the course of HF, resulting in inappropriate dose reduction or even discontinuation of decongestive or neurohormonal modulating therapy in clinical practice. As patients with HF are rarely naïve to pharmacologic therapies, the challenge is to adequately prioritize or select the most appropriate up-titration schedule according to patient profile. In this consensus document, we identified nine patient profiles that may be relevant for treatment implementation in HF patients with a reduced ejection fraction. These profiles take into account heart rate (<60 bpm or >70 bpm), the presence of atrial fibrillation, symptomatic low blood pressure, estimated glomerular filtration rate (<30 or >30 mL/min/1.73 m2 ) or hyperkalaemia. The pre-discharge patient, frequently still congestive, is also addressed. A personalized approach, adjusting guideline-directed medical therapy to patient profile, may allow to achieve a better and more comprehensive therapy for each individual patient than the more traditional, forced titration of each drug class before initiating treatment with the next.
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Affiliation(s)
| | - Brenda Moura
- Armed Forces Hospital, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marco Metra
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Centre, Petah Tikva, Israel
| | | | - Magdy Abdelhamid
- Faculty of Medicine, Department of Cardiology, Cairo University, Giza, Egypt
| | - Vasiliki Bistola
- Department of Cardiology, Attikon University Hospital, University of Athens Medical School, Athens, Greece
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
| | - Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest, Romania.,Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
| | | | - Roberto Ferrari
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy.,Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, University Hospital Attikon, Athens, Greece
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Northern Ireland, UK
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University and Center for Heart Diseases, University Hospital in Wroclaw, Wroclaw, Poland
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linkoping University, Linköping, Sweden.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pardeep Jhund
- Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yuri Lopatin
- Volgograd State Medical University, Regional Cardiology Centre Volgograd, Volgograd, Russian Federation
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Davor Milicic
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, BIOMED - Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium.,Department of Cardiology, Ziekenhuis Oost, Genk, Belgium
| | - Fausto Pinto
- Cardiology Department, University Hospital Santa Maria (CHULN), CAML, CCUL, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Piotr Ponikowski
- Centre for Heart Diseases, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Thum
- Hannover Medical School, Institute of Molecular and Translational Therapeutic Strategies, Hannover, Germany
| | | | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Petar M Seferovic
- Department Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
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Jiménez-Marrero S, Cainzos-Achirica M, Monterde D, Vela E, Cleries M, García-Eroles L, Enjuanes C, Yun S, Garay A, Moliner P, Alcoberro L, Corbella X, Comin-Colet J. Impacto clínico y en costes sanitarios de alteraciones de potasio en pacientes con enfermedades cardiovasculares, metabólicas y renales crónicas. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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Crespo-Leiro MG, Barge-Caballero E, Muñiz J. Importancia de las alteraciones del potasio. Más allá de la insuficiencia cardiaca. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Crespo-Leiro MG, Barge-Caballero E, Muñiz J. Significance of potassium alterations. Beyond heart failure. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2021; 74:293-295. [PMID: 33461927 DOI: 10.1016/j.rec.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 11/10/2020] [Indexed: 06/12/2023]
Affiliation(s)
- María G Crespo-Leiro
- Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Universidade da Coruña (UDC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Eduardo Barge-Caballero
- Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Javier Muñiz
- Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Universidade da Coruña (UDC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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11
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Caravaca Perez P, González-Juanatey JR, Nuche J, Morán Fernández L, Lora Pablos D, Alvarez-García J, Bascompte Claret R, Martínez Selles M, Vázquez García R, Martínez Dolz L, Cobo-Marcos M, Pascual Figal D, Crespo-Leiro MG, Nuñez Villota J, Cinca Cuscullola J, Delgado JF. Serum potassium dynamics during acute heart failure hospitalization. Clin Res Cardiol 2020; 111:368-379. [DOI: 10.1007/s00392-020-01753-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 09/30/2020] [Indexed: 12/27/2022]
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12
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Jiménez-Marrero S, Cainzos-Achirica M, Monterde D, Vela E, Cleries M, García-Eroles L, Enjuanes C, Yun S, Garay A, Moliner P, Alcoberro L, Corbella X, Comín-Colet J. Impact on clinical outcomes and health costs of deranged potassium levels in patients with chronic cardiovascular, metabolic, and renal conditions. ACTA ACUST UNITED AC 2020; 74:312-320. [PMID: 32694080 DOI: 10.1016/j.rec.2020.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/04/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND OBJECTIVES Potassium derangements are frequent among patients with chronic cardiovascular conditions. Studies on the associations between potassium derangements and clinical outcomes have yielded mixed findings, and the implications for health care expenditure are unknown. We assessed the population-based associations between hyperkalemia, hypokalemia and clinical outcomes and health care costs, in patients with chronic heart failure, chronic kidney disease, diabetes mellitus, hypertension, and ischemic heart disease. METHODS Population-based, longitudinal study including up to 36 269 patients from a health care area with at least one of the above-mentioned conditions. We used administrative, hospital and primary care databases. Participants were followed up between 2015 and 2017, were aged ≥ 55 years and had at least 1 potassium measurement. Four analytic designs were used to evaluate prevalent and incident cases and the use of renin-angiotensin-aldosterone system inhibitors. RESULTS Hyperkalemia was twice as frequent as hypokalemia. On multivariable-adjusted analyses, hyperkalemia was robustly and significantly associated with an increased risk of all-cause death (HR from Cox regression models ranging from 1.31-1.68) and with an increased odds of a yearly health care expenditure >85th percentile (OR, 1.21-1.29). Associations were even stronger in hypokalemic patients (HR for all-cause death, 1.92-2.60; OR for health care expenditure> percentile 85th, 1.81-1.85). CONCLUSIONS Experimental studies are needed to confirm whether the prevention of potassium derangements reduces mortality and health care expenditure in these chronic conditions. Until then, our findings provide observational evidence on the potential importance of maintaining normal potassium levels.
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Affiliation(s)
- Santiago Jiménez-Marrero
- Unidad Multidisciplinar de Insuficiencia Cardiaca Comunitaria (UMICO), Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Miguel Cainzos-Achirica
- Unidad Multidisciplinar de Insuficiencia Cardiaca Comunitaria (UMICO), Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Medical Institutions, Baltimore (MD), United States; Facultad de Medicina y Ciencias de la Salud, Universidad Internacional de Cataluña, Barcelona, Spain
| | - David Monterde
- Unitat d'Informació i Coneixement, Servei Català de la Salut (CatSalut), Barcelona, Spain
| | - Emili Vela
- Unitat d'Informació i Coneixement, Servei Català de la Salut (CatSalut), Barcelona, Spain
| | - Montse Cleries
- Unitat d'Informació i Coneixement, Servei Català de la Salut (CatSalut), Barcelona, Spain
| | - Luis García-Eroles
- Unitat d'Informació i Coneixement, Servei Català de la Salut (CatSalut), Barcelona, Spain
| | - Cristina Enjuanes
- Unidad Multidisciplinar de Insuficiencia Cardiaca Comunitaria (UMICO), Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sergi Yun
- Unidad Multidisciplinar de Insuficiencia Cardiaca Comunitaria (UMICO), Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Servicio de Medicina Interna, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alberto Garay
- Unidad Multidisciplinar de Insuficiencia Cardiaca Comunitaria (UMICO), Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Pedro Moliner
- Unidad Multidisciplinar de Insuficiencia Cardiaca Comunitaria (UMICO), Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Lidia Alcoberro
- Unidad Multidisciplinar de Insuficiencia Cardiaca Comunitaria (UMICO), Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Corbella
- Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Servicio de Medicina Interna, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Grupo de Evaluación de Determinantes de Salud y Políticas Sanitarias, Facultad de Medicina y Ciencias de la Salud, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Josep Comín-Colet
- Unidad Multidisciplinar de Insuficiencia Cardiaca Comunitaria (UMICO), Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Departamento de Ciencias Clínicas, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain.
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13
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Camps-Vilaró A, Delgado-Jiménez JF, Farré N, Tizón-Marcos H, Álvarez-García J, Cinca J, Dégano IR, Marrugat J. Estimated Population Prevalence of Heart Failure with Reduced Ejection Fraction in Spain, According to DAPA-HF Study Criteria. J Clin Med 2020; 9:jcm9072089. [PMID: 32635219 PMCID: PMC7408645 DOI: 10.3390/jcm9072089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/22/2022] Open
Abstract
Heart failure (HF) is one of the main causes of morbidity, mortality, and high healthcare costs. Dapagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor, reduced cardiovascular mortality and hospitalization for HF compared to placebo in patients with chronic HF, and reduced ejection fraction (EF) in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) study. Our aim was to estimate the number of patients with DAPA-HF characteristics in Spain. Our literature review identified epidemiological studies whose objective was to quantify the prevalence of HF and its comorbidities in Spain. We estimated the prevalence of HF with reduced EF, of New York Heart Association (NYHA) functional class II–IV, and with a glomerular filtration rate (GFR) ≥ 30 mL/min/1.73 m². In this population, we analysed the prevalence of diabetes using data from the REDINSCOR (Spanish Network for Heart Failure) registry. Our estimations indicate there are 594,684 patients ≥45 years old with HF in Spain (2.6% of this population age group), of which 52.4%, 84.0%, and 93.9% have reduced EF, are NYHA II–IV, and have a GFR ≥ 30 mL/min/1.73 m², respectively. By our calculations, approximately 245,789 Spanish patients would meet the DAPA-HF patient profile, and therefore could benefit from the protective cardiovascular effects of dapagliflozin.
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Affiliation(s)
- Anna Camps-Vilaró
- REGICOR Study Group, IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain;
- CIBER of Cardiovascular Diseases (CIBERCV), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (J.F.D.-J.); (J.Á.-G.); (J.C.)
| | - Juan F. Delgado-Jiménez
- CIBER of Cardiovascular Diseases (CIBERCV), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (J.F.D.-J.); (J.Á.-G.); (J.C.)
- Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
- Faculty of Medicine, Complutense University of Madrid (UCM), 28040 Madrid, Spain
| | - Núria Farré
- Department of Cardiology, Hospital del Mar, 08003 Barcelona, Spain; (N.F.); (H.T.-M.)
- Heart Diseases Biomedical Research Group (GREC), IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Faculty of Medicine, Universitat Autónoma de Barcelona (UAB), 08193 Barcelona, Spain
| | - Helena Tizón-Marcos
- Department of Cardiology, Hospital del Mar, 08003 Barcelona, Spain; (N.F.); (H.T.-M.)
- Heart Diseases Biomedical Research Group (GREC), IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
| | - Jesús Álvarez-García
- CIBER of Cardiovascular Diseases (CIBERCV), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (J.F.D.-J.); (J.Á.-G.); (J.C.)
- Faculty of Medicine, Universitat Autónoma de Barcelona (UAB), 08193 Barcelona, Spain
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain
| | - Juan Cinca
- CIBER of Cardiovascular Diseases (CIBERCV), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (J.F.D.-J.); (J.Á.-G.); (J.C.)
- Faculty of Medicine, Universitat Autónoma de Barcelona (UAB), 08193 Barcelona, Spain
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain
| | - Irene R. Dégano
- REGICOR Study Group, IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain;
- CIBER of Cardiovascular Diseases (CIBERCV), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (J.F.D.-J.); (J.Á.-G.); (J.C.)
- Faculty of Medicine, University of Vic-Central University of Catalonia (UVic-UCC), 08500 Vic, Spain
- Correspondence: (I.R.D.); (J.M.); Tel.: +349-3316-0714 (I.R.D.); +349-3316-0733 (J.M.)
| | - Jaume Marrugat
- REGICOR Study Group, IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain;
- CIBER of Cardiovascular Diseases (CIBERCV), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (J.F.D.-J.); (J.Á.-G.); (J.C.)
- Correspondence: (I.R.D.); (J.M.); Tel.: +349-3316-0714 (I.R.D.); +349-3316-0733 (J.M.)
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