1
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Parén P, Rosengren A, Zverkova Sandström T, Schaufelberger M. Decrease in loop diuretic treatment from 2005 to 2014 in Swedish real-life patients with chronic heart failure. Eur J Clin Pharmacol 2018; 75:247-254. [PMID: 30318559 PMCID: PMC6348069 DOI: 10.1007/s00228-018-2574-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/01/2018] [Indexed: 11/06/2022]
Abstract
Purpose Loop diuretics are recommended to treat congestive symptoms in patients with heart failure. However, observational studies have indicated that loop diuretic treatment in heart failure is associated with increased mortality. Therefore, loop diuretic discontinuation or dose reduction, when clinically possible, is recommended. Our aim was to study nationwide temporal trends in loop diuretic treatment from 2005 to 2014 in real-life patients with chronic heart failure. Methods Data from the nationwide Swedish National Patient, Prescribed Drug and Cause of Death Registers were linked. The annual proportions of patients with chronic heart failure treated with loop diuretics from 2005 to 2014 were calculated. In addition, the annual median loop diuretic doses (DDD) in patients with chronic heart failure treated with loop diuretics from 2005 to 2014 were calculated. Results The proportion of real-life patients with chronic heart failure treated with loop diuretics decreased from 73.2% in 2005 to 65.7% in 2014 (p for trend < 0.001). The median loop diuretic DDD in real-life patients with chronic heart failure decreased from 2.13 (IQR 1.09–2.77) in 2005 to 1.63 (IQR 1.09–2.25) in 2014 (p = 0.001 for trend). Conclusions Loop diuretic treatment decreased from 2005 to 2014 in real-life patients with chronic heart failure. The prognostic impact of changes in loop diuretic treatment in patients with heart failure remains unclear. Electronic supplementary material The online version of this article (10.1007/s00228-018-2574-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pär Parén
- Department of Internal Medicine, Sahlgrenska University Hospital/Mölndal, S-431 80, Mölndal, Sweden. .,Department of Molecular & Clinical Medicine, Institute of Medicine, Sahlgrenska Academy/University of Gothenburg, Gothenburg, Sweden.
| | - Annika Rosengren
- Department of Molecular & Clinical Medicine, Institute of Medicine, Sahlgrenska Academy/University of Gothenburg, Gothenburg, Sweden.,Department of Internal Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Tatiana Zverkova Sandström
- Department of Molecular & Clinical Medicine, Institute of Medicine, Sahlgrenska Academy/University of Gothenburg, Gothenburg, Sweden
| | - Maria Schaufelberger
- Department of Molecular & Clinical Medicine, Institute of Medicine, Sahlgrenska Academy/University of Gothenburg, Gothenburg, Sweden.,Department of Internal Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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2
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Matsumoto K, Ehara S, Nakamura Y, Otsuka K, Kawase Y. The effects of tolvaptan dose on cardiac mortality in patients with acute decompensated heart failure after hospital discharge. Heart Vessels 2018; 33:1204-1213. [PMID: 29687159 DOI: 10.1007/s00380-018-1177-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/20/2018] [Indexed: 11/30/2022]
Abstract
Tolvaptan (TLV) is a newly developed oral vasopressin-2 receptor antagonist that is mostly used for patients with acute decompensated heart failure (ADHF) refractory to conventional diuretic therapy. The aim of this study was to investigate the effects of outpatient TLV dose on cardiac mortality in patients discharged after hospitalization for ADHF. One hundred and five patients with ADHF who had been treated with TLV for the first time during hospitalization were retrospectively divided into three groups based on outpatient TLV use and dose. The non-TLV group comprised patients who were not treated with TLV after discharge (n = 36). Patients who continued TLV after discharge were further classified into two groups: low-dose (LD)-TLV (3.75 mg/day, n = 27) and high-dose (HD)-TLV (7.5 or 15 mg/day, n = 42). The primary endpoint was cardiac mortality. Secondary endpoint included the composite of all-cause mortality or re-hospitalization due to worsening of ADHF. There were no significant differences in demographic variables other than body mass index (p = 0.0026), echocardiographic data, laboratory data other than serum chloride before TLV administration (p = 0.041), serum sodium (p = 0.040) and potassium (p = 0.027) at discharge, and concomitant medications among the three groups. The Kaplan-Meier curve showed that the survival rate was lower in HD-TLV than in non-TLV, whereas LD-TLV showed the highest survival rate among the three groups (p = 0.0001). Multivariable Cox regression analysis of the clinical characteristics used for predicting cardiac mortality revealed that LD-TLV (hazard ratio [HR] 0.16, 95% confidence interval [CI] 0.01-0.93, p = 0.040) and HD-TLV (HR 2.43, 95% CI 1.06-6.26, p = 0.035) were significant predictors after adjustment for predictive covariates. In conclusion, the judgement of the continuation of LD-TLV according to patient hemodynamics and severity of congestion may not cause worsened prognosis.
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Affiliation(s)
- Kenji Matsumoto
- Division of Cardiology, Izumi City General Hospital, Izumi, Japan
| | - Shoichi Ehara
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | | | - Keiko Otsuka
- Division of Cardiology, Izumi City General Hospital, Izumi, Japan
| | - Yoshio Kawase
- Division of Cardiology, Izumi City General Hospital, Izumi, Japan
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3
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Dini FL, Bajraktari G, Zara C, Mumoli N, Rosa GM. Optimizing Management of Heart Failure by Using Echo and Natriuretic Peptides in the Outpatient Unit. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1067:145-159. [PMID: 29374825 DOI: 10.1007/5584_2017_137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic heart failure (HF) is an important public health problem and is associated with high morbidity, high mortality, and considerable healthcare costs. More than 90% of hospitalizations due to worsening HF result from elevations of left ventricular (LV) filling pressures and fluid overload, which are often accompanied by the increased synthesis and secretion of natriuretic peptides (NPs). Furthermore, persistently abnormal LV filling pressures and a rise in NP circulating levels are well known indicators of poor prognosis. Frequent office visits with the resulting evaluation and management are most often needed. The growing pressure from hospital readmissions in HF patients is shifting the focus of interest from traditionally symptom-guided care to a more specific patient-centered follow-up care based on clinical findings, BNP and echo. Recent studies supported the value of serial NP measurements and Doppler echocardiographic biomarkers of elevated LV filling pressures as tools to scrutinize patients with impending clinically overt HF. Therefore, combination of echo and pulsed-wave blood-flow and tissue Doppler with NPs appears valuable in guiding ambulatory HF management, since they are potentially useful to distinguish stable patients from those at high risk of decompensation.
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Affiliation(s)
- Frank Lloyd Dini
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy. .,Unità Operativa Malattie Cardiovascolari 1, Dipartimento Cardio, Toracico e Vascolare, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy.
| | - Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University and Heart Centre, Umeå, Sweden.,Clinic of Cardiology, University Clinical Centre of Kosova, Prishtina, Kosovo
| | - Cornelia Zara
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Livorno Hospital, Livorno, Italy
| | - Gian Marco Rosa
- Department of Internal Medicine and Medical Specialities, University of Genoa, Genoa, Italy
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4
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Dini FL, Carluccio E, Montecucco F, Rosa GM, Fontanive P. Combining echo and natriuretic peptides to guide heart failure care in the outpatient setting: A position paper. Eur J Clin Invest 2017; 47. [PMID: 29044493 DOI: 10.1111/eci.12846] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/12/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chronic heart failure (HF) is a relevant and growing public health problem. Although the prognosis has recently improved, it remains a lethal disease, with a mortality that equals or exceeds that of many malignancies. Furthermore, chronic HF is costly, representing a large and growing drain on healthcare resources. METHODS This narrative review is based on the material searched for and obtained via PubMed up to May 2017. The search terms we used were as follows: "heart failure, echocardiography, natriuretic peptides" in combination with "treatment, biomarkers, guidelines." RESULTS Recent studies have supported the value of natriuretic peptides (NPs) and Doppler echocardiographic biomarkers of increased left ventricular (LV) filling pressures or pulmonary congestion as tools to scrutinize patients with impending clinically overt HF. Therefore, combination of pulsed-wave tissue and blood flow Doppler with NPs appears valuable in guiding HF management in the outpatient setting. In as much as both the echo and the plasma levels of NPs may reflect the presence of fluid overload and elevations of LV filling pressures, integrating NP and echocardiographic biomarkers with clinical findings may help the cardiologist to identify high-risk patients, that is to recognize whether a patient is stable or the condition is likely to evolve into decompensated HF, to optimize treatment, to improve the prognosis and to reduce rehospitalization. CONCLUSION We discussed the rationale and the clinical significance of combining follow-up echo and NP assessment to guide management of ambulatory patients with chronic HF.
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Affiliation(s)
- Frank L Dini
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
| | - Erberto Carluccio
- Divisions of Cardiology, School of Medicine, University of Perugia, Perugia, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino, Genoa, Italy.,Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
| | - Gian Marco Rosa
- Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Paolo Fontanive
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
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5
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Dini FL, Simioniuc A, Carluccio E, Ghio S, Rossi A, Biagioli P, Reboldi G, Galeotti GG, Lu F, Zara C, Whalley G, Temporelli PL. Echo and BNP serial assessment in ambulatory heart failure care: Data on loop diuretic use and renal function. Data Brief 2016; 9:1074-1076. [PMID: 27921080 PMCID: PMC5126128 DOI: 10.1016/j.dib.2016.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/31/2016] [Accepted: 11/02/2016] [Indexed: 11/24/2022] Open
Abstract
We compared the follow-up data on loop diuretic use and renal function, as assessed by serum creatinine levels, and the estimated glomerular filtration rate (eGFR), of two groups of consecutive ambulatory HF patients: 1) the clinically-guided group, in which management was clinically driven based on the institutional protocol of the HF Unit of the Cardiovascular and Thoracic Department of Pisa (standard of care) and 2) the echo and B-type natriuretic peptide (BNP) guided group (patients conforming to the protocol of the Network Labs Ultrasound (NEBULA) in HF Study Group: Pisa, Perugia, Pavia; Verona, Auckland, and Veruno), in which therapy was delivered according to the serial assessment of BNP and echocardiography. Patients whose follow-up was based on standard of care had a significant higher prevalence of worsening renal function, that was likely related to higher diuretic dosages, whilst, a better management of renal function was observed in the echo-BNP-guided group. The data is related to “Echo and natriuretic peptide guided therapy improves outcome and reduces worsening renal function in systolic heart failure: An observational study of 1137 outpatients” (A. Simioniuc, E. Carluccio, S. Ghio, A. Rossi, P. Biagioli, G. Reboldi, G.G. Galeotti, F. Lu, C. Zara, G. Whalley, P.G. Temporelli, F.L. Dini, 2016; K.J. Harjai, H.K. Dinshaw, E. Nunez, M. Shah, H. Thompson, T. Turgut, H.O. Ventura, 1999; A. Ahmed, A. Husain, T.E. Love, G. Gambassi, L.J. Dell׳Italia, G.S. Francis, M. Gheorghiade, R.M. Allman, S. Meleth, R.C. Bourge, 2006) [1], [2], [3].
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Affiliation(s)
- Frank Lloyd Dini
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
| | - Anca Simioniuc
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
| | - Erberto Carluccio
- Divisions of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - Stefano Ghio
- Cardiovascular and Thoracic Department, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | - Andrea Rossi
- Department of Biomedical and Surgical Sciences, Cardiology Section, University of Verona, Verona, Italy
| | - Paolo Biagioli
- Divisions of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - Gianpaolo Reboldi
- Department of Internal Medicine, University of Perugia, Perugia, Italy
| | | | - Fei Lu
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
| | - Cornelia Zara
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
| | - Gillian Whalley
- Institute of Diagnostic Ultrasound, Australasian Sonographers Association, Auckland, New Zealand
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6
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Riley A, Gebhard DJ, Akcan-Arikan A. Acute Kidney Injury in Pediatric Heart Failure. Curr Cardiol Rev 2016; 12:121-31. [PMID: 26585035 PMCID: PMC4861941 DOI: 10.2174/1573403x12666151119165628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/15/2015] [Indexed: 01/11/2023] Open
Abstract
Acute kidney injury (AKI) is very common in pediatric medical and surgical cardiac patients. Not only is it an independent risk factor for increased morbidity and mortality in the short run, but repeated episodes of AKI lead to chronic kidney disease (CKD) especially in the most vulnerable hosts with multiple risk factors, such as heart transplant recipients. The cardiorenal syndrome, a term coined to emphasize the bidirectional nature of simultaneous or sequential cardiac-renal dysfunction both in acute and chronic settings, has been recently described in adults but scarcely reported in children. Despite the common occurrence and clinical and financial impact, AKI in pediatric heart failure outside of cardiac surgery populations remains poorly studied and there are no large-scale pediatric specific preventive or therapeutic studies to date. This article will review pediatric aspects of the cardiorenal syndrome in terms of pathophysiology, clinical impact and treatment options.
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Affiliation(s)
| | | | - Ayse Akcan-Arikan
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.
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7
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Schartum-Hansen H, Løland KH, Svingen GFT, Seifert R, Pedersen ER, Nordrehaug JE, Bleie Ø, Ebbing M, Berge C, Nilsen DWT, Nygård O. Use of Loop Diuretics is Associated with Increased Mortality in Patients with Suspected Coronary Artery Disease, but without Systolic Heart Failure or Renal Impairment: An Observational Study Using Propensity Score Matching. PLoS One 2015; 10:e0124611. [PMID: 26030195 PMCID: PMC4452510 DOI: 10.1371/journal.pone.0124611] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 03/03/2015] [Indexed: 11/18/2022] Open
Abstract
Background Loop diuretics are widely used in patients with heart and renal failure, as well as to treat hypertension and peripheral edema. However, there are no randomized, controlled trials (RCT) evaluating their long term safety, and several observational reports have indicated adverse effects. We sought to evaluate the impact of loop diuretics on long term survival in patients with suspected coronary artery disease, but without clinical heart failure, reduced left ventricular ejection fraction or impaired renal function. Method and Findings From 3101 patients undergoing coronary angiography for suspected stable angina pectoris, subjects taking loop diuretics (n=109) were matched with controls (n=198) in an attempted 1:2 ratio, using propensity scores based on 59 baseline variables. During median follow-up of 10.1 years, 37.6% in the loop diuretics group and 23.7% in the control group died (log-rank p-value 0.005). Treatment with loop diuretics was associated with a hazard ratio (95% confidence interval) of 1.82 (1.20, 2.76), and the number needed to harm was 7.2 (4.1, 30.3). Inclusion of all 3101 patients using propensity score weighting and adjustment for numerous covariates provided similar estimates. The main limitation is the potential of confounding from unmeasured patient characteristics. Conclusions The use of loop diuretics in patients with suspected coronary artery disease, but without systolic heart failure or renal impairment, is associated with increased risk of all-cause mortality. Considering the lack of randomized controlled trials to evaluate long term safety of loop diuretics, our data suggest caution when prescribing these drugs to patients without a clear indication.
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Affiliation(s)
- Hall Schartum-Hansen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- * E-mail:
| | - Kjetil H. Løland
- Section for Cardiology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Gard F. T. Svingen
- Section for Cardiology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Reinhard Seifert
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Eva R. Pedersen
- Section for Cardiology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jan E. Nordrehaug
- Section for Cardiology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Øyvind Bleie
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Marta Ebbing
- Norwegian Institute of Public Health, Bergen, Norway
| | - Christ Berge
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Dennis W. T. Nilsen
- Section for Cardiology, Department of Clinical Science, University of Bergen, Bergen, Norway
- Stavanger University Hospital, Stavanger, Norway
| | - Ottar Nygård
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Section for Cardiology, Department of Clinical Science, University of Bergen, Bergen, Norway
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8
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Dini FL, Ghio S, Klersy C, Rossi A, Simioniuc A, Scelsi L, Genta FT, Cicoira M, Tavazzi L, Temporelli PL. Effects on survival of loop diuretic dosing in ambulatory patients with chronic heart failure using a propensity score analysis. Int J Clin Pract 2013; 67:656-64. [PMID: 23758444 DOI: 10.1111/ijcp.12144] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 01/25/2013] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To ascertain whether increasing doses of orally administered furosemide are associated with impaired survival in outpatients with chronic heart failure (CHF) and left ventricular (LV) systolic dysfunction. METHODS Transthoracic echo-Doppler examination was carried out at baseline in 813 consecutive CHF outpatients with LV ejection fraction ≤ 45%. The total daily dose of furosemide was assessed for each patient. Chronic kidney disease (CKD) was defined by a glomerular filtration rate < 60 ml/min/1.73 m(2). The end-point was all-cause mortality. To control the prognostic effect of furosemide for the propensity of using high doses of the drug, the Cox model was stratified by the propensity score, itself computed from a multivariable logistic model. Mean follow up was 44 months. RESULTS After stratification for the propensity score, the risk of death increased linearly across quartiles of furosemide dose (HR 1.38, 95% CI 1.14-1.68, p < 0.001). A daily dose of 50 mg was identified as the best threshold value to predict a high risk of death within 3 years with an area under the ROC curve of 0.68 (95% CI 0.64-0.72). Increasing doses of furosemide were associated with an increased risk of death regardless of LV filling pattern, CKD and background therapy with ACE-inhibitors or beta-blockers. CONCLUSIONS In outpatients with CHF, after stratification for the propensity score, the risk of death increased linearly across quartiles of furosemide daily dose. A threshold furosemide dose of 50 mg was related with the worse outcome.
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Affiliation(s)
- F L Dini
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy.
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9
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Abstract
INTRODUCTION Despite widespread use of loop diuretics in congestive heart failure (HF) to achieve decongestion and relief of symptoms, as recommended by the current guidelines, there is uncertainty as to their long-term therapeutic efficacy and safety. Their efficacy and safety compared to venous ultrafiltration are currently under investigation in acute decompensated HF patients. AREAS COVERED In this article, the authors review current available data related to efficacy and safety of loop diuretics and ultrafiltration in HF. EXPERT OPINION The literature review highlights an unmet clinical need for evidence-based algorithms, potentially using not only the classical clinical signs and symptoms of congestion as well as the estimated glomerular filtration rate and serum electrolytes, but also biomarkers of congestion/decongestion, neurohumoural activation or urinary kidney injury molecules, in order to optimize both loop diuretics and renin-angiotensin-aldosterone system blocker use in HF patients.
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Affiliation(s)
- Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques, Université de Lorraine and CHU de Nancy, 9501, UMR 1116, Vandoeuvre lès Nancy, France
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10
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Yilmaz MB, Gayat E, Salem R, Lassus J, Nikolaou M, Laribi S, Parissis J, Follath F, Peacock WF, Mebazaa A. Impact of diuretic dosing on mortality in acute heart failure using a propensity-matched analysis. Eur J Heart Fail 2012; 13:1244-52. [PMID: 22024466 DOI: 10.1093/eurjhf/hfr121] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIMS Loop diuretics are recommended to treat congestion in heart failure (HF), despite limited quality evidence. High-dose (HD) loop diuretics seem to worsen outcomes in chronic HF, though; data for acute HF are scarce, with equivocal results. METHODS AND RESULTS The ALARM-HF study recorded in-hospital HF therapy in 4953 patients from nine countries. A post-hoc analysis was performed to determine if there was an interaction between intravenous (iv) bolus diuretic dosing and outcomes. Patients were classified as receiving high- or low-dose iv furosemide if their total initial 24 h dose was above (HD) or below [low dose (LD)] 1 mg/kg. Propensity scoring, matching an extensive list of variables, was performed. High-dose and LD patients were matched by propensity scores and outcomes determined. We identified 2460 LD and 848 HD patients, with overall in-hospital mortality of 9 and 13% (P= 0.002), respectively. After propensity matching, there were 506 patients in each subgroup, with the matched LD and HD cohorts having similar mortality (13 vs. 15%; P= 0.4). We further investigated in which subgroups of patients HD diuretics influenced mortality. Before matching, HD diuretics were associated with a greater risk of in-hospital death in some subgroups, including patients aged >80 years, those with an acute coronary syndrome, or with a left ventricular ejection fraction <40%. However, after propensity score matching, no association was found between diuretic dosing and death in any of the studied subgroups. CONCLUSIONS In the initial management of acute HF, HD iv diuretics, per se, do not influence short-term mortality.
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Affiliation(s)
- Mehmet Birhan Yilmaz
- Department of Cardiology, Cumhuriyet University School of Medicine, Sivas, Turkey
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11
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Rossignol P, Cleland JG, Bhandari S, Tala S, Gustafsson F, Fay R, Lamiral Z, Dobre D, Pitt B, Zannad F. Determinants and Consequences of Renal Function Variations With Aldosterone Blocker Therapy in Heart Failure Patients After Myocardial Infarction. Circulation 2012; 125:271-9. [DOI: 10.1161/circulationaha.111.028282] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background—
We evaluated the effect of the selective mineralocorticoid receptor antagonist eplerenone on renal function and the interaction between changes in renal function and subsequent cardiovascular outcomes in patients with heart failure and left ventricular systolic dysfunction after an acute myocardial infarction in the Eplerenone Post–Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS).
Methods and Results—
Serial changes in estimated glomerular filtration rate (eGFR) were available in 5792 patients during a 24-month follow-up. Patients assigned to eplerenone had a decline in eGFR with an adjusted mean difference of −1.4±0.3 mL · min
−1
· 1.73 m
−2
compared with placebo (
P
<0.0001), an effect that appeared within the first month (−1.3±0.4 mL · min
−1
· 1.73 m
−2
) and persisted throughout the study. Overall, 914 patients experienced a decline in eGFR >20% in the first month, 16.9% and 14.7% in the eplerenone and placebo groups, respectively (odds ratio, 1.15; 95% confidence interval, 1.02–1.30;
P
=0.017). In multivariate analyses, determinants of this early decline in eGFR were female sex, age ≥65 years, smoking, left ventricular ejection fraction <35%, and use of eplerenone and loop diuretic. An early decline in eGFR by >20% was associated with worse cardiovascular outcomes independently of baseline eGFR and of the use of eplerenone, which retained its prognostic benefits even under these circumstances.
Conclusions—
In patients with heart failure after acute myocardial infarction and receiving standard medical care, an early decline in eGFR is not uncommon and is associated with poor long-term outcome. Eplerenone induced a moderately more frequent early decline in eGFR, which did not affect its clinical benefit on cardiovascular outcomes.
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Affiliation(s)
- Patrick Rossignol
- From INSERM, Centre d'Investigations Cliniques- 9501, Nancy, France (P.R., S.T., R.F., Z.L., D.D., F.Z.); Nancy-Université, Nancy, France (P.R., R.F., Z.L., D.D., F.Z.); INSERM U961, Nancy, France (P.R., D.D., F.Z.); Hull York Medical School, University of Hull, Kingston Upon Hull, UK (J.G.F.C.); Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston Upon Hull, UK (S.B.); The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.); University of
| | - John G.F. Cleland
- From INSERM, Centre d'Investigations Cliniques- 9501, Nancy, France (P.R., S.T., R.F., Z.L., D.D., F.Z.); Nancy-Université, Nancy, France (P.R., R.F., Z.L., D.D., F.Z.); INSERM U961, Nancy, France (P.R., D.D., F.Z.); Hull York Medical School, University of Hull, Kingston Upon Hull, UK (J.G.F.C.); Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston Upon Hull, UK (S.B.); The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.); University of
| | - Sunil Bhandari
- From INSERM, Centre d'Investigations Cliniques- 9501, Nancy, France (P.R., S.T., R.F., Z.L., D.D., F.Z.); Nancy-Université, Nancy, France (P.R., R.F., Z.L., D.D., F.Z.); INSERM U961, Nancy, France (P.R., D.D., F.Z.); Hull York Medical School, University of Hull, Kingston Upon Hull, UK (J.G.F.C.); Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston Upon Hull, UK (S.B.); The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.); University of
| | - Stéphane Tala
- From INSERM, Centre d'Investigations Cliniques- 9501, Nancy, France (P.R., S.T., R.F., Z.L., D.D., F.Z.); Nancy-Université, Nancy, France (P.R., R.F., Z.L., D.D., F.Z.); INSERM U961, Nancy, France (P.R., D.D., F.Z.); Hull York Medical School, University of Hull, Kingston Upon Hull, UK (J.G.F.C.); Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston Upon Hull, UK (S.B.); The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.); University of
| | - Finn Gustafsson
- From INSERM, Centre d'Investigations Cliniques- 9501, Nancy, France (P.R., S.T., R.F., Z.L., D.D., F.Z.); Nancy-Université, Nancy, France (P.R., R.F., Z.L., D.D., F.Z.); INSERM U961, Nancy, France (P.R., D.D., F.Z.); Hull York Medical School, University of Hull, Kingston Upon Hull, UK (J.G.F.C.); Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston Upon Hull, UK (S.B.); The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.); University of
| | - Renaud Fay
- From INSERM, Centre d'Investigations Cliniques- 9501, Nancy, France (P.R., S.T., R.F., Z.L., D.D., F.Z.); Nancy-Université, Nancy, France (P.R., R.F., Z.L., D.D., F.Z.); INSERM U961, Nancy, France (P.R., D.D., F.Z.); Hull York Medical School, University of Hull, Kingston Upon Hull, UK (J.G.F.C.); Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston Upon Hull, UK (S.B.); The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.); University of
| | - Zohra Lamiral
- From INSERM, Centre d'Investigations Cliniques- 9501, Nancy, France (P.R., S.T., R.F., Z.L., D.D., F.Z.); Nancy-Université, Nancy, France (P.R., R.F., Z.L., D.D., F.Z.); INSERM U961, Nancy, France (P.R., D.D., F.Z.); Hull York Medical School, University of Hull, Kingston Upon Hull, UK (J.G.F.C.); Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston Upon Hull, UK (S.B.); The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.); University of
| | - Daniela Dobre
- From INSERM, Centre d'Investigations Cliniques- 9501, Nancy, France (P.R., S.T., R.F., Z.L., D.D., F.Z.); Nancy-Université, Nancy, France (P.R., R.F., Z.L., D.D., F.Z.); INSERM U961, Nancy, France (P.R., D.D., F.Z.); Hull York Medical School, University of Hull, Kingston Upon Hull, UK (J.G.F.C.); Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston Upon Hull, UK (S.B.); The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.); University of
| | - Bertram Pitt
- From INSERM, Centre d'Investigations Cliniques- 9501, Nancy, France (P.R., S.T., R.F., Z.L., D.D., F.Z.); Nancy-Université, Nancy, France (P.R., R.F., Z.L., D.D., F.Z.); INSERM U961, Nancy, France (P.R., D.D., F.Z.); Hull York Medical School, University of Hull, Kingston Upon Hull, UK (J.G.F.C.); Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston Upon Hull, UK (S.B.); The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.); University of
| | - Faiez Zannad
- From INSERM, Centre d'Investigations Cliniques- 9501, Nancy, France (P.R., S.T., R.F., Z.L., D.D., F.Z.); Nancy-Université, Nancy, France (P.R., R.F., Z.L., D.D., F.Z.); INSERM U961, Nancy, France (P.R., D.D., F.Z.); Hull York Medical School, University of Hull, Kingston Upon Hull, UK (J.G.F.C.); Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston Upon Hull, UK (S.B.); The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.); University of
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12
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Freda BJ, Slawsky M, Mallidi J, Braden GL. Decongestive treatment of acute decompensated heart failure: cardiorenal implications of ultrafiltration and diuretics. Am J Kidney Dis 2011; 58:1005-17. [PMID: 22014726 DOI: 10.1053/j.ajkd.2011.07.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 07/27/2011] [Indexed: 01/08/2023]
Abstract
In patients with acute decompensated heart failure (ADHF), treatment aimed at adequate decongestion of the volume overloaded state is essential. Despite diuretic therapy, many patients remain volume overloaded and symptomatic. In addition, adverse effects related to diuretic treatment are common, including worsening kidney function and electrolyte disturbances. The development of decreased kidney function during treatment affects the response to diuretic therapy and is associated with important clinical outcomes, including mortality. The occurrence of diuretic resistance and the morbidity and mortality associated with diuretic therapy has stimulated interest to develop effective and safe treatment strategies that maximize decongestion and minimize decreased kidney function. During the last few decades, extracorporeal ultrafiltration has been used to remove fluid from diuretic-refractory hypervolemic patients. Recent clinical studies using user-friendly machines have suggested that ultrafiltration may be highly effective for decongesting patients with ADHF. Many questions remain regarding the comparative impact of diuretics and ultrafiltration on important clinical outcomes and adverse effects, including decreased kidney function. This article serves as a summary of key clinical studies addressing these points. The overall goal is to assist practicing clinicians who are contemplating the use of ultrafiltration for a patient with ADHF.
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Affiliation(s)
- Benjamin J Freda
- Division of Nephrology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA 01107, USA.
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13
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Dini FL, Guglin M, Simioniuc A, Donati F, Fontanive P, Pieroni A, Orsini E, Caravelli P, Marzilli M. Association of furosemide dose with clinical status, left ventricular dysfunction, natriuretic peptides, and outcome in clinically stable patients with chronic systolic heart failure. ACTA ACUST UNITED AC 2011; 18:98-106. [PMID: 22432556 DOI: 10.1111/j.1751-7133.2011.00252.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In chronic heart failure (HF), high daily doses of furosemide have been associated with increased mortality. The authors sought to evaluate the relationships between orally administered furosemide doses, clinical status, left ventricular (LV) dysfunction, N-terminal proBNP (NT-proBNP), and outcome in 400 outpatients with chronic HF and LV ejection fraction (EF) ≤ 45%. Clinical status, NT-proBNP levels, and estimated glomerular filtration rate (eGFR) were evaluated. Median follow-up duration was 32 months. The median values of daily-dose furosemide and of furosemide dose normalized to body surface area were 25 mg (12.5-62.5 mg) and 15 mg/m(2) (13-34 mg/m(2)), respectively. A total of 32% of patients had decompensated HF according to Framingham score and criteria for congestion. In clinically stable patients, a multivariable Cox model, which included clinical and echocardiographic parameters plus NT-proBNP, hemoglobin, and eGFR, showed that normalized furosemide dose (P=.017), anemia (P=.060), age (P=.080), and New York Heart Association class (P=.080) were predictors of all cause-mortality. In patients with decompensated HF, LV end-systolic volume index (P=.018), NT-proBNP (P=.060), and reduced eGFR (P=.070) were independently related to the outcome. Normalized furosemide dose was a major determinant of prognosis in patients with chronic HF but without ongoing signs and symptoms, and this suggests a possible negative interaction of this drug in clinically stable patients.
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Affiliation(s)
- Frank L Dini
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy.
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14
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Martins J, Lourenço P, Araújo JP, Mascarenhas J, Lopes R, Azevedo A, Bettencourt P. Prognostic Implications of Diuretic Dose in Chronic Heart Failure. J Cardiovasc Pharmacol Ther 2011; 16:185-91. [DOI: 10.1177/1074248410388807] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Prognostic implications of diuretics dose are not completely understood. We aim to study the association between diuretic doses and long-term prognosis in patients with chronic stable heart failure (HF). Methods and Results: We conducted a retrospective cohort study of 244 patients followed at an outpatient HF clinic. Admission criteria were clinical stability in the previous 3 months and optimized medical therapy. Demographic characteristics, clinical, and laboratory parameters were recorded. Patients were followed for 2 years and the outcome was defined as all-cause death or hospital admission due to HF worsening. Patients on ≤80 mg furosemide were compared with those on higher doses. Patients were grouped according to furosemide dose (≤80 mg and >80 mg/d) and according to volemia as assessed by the sodium retention score: <3 (euvolemia) versus ≥3 (hypervolemia). Patients on higher diuretic doses (n = 79) were older, more hypervolemic, and more symptomatic. Patients on >80 mg furosemide had a higher risk of death or hospital admission (hazard ratio [HR]: 2.07, 95% confidence interval [CI]: 1.37-3.1). For each 40-mg furosemide tablet, there was a 67% increase in risk of an adverse outcome within 2 years. The increase in risk was independent of other variables crudely associated with prognosis. Among euvolemic patients, those on ≤80 mg/d furosemide performed better than those on higher doses. Among hypervolemic patients, the diuretic dose had no prognostic implications. Conclusions: Higher diuretic doses associated strongly and independently with adverse long-term outcome in chronic HF. Possibly, in euvolemic patients, efforts should be made to reduce diuretic dose.
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Affiliation(s)
- João Martins
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| | - Patrícia Lourenço
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal,
| | - José Paulo Araújo
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| | - Joana Mascarenhas
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| | - Ricardo Lopes
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| | - Ana Azevedo
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal, Serviço de Higiene e Epidemiologia, Faculdade de Medicina da Universidade de Porto, Institute of Public Health-University of Porto (ISPUP), Porto, Portugal
| | - Paulo Bettencourt
- Heart Failure Clinic, Serviço de Medicina Interna-Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
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15
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Frankenstein L, Clark AL, Ribeiro JP. Influence of sex on treatment and outcome in chronic heart failure. Cardiovasc Ther 2011; 30:182-92. [PMID: 21599874 DOI: 10.1111/j.1755-5922.2010.00253.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The population is aging, the prevalence of heart failure increases with age, and on average women live longer than men. There is evidence for sex-specific effects of individual, guideline-recommended drugs used for treatment of chronic heart failure. Women are underrepresented in most clinical trials and only a minority of drug applications to regulatory authorities have included sex analyses. The present review focuses on the potential female survival benefit in heart failure, the influence of sex on medical treatment in a broader sense, and the potential benefit to be derived from guideline recommended treatment and common adjunctive heart failure medication.
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Affiliation(s)
- Lutz Frankenstein
- Department of Cardiology, Angiology, Pulmonology, University of Heidelberg, Germany.
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16
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Gorelik O, Almoznino-Sarafian D, Alon I, Shteinshnaider M, Chachashvily S, Tzur I, Modai D, Cohen N. Heart Failure in Diabetes mellitus: Clinical Features and Prognostic Implications. Cardiology 2005; 103:161-6. [PMID: 15785022 DOI: 10.1159/000084587] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2004] [Accepted: 08/30/2004] [Indexed: 11/19/2022]
Abstract
We defined the prevalence and impact on survival of clinical bedside variables in 385 patients with symptomatic congestive heart failure (CHF), of whom there were 176 with and 209 without diabetes mellitus. Patients were consecutively hospitalized and admitted for various acute conditions. Following discharge all-cause mortality was recorded. Prevalence and association of various variables with mortality were statistically analyzed. Prevailing in the diabetics versus nondiabetics were younger age (p < 0.05), pulmonary edema on admission (p = 0.002), using furosemide > 80 mg/day (p < 0.01) for > 1 year (p < 0.01) and hyponatremia (p = 0.01). Less prevalent were chronic lung disease (p < 0.01) and cardiac arrhythmias (p = 0.001). On follow-up extending up to 60 months, diabetic patients, especially those with fasting blood glucose levels on admission > or = 180 mg/dl, survived for a shorter period of time than nondiabetics (p = 0.02). Associated with increased mortality in the diabetic group were female gender (p = 0.04), furosemide > or = 80 mg/day (p < 0.001) and renal dysfunction (RD; p = 0.04). The respective variables in the nondiabetics were advanced age (p < 0.001) and RD (p = 0.002). Although they were younger, diabetic patients presented more severe CHF. It is recommended that special attention should be given to diabetic females, those using higher furosemide dosages and those suffering from RD.
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Affiliation(s)
- Oleg Gorelik
- Department of Internal Medicine F, Assaf Harofeh Medical Center (affiliated to Sackler School of Medicine, Tel Aviv University), Zerifin, Israel.
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17
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Cohen N, Ilgiyaev E, Almoznino-Sarafian D, Alon I, Shteinshnaider M, Chachashvily S, Modai D, Gorelik O. Sex-related bedside clinical variables associated with survival of older inpatients with heart failure. Eur J Heart Fail 2004; 6:781-6. [PMID: 15542416 DOI: 10.1016/j.ejheart.2003.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2003] [Revised: 12/01/2003] [Accepted: 12/24/2003] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Little is known about sex-related differences in factors affecting prognosis of heart failure (HF). We prospectively investigated the relationship between bedside clinical variables and survival of older females vs. males with HF. METHODS Included were consecutive unselected inpatients, age >/=60 years, admitted for various acute conditions. HF was chronic and of diverse etiologies. Follow-up extended up to 5 years. All-cause mortality was registered and statistically analyzed for association with in-hospital clinical variables. RESULTS Included were 162 females and 200 males. Survival rates were 52.4% and 59%, respectively, (P=0.1). Advanced age and renal dysfunction (RD) were associated with low survival in both sexes (P<0.03 and 0.02, P<0.001 and 0.01, respectively). An association with low survival was found with respect to; admission for pulmonary edema (P<0.02), using furosemide >/=80 mg/day (P<0.005) and severe HF [NYHA class III-IV (P<0.01)] in females, as well as for hypokalemia (P<0.03) and hypocalcemia (P<0.03) in males. On multivariate analysis RD (P<0.001), increasing age (P=0.008) and furosemide dosage >/=80 mg (P=0.02) were most significantly associated with low survival in females, while RD only was significantly associated with low survival in males (P=0.03). CONCLUSIONS Several clinical variables, which affect prognosis in older HF patients are sex-related and probably carry practical significance.
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Affiliation(s)
- Natan Cohen
- Department of Internal Medicine F, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, 70300, Israel.
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