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Chrysohoou C, Magkas N, Antoniou CK, Manolakou P, Laina A, Tousoulis D. The Role of Antithrombotic Therapy in Heart Failure. Curr Pharm Des 2020; 26:2735-2761. [PMID: 32473621 DOI: 10.2174/1381612826666200531151823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022]
Abstract
Heart failure is a major contributor to global morbidity and mortality burden affecting approximately 1-2% of adults in developed countries, mounting to over 10% in individuals aged >70 years old. Heart failure is characterized by a prothrombotic state and increased rates of stroke and thromboembolism have been reported in heart failure patients compared with the general population. However, the impact of antithrombotic therapy on heart failure remains controversial. Administration of antiplatelet or anticoagulant therapy is the obvious (and well-established) choice in heart failure patients with cardiovascular comorbidity that necessitates their use, such as coronary artery disease or atrial fibrillation. In contrast, antithrombotic therapy has not demonstrated any clear benefit when administered for heart failure per se, i.e. with heart failure being the sole indication. Randomized studies have reported decreased stroke rates with warfarin use in patients with heart failure with reduced left ventricular ejection fraction, but at the expense of excessive bleeding. Non-vitamin K oral anticoagulants have shown a better safety profile in heart failure patients with atrial fibrillation compared with warfarin, however, current evidence about their role in heart failure with sinus rhythm is inconclusive and further research is needed. In the present review, we discuss the role of antithrombotic therapy in heart failure (beyond coronary artery disease), aiming to summarize evidence regarding the thrombotic risk and the role of antiplatelet and anticoagulant agents in patients with heart failure.
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Affiliation(s)
- Christina Chrysohoou
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Nikolaos Magkas
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | | | - Panagiota Manolakou
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Aggeliki Laina
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
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Drug-Drug Interactions in Acute Coronary Syndrome Patients: Systematic Review. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2019-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Drug-drug interaction (DDI) is defined as a clinically significant change in the exposure and/or response to a drug caused by co-administration of another drug which may result in a precipitation of an adverse event or alteration of its therapeutic effects. The aim of this systematic review was to provide an overview of DDIs that were actually observed or evaluated in acute coronary syndrome (ACS) patients with particular focus on DDIs with clinical relevance. Electronic searches of the literature were conducted in the following databases: MEDLINE, EBSCO, Scopus, Google Scholar and SCIndeks. A total of 117 articles were included in the review. This review showed that ACS patients can be exposed to a variety of DDIs with diverse outcomes which include decreased efficacy of antiplatelet drugs, thrombolytics or anticoagulants, increased risk of bleeding, rhabdomyolysis, hepatotoxicity, adverse effects on cardiovascular system (e.g. QT interval prolongation, arrhythmias, excessive bradycardia, severe hypotension), serotonin syndrome and drug-induced fever. Majority of the DDIs involved antiplatelet drugs (e.g. aspirin, clopidogrel and ticagrelor). Evidence of some of the reported DDIs is inconclusive as some of the studies have shown conflicting results. There is a need for additional post-marketing and population-based studies to evaluate the true effects of disease states and other factors on the clinical outcomes of DDIs. Clinicians should be attentive to the potential for DDIs and their associated harm in order to minimize or, if possible, avoid medication-related adverse events in ACS patients.
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Al-Zakwani I, Panduranga P, Al-Lawati JA, Sulaiman K, Alsheikh-Ali AA, AlHabib KF, Suwaidi JA, Al-Mahmeed W, AlFaleh H, Alnobani O, Al-Motarreb A, Ridha M, Bulbanat B, Al-Jarallah M, Bazargani N, Asaad N, Amin H. Impact of Clopidogrel on Mortality in Patients With Acute Heart Failure Stratified by Coronary Artery Disease: Findings From the Arabian Gulf Acute Heart Failure Registry (Gulf CARE). Angiology 2018; 69:884-891. [PMID: 29747514 DOI: 10.1177/0003319718775552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We evaluated the impact of clopidogrel use on 3- and 12-months all-cause mortality in patients with acute heart failure (AHF) stratified by coronary artery disease (CAD) in patients admitted to 47 hospitals in 7 Middle Eastern countries with AHF from February to November 2012. Clopidogrel use was associated with significantly lower risk of all-cause mortality at 3 months (adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI]: 0.42-0.87; P = .007) and 12 months (aOR, 0.61; 95% CI: 0.47-0.79; P < .001). When the analysis was stratified by CAD, the clopidogrel group in those with AHF and CAD was also associated with significantly lower risk of all-cause mortality at 3 months (aOR, 0.56; 95% CI: 0.38-0.83; P = .003) and 12 months (aOR, 0.58; 95% CI: 0.44-0.77; P < .001). However, in AHF patients without CAD, clopidogrel use was not associated with any survival advantages, neither at 3 months (aOR, 0.99; 95% CI: 0.32-3.11; P = .987) nor at 12 months (aOR, 0.80; 95% CI: 0.37-1.72; P = .566). Clopidogrel use was associated with short- and long-term all-cause mortality in patients with AHF and CAD. In AHF patients without CAD, clopidogrel use did not offer any survival advantage.
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Affiliation(s)
- Ibrahim Al-Zakwani
- 1 Department of Pharmacology & Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos University and Gulf Health Research, Muscat, Oman
| | | | | | - Kadhim Sulaiman
- 2 Department of Cardiology, Royal Hospital, Muscat, Oman.,3 Ministry of Health, Muscat, Oman
| | - Alawi A Alsheikh-Ali
- 4 College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Khalid F AlHabib
- 5 Department of Cardiac Sciences, King Fahad Cardiac Centre, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jassim Al Suwaidi
- 6 Department of Adult Cardiology, Hamad Medical Corporation and Qatar Cardiovascular Research Centre, Doha, Qatar
| | - Wael Al-Mahmeed
- 7 Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Hussam AlFaleh
- 5 Department of Cardiac Sciences, King Fahad Cardiac Centre, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Omar Alnobani
- 5 Department of Cardiac Sciences, King Fahad Cardiac Centre, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmed Al-Motarreb
- 8 Department of Internal Medicine, Faculty of Medicine, Sana'a University, Sana'a, Yemen
| | - Mustafa Ridha
- 9 Division of Cardiology, Al-Dabous Cardiac Centre, Al Adan Hospital, Kuwait City, Kuwait
| | - Bassam Bulbanat
- 10 Department of Cardiology, Sabah Al Ahmed Cardiac Centre, Kuwait City, Kuwait
| | | | - Nooshin Bazargani
- 11 Department of Cardiology, Dubai Hospital, Dubai, United Arab Emirates
| | - Nidal Asaad
- 6 Department of Adult Cardiology, Hamad Medical Corporation and Qatar Cardiovascular Research Centre, Doha, Qatar
| | - Haitham Amin
- 12 Mohammed Bin Khalifa Cardiac Centre, Manama, Bahrain
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4
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Aspirin and blood pressure: Effects when used alone or in combination with antihypertensive drugs. Rev Port Cardiol 2017; 36:551-567. [PMID: 28684123 DOI: 10.1016/j.repc.2017.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 05/22/2017] [Indexed: 12/31/2022] Open
Abstract
Arterial hypertension is a major risk factor for cardiovascular and renal events. Lowering blood pressure is thus an important strategy for reducing morbidity and mortality. Since low-dose aspirin is a cornerstone in the prevention of adverse cardiovascular outcomes, combined treatment with aspirin and antihypertensive drugs is very common. However, the impact of aspirin therapy on blood pressure control remains a subject of intense debate. Recent data suggest that the cardioprotective action of aspirin extends beyond its well-known antithrombotic effect. Aspirin has been shown to trigger the synthesis of specialized pro-resolving lipid mediators from arachidonic acid and omega-3 fatty acids. These novel anti-inflammatory and pro-resolving mediators actively stimulate the resolution of inflammation and tissue regeneration. Additionally, they may contribute to other protective effects on redox status and vascular reactivity that have also been attributed to aspirin. Of note, aspirin has been shown to improve vasodilation through cyclooxygenase-independent mechanisms. On the other hand, higher aspirin doses have been reported to exert a negative impact on blood pressure due to inhibition of cyclooxygenase-2 activity, which reduces renal blood flow, glomerular filtration rate and sodium and water excretion. This review aims to provide an overview of the effects of aspirin on blood pressure and the underlying mechanisms, focusing on the interaction between aspirin and antihypertensive drugs. Studies in both experimental and human hypertension are presented.
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Costa AC, Reina-Couto M, Albino-Teixeira A, Sousa T. Aspirin and blood pressure: Effects when used alone or in combination with antihypertensive drugs. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Abstract
Heart failure (HF) with abnormal left ventricular (LV) ejection fraction should be identified and treated. Treat hypertension with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Treat myocardial ischemia with nitrates and β-blockers. Treat volume overload and HF with diuretics. Treat HF with ACE inhibitors and β-blockers. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in chronic symptomatic HF and abnormal LV ejection fraction. Add isosorbide dinitrate/hydralazine in African Americans with class II to IV HF treated with diuretics, ACE inhibitors, and β-blockers. Exercise training is recommended. Indications for implantable cardioverter-defibrillator and cardiac resynchronization therapy are discussed.
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Affiliation(s)
- Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Macy Pavilion, Room 141, Valhalla, NY 10595, USA.
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Abstract
Heart failure continues to be a leading cause of morbidity and mortality throughout the United States. The pathophysiology of heart failure involves the activation of complex neurohormonal pathways, many of which mediate not only hypertrophy and fibrosis within ventricular myocardium and interstitium, but also activation of platelets and alteration of vascular endothelium. Platelet activation and vascular endothelial dysfunction may contribute to the observed increased risk of thromboembolic events in patients with chronic heart failure. However, current data from clinical trials do not support the routine use of chronic antiplatelet or oral anticoagulation therapy for ambulatory heart failure patients without other indications (atrial fibrillation and/or coronary artery disease) as the risk of bleeding seems to outweigh the potential benefit related to reduction in thromboembolic events. In this review, we consider the potential clinical utility of targeting specific pathophysiological mechanisms of platelet and vascular endothelial activation to guide clinical decision making in heart failure patients.
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Aronow WS. Update of treatment of heart failure with reduction of left ventricular ejection fraction. Arch Med Sci Atheroscler Dis 2016; 1:e106-e116. [PMID: 28905031 PMCID: PMC5421520 DOI: 10.5114/amsad.2016.63002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 10/02/2016] [Indexed: 12/11/2022] Open
Abstract
Underlying and precipitating causes of heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) should be identified and treated when possible. Hypertension should be treated with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Diuretics are the first-line drugs in the treatment of patients with HFrEF and volume overload. Angiotensin-converting enzyme inhibitors and β-blockers (carvedilol, sustained-release metoprolol succinate, or bisoprolol) should be used in treatment of HFrEF. Use an angiotensin II receptor blocker (ARB) (candesartan or valsartan) if intolerant to ACE inhibitors because of cough or angioneurotic edema. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in patients with chronic symptomatic HFrEF class II or III to further reduce morbidity and mortality. Add an aldosterone antagonist (spironolactone or eplerenone) in selected patients with class II-IV HF who can be carefully monitored for renal function and potassium concentration. (Serum creatinine should be ≤ 2.5 mg/dl in men and ≤ 2.0 mg/dl in women. Serum potassium should be < 5.0 mEq/l). Add isosorbide dinitrate plus hydralazine in patients self-described as African Americans with class II-IV HF being treated with diuretics, ACE inhibitors, and β-blockers. Ivabradine can be used in selected patients with HFrEF.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Division of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
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9
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Aronow WS. Current treatment of heart failure with reduction of left ventricular ejection fraction. Expert Rev Clin Pharmacol 2016; 9:1619-1631. [PMID: 27673415 DOI: 10.1080/17512433.2016.1242067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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10
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Meune C, Mourad JJ, Bergmann JF, Spaulding C. Interaction between cyclooxygenase and the renin-angiotensin-aldosterone system: rationale and clinical relevance. J Renin Angiotensin Aldosterone Syst 2016; 4:149-54. [PMID: 14608518 DOI: 10.3317/jraas.2003.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Increased understanding of pathophysiological mechanisms of cardiovascular diseases has shown that the renin-angiotensin-aldosterone system (RAAS) is activated in this setting and suggests a central role for the angiotensin-converting enzyme (ACE). ACE transforms angiotensin I (Ang I) to angiotensin II (Ang II), and also promotes the degradation of bradykinin into inactive metabolites. These bradykinins stimulate nitric oxide synthesis and vasodilatator prostaglandin synthesis via a cyclooxygenase (COX) pathway. COX inhibitors may therefore be deleterious in cardiovascular disease and/or counteract part of ACE inhibitor (ACE-I) efficacy. This has been clearly demonstrated with non-steroidal anti-inflammatory drugs (NSAIDs), including high-dose aspirin, in avoiding their use in such patients. hypertension, coronary artery disease and chronic heart failure (CHF); most guidelines recommend avoiding their use in such patients. Theoretically, this effect is dose-mediated and the existence of an identical deleterious effect with low-dose aspirin has been an area of intense debate. In this article, we review studies, most of them conducted in CHF, that pointed out such a possible deleterious effect and a counteraction of ACE-Is with low-dose aspirin , using various criteria of assessment. However, there are no prospective long-term studies that have validated such an effect, and the role of other anti-aggregating agents has not been evaluated. Until such studies are published, the use of low-dose aspirin (100 mg/day) in such patients can be recommended.
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Affiliation(s)
- Christophe Meune
- Department of Cardiology, Cochin Hospital, Rene Descartes University, Paris, France
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11
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Lip GYH, Wrigley BJ, Pisters R. WITHDRAWN: Antiplatelet agents versus control or anticoagulation for heart failure in sinus rhythm. Cochrane Database Syst Rev 2016:CD003333. [PMID: 27140950 DOI: 10.1002/14651858.cd003333.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Gregory Y H Lip
- Institute Cardiovascular Sciences, University of Birmingham, City Hospital, Birmingham, UK, B18 7QH
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12
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Chin KL, Collier TJ, Pitt B, McMurray JJV, Swedberg K, van Veldhuisen DJ, Pocock SJ, Vincent J, Turgonyi E, Zannad F, Krum H. Aspirin does not reduce the clinical benefits of the mineralocorticoid receptor antagonist eplerenone in patients with systolic heart failure and mild symptoms: an analysis of the EMPHASIS-HF study. Eur J Heart Fail 2016; 18:1175-81. [PMID: 26833642 DOI: 10.1002/ejhf.485] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 11/12/2015] [Accepted: 11/20/2015] [Indexed: 11/10/2022] Open
Abstract
AIMS It is not known whether concomitant use of aspirin might attenuate the beneficial effects of mineralocorticoid receptor antagonists (MRAs). The purpose of this subgroup analysis was to explore the interaction between baseline aspirin treatment and the effect of eplerenone on the primary efficacy outcomes (composite of hospitalization for heart failure or cardiovascular mortality), its components, and safety markers [estimated glomerular filtration rate (eGFR), systolic blood pressure (SBP), and serum potassium >5.5 mmol/L] in the Eplerenone in Mild Patients Hospitalization and SurvIval Study in Heart Failure trial (EMPHASIS-HF). METHODS AND RESULTS Patients with chronic heart failure, reduced ejection fraction (HFREF), and mild symptoms were enrolled in EMPHASIS-HF. We evaluated baseline characteristics according to aspirin use. We explored the interaction between aspirin and eplerenone, using Cox proportional hazards models providing adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) and P-values for interaction. Of the 2737 patients randomized, 1605 patients (58.6%) were taking aspirin. The beneficial effects of eplerenone on the primary endpoint were similar in patients not treated (adjusted HR 0.59, 95% CI 0.46-0.75) or treated (adjusted HR 0.71, 95% CI 0.59-0.87) with aspirin at baseline (interaction P-value = 0.19). We did not observe any significant modification of the safety markers by aspirin that was clinically meaningful. CONCLUSION Aspirin use in patients with chronic systolic heart failure and mild symptoms did not substantially reduce the overall beneficial effects of the MRA eplerenone contrary to what has been described in some studies with ACE inhibitors.
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Affiliation(s)
- Ken Lee Chin
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.,National Heart and Lung Institute, Imperial College, London, UK
| | | | | | | | | | - Faiez Zannad
- CHU and University Henri Poincaré, Nancy, France
| | - Henry Krum
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
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Hopper I, Samuel R, Hayward C, Tonkin A, Krum H. Can medications be safely withdrawn in patients with stable chronic heart failure? systematic review and meta-analysis. J Card Fail 2014; 20:522-32. [PMID: 24747201 DOI: 10.1016/j.cardfail.2014.04.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/19/2014] [Accepted: 04/10/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Heart failure (HF) therapy involves use of multiple medications. There is little guidance on the safety and impact on clinical outcomes of stopping HF medications. METHODS AND RESULTS A comprehensive systematic search for studies of drug therapy withdrawal in HF was performed. Meta-analysis of the risk ratio (RR) was performed with the use of the Mantel-Haenszel random effects model for all-cause mortality and cardiovascular outcomes. Twenty-six studies met the inclusion criteria. Studies on withdrawal of renin-angiotensin-aldosterone system (RAAS) inhibitors and beta-blockers in HF are scarce and small, yet show relatively convincingly that such withdrawals have untoward effects on cardiac structure, symptoms, and major outcomes. Meta-analysis of 7 studies of digoxin withdrawal (2,987 participants) without background beta-blocker showed increased HF hospitalizations (RR 1.30, 95% confidence interval [CI] 1.16-1.46; P < .0001), but no impact on all-cause mortality (RR 1.00, 95% CI 0.90-1.12; P = .06) nor reduction in all-cause hospitalization (RR 1.03, 95% CI 0.98-1.09; P = .27). Diuretic withdrawal trials demonstrated an ongoing need for these agents in chronic HF. Studies in peripartum cardiomyopathy showed that medications could be successfully withdrawn after recovery. CONCLUSION Current evidence discourages any attempt to discontinue RAAS inhibitors or beta-blockers in patients with stable HF, regardless of clinical and/or echocardiographic status. Formal withdrawal trials of other classes are needed.
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Affiliation(s)
- Ingrid Hopper
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Clinical Pharmacology, Alfred Health, Melbourne, Australia.
| | - Rohit Samuel
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher Hayward
- St Vincent's Hospital and Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Andrew Tonkin
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Clinical Pharmacology, Alfred Health, Melbourne, Australia
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Bermingham M, Shanahan MK, O’Connell E, Dawkins I, Miwa S, O’Hanlon R, Gilmer J, McDonald K, Ledwidge M. Aspirin Use in Heart Failure. Circ Heart Fail 2014; 7:243-50. [DOI: 10.1161/circheartfailure.113.000132] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background—
Aspirin use in heart failure (HF) is controversial. The drug has proven benefit in comorbidities associated with HF; however, retrospective analysis of angiotensin-converting enzyme inhibitor trials and prospective comparisons with warfarin have shown increased risk of morbidity with aspirin use. This study aims to evaluate the association of low-dose aspirin with mortality and morbidity risk in a large community-based cohort.
Methods and Results—
This was a retrospective cohort study of patients attending an HF disease management program. Aspirin use at baseline and its association with mortality and HF hospitalization in the population was examined. Of 1476 patients (mean age, 70.4±12.4 years; 63% men), 892 (60.4%) were prescribed aspirin. Low-dose aspirin (75 mg/d) was prescribed to 828 (92.8%) patients. Median follow-up time was 2.6 (0.8–4.5) years. During the follow-up period, 464 (31.4%) patients died. In adjusted analysis, low-dose aspirin use was associated with reduced mortality risk compared with nonaspirin use (hazard ratio=0.58; 95% confidence interval, 0.46–0.74), and this was confirmed by a propensity-matched subgroup analysis. Low-dose aspirin use was associated with reduced risk of HF hospitalization compared with nonaspirin use in the total population (adjusted hazard ratio=0.70; 95% confidence interval, 0.54–0.90). In adjusted analysis, there was no difference in mortality or HF hospitalization between high-dose aspirin users (>75 mg/d) and nonaspirin users.
Conclusions—
In this study, low-dose aspirin therapy was associated with a significant reduction in mortality and morbidity risk during long-term follow-up. These results suggest that low-dose aspirin may have a continuing role in secondary prevention in HF and underline the need for more trials of low-dose aspirin use in HF.
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Affiliation(s)
- Margaret Bermingham
- From the Heart Failure Unit, St. Vincent’s University Hospital, Dublin, Ireland (M.B., M.K.S., I.D., K.M., M.L.); School of Medicine and Medical Science, University College Dublin, Dublin, Ireland (M.B., E.O., K.M., M.L.); School of Medicine, University College Cork, Cork, Ireland (S.M.); Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, County Dublin, Ireland (R.O.); and School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland (J.G.)
| | - Mary Katherine Shanahan
- From the Heart Failure Unit, St. Vincent’s University Hospital, Dublin, Ireland (M.B., M.K.S., I.D., K.M., M.L.); School of Medicine and Medical Science, University College Dublin, Dublin, Ireland (M.B., E.O., K.M., M.L.); School of Medicine, University College Cork, Cork, Ireland (S.M.); Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, County Dublin, Ireland (R.O.); and School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland (J.G.)
| | - Eoin O’Connell
- From the Heart Failure Unit, St. Vincent’s University Hospital, Dublin, Ireland (M.B., M.K.S., I.D., K.M., M.L.); School of Medicine and Medical Science, University College Dublin, Dublin, Ireland (M.B., E.O., K.M., M.L.); School of Medicine, University College Cork, Cork, Ireland (S.M.); Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, County Dublin, Ireland (R.O.); and School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland (J.G.)
| | - Ian Dawkins
- From the Heart Failure Unit, St. Vincent’s University Hospital, Dublin, Ireland (M.B., M.K.S., I.D., K.M., M.L.); School of Medicine and Medical Science, University College Dublin, Dublin, Ireland (M.B., E.O., K.M., M.L.); School of Medicine, University College Cork, Cork, Ireland (S.M.); Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, County Dublin, Ireland (R.O.); and School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland (J.G.)
| | - Saki Miwa
- From the Heart Failure Unit, St. Vincent’s University Hospital, Dublin, Ireland (M.B., M.K.S., I.D., K.M., M.L.); School of Medicine and Medical Science, University College Dublin, Dublin, Ireland (M.B., E.O., K.M., M.L.); School of Medicine, University College Cork, Cork, Ireland (S.M.); Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, County Dublin, Ireland (R.O.); and School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland (J.G.)
| | - Rory O’Hanlon
- From the Heart Failure Unit, St. Vincent’s University Hospital, Dublin, Ireland (M.B., M.K.S., I.D., K.M., M.L.); School of Medicine and Medical Science, University College Dublin, Dublin, Ireland (M.B., E.O., K.M., M.L.); School of Medicine, University College Cork, Cork, Ireland (S.M.); Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, County Dublin, Ireland (R.O.); and School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland (J.G.)
| | - John Gilmer
- From the Heart Failure Unit, St. Vincent’s University Hospital, Dublin, Ireland (M.B., M.K.S., I.D., K.M., M.L.); School of Medicine and Medical Science, University College Dublin, Dublin, Ireland (M.B., E.O., K.M., M.L.); School of Medicine, University College Cork, Cork, Ireland (S.M.); Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, County Dublin, Ireland (R.O.); and School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland (J.G.)
| | - Kenneth McDonald
- From the Heart Failure Unit, St. Vincent’s University Hospital, Dublin, Ireland (M.B., M.K.S., I.D., K.M., M.L.); School of Medicine and Medical Science, University College Dublin, Dublin, Ireland (M.B., E.O., K.M., M.L.); School of Medicine, University College Cork, Cork, Ireland (S.M.); Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, County Dublin, Ireland (R.O.); and School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland (J.G.)
| | - Mark Ledwidge
- From the Heart Failure Unit, St. Vincent’s University Hospital, Dublin, Ireland (M.B., M.K.S., I.D., K.M., M.L.); School of Medicine and Medical Science, University College Dublin, Dublin, Ireland (M.B., E.O., K.M., M.L.); School of Medicine, University College Cork, Cork, Ireland (S.M.); Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, County Dublin, Ireland (R.O.); and School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland (J.G.)
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15
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Gurbel PA, Tantry US. Antiplatelet and Anticoagulant Agents in Heart Failure. JACC-HEART FAILURE 2014; 2:1-14. [DOI: 10.1016/j.jchf.2013.07.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/25/2013] [Accepted: 07/25/2013] [Indexed: 01/11/2023]
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16
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Juhlin T, Jönsson BA, Höglund P. Renal effects of aspirin are clearly dose-dependent and are of clinical importance from a dose of 160 mg. Eur J Heart Fail 2014; 10:892-8. [DOI: 10.1016/j.ejheart.2008.06.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 12/05/2007] [Accepted: 06/24/2008] [Indexed: 11/27/2022] Open
Affiliation(s)
- Tord Juhlin
- Department of Cardiology; Malmö University Hospital; Malmö Sweden
| | - Bo A.G. Jönsson
- Department of Occupational and Environmental Medicine; Lund University Hospital; Lund Sweden
| | - Peter Höglund
- Department of Clinical Pharmacology; Lund University Hospital; Lund Sweden
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17
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Chang SM, Granger CB, Johansson PA, Kosolcharoen P, McMurray JJ, Michelson EL, Murray DR, Olofsson B, Pfeffer MA, Solomon SD, Swedberg K, Yusuf S, Dunlap ME. Efficacy and safety of angiotensin receptor blockade are not modified by aspirin in patients with chronic heart failure: a cohort study from the Candesartan in Heart failure - Assessment of Reduction in Mortality and morbidity (CHARM) programme. Eur J Heart Fail 2014; 12:738-45. [DOI: 10.1093/eurjhf/hfq065] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Su Min Chang
- Department of Cardiology; The Methodist DeBakey Heart and Vascular Center; Houston TX USA
| | | | | | - Peter Kosolcharoen
- Section of Cardiovascular Medicine; University of Wisconsin; Madison WI USA
| | - John J.V. McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre; University of Glasgow; Glasgow Scotland UK
| | | | - David R. Murray
- Section of Cardiovascular Medicine; University of Wisconsin; Madison WI USA
| | | | | | | | - Karl Swedberg
- Department of Emergency and Cardiovascular Medicine; University of Gothenburg; Sweden
| | - Salim Yusuf
- Hamilton Health Sciences and McMaster University; Hamilton ON Canada
| | - Mark E. Dunlap
- Heart and Vascular Center H350, MetroHealth Medical Center and Case Western Reserve University; 2500 MetroHealth Dr. Cleveland OH 44109 USA
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18
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Kohsaka S, Homma S. Anticoagulation for heart failure: selecting the best therapy. Expert Rev Cardiovasc Ther 2014; 7:1209-17. [DOI: 10.1586/erc.09.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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19
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Mentz RJ, Lazzarini V, Fiuzat M, Metra M, O'Connor CM, Felker GM. Is there a rationale for antiplatelet therapy in acute heart failure? Circ Heart Fail 2013; 6:869-76. [PMID: 23861506 DOI: 10.1161/circheartfailure.112.000381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA
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20
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Nonsurgical Therapy for Heart Failure. Int Anesthesiol Clin 2012; 50:1-21. [DOI: 10.1097/aia.0b013e31825c2b7b] [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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21
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Aspirin, clopidogrel, and warfarin use and outcomes in a cohort of 580 patients discharged after hospitalization for decompensated heart failure. Heart Vessels 2011; 27:568-75. [DOI: 10.1007/s00380-011-0185-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 08/05/2011] [Indexed: 10/17/2022]
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22
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23
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Levy PD, Nandyal D, Welch RD, Sun JL, Pieper K, Ghali JK, Fonarow GC, Gheorgiade M, O'Connor CM. Does aspirin use adversely influence intermediate-term postdischarge outcomes for hospitalized patients who are treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers? Findings from Organized Program to Facilitate Life-Saving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Am Heart J 2010; 159:222-230.e2. [PMID: 20152220 DOI: 10.1016/j.ahj.2009.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Accepted: 11/11/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND Conflicting data exist regarding a potential deleterious association between aspirin (ASA) and angiotensin-converting enzyme inhibitors (ACEIs) when used concurrently in patients with heart failure (HF). How such an interaction may be influenced by underlying etiology of HF and whether it extends to patients treated with angiotensin receptor blockers (ARBs), however, are not known. METHODS Eligible patients from the OPTIMIZE-HF registry were dichotomized into those with ischemic or nonischemic HF. Potential associations between ASA and ACEI or ARB use and 60- to 90-day postdischarge outcomes were assessed using Cox proportional and logistic regression modeling. Models were adjusted for factors known to influence the outcome of interest and by propensity score for ACEI or ARB prescription after an index HF admission. RESULTS Mortality was not increased (hazard ratio [95% CI]) when ASA was used in conjunction with ACEI (0.51 [0.29-0.87]) or ARB (0.29 [0.09-0.96]) in patients with ischemic or nonischemic (ACEI 0.71 [0.42-1.21], ARB 1.42 [0.74-2.74]) HF. Regression model parameter estimates trended toward harm reduction, but interaction terms for mortality and a composite of mortality or rehospitalization were nonsignificant (P for all >.05). CONCLUSIONS When combined with ACEI or ARB, ASA had no demonstrable adverse effect on intermediate-term postdischarge outcomes for patients with ischemic or nonischemic HF.
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Abstract
Chronic heart failure (CHF) remains the only cardiovascular disease with an increasing hospitalization burden and an ongoing drain on health care expenditures. The prevalence of CHF increases with advancing life span, with diastolic heart failure predominating in the elderly population. Primary prevention of coronary artery disease and risk factor management via aggressive blood pressure control are central in preventing new occurrences of left ventricular dysfunction. Optimal therapy for CHF involves identification and correction of potentially reversible precipitants, target-dose titration of medical therapy, and management of hospitalizations for decompensation. The etiological phenotype, absolute decrease in left ventricular ejection fraction and a widening of QRS duration on electrocardiography, is commonly used to identify patients at increased risk of progression of heart failure and sudden death who may benefit from prophylactic implantable cardioverter-defibrillator placement with or without cardiac resynchronization therapy. Patients who transition to advanced stages of disease despite optimal traditional medical and device therapy may be candidates for hemodynamically directed approaches such as a left ventricular assist device; in selected cases, listing for cardiac transplant may be warranted.
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Affiliation(s)
| | | | - Mandeep R. Mehra
- Address correspondence to Mandeep R. Mehra, MBBS, Division of Cardiology, University of Maryland School of Medicine, 22 S Greene St, Room S-3B06, Baltimore, MD 21201-1559 (). Individual reprints of this article and a bound reprint of the entire Symposium on Cardiovascular Diseases will be available for purchase from our Web site www.mayoclinicproceedings.com
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25
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Subramaniam V, Davis RC, Shantsila E, Lip GY. Antithrombotic therapy for heart failure in sinus rhythm. Fundam Clin Pharmacol 2009; 23:705-17. [DOI: 10.1111/j.1472-8206.2009.00776.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Patterson ME, Grant WC, Glickman SW, Massie BM, Ammon SE, Armstrong PW, Cleland JGF, Collins JF, Teo KK, Schulman KA, Reed SD. Resource use and costs of treatment with anticoagulation and antiplatelet agents: results of the WATCH trial economic evaluation. J Card Fail 2009; 15:819-27. [PMID: 19944357 DOI: 10.1016/j.cardfail.2009.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Revised: 05/01/2009] [Accepted: 07/01/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) trial revealed no significant differences among 1587 symptomatic heart failure patients randomized to warfarin, clopidogrel, or aspirin in time to all-cause death, nonfatal myocardial infarction, or nonfatal stroke. We compared within-trial medical resource use and costs between treatments. METHODS AND RESULTS We assigned country-specific costs to medical resources incurred during follow-up. Annualized rates of hospitalizations, inpatient and outpatient procedures, and emergency department visits did not differ significantly between groups. Annualized total costs averaged $5901 (95% confidence interval [CI], $4776-$7520) for the aspirin group, $5646 (95% CI, $4903-$6584) for the clopidogrel group, and $5830 (95% CI, $4838-$7400) for the warfarin group. CONCLUSIONS Consistent with clinical findings, our analyses did not identify significant cost differences between treatments.
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Affiliation(s)
- Mark E Patterson
- Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina 27715, USA
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27
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Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol 2009; 53:e1-e90. [PMID: 19358937 DOI: 10.1016/j.jacc.2008.11.013] [Citation(s) in RCA: 1185] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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28
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Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391-479. [PMID: 19324966 DOI: 10.1161/circulationaha.109.192065] [Citation(s) in RCA: 1080] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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29
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Abstract
The role of the platelet and the endothelium in the pathogenesis of atherosclerosis and subsequent ischemic events has been the subject of extensive investigation. Arterial sites where endothelial function is severely impaired are often the sites of atheroma development. Lesion evolution impairs endothelial function, leading to a self-perpetuating cycle of growth. During early lesion development, overt thrombotic events are rare. However, rupture of an advanced, necrotic plaque or intimal ulceration triggers arterial thrombosis, at which point the importance of platelet function may be seen clearly. The Antiplatelet Trialists' Collaboration meta-analysis demonstrated the benefit of antiplatelet therapy to patients with atherosclerotic disease. Aspirin is the most widely studied agent and is considered the standard of antiplatelet therapy. Newer agents that intervene at different stages of the platelet activation pathway have been developed. Clopidogrel, a new adenosine diphosphate receptor antagonist, is more effective than aspirin in reducing vascular events in patients with prior myocardial infarction, stroke, or established peripheral arterial disease. The glycoprotein IIb-IIIa antagonists such as abciximab have proven effective in the setting of active arterial thrombosis and percutaneous revascularization, but their value in secondary prevention remains unknown. All patients with atherosclerosis should be treated with an antiplatelet drug. Current evidence suggests that either aspirin or clopidogrel are appropriate first-line agents. There is urgent need for an analysis of the risk/benefit ratio in various populations and clinical settings to determine the most appropriate type and intensity of therapy for a given patient.
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Affiliation(s)
- J M Wilson
- Department of Cardiology, St. Luke's Episcopal Hospital/Texas Heart Institute, Baylor College of Medicine, University of Texas Health Sciences Center at Houston, USA
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30
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Chung I, Choudhury A, Patel J, Lip GYH. Soluble, platelet-bound, and total P-selectin as indices of platelet activation in congestive heart failure. Ann Med 2009; 41:45-51. [PMID: 18618353 DOI: 10.1080/07853890802227089] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Many complications associated with congestive heart failure (CHF) have a thrombosis-related aetiology. Platelets play an important role in thrombogenesis, but it is not clear whether circulating platelets actively participate in thrombosis-related complications associated with CHF. OBJECTIVE To determine whether soluble P-selectin, platelet surface P-selectin, and total platelet P-selectin as indices of platelet activation in CHF patients-compared to 'disease controls' and 'healthy controls'-and to assess their prognostic value in CHF. METHODS We measured soluble P-selectin (sP-sel, by enzyme-linked immunosorbent assay, ELISA), total platelet P-selectin (pP-sel, by a novel 'platelet lysate' assay), platelet surface P-selectin (CD62P%G) and platelet surface CD63 (CD63%G) expression by flow cytometry-in 108 patients with stable congestive heart failure (all with left ventricular ejection fraction (LVEF) <50%). Levels were compared with 50 healthy controls and 70 'disease controls' (patients with coronary artery disease with normal left ventricular systolic function). RESULTS CHF patients and disease controls had higher sP-sel, CD62P%G and CD63%G than healthy controls. There were no significant correlations between sP-sel, pP-sel, CD62P%G and CD63%G with ejection fraction (all P>0.05). There were no differences in these markers when ischaemic and non-ischaemic aetiologies of CHF were compared. After a median follow-up of 490 days (range 340-535), there were 7 deaths, 15 hospitalizations for worsening heart failure, 1 for cardiac resynchronization therapy, 4 for revascularizations, 4 for myocardial infarctions, and 1 stroke. None of the platelet markers were predictive of the composite end-point at follow-up. CONCLUSIONS Patients with stable CHF exhibit evidence of abnormal platelet activation, despite usage of antiplatelet agents. These abnormalities did not determine prognosis and were broadly similar to those seen in 'disease controls' indicating that platelet abnormalities in CHF may simply be related to associated comorbidities.
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Affiliation(s)
- Irene Chung
- Haemostasis, Thrombosis, and Vascular Biology Unit, University Department of Medicine, City Hospital, Birmingham, UK
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31
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Airee A, Draper HM, Finks SW. Aspirin resistance: disparities and clinical implications. Pharmacotherapy 2008; 28:999-1018. [PMID: 18657017 DOI: 10.1592/phco.28.8.999] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract Aspirin is one of the most widely prescribed drugs for the prevention of thrombosis in patients with vascular disease. Yet, aspirin is unable to prevent thrombosis in all patients. The term "aspirin resistance" has been used to broadly define the failure of aspirin to prevent a thrombotic event. Whether this is directly related to aspirin itself through biochemical aspirin resistance or treatment failure, or if it is because of aspirin's inability to overcome the thrombogenic aspects of the disease process itself, has not been elucidated. This can have dramatic clinical implications for a variety of vascular disease subsets and is cause for concern, considering the high prevalence of aspirin use for both primary and secondary prevention. Disparities exist in the rates of aspirin resistance among certain patient populations, such as women, patients with diabetes mellitus, and those with heart failure, and across clinical conditions, such as cardiovascular and cerebrovascular disease. Clinical trial data from studies observing resistance have revealed that regardless of study size, dose of aspirin, control for drug interactions and adherence, or assay used to measure platelet function, aspirin resistance is associated with an increased risk for adverse events. Although the evidence is mounting, there has yet to be a consensus on the appropriate clinical response to aspirin resistance.
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Affiliation(s)
- Anita Airee
- University of Tennessee College of Pharmacy, Knoxville Campus, 1924 Alcoa Highway, Knoxville, TN 37920, USA.
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32
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Abstract
Adverse drug reactions (ADRs) occur frequently in modern medical practice, increasing morbidity and mortality and inflating the cost of care. Patients with cardiovascular disease are particularly vulnerable to ADRs due to their advanced age, polypharmacy, and the influence of heart disease on drug metabolism. The ADR potential for a particular cardiovascular drug varies with the individual, the disease being treated, and the extent of exposure to other drugs. Knowledge of this complex interplay between patient, drug, and disease is a critical component of safe and effective cardiovascular disease management. The majority of significant ADRs involving cardiovascular drugs are predictable and therefore preventable. Better patient education, avoidance of polypharmacy, and clear communication between physicians, pharmacists, and patients, particularly during the transition between the inpatient to outpatient settings, can substantially reduce ADR risk.
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33
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Rosen D, Decaro MV, Graham MG. Evidence-based treatment of chronic heart failure. ACTA ACUST UNITED AC 2008; 33:2-17. [PMID: 17984487 DOI: 10.1007/s12019-007-0006-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Revised: 11/30/1999] [Accepted: 01/09/2007] [Indexed: 10/23/2022]
Abstract
The past two decades have seen a knowledge explosion in the field of cardiovascular diseases, in general, and in the understanding of chronic heart failure (HF) as a complex neurohumoral syndrome in particular. A new staging system for chronic HF has been developed within the last decade to facilitate the evidence-based prescription of medications and medical devices for each of its four stages. The burden of care for patients with chronic HF is substantially provided in primary care settings. Primary care physicians need to understand the underlying pathophysiology of chronic HF, the elements of its evaluation and treatment by stage, and when referral is necessary.
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Affiliation(s)
- David Rosen
- Beth Israel Medical Center, New York, NY, USA
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34
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O'Connor CM, Arumugham P. Inotropic drugs and neurohormonal antagonists in the treatment of HF in the elderly. Heart Fail Clin 2007; 3:477-84. [PMID: 17905382 DOI: 10.1016/j.hfc.2007.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Heart failure (HF) is the most common reason for hospital admission among individuals over age 65 years and results in more than 1 million admissions each year. The overall annual death rate for HF is approximately 20%. HF results from decreased contractile function of the heart, and neurohormonal dysregulation plays a major part in the morbidity and mortality of the heart. The purpose of this article is to review recent studies on inotropic drugs and neurohormonal antagonists used in the treatment of patients who have HF, especially the elderly.
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Affiliation(s)
- Christopher M O'Connor
- Duke University Medical Center, Division of Cardiology, Department of Medicine, Durham, NC 27710-0001, USA.
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35
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Aronow WS. Treatment of Heart Failure with Abnormal Left Ventricular Systolic Function in the Elderly. Heart Fail Clin 2007; 3:423-36. [PMID: 17905378 DOI: 10.1016/j.hfc.2007.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This article summarizes the four stages of heart failure (HF) as defined by the American College of Cardiology and the American Heart Association and discusses the treatments for elderly patients with HF and abnormal left ventricular systolic function. The article explains the important role of diuretics, the first-line drugs in the treatment of older patients with HF and volume overload. Other treatments described include angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, aldosterone antagonists, isosorbide dinitrate plus hydralazine, digoxin, and calcium channel blockers. The article explains the role each of these plays and reports on studies that have examined and compared various treatments.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA.
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36
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Klein L, O'connell JB. Thromboembolic risk in the patient with heart failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2007; 9:310-7. [PMID: 17761116 DOI: 10.1007/s11936-007-0026-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although heart failure is a procoagulant state, the incidence of arterial thromboembolism (peripheral arterial emboli and strokes) is relatively low in the outpatient setting and seems to be higher in those with concomitant atrial fibrillation or recent large anterior myocardial infarction, especially in the presence of a dyskinetic apex. Hospitalized heart failure patients, on the other hand, have an extremely high rate of deep venous thrombosis and pulmonary emboli. Outpatients with heart failure should receive anticoagulation only in the presence of atrial fibrillation or if they have experienced a prior embolic event. Patients with recent large anterior infarction or recent infarction with documented thrombus should be treated with anticoagulation for the initial 3 months after the infarct, whereas those with evidence of a mural thrombus should receive anticoagulation at least until the thrombus has resolved. Heart failure patients with ischemic cardiomyopathy should receive antiplatelet agents for the prevention of myocardial infarction, stroke, or death. Antiplatelet agents should not be prescribed for heart failure patients with nonischemic cardiomyopathy or without other evidence of atherosclerotic vascular disease. All hospitalized heart failure patients who are not taking oral anticoagulants should receive prophylaxis with low molecular weight heparins or factor Xa inhibitors.
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Affiliation(s)
- Liviu Klein
- Northwestern University Feinberg School of Medicine, 201 E. Huron Street, Galter 11-120, Chicago, IL 60611, USA
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37
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O'Connor CM, Arumugham P. Inotropic drugs and neurohormonal antagonists in the treatment of HF in the elderly. Clin Geriatr Med 2007; 23:141-53. [PMID: 17126759 DOI: 10.1016/j.cger.2006.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
HF (HF) is the most common reason for hospital admission among individuals over age 65 years and results in more than 1 million admissions each year. The overall annual death rate for HF is approximately 20%. HF results from decreased contractile function of the heart, and neurohormonal dysregulation plays a major part in the morbidity and mortality of the heart. The purpose of this article is to review recent studies on inotropic drugs and neurohormonal antagonists used in the treatment of patients who have HF, especially the elderly.
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Affiliation(s)
- Christopher M O'Connor
- Division of Clinical Pharmacology, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27710, USA.
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38
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Aronow WS. Treatment of Heart Failure with Abnormal Left Ventricular Systolic Function in the Elderly. Clin Geriatr Med 2007; 23:61-81. [PMID: 17126755 DOI: 10.1016/j.cger.2006.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This article summarizes the four stages of heart failure (HF) as defined by the American College of Cardiology and the American Heart Association and discusses the treatments for elderly patients with HF and abnormal left ventricular systolic function. The article explains the important role of diuretics, the first-line drugs in the treatment of older patients with HF and volume overload. Other treatments described include angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, aldosterone antagonists, isosorbide dinitrate plus hydralazine, digoxin, and calcium channel blockers. The article explains the role each of these plays and reports on studies that have examined and compared various treatments.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Division of Cardiology, Westchester Medical Center, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595, USA.
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39
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Dotsenko O, Kakkar VV. Antithrombotic therapy in patients with chronic heart failure: rationale, clinical evidence and practical implications. J Thromb Haemost 2007; 5:224-31. [PMID: 17067363 DOI: 10.1111/j.1538-7836.2007.02288.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Chronic heart failure (CHF) is traditionally associated with increased risk of thromboembolic complications. Key features of CHF pathophysiology, such as impairment of intracardiac hemodynamics, peripheral blood flow deceleration, neuroendocrine activation, chronic oxidative stress and proinflammatory changes, could explain the predisposition to thromboembolism. However, conclusive epidemiologic data on thromboembolic event incidence in CHF are lacking. Furthermore, the place of antithrombotic therapy in CHF management is still uncertain. Apart from established indications for warfarin (e.g. atrial fibrillation and previous embolic events), there is no robust evidence to support administration of vitamin K antagonists to other patients with CHF, particularly to patients in sinus rhythm. The role of aspirin in preventing thromboembolism in these patients is also controversial. Large randomized trial data on the effectiveness and risks of warfarin and aspirin use in CHF patients with sinus rhythm are forthcoming. This article provides a brief overview of the epidemiologic and pathobiological background of thromboembolism in CHF, and discusses the up-to-date clinical evidence on antithrombotic therapy in detail.
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Affiliation(s)
- O Dotsenko
- Thrombosis Research Institute, London, UK.
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40
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Gulliver GA, Sweitzer NK. Risk Factor Management and Lifestyle Modification in Heart Failure. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50019-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Lipinski MJ, Vetrovec GW. Medical treatment of patients with heart failure or left ventricular dysfunction undergoing percutaneous coronary intervention. Am J Cardiovasc Drugs 2006; 6:313-25. [PMID: 17083266 DOI: 10.2165/00129784-200606050-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Management of ischemic patients with pre-existing or new-onset left ventricular (LV) dysfunction poses a special challenge in terms of the timing of percutaneous coronary intervention (PCI) and appropriate adjunctive medications to optimize outcome while minimizing risk. In a systematic fashion, this review attempts to provide a management scheme for patients with heart failure or LV dysfunction that present with stable angina, ST-segment elevation myocardial infarction, or unstable angina/non-ST-segment elevation myocardial infarction. By addressing therapeutic approaches to acute or decompensated heart failure and timing of coronary angiography based on severity of ischemia, we provide evidence-based recommendations for medications to initiate before, during, and following PCI.
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Affiliation(s)
- Michael J Lipinski
- Division of Cardiology, Medical College of Virginia Campus of Virginia Commonwealth University, Richmond, Virginia, USA
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Howard PA, Cheng JWM, Crouch MA, Colucci VJ, Kalus JS, Spinler SA, Munger M. Drug therapy recommendations from the 2005 ACC/AHA guidelines for treatment of chronic heart failure. Ann Pharmacother 2006; 40:1607-17. [PMID: 16896019 DOI: 10.1345/aph.1h059] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review and discuss key aspects of the drug therapy recommendations in the American College of Cardiology (ACC)/American Heart Association (AHA) 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure (HF) in the Adult. DATA SOURCES Data were obtained from the ACC/AHA 2005 Guideline Update for Chronic HF. English-language clinical trials, observational studies, and pertinent review articles evaluating the pharmacotherapy of chronic HF were identified, based on MEDLINE searches through January 2006. STUDY SELECTION Articles presenting information that impacts the evidence base for recommendations regarding the use of various drug therapies in patients with chronic HF were evaluated. DATA SYNTHESIS The ACC/AHA 2005 Guideline Update for HF provides revised, evidence-based recommendations for the treatment of chronic HF. The new guidelines are based on a staging system that recognizes both the development and progression of HF. Recommendations are provided for 2 stages of patients (A and B) who do not yet have clinical HF but are clearly at risk and 2 stages (C and D) that include patients with symptomatic HF. The guidelines continue to emphasize the important role of neurohormonal blockade with angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-adrenergic blockers, and aldosterone antagonists. Based on recent trials, updated recommendations address the roles of combination therapy and the selective addition of hydralazine and isosorbide dinitrate. Along with specific drug recommendations, information on the practical use of various drugs is provided. Although the guidelines primarily focus on HF due to systolic dysfunction, general recommendations are also provided for patients with preserved systolic function. CONCLUSIONS The ACC/AHA 2005 Guideline Update provides evidence-based recommendations for healthcare professionals involved in the care of adults with chronic HF. Recent clinical trial findings have further clarified the evolving role of neurohormonal-blocking drugs in the prevention and treatment of HF.
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Affiliation(s)
- Patricia A Howard
- Department of Pharmacy Practice, University of Kansas Medical Center, Kansas City, KS 66160-7231, USA.
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Juhlin T, Erhardt LR, Ottosson H, Jönsson BAG, Höglund P. Treatments with losartan or enalapril are equally sensitive to deterioration in renal function from cyclooxygenase inhibition. Eur J Heart Fail 2006; 9:191-6. [PMID: 16859993 DOI: 10.1016/j.ejheart.2006.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2004] [Revised: 09/12/2005] [Accepted: 05/25/2006] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The beneficial effects of angiotensin converting enzyme (ACE)-inhibitors are in part mediated through the inhibition of the degradation of the vasodilator bradykinin. The bradykinin effect is counteracted by cyclooxygenase-inhibitors. Angiotensin receptor blockers (ARBs) do not affect bradykinin. AIMS To test the hypothesis that renal counteraction from a cyclooxygenase-inhibitor, diclofenac, is different in subjects treated with an ACE-inhibitor, enalapril compared with an ARB, losartan. METHODS Twelve elderly, healthy, slightly over-hydrated subjects received diclofenac orally after pre-treatment with a diuretic, bendroflumethiazide, and enalapril or bendroflumethiazide and losartan, in a double-blind cross-over fashion, with a wash-out period of at least 1 week. RESULTS Diclofenac reduced GFR significantly from 81(64-98) ml/min at first observations after dose for enalapril to 29(16-42) and from 76(64-88) after losartan to 35(24-46). There was no significant difference between enalapril and losartan in GFR. Diclofenac induced decreases in urine flow, excretion rates and clearances of sodium, osmolality clearance and free water clearance, irrespective of treatment with enalapril or losartan. However, serum potassium and handling of potassium were significantly lower after losartan-treatment. CONCLUSION The negative renal effects of diclofenac administration in subjects with activation of the renin-angiotensin system and enalapril treatment are the same in subjects with activation of the renin-angiotensin system and losartan treatment.
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Affiliation(s)
- Tord Juhlin
- Department of Cardiology, Malmö University Hospital, Malmö, Sweden
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Jhund P, McMurray JJV. Does aspirin reduce the benefit of an angiotensin-converting enzyme inhibitor? Choosing between the Scylla of observational studies and the Charybdis of subgroup analysis. Circulation 2006; 113:2566-8. [PMID: 16754810 DOI: 10.1161/circulationaha.106.629212] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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McAlister FA, Ghali WA, Gong Y, Fang J, Armstrong PW, Tu JV. Aspirin Use and Outcomes in a Community-Based Cohort of 7352 Patients Discharged After First Hospitalization for Heart Failure. Circulation 2006; 113:2572-8. [PMID: 16735672 DOI: 10.1161/circulationaha.105.602136] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background—
The safety of aspirin in heart failure (HF) has been called into question, particularly in those patients (1) without coronary disease, (2) with renal dysfunction, or (3) treated with low-dose angiotensin-converting enzyme (ACE) inhibitors and high-dose aspirin.
Methods and Results—
We examined prescription patterns and outcomes (all-cause mortality and/or HF readmission) in patients discharged from 103 Canadian hospitals between April 1999 and March 2001 after a first hospitalization for HF. Of 7352 patients with HF (mean age, 75 years; 44% without coronary disease and 29% with renal dysfunction), 2785 (38%) died or required HF readmission within the first year. Compared with nonusers, aspirin users were no more likely to die or require HF readmission (hazard ratio [HR], 1.02 [0.91 to 1.16]), even in patients without coronary disease (HR, 0.98 [0.78 to 1.22]) or patients with renal dysfunction (HR, 1.13 [0.94 to 1.36]). On the other hand, users of ACE inhibitors were less likely to die or require HF readmission (HR, 0.87 [0.79 to 0.96]), even if they were using aspirin (HR, 0.86 [0.77 to 0.95]). There were no dose-dependent interactions between aspirin and ACE inhibitors.
Conclusions—
In this observational study, aspirin use was not associated with an increase in mortality rates or HF readmission rates, and aspirin did not attenuate the benefits of ACE inhibitors, even in patients without coronary disease, patients with renal dysfunction, or patients treated with high-dose aspirin and low-dose ACE inhibitors.
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Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine, University of Alberta, Edmonton, Canada.
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Juhlin T, Björkman S, Gunnarsson B, Fyge A, Roth B, Höglund P. Acute administration of diclofenac, but possibly not long term low dose aspirin, causes detrimental renal effects in heart failure patients treated with ACE-inhibitors. Eur J Heart Fail 2006; 6:909-16. [PMID: 15556053 DOI: 10.1016/j.ejheart.2004.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2003] [Revised: 12/19/2003] [Accepted: 02/23/2004] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAID) or high doses of aspirin (acetylsalicylic acid) can exert detrimental effects on renal function and counteract the beneficial effects of angiotensin-converting enzyme (ACE) inhibitors in patients with congestive heart failure. AIMS The objective of our study was to evaluate the renal effects of low dose aspirin and the NSAID diclofenac in patients with congestive heart failure treated with ACE-inhibitors. METHODS Ten patients on their individually titrated dose of ACE-inhibitors and low dose aspirin (< or =125 mg daily) with stable congestive heart failure from coronary artery disease, entered an open investigation while on low dose aspirin, which was then discontinued. After one week wash-out they received an oral dose of 50 mg diclofenac potassium or placebo in a double-blind cross-over fashion with a one week wash-out period between treatments. RESULTS Diclofenac caused significant (P<0.05) decreases in GFR, urine flow, osmolality clearance, and excretion rates of sodium and potassium compared to placebo and aspirin. At t(max) for diclofenac or corresponding time for placebo diclofenac caused 40 (11-59)% (geometric mean and 95% confidence limits) reduction in GFR compared to placebo and 36 (5.4-56)% reduction to low-dose aspirin. No significant changes between low dose aspirin and placebo were found. CONCLUSION Acute administration of diclofenac, but not long term low dose aspirin, has profound impact on renal function in patients with heart failure treated with ACE-inhibitors and may cause worsened heart failure.
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Affiliation(s)
- Tord Juhlin
- Department of Cardiology, Malmö University Hospital, Malmö, Sweden
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Abstract
Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF such as nonsteroidal antiinflammatory drugs should be stopped. Patients with HF and a low left ventricular ejection fraction (systolic heart failure) or normal ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Division of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, New York 10595, USA.
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Juhlin T, Björkman S, Höglund P. Cyclooxygenase inhibition causes marked impairment of renal function in elderly subjects treated with diuretics and ACE-inhibitors. Eur J Heart Fail 2006; 7:1049-56. [PMID: 16227143 DOI: 10.1016/j.ejheart.2004.10.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2004] [Revised: 07/12/2004] [Accepted: 10/14/2004] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Treatment with angiotensin-converting enzyme (ACE)-inhibitors is known to cause an initial reduction in glomerular filtration rate (GFR) in patients with congestive heart failure. The long-term beneficial effects of ACE-inhibitors in these patients can be counteracted by cyclooxygenase-inhibitors. AIMS To quantify the negative renal effects of the cyclooxygenase-inhibitor diclofenac in elderly healthy subjects and to assess how treatment with an ACE-inhibitor, after activation of the renin-angiotensin system, influences these renal effects. METHODS Fourteen elderly, healthy subjects received oral diclofenac and placebo in a double-blind cross-over fashion. The study was divided in two parts; in part one, subjects received no pre-treatment and in part two, the subjects were given pre-treatment with bendroflumethiazide and enalapril in order to activate the renin-angiotensin system. RESULTS Diclofenac induced significant (p<0.05) decreases in GFR, urine flow, excretion rates of sodium and potassium, electrolyte clearance, osmolality clearance and free water clearance both with and without renin-angiotensin system activation. Least square means (95% CI) of all observations during the first 6 h after dosing showed that diclofenac caused a reduction in GFR from 71 (64-78) to 59 (52-66) ml/min. After pre-treatment, diclofenac further reduced GFR from 60 (52-67) to 48 (40-55) ml/min. After diclofenac administration, urine flow fell from 7.4 (6.4-8.3) to 5.1 (4.2-6.1) ml/min, after pre-treatment, diclofenac gave a further reduction from 4.1 (3.1-5.1) to 2.2 (1.3-3.2) ml/min. More than half of the reductions were caused by the pre-treatment. CONCLUSION Renal function in elderly, healthy subjects is impaired after acute intake of diclofenac. This impairment is observed both with and without activation of the renin-angiotensin system and ACE-inhibitor treatment but is more pronounced after pre-treatment.
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Affiliation(s)
- Tord Juhlin
- Department of Cardiology, Malmö University Hospital, Malmö, Sweden
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Feher G, Koltai K, Papp E, Alkonyi B, Solyom A, Kenyeres P, Kesmarky G, Czopf L, Toth K. Aspirin Resistance. Drugs Aging 2006; 23:559-67. [PMID: 16930084 DOI: 10.2165/00002512-200623070-00002] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Recent studies have described the incidence (approximately one in eight high-risk patients will experience a further atherothrombotic event over a 2-year period) of aspirin (acetylsalicylic acid) resistance and its possible background. The aim of this study was to compare the characteristics (risk profile, previous diseases, medications and haemorrheological variables) of patients in whom aspirin provided effective platelet inhibition with those in whom aspirin was not effective in providing platelet inhibition. METHODS 599 patients with chronic cardio- and cerebrovascular diseases (355 men, mean age 64 +/- 11 years; 244 women, mean age 63 +/- 10 years) taking aspirin 100-325 mg/day were included in the study. Blood was collected between 8:00am and 9:00am from these patients after an overnight fast. The cardiovascular risk profiles, history of previous diseases, medication history and haemorrheological parameters of patients who responded to aspirin and those who did not were compared. Platelet and red blood cell (RBC) aggregation were measured by aggregometry, haematocrit by a microhaematocrit centrifuge, and plasma fibrinogen by Clauss' method. Plasma and whole blood viscosities were measured using a capillary viscosimeter. RESULTS Compared with aspirin-resistant patients, patients who demonstrated effective aspirin inhibition had a significantly lower plasma fibrinogen level (3.3 g/L vs 3.8 g/L; p < 0.05) and significantly lower RBC aggregation values (24.3 vs 28.2; p < 0.01). In addition, significantly more patients with effective aspirin inhibition were hypertensive (80% vs 62%; p < 0.05). Patients who had effective platelet aggregation were significantly more likely to be taking beta-adrenoceptor antagonists (75% vs 55%; p < 0.05) and ACE inhibitors (70% vs 50%; p < 0.05), whereas patients with ineffective platelet aggregation were significantly more likely to be taking HMG-CoA reductase inhibitors (statins) [52% vs 38%; p < 0.05]. Use of statins remained an independent predictor of aspirin resistance even after adjustment for risk factors and medication use (odds ratio 5.92; 95% CI 1.83, 16.9; p < 0.001). CONCLUSIONS The mechanisms underlying aspirin resistance are multifactorial. Higher fibrinogen concentrations increase RBC aggregation and can also result in increased platelet aggregation. The higher rate of hypertension in patients with effective platelet aggregation on aspirin could explain the differences in beta-adrenoceptor antagonist and ACE inhibitor use between these patients and aspirin-resistant patients. Furthermore, an additive effect of these drugs may contribute to effective antiplatelet therapy. It is also possible that drug interactions with statins might reduce aspirin bioavailability and/or activity, thereby reducing platelet inhibition in aspirin-resistant patients.
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Affiliation(s)
- Gergely Feher
- First Department of Medicine, Medical School, University of Pecs, Pecs, Hungary.
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