Evidence-Based Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction and Chronic Kidney Disease

Using guideline-directed medical therapies to improve kidney and cardiovascular outcomes in patients with chronic kidney disease

PURPOSE

An estimated 37 million people currently live with chronic kidney disease in the US, which places them at increased risk for kidney disease progression, cardiovascular disease, and mortality. This review discusses current standard-of-care management of patients with chronic kidney disease, identifies key gaps in care, and briefly highlights how pharmacists can address gaps in care as members of the multidisciplinary care team.

SUMMARY

Recent advances in guideline-directed medical therapies for patients with chronic kidney disease, including agents from the sodium-glucose cotransporter, glucagon-like peptide-1 receptor agonist, and nonsteroidal mineralocorticoid receptor antagonist classes, can dramatically improve cardiovascular-kidney-metabolic care and outcomes. Unfortunately, gaps in screening, diagnosis, and implementation of recommended therapies persist. Team-based models of care-inclusive of the person with chronic kidney disease-have the potential to significantly improve care and outcomes for people with chronic kidney disease by addressing current gaps in care.

CONCLUSION

As members of the multidisciplinary care team, pharmacists can play a critical role in addressing current gaps in care, including optimized use of guideline-directed medical therapies, in patients with chronic kidney disease.

Finerenone Across the Spectrum of Kidney Risk in Heart Failure: The FINEARTS-HF Trial

BACKGROUND

Estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio are complementary domains of kidney disease staging and independently associated with heart failure (HF) progression.

OBJECTIVES

The purpose of this study was to evaluate whether the efficacy and safety of finerenone varies according to kidney risk among patients with HF with mildly reduced or preserved ejection fraction.

METHODS

In this prespecified analysis of FINEARTS-HF (Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients with Heart Failure), clinical outcomes and treatment effects of finerenone on the primary endpoint (cardiovascular death and total [first and recurrent] HF events) and key secondary endpoints were evaluated according to baseline KDIGO (Kidney Disease: Improving Global Outcomes) risk category (low, moderately increased, and high or very high). Key exclusion criteria in FINEARTS-HF were eGFR <25 mL/min/1.73 m2 or serum potassium >5.0 mmol/L.

RESULTS

Overall, 5,797 (97%) FINEARTS-HF participants had classifiable KDIGO risk category at baseline, of whom 2,022 (35%), 1,688 (29%), and 2,087 (36%) were low, moderate, and high/very high risk, respectively. Over a median follow-up of 2.7 years, higher kidney risk was associated with a higher rate of primary outcome events, with similar findings for other key endpoints, including the composite kidney outcome, new-onset atrial fibrillation, and vascular events. Benefits of finerenone vs placebo on the primary endpoint (Pinteraction = 0.24) and Kansas City Cardiomyopathy Questionnaire-Total Symptom Score at 12 months (Pinteraction = 0.36) were consistent irrespective of baseline kidney risk category. Participants with higher kidney risk experienced greater reductions in urine albumin-to-creatinine ratio after 6 months (Pinteraction = 0.031), without differences in eGFR slope. Risks of safety events, including hyperkalemia, with finerenone vs placebo were not enhanced among participants with higher kidney risk.

CONCLUSIONS

Finerenone appears to consistently improve clinical outcomes, HF-related health status, and albuminuria across a broad spectrum of kidney risk in patients with HF with mildly reduced or preserved ejection fraction. (Study to Evaluate the Efficacy [Effect on Disease] and Safety of Finerenone on Morbidity [Events Indicating Disease Worsening] and Mortality [Death Rate] in Participants With Heart Failure and Left Ventricular Ejection Fraction [Proportion of Blood Expelled Per Heart Stroke] Greater or Equal to 40% [FINEARTS-HF]; NCT04435626).

Gut microbiota-derived metabolites: Potential targets for cardiorenal syndrome

The characteristic of cardiorenal syndrome (CRS) is simultaneous damage to both the heart and kidneys. CRS has caused a heavy burden of mortality and incidence rates worldwide. The regulation of host microbiota metabolism that triggers heart and kidney damage is an emerging research field that promotes a new perspective on cardiovascular risk. We summarize current studies from bench to bedside of gut microbiota-derived metabolites to better understand CRS in the context of gut microbiota-derived metabolites. We focused on the involvement of gut microbiota-derived metabolites in the pathophysiology of CRS, including lipid and cholesterol metabolism disorders, coagulation abnormalities and platelet aggregation, oxidative stress, endothelial dysfunction, inflammation, mitochondrial damage and energy metabolism disorders, vascular calcification and renal fibrosis, as well as emerging therapeutic approaches targeting CRS metabolism in gut microbiota-derived metabolites which provides an innovative treatment approach for CRS to improve patient prognosis and overall quality of life.

Systematic Review of the Effects of Iron on Cardiovascular, Kidney, and Safety Outcomes in Patients With CKD

Introduction

Heart failure and chronic kidney disease (CKD) are closely associated, and iron deficiency is highly prevalent in both conditions. However, major cardiovascular and nephrology guidelines offer contrasting recommendations for iron use. We evaluated the effects of iron versus usual care or placebo on the clinical outcomes in patients with CKD.

Methods

We conducted a systematic review and meta-analysis of randomized trials on i.v. or oral iron in patients with CKD (PROSPERO CRD42023453468). We searched Medline, Embase, and the Cochrane Register from database inception until February 1, 2024 to identify eligible trials. We determined the overall results and stratified them by dialysis- and nondialysis-requiring CKD using random effects models, with certainty of evidence assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary composite endpoint was hospitalization for heart failure or cardiovascular death.

Results

We identified 45 trials that met the inclusion criteria. Compared with usual care or placebo, iron reduced the risk of the primary composite endpoint (1659 events; risk ratio [RR]: 0.84, 95% confidence interval [CI]: 0.75-0.94; moderate certainty), an effect consistent across dialysis and nondialysis requiring CKD (P-heterogeneity = 0.70). The effect on the primary endpoint appeared driven by both components of hospitalization for heart failure (RR: 0.77; 95% CI: 0.61-0.96; moderate certainty) and cardiovascular death (RR: 0.81; 95% CI: 0.65-1.02; low certainty). The incidence of serious adverse events was lower for iron compared with usual care or placebo (RR: 0.90, 95% CI: 0.82-0.98; moderate certainty; P-heterogeneity = 0.09).

Conclusion

Iron therapy may reduce the risk of heart failure and cardiovascular death in patients with CKD. Randomized trials evaluating the effects of iron on clinical outcomes are needed, especially in nondialysis patients with CKD with or without anemia.

[Multimorbidity and the Kidney]

Multimorbidity, i.e. the simultaneous presence of 2 or more diseases, is common in patients with chronic kidney disease (CKD). Cardiovascular diseases such as coronary heart disease, heart failure, stroke or vascular dementia are of particular importance. CKD and comorbidities influence each other, which is why the current KDIGO guidelines emphasize the need for personalized treatment approaches. This applies in particular to older patients, who are especially frequently affected by CKD. The diagnosis of CKD patients should not only include typical comorbidities, but also a comprehensive risk assessment and an evaluation to avoid polypharmacy.Recognising CKD is of particular importance for patients with chronic diseases in old age, as kidney disease can have a profound effect on or worsen the course of other diseases and the limitation of kidney function has a significant influence on the treatment approach. Particular attention must be paid to the correct assessment of kidney function in older people in terms of determining the estimated glomerular filtration rate (eGFR). Here, a measurement of serum creatinine is not always sufficient due to lower muscle mass and may need to be supplemented by additional parameters to estimate the glomerular filtration rate, such as cystatin C.Depending on the eGFR, kidney disease is categorized into the stages CKD G1-G5. In addition, if kidney disease is suspected, a test for proteinuria should also be performed, preferably as a measurement of albumin excretion in spontaneous urine (albumin-to-creatinine ratio, ACR). Geriatric screening and assessment are also crucial to recognize the multimorbidity, frailty and psychosocial aspects of older patients.The treatment of multimorbidity in CKD patients focusses on progression reduction and secondary and tertiary prevention, whereby a healthy lifestyle, regular exercise and a balanced diet are also important. The prevention of cardiovascular disease, particularly in the case of high blood pressure and diabetes mellitus, requires individualized therapy, in which the choice and dosage of medication must also be taken into account, particularly in the case of advanced renal impairment. If heart failure and/or atrial fibrillation are also present, close interdisciplinary collaboration between nephrologists, cardiologists and GPs is helpful in order to optimize treatment. In addition, CKD patients with dementia face particular challenges in terms of medication and the avoidance of delirium and mental symptoms.

Withdrawal of Guideline-Directed Medical Therapy in Patients With Heart Failure and Improved Ejection Fraction

BACKGROUND

Limited evidence exists on the prognostic role of continuing medical therapy in patients with heart failure (HF) and an ejection fraction (EF) that has improved over time. This study assessed rates of, patient profiles, and associations with morbidity/mortality of renin-angiotensin inhibitors (RASi), angiotensin receptor-neprilysin inhibitors (ARNi), beta-blockers (BBL), and mineralocorticoid receptor antagonists (MRA) withdrawal in patients with HF with improved EF.

METHODS

Patients with a first recorded EF <40% and a later EF ≥40% from the Swedish HF registry between June 11, 2000, and December 31, 2023, were included in this retrospective observational study. Withdrawal was defined as a patient on treatment at the first (reduced) but not at the second (improved) registration. The association between withdrawal and time to first cardiovascular mortality/hospitalization for HF with censoring at 1 year was assessed by Cox regression model using overlap weighting.

RESULTS

Of 8728 patients with HF with improved EF (median age, 70 years [25th to 75th percentile, 61-78], 2611 [29.9%] women), 96%, 94%, and 46% received RASi/ARNi, BBL, and MRA, respectively, when EF was <40%. The withdrawal rates at the time of the improved EF registration were 4.4% for RASi/ARNi, 3.3% for BBL, and 17.2% for MRA. Predictors of withdrawal included lower use of other HF medications, higher EF at the later EF registration, and a longer time between the 2 EF assessments. After weighting, withdrawal was independently associated with a higher risk of cardiovascular mortality/hospitalization for HF by 38% for RASi/ARNi and 36% for MRA, but not for BBL. Withdrawal of BBL was associated with a higher risk of the primary outcome in the subgroup of patients with an improved EF of 40% to 49% versus ≥50% (P-interaction 0.03).

CONCLUSIONS

In patients with HF with improved EF, HF therapy withdrawal was rare. Withdrawing RASi/ARNi and MRA was associated with higher mortality/morbidity at 1 year. No association was found for BBL withdrawal, albeit with a significant heterogeneity for EF at improvement, suggesting better outcomes with continuing BBL only until EF improves up to 50%. These results are hypothesis-generating and highlight the need for randomized controlled trials testing BBL withdrawal in patients with HF with improved EF.

How to handle polypharmacy in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC

The multiplicity of coexisting comorbidities affecting patients with heart failure (HF), together with the availability of multiple treatments improving prognosis in HF with reduced ejection fraction, has led to an increase in the number of prescribed medications to each patient. Polypharmacy is defined as the regular use of multiple medications, and over the last years has become an emerging aspect of HF care, particularly in older and frailer patients who are more frequently on multiple treatments, and are therefore more likely exposed to tolerability issues, drug-drug interactions and practical difficulties in management. Polypharmacy negatively affects adherence to treatment, and is associated with a higher risk of adverse drug reactions, impaired quality of life, more hospitalizations and worse prognosis. It is important to adopt and implement strategies for the management of polypharmacy from other medical disciplines, including medication reconciliation, therapeutic revision and treatment prioritization. It is also essential to develop new HF-specific strategies, with the primary goal of avoiding the use of redundant treatments, minimizing adverse drug reactions and interactions, and finally improving adherence. This clinical consensus statement document from the Heart Failure Association of the European Society of Cardiology proposes a rationale, pragmatic and multidisciplinary approach to drug prescription in the current era of multimorbidity and 'multi-medication' in HF.

Efficacy and safety of SGLT2 inhibitors in patients with heart failure according to kidney function: a systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

This study aimed to evaluate the efficacy and safety of sodium-glucose cotransporter 2 (SGLT2) inhibitors throughout the spectrum of kidney function in patients with heart failure (HF).

METHODS

This meta-analysis included randomized controlled trials comparing SGLT2 inhibitors with placebo in patients with HF stratified by renal function. Literature from inception to June 8, 2024 was searched. The primary outcome was a composite of cardiovascular death or HF events.

RESULTS

Five trials were identified, comprising 21 204 patients (10 605 in the SGLT2 inhibitor group and 10 599 in the placebo group) who were randomized and followed up for a weighted median duration of 1.8 years. When patients were classified by estimated glomerular filtration rate (eGFR) of 60mL/min/1.73 m2, SGLT2 inhibitors reduced the risk of the primary outcome irrespective of kidney function (RR, 0.81; 95%CI, 0.75-0.87; P<.01 for eGFR <60mL/min/1.73 m2; RR, 0.79; 95%CI, 0.72-0.87; P<.01 for eGFR≥ 60mL/min/1.73 m2; test for subgroup differences P=.75). The beneficial impact of SGLT2 inhibitors was consistently observed when patients were further subclassified by eGFR values of 20-30, 30-45, 45-60, and >60mL/min/1.73 m2 (test for subgroup differences, P=.54). Early eGFR decline showed a differential impact with increased risk only in the placebo subgroup (RR, 1.30; 95%CI, 1.15-1.47; P<.01), but not in the SGLT2 inhibitor subgroup (RR, 0.99; 95%CI, 0.86-1.13; P=.84) (test for subgroup differences, P<.01).

CONCLUSIONS

SGLT2 inhibitor therapy is safe and effective throughout the spectrum of kidney function and regardless of the initial decline in kidney function in patients with chronic HF. Registered at PROSPERO: CRD42024565218.

Management of heart disease in renal transplant recipients: a national Delphi survey-based SET/SEC/SEN consensus document

Renal transplantation improves the survival and quality of life of patients with end-stage renal disease. Cardiovascular disease is the leading cause of morbidity and mortality in renal transplant recipients. The bidirectional relationship between renal and heart disease creates a unique clinical scenario that demands a comprehensive and personalized approach. This expert consensus, drafted by the Spanish Society of Transplantation, the Spanish Society of Cardiology, and the Spanish Society of Nephrology, aims to assess current practices and propose strategies for the management of heart disease in renal transplant recipients. A panel of Spanish nephrologists and cardiologists with expertise in renal and heart transplantation reviewed the scientific evidence concerning the current management of heart disease in renal transplant recipients. Subsequently, consensus statements were created through a 2-round Delphi methodology, resulting in 30 statements covering key topics such as the identification of renal transplant candidates, the management of heart disease in renal transplant recipients, and eligibility for combined heart-kidney transplantation in patients with both end-stage renal disease and cardiac disease. These consensus statements provide expert guidance for the management of heart disease in renal transplant recipients, an area where published clinical evidence remains limited.

Multidisciplinary cardiorenal program for heart failure patients: Improving outcomes through comprehensive care

The cardiorenal program (CRP), implemented within a specialized heart failure and kidney disease clinic, encompasses a multidisciplinary approach to the management of patients with heart failure and kidney disease. It focuses on optimizing therapy and improving patient outcomes. The CRP includes a range of services, including clinical evaluation, diagnostic testing, medical treatment, and patient education. The program provides comprehensive care for patients with cardiorenal syndrome, and includes a variety of healthcare professionals, such as cardiologists, nephrologists, pharmacists, and nurses, working together to provide the best possible care. The program also incorporates specific performance indicators to continuously evaluate and improve patient outcomes. The CRP's integrated multidisciplinary care and patient-centered approach is promising for the management of patients with cardiorenal syndrome.

Frailty and Heart Failure: Clinical Insights, Patient Outcomes and Future Directions

Frailty is common among heart failure (HF) patients and linked to increased risk of adverse outcomes. Contributing factors include inflammation, sarcopenia and neurohormonal issues which diminish physiological reserves and accelerate the decline of health. Managing frailty in HF requires a multidisciplinary approach to address physical, nutritional and pharmacological needs. Structured exercise and dietary support can improve physical function, while careful medication management, especially with polypharmacy, reduces frailty-related risks. Telemedicine and wearable tech facilitate continuous monitoring and timely intervention, especially for those in remote areas. Future research should develop standardised frailty assessment tools specific to HF, enhancing risk stratification and personalised care. Studies on underlying mechanisms, such as inflammation and mitochondrial dysfunction, could lead to new therapies. Addressing socioeconomic factors can also improve care equity. This review summarises the mechanisms, clinical characteristics and impact of frailty on HF, highlighting challenges in treatment and opportunities for improving patient outcomes.

Initial Decline in Glomerular Filtration Rate With Finerenone in HFmrEF/HFpEF: A Prespecified Analysis of FINEARTS-HF

BACKGROUND

An initial decline in estimated glomerular filtration rate (eGFR) often leads to reluctance to continue life-saving therapies in patients with heart failure (HF).

OBJECTIVES

The goal of this study was to describe the association between initial decline in eGFR and subsequent clinical outcomes in patients randomized to placebo or finerenone.

METHODS

In this prespecified analysis of FINEARTS-HF (Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients with Heart Failure), we examined the association between initial decline in eGFR (≥15%) from randomization to 1 month and subsequent outcomes in patients assigned to finerenone or placebo. The primary outcome was the composite of total HF events and cardiovascular death.

RESULTS

Among 5,587 patients with an eGFR measurement at both baseline and 1 month, 1,018 (18.2%) experienced a ≥15% decline in eGFR. The proportion of patients experiencing a ≥15% decline in eGFR was 23.0% with finerenone and 13.4% with placebo (OR: 1.95; 95% CI: 1.69-2.24; P < 0.001). After adjustment, an eGFR decline was associated with a higher risk of the primary outcome in patients assigned to placebo (adjusted rate ratio: 1.50; 95% CI: 1.20-1.89) but not in those assigned to finerenone (adjusted rate ratio: 1.07; 95% CI: 0.84-1.35; Pinteraction = 0.04). By contrast, the efficacy of finerenone was consistent across the range of change in eGFR from baseline to 1 month (Pinteraction = 0.50 for percent change in eGFR), and safety, including hyperkalemia, was similar regardless of an early eGFR decline.

CONCLUSIONS

Although an initial decline in eGFR was associated with worse outcomes in patients assigned to placebo, this relationship was not as strong in those treated with finerenone. An early decline in eGFR can be anticipated with finerenone and should not automatically lead to the discontinuation of this disease-modifying therapy (FINEARTS-HF Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients with Heart Failure [NCT04435626]; A Multicenter, Randomized, Double-Bline, Parallel-Group, Placebo-Controlled Study to Evaluate the efficacy and safety of finerenone on morbidity and mortality in participants With Heart Failure [NYHA II-IV] and left ventricular ejection fraction ≥40% [EudraCT 2020-000306-29]).

Critical Appraisal of Pharmaceutical Therapy in Diabetic Cardiomyopathy-Challenges and Prospectives

Diabetes mellitus (DM) is a multifaceted disorder with a pandemic spread and a remarkable burden of cardiovascular mortality and morbidity. Diabetic cardiomyopathy (DBCM) has been increasingly recognized as the development of cardiac dysfunction, which is accompanied by heart failure (HF) symptoms in the absence of obvious reasons like ischemic heart disease, hypertension, or valvulopathies. Several pathophysiological mechanisms have been proposed, including metabolic disorders (e.g., glycation products), oxidative stress, low-grade inflammation, mitochondrial dysfunction, etc., which should guide the development of new therapeutic strategies. Up to now, HF treatment has not differed between patients with and without diabetes, which limits the expected benefits despite the high cardiovascular risk in the former group. However, DBCM patients may require different management, which prioritize anti-diabetic medications or testing other novel therapies. This review aims to appraise the challenges and prospectives of the individualized pharmaceutical therapy for DBCM.

Inferior vena cava diameter in patients with chronic heart failure and chronic kidney disease: a retrospective study

BACKGROUND

Chronic kidney disease (CKD) carries the highest population attributable risk for mortality among all comorbidities in chronic heart failure (CHF). No studies about the association between inferior vena cava (IVC) diameter and all-cause mortality in patients with the comorbidity of CKD and CHF has been published.

METHODS

In this retrospective cohort study, a total of 1327 patients with CHF and CKD were included. All patients underwent standardized echocardiography examination and data on demographic characteristics, medical history, and laboratory tests were recorded. Information on all-cause mortality was collected by telephone interview and medical records review. We used Cox regression to evaluate the risk of all-cause mortality among groups, and used mediation analysis to examine the mediation role of N-terminal-pro-B-type natriuretic peptide (NT-proBNP) and serum albumin in the association between IVC and all-cause mortality.

RESULTS

During a median follow-up of 3.46 years (IQR: 1.55-5.15 years), 757 (57.05%) cases of all-cause mortality were observed. Compared with patients with IVC diameter < 21 mm, those with IVC diameter > 21 mm were associated with higher risk of all-cause mortality (HR (95%CI):1.31(1.07-1.61), log rank: P = 0.01) and cardiovascular mortality (HR (95%CI): 1.55(1.19-2.04), log rank: P = 0.001). When assessing IVC as a continuous variable, each 1% increase in IVC was associated with 4% increased risk of all-cause mortality (HR: 1.04, 95%CI 1.02-1.06, P < 0.001). This association were mediated by log NT-proBNP (mediated effect: 37.8% (95%CI 22.0-73.0%), P < 0.001) and serum albumin (mediated effect: 14.1% (95%CI 6.2-28.0%), P < 0.001). In subgroup analyses, there was no significant interaction in different subgroups of cardiac and renal function for the association between IVC and all-cause mortality.

CONCLUSIONS

Elevated IVC diameter was associated with worse prognosis in patients with CHF and CKD, and the associations were mediated by log NT-proBNP and serum albumin.

Heart Failure Mortality in Chronic Kidney Disease: The Fatal Crossover

BACKGROUND

Real-world mortality data regarding heart failure in patients with comorbid chronic kidney disease remains limited, especially following the advent of advanced heart failure therapies.

METHODS

Using the CDC WONDER database, we included patients ≥ 25 years old who died primarily from heart failure (2011-2020) with comorbid chronic kidney disease. We calculated age-adjusted mortality rates (AAMR) per 100,000 individuals. We determined the trends over time by estimating the annual percent change (APC) using the Joinpoint regression program.

RESULTS

There were 82,454 heart failure deaths with comorbid chronic kidney disease. The AAMR increased from 2.34 (95% CI, 2.28-2.41) in 2011 to 4.79 (95% CI, 4.71-4.88) in 2020. During the study period, Heart failure deaths among patients with comorbid chronic kidney disease increased by 149.0% compared to 59.9% in those without. Men had higher AAMR than women (3.92 [95% CI, 3.88-3.96] vs. 2.96 [95% CI, 2.93-2.99]). African American patients had the highest AAMR (5.85 [95% CI, 5.75-5.96]). The Midwest region had the highest AAMR (3.83 [95% CI, 3.78-3.89]). The AAMR was higher in the rural areas than in the urban regions (3.77 [95% CI, 3.71-3.83] vs. 3.23 [95% CI, 3.20-3.25]). Most patients died in hospices or nursing homes (29,000, 35.2%).

CONCLUSION

Our study showed a significant increase in heart failure AAMR in patients with comorbid chronic kidney disease in recent eras. Further effort is needed to optimize cardioprotective agents for this population and to address demographic discrepancies at the policy level.

Angiotensin Receptor Neprilysin Inhibition and Cardiovascular Outcomes Across the Kidney Function Spectrum: The PARAGON-HF Trial

BACKGROUND

Lower estimated glomerular filtration rate (eGFR) may be one of the major reasons for hesitation or failure to initiate potentially beneficial therapies in patients with heart failure (HF).

OBJECTIVES

This study sought to assess if the effects of sacubitril/valsartan (vs valsartan) on cardiovascular outcomes differ according to baseline kidney function in patients with HF with preserved ejection fraction.

METHODS

The PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction) trial was global clinical trial of 4,796 patients with chronic HF and left ventricular ejection fraction (LVEF) ≥45% randomly assigned to sacubitril/valsartan or valsartan. We examined the effect of treatment on cardiovascular outcomes using Cox regression models, stratified by region, and assessed for differential treatment effects according to the baseline eGFR and ejection fraction.

RESULTS

At randomization, mean eGFR was 67 ± 19 mL/min/1.73 m2; 1,955 (41%) participants had an eGFR <60 mL/min/1.73 m2. Compared with valsartan, sacubitril/valsartan reduced the primary cardiovascular outcome (cardiovascular death and total HF hospitalizations) to a greater extent among those with lower baseline eGFR (P interaction = 0.07 for continuous eGFR), and was most pronounced for those with eGFR ≤45 mL/min/1.73 m2 (RR: 0.69; 95% CI: 0.51-0.94). The influence of eGFR on the treatment effect for cardiovascular death was nonlinear, with the most pronounced treatment effect for those with baseline eGFR <45 mL/min/1.73 m2 (HR: 0.65; 95% CI: 0.43-0.97). In further subgroup analyses according to LVEF and eGFR, the treatment effect for the primary outcome was most pronounced among those with LVEF ≤57% and eGFR ≤45 mL/min/1.73 m2 (HR: 0.66; 95% CI: 0.45-0.97).

CONCLUSIONS

In the PARAGON-HF trial, the benefits of sacubitril/valsartan to reduce the frequency of HF hospitalizations and cardiovascular death were most apparent in patients with lower baseline eGFR and lower ejection fraction. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).

Natriuretic Peptides, Kidney Function, and Clinical Outcomes in Heart Failure With Preserved Ejection Fraction

BACKGROUND

N-terminal pro-B-type natriuretic peptides (NT-proBNPs) are guideline-recommended biomarkers for risk stratification in patients with heart failure. However, NT-proBNP levels are often elevated in chronic kidney disease, introducing uncertainty about their prognostic relevance in persons across a broad range of estimated glomerular filtration rate (eGFR).

OBJECTIVES

The aim of this study was to assess the association of NT-proBNP with cardiovascular and mortality outcomes in patients with heart failure and mildly reduced or preserved ejection fraction, stratified by baseline kidney function.

METHODS

A pooled analysis was conducted of participants with NT-proBNP and eGFR measured at baseline in the I-PRESERVE (Irbesartan in Heart Failure and Preserved Ejection Fraction), TOPCAT (Americas region) (Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function), PARAGON (Prospective Comparison of ARNI with ARB Global Outcomes in HF With Preserved Ejection Fraction), and DELIVER (Dapagliflozin Evaluation to Improve the LIVEs of Patients With PReserved Ejection Fraction Heart Failure) trials. The relationship between NT-proBNP and eGFR was assessed using piecewise linear regression. Using multivariable Cox and Poisson regression models, the association of NT-proBNP with outcomes across a range of eGFR was evaluated. The primary outcome was hospitalization for heart failure or cardiovascular death.

RESULTS

Among 14,831 participants (mean age: 72.1 years; 50.3% female; mean eGFR: 63.3 mL/min/1.73 m2, and median NT-proBNP: 840 pg/mL) followed up for a median 33.5 months, there were 3,092 primary outcomes. NT-proBNP levels increased by 9%, 8%, and 23% per 10 mL/min/1.73 m2 lower eGFR in patients with baseline eGFR ≥60, 45-<60, and <45 mL/min/1.73 m2, respectively (P for nonlinearity < 0.001). Each doubling in NT-proBNP was associated with a 37% relative increase in the primary outcome (HR: 1.37; 95% CI: 1.34-1.41), consistent across different eGFR categories (P for interaction = 0.42). For the same incidence of the primary outcome, NT-proBNP levels were approximately 2.5- to 3.5-fold lower in patients with eGFR <45 mL/min/1.73 m2, compared with patients with eGFR ≥60 mL/min/1.73 m2. Similar patterns were observed across all outcomes studied, including cardiovascular and noncardiovascular death.

CONCLUSIONS

The same NT-proBNP concentration predicts a substantially higher absolute risk of adverse outcomes for people with heart failure and reduced kidney function, compared with those with preserved kidney function. These data call into question proposals for higher NT-proBNP references ranges in people with CKD, and suggest that reduced kidney function per se should not be a reason to disregard higher NT-proBNP levels.

Recent Advances and Perspectives on the Use of Mineralocorticoid Receptor Antagonists for the Treatment of Hypertension and Chronic Kidney Disease: A Review

Chronic kidney disease (CKD) is a major public health concern around the world. It is a significant risk factor for cardiovascular disease (CVD), and, as it progresses, the risk of cardiovascular events increases. Furthermore, end-stage kidney disease severely affects life expectancy and quality of life. Type 2 diabetes and hypertension are not only primary causes of CKD but also independent risk factors for CVD, which underscores the importance of effective treatment strategies for these conditions. The current therapies, including angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and sodium-glucose co-transporter 2 inhibitors, are administered to control hypertension, slow the progression of CKD, and reduce cardiovascular risk. However, their efficacy remains suboptimal in certain instances. Mineralocorticoid receptor (MR), a nuclear receptor found in various tissues, such as the kidney and heart, plays a pivotal role in the progression of CKD. Overactivation of MR triggers inflammation and fibrosis, which exacerbates kidney damage and accelerates disease progression. MR antagonists (MRAs) have substantial beneficial effects in patients with cardiac and renal conditions; however, their use has been constrained because of adverse effects, such as hyperkalemia and kidney dysfunction. Recently, novel non-steroidal MRAs are more efficacious and have superior safety profiles to steroidal MRAs, making them promising potential components of future treatment strategies. Here, we discuss recent findings and the roles of MRAs in the management of hypertension and CKD, with a focus on the evidence obtained from fundamental research and major clinical trials.

Clinical and proteomic profiles of chronic kidney disease in heart failure with reduced and preserved ejection fraction

BACKGROUND

Chronic kidney disease (CKD) is prevalent and related to poor clinical outcomes in patients with heart failure (HF). The pathophysiology of CKD in HF with a reduced ejection fraction (HFrEF) and HF with a preserved ejection fraction (HFpEF) is not well defined. In this study we compared clinical and proteomic profiles of CKD between patients with HFrEF and HFpEF.

METHODS

We included 478 patients of the Scottish BIOSTAT-CHF cohort, of which 246 had HFrEF and 232 had HFpEF. CKD was defined as an eGFR <60 mL/min/1.73m2. We compared HFrEF-patients with CKD to HFpEF-patients with CKD using logistic- and Cox-regression. We performed a differential expression analysis using 6376 proteins.

RESULTS

The prevalence of CKD was 36 % and 32 % in patients with HFpEF and HFrEF, respectively. CKD patients were on average 7 years older. BMI, higher NT-proBNP, ACE-inhibitors, HDL-cholesterol and Stroke were associated with CKD- patients with HFrEF. In HFpEF, CKD was associated with MRA-use and higher platelet count. CKD was associated with increased risk of death or heart failure hospitalization (HR 1.82, p < 0.001), with similar effect in HFrEF and HFpEF. The pattern of differentially expressed proteins between patients with and without CKD was similar in both HF-groups.

CONCLUSION

Clinical profiles related to CKD- patients with HFrEF were different from CKD-patients with HFrEF. CKD was associated with an increased risk of death or heart failure hospitalization, which was not different between HFpEF and HFrEF. Patterns of circulating proteins were similar between CKD-patients with HFpEF and HFrEF, suggesting no major differences in CKD-pathophysiology.

The Prognostic Role of RDW in Hospitalized Heart Failure Patients with and Without Chronic Kidney Disease

Background: Chronic kidney disease (CKD) and heart failure (HF) are interrelated conditions that exacerbate each other through mechanisms like fluid retention, neurohormonal activation, and inflammation. Red blood cell distribution width (RDW), a measure of red blood cell size variability, has emerged as a potential prognostic marker in HF. This study aimed to assess the prognostic value of RDW in HF patients, both with and without CKD, focusing on all-cause mortality and HF rehospitalizations. Methods: This observational retrospective study included 171 patients hospitalized for acute decompensated HF in a tertiary university hospital in Greece. Patients were divided into two groups based on their estimated glomerular filtration rate (eGFR), as Group 1 (eGFR < 60 mL/min/1.73 m2) and Group 2 (eGFR ≥ 60 mL/min/1.73 m2). RDW was measured upon admission, and outcomes of interest were all-cause mortality and HF rehospitalizations over a median follow-up period of 6.1 months. Statistical analyses included Kaplan-Meier survival curves, whereas the discrimination traits of RDW were evaluated by constructing receiver operating characteristic (ROC) curves and by calculating the area under the ROC curve (AUC). A p-value <0.05 was indicative of a statistically important result. Results: Patients in Group 1 (eGFR < 60 mL/min/1.73 m2) were older (80 (73-86) vs. 75 (62-83)) and manifested higher median RDW values (16.6 (15.0-18.8) vs. 15.6 (14.1-17.8)) and received less frequent (57.9% vs. 75%) mineralocorticoid receptor antagonists (MRAs) as compared to those in Group 2 (eGFR ≥ 60 mL/min/1.73 m2). RDW demonstrated better prognostic value in predicting combined mortality and rehospitalization outcomes in Group 2 patients (area under the curve: 0.70; 95% CI (0.62-0.80)) compared to those in Group 1 (area under the curve: 0.53; 95% CI (0.35-0.72)). No statistically significant differences (p = 0.579) were observed in survival between patients with high (≥15%) and low (<15%) RDW values in the overall population, though trends favored worse outcomes with elevated RDW. Similarly, no significant differences (p = 0.374) were observed in survival between patients with high (Group 2) and low (Group 1) eGFR values. Conclusions: RDW appears to be a meaningful prognostic biomarker for HF patients, particularly in those without CKD. Further multicenter studies are needed to validate its clinical utility and potential for guiding treatment in this high-risk population.

The Correlation of Serum Adropin with Cardiovascular Risk Factors in the Experimental Rat Model of Chronic Kidney Disease and Its Implication in the Ameliorative Effect of Angiotensin-Converting Enzyme Inhibitors

Background

The risk of cardiovascular disease (CVD) in patients with chronic kidney disease (CKD) is estimated to be far greater than that in the general population. Adropin regulates endothelial function and may play a role in the pathogenesis of CVD. Angiotensin-converting enzyme inhibitor (ACEI) treatment was reported to have a protective effect on both renal and cardiovascular function. This study investigated whether adropin is associated with renal and cardiovascular outcomes after using ACEI treatment in CKD rats.

Methods

In 2021, in Zagazig, Egypt, rats were assigned to: GI, control group (n=8); GII, CKD group (n=8), and GIII, CKD+captopril group (n=8), in which CKD rats received 100 mg/Kg/day captopril orally. Adropin levels, renal function, blood pressure, and various CVD risk factors were measured. Renal, cardiac, and aortic tissues were examined histologically and immunohistochemically to detect the expression of vascular endothelial growth factor receptor-2 (VEGFR-2). To analyze data, ANOVA and Pearson's correlation tests were used (SPSS version 18, P<0.05 is significant).

Results

Adropin was significantly lower in GII than in GI and GIII (P<0.001). Adropin in GII and GIII was negatively correlated with atherogenic index (P=0.019 and P=0.001, respectively), atherogenic co-efficient (P=0.012 and P=0.013, respectively), troponin I (P=0.021 and P=0.043, respectively), and nitric oxide (P=0.025 and P=0.038, respectively). VEGFR-2 expression decreased in GII and was elevated in GIII (P<0.001).

Conclusion

Adropin levels were significantly correlated with most CVD risk factors in CKD and captopril-treated CKD rats, indicating a role for adropin in the pathogenesis of CVD in CKD. It also refers to its implication in the ameliorative effect of ACEI treatment, possibly by affecting VEGFR-2 and nitric oxide release.

Association between Serum Albumin-to-Creatinine Ratio and Readmission in Elderly Heart Failure Patients: A Retrospective Cohort Study

INTRODUCTION

This study aimed to investigate the relationship between the serum albumin-to-serum creatinine ratio (sACR) and readmission in elderly heart failure patients.

METHODS

We conducted a retrospective cohort study using data from the PhysioNet Restricted Health Data database. The exposure variable was sACR and the outcome variable readmission. Multivariate logistic regression and subgroup analyses were performed to assess the independent association between sACR and readmission. Smooth curve fits were applied to examine the nonlinear relationship. We employed multiple imputation and E-value sensitivity analyses to assess the robustness of our results.

RESULTS

Our study included 1,725 participants, of whom 40.6% were male, 59.2% were aged 60-79 years, and 40.8% were aged 80 years and older. After adjusting for potential confounders, we found that for each unit increase in sACR, the 28-day readmission rate decreased by 48% (odds ratio [OR] = 0.52, 95% CI: 0.29-0.95, p = 0.003). The 28-day readmission rate was significantly higher in the low sACR group (sACR <0.32) than in the high sACR group (sACR >0.51) (OR = 0.47, 95% CI: 0.3-0.76, p = 0.002). Similar results were observed for 3-month and 9-month readmission. Subgroup analysis showed no significant interactions. A nonlinear relationship was observed between the sACR and readmission. Sensitivity analyses have confirmed the robustness of our results.

CONCLUSION

There is a negative association between sACR and readmission in Chinese heart failure patients. Our study may offer novel insights into the management of heart failure readmissions.

Meta-analysis of the efficacy and impact on cardiac function of sodium-glucose cotransporter 2 inhibitor Empagliflozin in heart failure patients

BACKGROUND

Currently, there is no comprehensive systematic review available to comprehensively assess the efficacy and safety of Empagliflozin and other sodium-glucose cotransporter 2 inhibitors in the treatment of heart failure (HF). This study employed a meta-analysis approach to systematically evaluate the therapeutic effects of Empagliflozin in HF patients and its impact on cardiac function.

METHOD

The keywords including "heart failure," "HF," "cardiac failure," "cardiac disease," "Empagliflozin," and "sodium-glucose cotransporter 2 inhibitors" were utilized to search for relevant clinical studies on Empagliflozin in the treatment of HF in various databases, such as China National Knowledge Infrastructure, Wanfang, VIP Chinese Medical Journal Database, PubMed, MEDLINE, Embase, Cochrane Library, Springer, and Science Direct. The studies included patients with HF who received drug treatment. Data on baseline characteristics and posttreatment outcomes, including HF hospitalization (HHF), cardiovascular mortality, all-cause mortality, estimated glomerular filtration rate changes, Kansas City Cardiomyopathy Questionnaire quality of life (QoL) scores, N-terminal pro-B-type natriuretic peptide, left ventricular ejection fraction, hematocrit, and other relevant indicators were collected. Meta-analysis was conducted using RevMan5.3 to analyze the extracted data.

RESULTS

A total of 15 studies were included in the final analysis, comprising 36,917 patients with HF. Among them, 18,486 patients were in Empagliflozin group, and 18,431 patients were in control (Ctrl) group. The results of the meta-analysis demonstrated that, relative to Ctrl group, Empagliflozin group showed a substantially lower HHF rate, a substantial improvement in estimated glomerular filtration rate changes, a reduced cardiovascular mortality rate, a higher Kansas City Cardiomyopathy Questionnaire QoL score, increased hematocrit values, reduced N-terminal pro-B-type natriuretic peptide changes, and enhanced left ventricular ejection fraction changes. These findings suggest that remarkable improvements in various outcomes compared to the Ctrl group.

CONCLUSION

The sodium-glucose cotransporter 2 inhibitor Empagliflozin markedly reduces the HHF rate and cardiovascular mortality in HF patients. It also improves patients' QoL, enhances renal function, and increases cardiac function while reducing both, the preload and afterload.

Contemporary epidemiology of hospitalised heart failure with reduced versus preserved ejection fraction in England: a retrospective, cohort study of whole-population electronic health records

BACKGROUND

Heart failure is common, complex, and often associated with coexisting chronic medical conditions and a high mortality. We aimed to assess the epidemiology of people admitted to hospital with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF), including the period covering the COVID-19 pandemic, which was previously not well characterised.

METHODS

In this retrospective, cohort study, we used whole-population electronic health records with 57 million individuals in England to identify patients hospitalised with heart failure as the primary diagnosis in any consultant episode of an in-patient admission to a National Health Service (NHS) hospital. We excluded individuals with less than 1 year of medical history records in primary or secondary care; admissions to NHS hospitals for which less than 10% of heart failure cases were linkable to the National Heart Failure Audit (NHFA); individuals younger than 18 years at the time of the heart failure hospitalisation; and patients who died in hospital during the index heart failure admission. For patients with new onset heart failure, we assessed incidence rates of 30-day and 1-year all-cause and cause-specific (cardiovascular, non-cardiovascular, and heart failure-related) emergency rehospitalisation and mortality after discharge, and dispensed guideline-recommended medical therapy (GRMT). Follow-up occurred from the index admission to the earliest occurrence of the event of interest, death, or end of data coverage. We estimated adjusted hazard ratios (HRs) to compare HFrEF with HFpEF. We computed population-attributable fractions to quantify the percentage of outcomes attributable to coexisting chronic medical conditions.

FINDINGS

Among 233 320 patients identified who survived the index heart failure admission across 335 NHS hospitals between Jan 1, 2019, and Dec 31, 2022, 101 320 (43·4%) had HFrEF, 71 910 (30·8%) had HFpEF, and 60 090 (25·8%) had an unknown classification. In patients with new onset heart failure, there were reductions in all-cause 30-day (-5·2% [95% CI -7·7 to -2·6] in 2019-22) and 1-year rehospitalisation rates (-3·9% [-6·6 to -1·2]). Declining 30-day rehospitalisation rates affected patients with HFpEF (-4·8% [-9·2 to -0·2]) and HFrEF (-6·2% [-10·5 to -1·6]), although 1-year rates were not statistically significant for patients with HFpEF (-2·2% [-6·6 to 2·3] vs -5·7% [-10·6 to -0·5] for HFrEF). There were no temporal trends in incidence rates of 30-day or 1-year mortality after discharge. The rates of all-cause (HR 1·20 [1·18-1·22]) and cause-specific rehospitalisation were uniformly higher in those with HFpEF than those with HFrEF. Patients with HFpEF also had higher rates of 1-year all-cause mortality after discharge (HR 1·07 [1·05-1·09]), driven by excess risk of non-cardiovascular death (HR 1·25 [1·21-1·29]). Rates of rehospitalisation and mortality were highest in patients with coexisting chronic kidney disease, chronic obstructive pulmonary disease, dementia, and liver disease. Chronic kidney disease contributed to 6·5% (5·6-7·4) of rehospitalisations within 1 year for HFrEF and 5·0% (4·1-5·9) of rehospitalisations for HFpEF, double that of any other coexisting condition. There was swift implementation of newer GRMT, but markedly lower dispensing of these medications in patients with coexisting chronic kidney disease.

INTERPRETATION

Rates of rehospitalisation in patients with heart failure in England have decreased during 2019-22. Further population health improvements could be reached through enhanced implementation of GRMT, particularly in patients with coexisting chronic kidney disease, who, despite being at high risk, remain undertreated.

FUNDING

Wellcome Trust, Health Data Research UK, British Heart Foundation Data Science Centre.

Comparison of value of 640-slice CT kidney scan and kidney ultrasound in the diagnosis of chronic kidney disease

To explore the value of 640-slice CT kidney scan and kidney ultrasound (KUS) in the diagnosis of chronic kidney disease (CKD). The data of 120 CKD patients at our institution between June 2019 and September 2020 were analyzed, and they were randomly divided into ultrasound (US) group (n = 40, KUS), CT group (n = 40) first receiving a plane CT scan to determine the scope of dynamic volume scan, which was performed for scans in cortical, parenchymal, and delayed phases with bolus injection of contrast medium, and combined group (n = 40, KUS and 640-slice CT kidney scan), with the images obtained read and analyzed. The subjective scores and effective radiation doses of 640-layer CT kidney scan were counted to calculate the detection rates. The subjective scores of 640-slice CT kidney scan in plane scan, cortical phase, parenchymal phase, and delayed phase were (1.23 ± 0.42), (1.80 ± 0.40), (2.08 ± 0.26), (2.18 ± 0.38) in the CT group and (1.18 ± 0.38), (1.85 ± 0.36), (2.08 ± 0.26), (2.20 ± 0.40) in the combined group. The effective radiation doses in the CT and combined groups were (1.92 ± 0.32) mSv and (1.95 ± 0.35) mSv. The reading results showed that 26 cases (65.0%), 30 cases (75.0%), and 38 cases (95.0%) were detected in the US, CT and combined groups, respectively, with remarkably higher detection rate in the combined group than the US and CT groups (P < 0.05). 640-slice CT kidney scan and KUS can be adopted for the diagnosis of CKD; with low radiation dose, good image quality, and higher detection rate in the former, their combination can improve the clinical detection rate of CKD and is worth promoting.

Cardiorenal interactions in heart failure: insights from recent therapeutic advances

Heart failure is a syndrome that may develop when cardiovascular disease progresses or is insufficiently treated and associated with a poor quality of life, high mortality rates, and increased healthcare expenditures. Prevention and treatment of heart failure are therefore of utmost importance. New therapies in patients with cardiovascular disease have recently been shown to be effective in the prevention and sometimes treatment of heart failure, and additional research is underway. Specifically, in high-risk patients with either (a combination of) diabetes, chronic kidney disease, and/or heart failure, three specific drug classes [sodium-glucose co-transporter 2 inhibitors (SGLT2i), glucagon-like peptide 1 receptor agonists (GLP-1-RAs), and non-steroidal mineralocorticoid receptor antagonists (MRAs)] have taken centre stage in therapeutic approach for these high cardiovascular risk patients. The commonality of these drugs is the finding that they improve cardiovascular and renal endpoints across the cardiorenal continuum and SGTL2i have already proved effective in all subtypes of heart failure, while we await data on non-steroidal MRA therapy in heart failure. The story may be different for GLP-1-RA in patients with established heart failure, but these drugs are effective in reducing cardiovascular events in patients with diabetes. Taken together, these new therapies advance the treatment and improve the associated outcomes of patients with cardiorenal disease and diabetes, with similar characteristics and effectiveness in different conditions.

Characteristics and outcome of hospitalized patients with heart failure stratified for chronic kidney disease

AIMS

Heart failure (HF) and chronic kidney disease (CKD) place significant challenges on the healthcare system, and their co-existence is associated with shared adverse outcomes. The multinational CaReMe project was initiated to provide contemporary, real-world epidemiological data on cardiovascular and reno-metabolic diseases. Utilizing data from the German CaReMe cohort, we characterize a multicentric HF population and describe in-hospital outcomes stratified for co-morbid CKD.

METHODS AND RESULTS

This retrospective, observational study analysed administrative data from inpatient cases hospitalized in 87 German Helios hospitals between 1 January 2016 and 31 August 2022. The first hospitalization of patients aged ≥18 years with a primary discharge diagnosis of HF, based on ICD-10 codes, were considered the index cases, and subsequent hospitalizations were considered as readmissions. Baseline characteristics and outcomes were stratified for co-morbid CKD using ICD-10-encoding from the index cases. Cox regression was utilized for readmission endpoints and in-hospital mortality. In total, 174 829 index cases (mean age 79 ± 15 years, 49.9% female) were included; of these, 55.0% had coexisting CKD. Patients with CKD were older, suffered from worse HF-related symptoms, had a higher co-morbidity burden, and in-hospital mortality was increased at index and during follow-up. Prevalent CKD was associated with higher rehospitalization rates and was an independent predictor for in-hospital death.

CONCLUSIONS

Within this HF inpatient cohort from a multicentric German database, CKD was diagnosed in more than half of the patients and was associated with increased in-hospital mortality at baseline and during follow-up. Rehospitalizations were observed earlier and more frequently in patients with HF and co-morbid CKD.

Management of patients with heart failure and chronic kidney disease

Chronic kidney disease (CKD) and heart failure are often co-existing conditions due to a shared pathophysiological process involving neurohormonal activation and hemodynamic maladaptation. A wide range of pharmaceutical and interventional tools are available to patients with CKD, consisting of traditional ones with decades of experience and newer emerging therapies that are rapidly reshaping the landscape of medical care for this population. Management of patients with heart failure and CKD requires a stepwise approach based on renal function and the clinical phenotype of heart failure. This is often challenging due to altered drug pharmacokinetics interactions with various degrees of kidney function and frequent adverse effects from the therapy that lead to poor patient tolerance. Despite a great body of clinical evidence and guidelines that have offered various treatment options for patients with heart failure and CKD, respectively, patients with CKD are still underrepresented in heart failure clinical trials, especially for those with advanced CKD and end-stage renal disease (ESRD). Future studies are needed to better understand the generalizability of these therapeutic options among heart failures with different stages of CKD.

From Hospital to Home: Evidence-Based Care for Worsening Heart Failure

Heart failure (HF) is a leading cause of hospitalization in older adults. Patients are at high risk of readmission and death following hospitalization for HF. There is no standard approach of health care delivery during the hospital-to-home transition period, leaving missed opportunities in care optimization. In this review, we discuss contemporary randomized clinical trials that tested decongestion strategies, disease-modifying therapies, and health care services that inform the care of patients with worsening HF. We provide evidence-informed recommendations for optimizing therapies and improving outcomes during and following hospitalization for HF. These include adequate decongestion with loop diuretics and select sequential nephron blockade strategies based on early evaluation of diuretic response; initiation of disease-modifying pharmacotherapies prior to hospital discharge with close follow-up and optimization after discharge; cardiac rehabilitation; and transitional or palliative care referral post-hospitalization. Evidence-based implementation strategies to facilitate broad uptake include digital health tools and algorithm-driven optimization of pharmacotherapies.

A diagnostic prediction model for the early detection of heart failure following primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction

BACKGROUND

In this study, we aimed to construct a robust diagnostic model that can predict the early onset of heart failure in patients with ST-elevation myocardial infarction (STEMI) following a primary percutaneous coronary intervention (PCI). This diagnostic model can facilitate the early stratification of high-risk patients, thereby optimizing therapeutic management.

METHODS

We performed a retrospective analysis of 664 patients with STEMI who underwent their inaugural PCI. We performed logistic regression along with optimal subset regression and identified important risk factors associated with the early onset of heart failure during the time of admission. Based on these determinants, we constructed a predictive model and confirmed its diagnostic precision using a receiver operating characteristic (ROC) curve.

RESULTS

The logistic and optimal subset regression analyses revealed the following three salient risk factors crucial for the early onset of heart failure: the Killip classification, the presence of renal insufficiency, and increased troponin T levels. The constructed prognostic model exhibited excellent discriminative ability, which was indicated by an area under the curve value of 0.847. The model's 95% confidence interval following 200 Bootstrap iterations was found to be between 0.767 and 0.925. The Hosmer-Lemeshow test revealed a chi-square value of 3.553 and a p-value of 0.938. Notably, the calibration of the model remained stable even after 500 Bootstrap evaluations. Furthermore, decision curve analysis revealed a substantial net benefit of the model.

CONCLUSION

We have successfully constructed a diagnostic prediction model to predict the incipient stages of heart failure in patients with STEMI following primary PCI. This diagnostic model can revolutionize patient care, allowing clinicians to quickly identify and create individualized interventions for patients at a higher risk.

AI hybrid survival assessment for advanced heart failure patients with renal dysfunction

Renal dysfunction (RD) often characterizes the worse course of patients with advanced heart failure (AHF). Many prognosis assessments are hindered by researcher biases, redundant predictors, and lack of clinical applicability. In this study, we enroll 1736 AHF/RD patients, including data from Henan Province Clinical Research Center for Cardiovascular Diseases (which encompasses 11 hospital subcenters), and Beth Israel Deaconess Medical Center. We developed an AI hybrid modeling framework, assembling 12 learners with different feature selection paradigms to expand modeling schemes. The optimized strategy is identified from 132 potential schemes to establish an explainable survival assessment system: AIHFLevel. The conditional inference survival tree determines a probability threshold for prognostic stratification. The evaluation confirmed the system's robustness in discrimination, calibration, generalization, and clinical implications. AIHFLevel outperforms existing models, clinical features, and biomarkers. We also launch an open and user-friendly website www.hf-ai-survival.com , empowering healthcare professionals with enhanced tools for continuous risk monitoring and precise risk profiling.

Hospitalization Causes and Epidemiological Characteristics Among Patients With End-Stage Renal Disease: A Six-Year Retrospective Study

BACKGROUND

Chronic kidney disease (CKD) leads to a high rate of complications requiring hospital admission for advanced management. Therefore, this study aims to analyze the main causes of hospitalization following the initiation of renal replacement therapy (RRT).

MATERIALS AND METHODS

This observational and descriptive study utilized a non-probabilistic quota sampling method, reviewing a total of 423 medical records from General Regional Hospital 1 of the Mexican Social Security Institute in Querétaro. The study evaluated the frequency and causality of hospitalizations during a retrospective period from 2018 to 2023.

RESULTS

There were 1,162 hospitalization events involving 423 patients; 71.63% of patients started RRT with peritoneal dialysis, while 26% began with hemodialysis. The leading cause of hospitalization was electrolyte imbalance (397; 34.17%), followed by peritonitis associated with peritoneal dialysis (351; 30.21%), change to hemodialysis (270; 23.24%), Tenckhoff catheter dysfunction (209; 17.99%), and fluid overload (205; 17.64%). The group with the highest number of events was renal-related complications, followed by infectious causes.

CONCLUSIONS

Hospitalizations in end-stage CKD patients often arise from the complex renal pathophysiology and complications related to acute and decompensated renal function. This condition refers to the kidneys' failure to maintain essential physiological functions despite ongoing treatment, leading to issues such as electrolyte imbalances, fluid overload, and uremic syndrome. To reduce morbidity and mortality, measures such as enhanced training in ambulatory dialysis, improved catheter care, and early infection detection are crucial. A comprehensive approach that addresses both acute issues and preventive strategies is essential for improving clinical outcomes and quality of life for these patients.

Multi-year population-based analysis of Asian patients with acute decompensated heart failure and advanced chronic kidney disease

BACKGROUND

Data on disparities in outcomes and risk factors in Asian patients with advanced chronic kidney disease admitted for heart failure are scare.

METHODS

This was a retrospective cohort study that utilized data from the National Inpatient Sample between January 2016 and December 2019. Patients who had a primary diagnosis of acute decompensated heart failure and a concomitant diagnosis of advanced CKD were included. The primary outcome of interest was in-hospital mortality. Secondary outcomes include hospital cost, length of stay, and other clinical outcomes. Weighted multivariable logistic regression was used to adjust for comorbidities.

RESULTS

There were 251,578 cases of ADHF with advanced CKD, out of which 2.6 % were from individuals of Asian ethnicity. Asian patients exhibited a higher burden of comorbidities in comparison to other UREM patients, but a lower burden than White patients. Regardless of differences in comorbidity burden, Asian patients exhibited a higher likelihood of experiencing severe consequences. After adjusting for comorbidies, White (OR:1.11; 95 % CI 1.03-1.20;0.009) patients had higher odds of mortality than Asian patients. However, Blacks (OR: 0.58; 95 % CI 0.53 to 0.63; p < 0.001) and Hispanics (OR: 0.69; 95 % CI 0.62 to 0.78; p < 0.001) had lower odds of mortality.

CONCLUSION

This first population-based studies shows that Asian patients with advanced CKD admitted for ADHF have greater comorbidity burden and poorer outcomes Black and Hispanic patients. This data underscores the importance of comprehensive approaches in phenotyping, and ethnic specific interventions.

Influence of the medical treatment schedule in new diagnoses patients with heart failure and reduced ejection fraction

AIMS

Heart failure (HF) guidelines recommend treating all patients with HF and reduced ejection fraction (HFrEF) with quadruple therapy, although they do not establish how to start it. This study aimed to evaluate the implementation of these recommendations, analyzing the efficacy and safety of the different therapeutic schedules.

METHODS AND RESULTS

Prospective, observational, and multicenter registry that evaluated the treatment initiated in patients with newly diagnosed HFrEF and its evolution at 3 months. Clinical and analytical data were collected, as well as adverse reactions and events during follow-up. Five hundred and thirty-three patients were included, selecting four hundred and ninety-seven, aged 65.5 ± 12.9 years (72% male). The most frequent etiologies were ischemic (25.5%) and idiopathic (21.1%), with a left ventricular ejection fraction of 28.7 ± 7.4%. Quadruple therapy was started in 314 (63.2%) patients, triple in 120 (24.1%), and double in 63 (12.7%). Follow-up was 112 days [IQI 91; 154], with 10 (2%) patients dying. At 3 months, 78.5% had quadruple therapy (p < 0.001). There were no differences in achieving maximum doses or reducing or withdrawing drugs (< 6%) depending on the starting scheme. Twenty-seven (5.7%) patients had any emergency room visits or admission for HF, less frequent in those with quadruple therapy (p = 0.02).

CONCLUSION

It is possible to achieve quadruple therapy in patients with newly diagnosed HFrEF early. This strategy makes it possible to reduce admissions and visits to the emergency room for HF without associating a more significant reduction or withdrawal of drugs or significant difficulty in achieving the target doses.

The relationship between serum 1,5-anhydroglucitol and adverse outcomes in acute coronary syndrome with and without chronic kidney disease patients

Purpose

Individuals with chronic kidney disease (CKD) face an elevated residual risk of cardiovascular events, but the relationship between this residual risk and 1,5-anhydroglucitol (1,5-AG) is uncertain. Our study aimed to examine the effect of 1,5-AG on major adverse cardiovascular events (MACEs) and all-cause mortality in acute coronary syndrome (ACS) individuals.

Methods

1253 ACS participants hospitalized were enrolled at Beijing Hospital between March 2017 and March 2020. All participants were classified into 2 groups based on their eGFR (60 ml/min/1.73 m2). The link between 1,5-AG and adverse outcome was investigated in non-CKD and CKD participants.

Results

CKD patients had reduced concentrations of 1,5-AG than those without CKD. Throughout a median follow-up duration of 43 months, 1,5-AG was an autonomous hazard factor for MACEs and all-cause mortality. 1,5-AG<14 μg/ml participants had greater MACEs and all-cause mortality risk than those with 1,5-AG≥14 μg/ml, regardless of renal function. Furthermore, concomitant reduced concentrations of 1,5-AG and CKD portended a dismal prognosis in ACS patients.

Conclusions

1,5-AG was autonomously linked to MACEs and all-cause mortality in ACS participants with both non-CKD and CKD. Co-presence of reduced concentrations of 1,5-AG and CKD may portend adverse clinical outcomes.

[Chronic kidney disease and chronic heart failure: impact on prognosis and choice of pathogenetic therapy]

AIM

To evaluate the impact of a decrease in glomerular filtration rate (GFR) on the prognosis of patients with chronic heart failure (CHF), to analyze real clinical practice regarding the frequency of prescribing pathogenetic therapy for CHF, achieving target dosages depending on the gradation of GFR in patients included in the CHF Register of the Tyumen region.

MATERIALS AND METHODS

The analysis included medical data of 4077 patients (1662 men and 2415 women) with NYHA class I-IV CHF who underwent examination and treatment in medical organizations of the Tyumen region for the period from January 2020 to May 2023. Criteria for inclusion in the register: proven heart failure. Chronic kidney disease (CKD) was assessed by GFR calculated using the CKD-EPI formula (ml/min/1.73 m2). The primary end point was defined as death from all causes.

RESULTS

GFR<60 ml/min/1.73 m2 was recorded in 34.6% of patients, more common in women (40.2 and 26.6%, respectively; p<0.001). When dividing patients into phenotypes according to LVEF, no statistically significant differences were found in the distribution of patients according to GFR. In patients with HFrEF and HFpEF GFR<45 ml/min/1.73 m2 was associated with an increased risk of meeting the endpoint. Analysis of prescribed pathogenetic therapy showed that in patients with HFrEF, the frequency of prescription of ACE inhibitors, â-blockers and MRA decreased (p=0.023, 006 and 0.01, respectively), and ARNI, on the contrary, increased with a decrease in GFR (p=0.026). In patients with HFpEF, a similar trend towards a decrease in the frequency of prescription of ACEIs and MCBs with a decrease in GFR (p<0.001) remained, but it was compensated by an inversely proportional increase in the frequency of prescription of ARBs (p<0.001). 100% of the target dosage is achieved in more than 90% of patients taking MRA across the entire LVEF range. While for â-blockers and ARNI/ACE/ARB the percentage of patients receiving the full therapeutic dosage of drugs is significantly lower. When analyzing target dosages of pathogenetic drugs, gradations of achieved doses were distributed evenly throughout the entire range of GFR.

CONCLUSION

GFR<60 ml/min/1.73 m2 occurs in every 3 patients with CHF across the entire range of LVEF. A decrease in GFR worsens the prognosis of patients with both HFrEF and HFpEF, increasing in direct proportion with the severity of the stage of CKD. Inclusion of patients in the monitoring program within the framework of the CHF service allows the treatment to be significantly brought closer to optimal drug therapy, at the same time, certain efforts are required to overcome difficulties with titration to target dosages.

Mineralocorticoid Receptor Antagonists in Patients With Heart Failure and Impaired Renal Function

BACKGROUND

Kidney dysfunction often leads to reluctance to start or continue life-saving heart failure (HF) therapy.

OBJECTIVES

This study sought to examine the efficacy and safety of mineralocorticoid receptor antagonists (MRAs) in patients with HF with reduced ejection fraction experiencing significant kidney dysfunction.

METHODS

We pooled individual patient data from the RALES (Randomized Aldactone Evaluation Study) and EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure) trials. The association between MRA treatment and outcomes was assessed according to whether the estimated glomerular filtration rate (eGFR) declined to <30 mL/min/1.73 m2 or not. The primary outcome was cardiovascular death or HF hospitalization.

RESULTS

Among 4,355 patients included, 295 (6.8%) experienced a deterioration of eGFR after randomization to <30 mL/min/1.73 m2. These patients had more impaired baseline cardiac and kidney function (eGFR 47.3 ± 13.4 mL/min/1.73 m2 vs 70.5 ± 21.8 mL/min/1.73 m2) and had a higher risk of the primary outcome than patients without eGFR deterioration (HR: 2.49; 95% CI: 2.01-3.08; P < 0.001). However, the risk reduction in the primary outcome with MRA therapy was similar in those who experienced a decrease in eGFR to <30 mL/min/1.73 m2 (HR: 0.65; 95% CI: 0.43-0.99) compared with those who did not (HR: 0.63; 95% CI: 0.56-0.71) (Pinteraction = 0.87). In patients with a decrease in eGFR to <30 mL/min/1.73 m2, 21 fewer individuals (per 100 person-years) experienced the primary outcome with MRA treatment, vs placebo, compared with an excess of 3 more patients with severe hyperkalemia (>6.0 mmol/L).

CONCLUSIONS

Because patients experiencing a decrease in eGFR to <30 mL/min/1.73 m2 are at very high risk, the absolute risk reduction with an MRA in these patients is large and this decline in eGFR should not automatically lead to treatment discontinuation.

Can we effectively manage chronic kidney disease with a precision-based pharmacotherapy plan? Where are we?

INTRODUCTION

In recent years, thanks to significant advances in basic science and biotechnologies, nephrology has witnessed a deeper understanding of the mechanisms leading to various conditions associated with or causing kidney disease, opening new perspectives for developing specific treatments. These new possibilities have brought increased challenges to physicians, who face with a new complexity in disease characterization and selection the right treatment for individual patients.

AREAS COVERED

We chose four therapeutic situations: anaemia in chronic kidney disease (CKD), heart failure in CKD, IgA nephropathy (IgAN) and membranous nephropathy (MN). The literature search was made through PubMed.

EXPERT OPINION

Anaemia management remains challenging in CKD; a personalized therapeutic approach is often needed. Identifying patients who could benefit from a specific therapy is also an important goal for patients with CKD and heart failure with reduced ejection fraction. Several new treatments are under clinical development for IgAN; interestingly, they target specifically the pathogenetic mechanisms of the disease. The understanding of MN pathogenesis as an autoimmune disease and the discovery of several autoantibodies allows a better characterization of patients. High-sensible techniques for lymphocyte counting open the possibility of more personalized use of anti CD20 therapies.

Management of Chronic Heart Failure in Dialysis Patients: A Challenging but Rewarding Path

Chronic heart failure (CHF) is a common complication and cause of death in dialysis patients. Although several clinical guidelines and expert consensus on heart failure (HF) in the general population have been issued in China and abroad, due to abnormal renal function or even no residual renal function (RRF) in dialysis patients, the high number of chronic complications, as well as the specificity, variability, and limitations of hemodialysis (HD) and peritoneal dialysis (PD) treatments, there are significant differences between dialysis patients and the general population in terms of the treatment and management of HF. The current studies are not relevant to all dialysis-combined HF populations, and there is an urgent need for high-quality studies on managing HF in dialysis patients to guide and standardize treatment. After reviewing the existing guidelines and literature, we focused on the staging and diagnosis of HF, management of risk factors, pharmacotherapy, and dialysis treatment in patients on dialysis. Based on evidence-based medicine and clinical trial data, this report reflects new perspectives and future trends in the diagnosis and treatment of HF in dialysis patients, which will further enhance the clinicians' understanding of HF in dialysis patients.

Non-cardiac comorbidities in heart failure: an update on diagnostic and management strategies

Managing non-cardiac comorbidities in heart failure (HF) requires a tailored approach that addresses each patient's specific conditions and needs. Regular communication and coordination among healthcare providers is crucial to providing the best possible care for these patients. Poorly controlled hypertension contributes to left ventricular remodeling and diastolic dysfunction, emphasizing the importance of optimal blood pressure control while avoiding adverse effects. Among HF patients with diabetes, SGLT2 inhibitors and mineralocorticoid receptor antagonists have shown promise in reducing HF-related morbidity and mortality. Chronic kidney disease exacerbates HF and vice versa, forming the vicious cardiorenal syndrome, so disease-modifying therapies should be maintained in HF patients with comorbid CKD, even with transient changes in kidney function. Anemia in HF patients may be multifactorial, and there is growing evidence for the benefit of intravenous iron supplementation in HF patients with iron deficiency with or without anemia. Obesity, although a risk factor for HF, paradoxically offers a better prognosis once HF is established, though developing treatment strategies may improve symptoms and cardiac performance. In HF patients with stroke and atrial fibrillation, anticoagulation therapy is recommended. Among HF patients with sleep-disordered breathing, continuous positive airway pressure may improve sleep quality. Chronic obstructive pulmonary disease often coexists with HF, and many patients can tolerate cardioselective beta-blockers. Cancer patients with comorbid HF require careful consideration of cardiotoxicity risks associated with cancer therapies. Depression is underdiagnosed in HF patients and significantly impacts prognosis. Cognitive impairment is prevalent in HF patients and impacts their self-care and overall quality of life.

Renal function and natriuresis-guided diuretic therapy - a pre-specified analysis from the PUSH-AHF trial

AIM

In a randomized controlled trial, we recently showed that a natriuresis-guided diuretic approach improved natriuresis and diuresis in patients with acute heart failure (HF). In this pre-specified analysis, we investigated the association between (worsening) renal function, outcomes and the effect of intensive natriuresis-guided loop diuretic therapy as compared with standard of care.

METHODS AND RESULTS

The Pragmatic Urinary Sodium-based algoritHm in Acute Heart Failure (PUSH-AHF) trial randomized patients to natriuresis-guided diuretic therapy or standard of care. Serum creatinine and estimated glomerular filtration rate (eGFR) were assessed at fixed timepoints, and worsening renal function (WRF) was assessed at 72 h. The primary outcome was the interaction between randomized treatment allocation, baseline eGFR and the dual primary outcome of PUSH-AHF: total natriuresis at 24 h and time to all-cause mortality or HF rehospitalization at 180 days. In 309 patients, median baseline eGFR was 53 (35-73) ml/min/1.73 m2, and 58% had eGFR <60 ml/min/1.73 m2. Baseline eGFR did not significantly modify the treatment effect of natriuresis-guided diuretic therapy on natriuresis at 24 h (p for interaction = 0.730). However, baseline eGFR significantly modified the effect on all-cause mortality and HF rehospitalization (p for interaction = 0.017): the risk of this second primary outcome was lower in patients with lower eGFR who were randomized to the natriuresis-guided group. In the natriuresis-guided arm, eGFR decreased more (-11.0 vs. -6.91 ml/min/1.73 m2; p = 0.002) during the first 3 days, but this effect was attenuated at discharge (-10.3 vs. -8.69 ml/min/1.73 m2; p = 0.38). WRF was more frequently observed in patients randomized to natriuresis-guided treatment, but was not associated with worse clinical outcomes.

CONCLUSIONS

Natriuresis-guided diuretic treatment improved diuresis and natriuresis irrespective of baseline eGFR and occurrence of WRF, was effective even in patients with low eGFR, and the observed effect on eGFR was transient and not associated with worse clinical outcomes.

A Case-based Implementation of Heart Failure Therapies, a Consensus Pathway by the Saudi Heart Failure Working Group

The implementation of guideline-directed medical therapy (GDMT) in heart failure (HF) has many challenges in real-world clinical practice. The consensus document is written considering the variability of the clinical presentation of HF patients. HF medical therapies need frequent dose adjustment during hospital admission or when patients develop electrolyte imbalance, acute kidney injury, and other acute illnesses. The paper describes clinical scenarios and graphs that will aid the managing physicians in decision-making for HF therapy optimization.

Causal association of plasma circulating metabolites with nephritis: a Mendelian randomization study

Background

Nephritis is a pivotal catalyst in chronic kidney disease (CKD) progression. Although epidemiological studies have explored the impact of plasma circulating metabolites and drugs on nephritis, few have harnessed genetic methodologies to establish causal relationships.

Methods

Through Mendelian randomization (MR) in two substantial cohorts, spanning large sample sizes, we evaluated over 100 plasma circulating metabolites and 263 drugs to discern their causal effects on nephritis risk. The primary analytical tool was the inverse variance weighted (IVW) analysis. Our bioinformatic scrutiny of GSE115857 (IgA nephropathy, 86 samples) and GSE72326 (lupus nephritis, 238 samples) unveiled anomalies in lipid metabolism and immunological characteristics in nephritis. Thorough sensitivity analyses (MR-Egger, MR-PRESSO, leave-one-out analysis) were undertaken to verify the instrumental variables' (IVs) assumptions.

Results

Unique lipoprotein-related molecules established causal links with diverse nephritis subtypes. Notably, docosahexaenoic acid (DHA) emerged as a protective factor for acute tubulointerstitial nephritis (ATIN) (OR1 = 0.84, [95% CI 0.78-0.90], p1 = 0.013; OR2 = 0.89, [95% CI 0.82-0.97], p2 = 0.007). Conversely, multivitamin supplementation minus minerals notably increased the risk of ATIN (OR = 31.25, [95% CI 9.23-105.85], p = 0.004). Reduced α-linolenic acid (ALA) levels due to lipid-lowering drugs were linked to both ATIN (OR = 4.88, [95% CI 3.52-6.77], p < 0.001) and tubulointerstitial nephritis (TIN) (OR = 7.52, [95% CI 2.78-20.30], p = 0.042). While the non-renal drug indivina showed promise for TIN treatment, the use of digoxin, hydroxocobalamin, and liothyronine elevated the risk of chronic tubulointerstitial nephritis (CTIN). Transcriptome analysis affirmed that anomalous lipid metabolism and immune infiltration are characteristic of IgA nephropathy and lupus nephritis. The robustness of these causal links was reinforced by sensitivity analyses and leave-one-out tests, indicating no signs of pleiotropy.

Conclusion

Dyslipidemia significantly contributes to nephritis development. Strategies aimed at reducing plasma low-density lipoprotein levels or ALA supplementation may enhance the efficacy of existing lipid-lowering drug regimens for nephritis treatment. Renal functional status should also be judiciously considered with regard to the use of nonrenal medications.

Trajectories of Kidney Function in Heart Failure Over a 15-Year Follow-Up: Clinical Profiling and Mortality

BACKGROUND

Limited data are available on the long-term trajectory of estimated glomerular filtration rate (eGFR) in patients with chronic heart failure.

OBJECTIVES

The authors evaluated eGFR dynamics using the 2009 Chronic Kidney Disease Epidemiology Collaboration equation and its prognostic significance in a real-world cohort over a 15-year follow-up.

METHODS

A prospective observational registry of ambulatory heart failure outpatients was conducted, with regular eGFR assessments at baseline and on a 3-month schedule for ≤15 years. Urgent kidney function assessments were excluded. Locally weighted error sum of squares curves were plotted for predefined subgroups. Multivariable longitudinal Cox regression analyses were conducted to assess associations with all-cause and cardiovascular death.

RESULTS

A total of 2,672 patients were enrolled consecutively between August 2001 and December 2021. The average age was 66.8 ± 12.6 years, and 69.8% were men. Among 40,970 creatinine measurements, 28,634 were used for eGFR analysis, averaging 10.7 ± 8.5 per patient. Over the study period, a significant decline in eGFR was observed in the entire cohort, with a slope of -1.70 mL/min/1.73 m2 per year (95% CI: -1.75 to -1.66 mL/min/1.73 m2 per year). Older patients, those with diabetes, a preserved ejection fraction, a higher baseline eGFR, elevated hospitalization rates, and those who died during follow-up experienced more pronounced decreases in the eGFR. Moreover, the decrease in kidney function correlated independently with all-cause mortality and cardiovascular death.

CONCLUSIONS

These findings highlight the sustained decline in eGFR over 15 years in patients with heart failure, with variations based on clinical characteristics, and emphasize the importance of regular eGFR monitoring in this population.

Advancing Guideline-Directed Medical Therapy in Heart Failure: Overcoming Challenges and Maximizing Benefits

The delayed titration of guideline-directed drug therapy (GDMT) is a complex event influenced by multiple factors that often result in poor prognosis for patients with heart failure (HF). Individualized adjustments in GDMT titration may be necessary based on patient characteristics, and every clinician is responsible for promptly initiating GDMT and titrating it appropriately within the patient's tolerance range. This review examines the current challenges in GDMT implementation and scrutinizes titration considerations within distinct subsets of HF patients, with the overarching goal of enhancing the adoption and effectiveness of GDMT. The authors also underscore the significance of establishing a novel management strategy that integrates cardiologists, nurse practitioners, pharmacists, and patients as a unified team that can contribute to the improved promotion and implementation of GDMT.

Contemporary American and European Guidelines for Heart Failure Management: JACC: Heart Failure Guideline Comparison

This review serves to compare contemporary clinical practice recommendations for the management of heart failure (HF), as codified in the 2021 European Society of Cardiology (ESC) guideline, the 2022 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) guideline, and the 2023 focused update of the 2021 ESC document. Overall, these guidelines aim to solidify significant advances throughout the HF continuum since the publication of previous full guideline iterations (2013 and 2016 for the ACC/AHA and ESC, respectively). All guidelines provide new recommendations for an increasingly complex landscape of HF care, with focus on primary HF prevention, HF stages, rapid initiation and optimization of evidence-based pharmacotherapies, overlapping cardiac and noncardiac comorbidities, device-based therapies, and management pathways for special groups of patients, including those with cardiac amyloidosis. Importantly, the ACC/AHA/HFSA document features special emphasis on HF risk prediction and screening, cost/value, social determinants of health, and health care disparities. The review discusses major similarities and differences between these recent guidelines and guideline updates, as well as their potential downstream implications for clinical care.