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Red Blood Cell Distribution Width in Heart Failure: Pathophysiology, Prognostic Role, Controversies and Dilemmas. J Clin Med 2022; 11:jcm11071951. [PMID: 35407558 PMCID: PMC8999162 DOI: 10.3390/jcm11071951] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/26/2022] [Accepted: 03/30/2022] [Indexed: 12/12/2022] Open
Abstract
Red blood cell distribution width (RDW), an integral parameter of the complete blood count (CBC), has been traditionally used for the classification of several types of anemia. However, over the last decade RDW has been associated with outcome in patients with several cardiovascular diseases including heart failure. The role of RDW in acute, chronic and advanced heart failure is the focus of the present work. Several pathophysiological mechanisms of RDW’s increase in heart failure have been proposed (i.e., inflammation, oxidative stress, adrenergic stimulation, undernutrition, ineffective erythropoiesis, reduced iron mobilization, etc.); however, the exact mechanism remains unknown. Although high RDW values at admission and discharge have been associated with adverse prognosis in hospitalized heart failure patients, the prognostic role of in-hospital RDW changes (ΔRDW) remains debatable. RDW has been incorporated in recent heart failure prognostic models. Utilizing RDW as a treatment target in heart failure may be a promising area of research.
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Blockade of mineralocorticoid receptor ameliorates oral contraceptive-induced insulin resistance by suppressing elevated uric acid and glycogen synthase kinase-3 instead of circulating mineralocorticoid. Arch Physiol Biochem 2020; 126:225-234. [PMID: 30318954 DOI: 10.1080/13813455.2018.1509220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Context: Estrogen-progestin combined oral contraceptive (COC) has been connected to mineralocorticoid receptor (MR) activation and adverse cardiometabolic events. We consequently hypothesised that insulin resistance (IR), hyperuricemia, and elevated circulating GSK-3 induced by COC is through activation of MR via mineralocorticoid and glucocorticoid pathways.Methods: Female Wistar rats aged 12 weeks received (po) vehicle and COC (1.0 μg ethinylestradiol plus 5.0 μg levonorgestrel) with or without MR blocker (0.25 mg/kg spironolactone; Spl), daily for eight weeks.Results: Data showed that COC treatment led to increased IR, 1-hour postload glucose level, insulinemia, triglyceride/HDL-cholesterol ratio, total cholesterol/HDL-cholesterol ratio, uric acid, GSK-3, aldosterone, corticosterone values, impaired glucose tolerance and pancreatic β-cell function. However, MR blockade by Spl ameliorated all these alterations except that of aldosterone.Conclusion: The results demonstrate that COC induces IR, hyperuricemia and high GSK-3 levels through activation of MR via glucocorticoid dependent pathway.
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Abstract
There is a close physiological relationship between the kidneys and the heart. Cardiovascular diseases are the most prevalent cause of death in patients with chronic kidney disease (CKD), whereas CKD may directly accelerate the progression of cardiovascular diseases and is considered to be a cardiovascular risk factor. In patients with mild CKD, i.e. an estimated glomerular filtration rate (eGFR) >60 ml/min/1.73 m2, treatment of coronary artery disease and chronic heart failure is not essentially different from patients with preserved renal function; however, as most pivotal trials have systematically excluded patients with advanced renal failure, many treatment recommendations in this patient group are based on observational studies, post hoc subgroup analyses and meta-analyses or pathophysiological considerations, which are not supported by controlled studies. Therefore, prospective randomized studies on the management of heart failure and coronary artery disease are needed, which should specifically focus on the growing number of patients with advanced renal functional impairment.
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Practical management of concomitant acute heart failure and worsening renal function in the emergency department. Eur J Emerg Med 2018; 25:229-236. [PMID: 28984663 DOI: 10.1097/mej.0000000000000505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Worsening renal function (i.e. any increase in creatinine or decrease in the estimated glomerular filtration rate) is common in patients admitted for acute heart failure in the emergency department. Although worsening renal function (WRF) has been associated with the occurrence of dismal outcomes, this only appears to be the case when associated with clinical deterioration. However, if the clinical status of the patient is improving, a certain increase in serum creatinine may be acceptable. This WRF, which is not associated with clinical deterioration or adverse outcomes (e.g. during treatment up-titration), has been referred to as 'pseudo-WRF' and should not detract clinicians from targeting 'guideline-recommended' therapies. This is an important message for emergency physicians to pursue diuretics as long as signs of pulmonary congestion persist to improve the clinical status of the patient. In the present review, we aim to provide clinicians in acute settings with an integrative and comprehensive approach to cardiorenal interactions in acute heart failure.
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Red cell distribution width predicts death and appropriate therapy in patients with implantable cardioverter defibrillator: A simple measurement with prognostic value in a variety of diseases, may help in better selection of patients who will benefit the most from this device. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1384-1388. [PMID: 29067703 DOI: 10.1111/pace.13226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 09/24/2017] [Accepted: 10/16/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Red cell distribution width (RDW) is a measure of the size variation of erythrocytes. Its prognostic value has been described in a variety of cardiac and noncardiac diseases. Implantable cardioverter defibrillator (ICD) is useful in preventing sudden cardiac death in high-risk patients, but many of these patients continue to survive without needing ICD therapy. We sought to examine whether RDW, with its prognostic values, can benefit in risk stratification of patients with ICD by predicting death and ICD therapy, and thus help in the selection of patients who will benefit the most from ICD, and minimizing its implantation in others at low risk of death and arrhythmias. METHODS In a retrospective study, we enrolled patients with ICD implanted for both primary and secondary prevention of sudden cardiac death. Baseline RDW values, demographics, and clinical characteristics, as well as the occurrence of death or first appropriate ICD therapy in postimplantation follow-up were collected. We examined whether RDW can predict higher-risk ICD-implanted patients prone to death and first appropriate ICD therapy (the combined outcome). RESULTS Final population included 432 patients. Compared to others, patients in the upper RDW tertile were older and had more comorbidities and outcomes. In multivariate analysis including RDW, age, gender, and ejection fraction, RDW was the only predictor of the combined outcome. CONCLUSION RDW may be useful in risk stratification of patients selected for ICD implantation. But larger prospective randomized trials are needed.
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Implications of Alternative Hepatorenal Prognostic Scoring Systems in Acute Heart Failure (from DOSE-AHF and ROSE-AHF). Am J Cardiol 2017; 119:2003-2009. [PMID: 28433216 DOI: 10.1016/j.amjcard.2017.03.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/14/2017] [Accepted: 03/14/2017] [Indexed: 12/28/2022]
Abstract
Because hepatic dysfunction is common in patients with heart failure (HF), the Model for End-Stage Liver Disease (MELD) may be attractive for risk stratification. Although alternative scores such as the MELD-XI or MELD-Na may be more appropriate in HF populations, the short-term clinical implications of these in patients with acute heart failure (AHF) are unknown. The MELD-XI and MELD-Na were calculated at baseline in 453 patients with AHF in the DOSE-AHF and ROSE-AHF trials. The correlations and associations for each score with cardiorenal biomarkers, short-term end points at 72 hours including worsening renal function and clinical events to 60 days were determined. The median MELD-XI and MELD-Na was 16 and 17, respectively. Both were correlated with baseline cystatin C, amino terminus pro-B-type natriuretic peptide, and plasma renin activity (p <0.003 for all). MELD-XI ≤16 and MELD-Na ≤17 were associated with a slight increase in cystatin C (p <0.02 for both), higher diuretic efficiency (p <0.001 for both), but not with change in global visual assessment scores (p >0.05 for both) at 72 hours. Neither score was associated with worsening renal function or worsening HF (p >0.05 for all). Similarly, both the MELD-XI and MELD-Na were not associated with 60-day death/any rehospitalization and 60-day death/HF rehospitalization in adjusted analyses when analyzes as a dichotomous or continuous variable (p >0.05 for all). In conclusion, the alternative MELD scores correlated with baseline cardiorenal biomarkers, and lower baseline MELD scoring was associated with higher diuretic efficiency and a slight increase in cystatin C through 72 hours. However, MELD-Na and MELD-XI were not predictive of 60-day clinical events.
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Tailoring mineralocorticoid receptor antagonist therapy in heart failure patients: are we moving towards a personalized approach? Eur J Heart Fail 2017; 19:974-986. [DOI: 10.1002/ejhf.814] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/30/2016] [Accepted: 02/21/2017] [Indexed: 12/28/2022] Open
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Lack of Diuretic Efficiency (but Not Low Diuresis) Early in An Acutely Decompensated Heart Failure Episode Is Associated with Increased 180-Day Mortality. Cardiorenal Med 2017; 7:137-149. [PMID: 28611787 DOI: 10.1159/000455903] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 12/07/2016] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The assessment of the amount of urine produced by the dose of administered diuretic has been proposed as the main signal of interest in diuretic responsiveness - diuretic efficiency (DE). The main aim of our study is to determine if a low DE is associated with 180-day all-cause mortality (ACM). METHODS During a 3-year period, we retrospectively studied patients with acutely decompensated heart failure (ADHF) and respiratory insufficiency admitted to the emergency room of a tertiary university hospital in Porto, Portugal. A total of 170 patients (age 76.2 ± 10.3 years) were included. The outcome of ACM occurred in 43 (25.3%) patients during the 180-day follow-up period. DE was evaluated for a maximum of 3 h after emergency room admission. The lowest DE was defined as ≤140 mL of diuresis per 40 mg of furosemide equivalents. RESULTS No significant differences in age, comorbidities, baseline HF symptoms, or disease-modifying medication were found between the lowest and highest DE groups. The lowest DE group had higher blood urea and lower estimated glomerular filtration rate (eGFR) levels (41.3 ± 24.5 vs. 56.7 ± 23.2 mL/min/1.73 m2, p < 0.001). The patients with the lowest DE had significantly higher rates of ACM during the 180-day follow-up, even after adjustment for other clinically relevant variables: hazard ratio (HR) [95% CI] = 2.31 [1.16-4.58], p = 0.016. The lowest diuresis (≤300 mL) and the highest intravenous furosemide dose (>80 mg) alone were not significantly associated with the outcome. After adjustment for N-terminal prohormone of brain natriuretic peptide, the association between the lowest DE and the outcome lost strength (HR [95% CI] = 1.53 [0.75-3.13], p = 0.240). CONCLUSION A low DE (≤140 mL/40 mg of furosemide) in the first 3 h after an ADHF episode was associated with increased mid-term mortality rates.
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Mineralocorticoid receptor antagonists in patients with heart failure: current experience and future perspectives. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2016; 3:48-57. [DOI: 10.1093/ehjcvp/pvw016] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 01/14/2023]
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Enlarging Red Blood Cell Distribution Width During Hospitalization Identifies a Very High-Risk Subset of Acutely Decompensated Heart Failure Patients and Adds Valuable Prognostic Information on Top of Hemoconcentration. Medicine (Baltimore) 2016; 95:e3307. [PMID: 27057905 PMCID: PMC4998821 DOI: 10.1097/md.0000000000003307] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Red blood cell distribution width (RDW) may serve as an integrative marker of pathological processes that portend worse prognosis in heart failure (HF). The prognostic value of RDW variation (ΔRDW) during hospitalization for acute heart failure (AHF) has yet to be studied.We retrospectively analyzed 2 independent cohorts: Centro Hospitalar do Porto (derivation cohort) and Lariboisière hospital (validation cohort). In the derivation cohort a total of 170 patients (age 76.2 ± 10.3 years) were included and in the validation cohort 332 patients were included (age 76.4 ± 12.2 years). In the derivation cohort the primary composite outcome of HF admission and/or cardiovascular death occurred in 78 (45.9%) patients during the 180-day follow-up period.Discharge RDW and ΔRDW were both increased when hemoglobin levels were lower; peripheral edema was also associated with increased discharge RDW (all P < 0.05). Discharge RDW value was significantly associated with adverse events: RDW > 15% at discharge was associated with a 2-fold increase in event rate, HR = 1.95 (1.05-3.62), P = 0.04, while a ΔRDW >0 also had a strong association with outcome, HR = 2.47 (1.35-4.51), P = 0.003. The addition of both discharge RDW > 15% and ΔRDW > 0 to hemoconcentration was associated with a significant improvement in the net reclassification index, NRI = 18.3 (4.3-43.7), P = 0.012. Overlapping results were found in the validation cohort.As validated in 2 independent AHF cohorts, an in-hospital RDW enlargement and an elevated RDW at discharge are associated with increased rates of mid-term events. RDW variables improve the risk stratification of these patients on top of well-established prognostic markers.
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Effects of serelaxin in acute heart failure patients with renal impairment: results from RELAX-AHF. Clin Res Cardiol 2016; 105:727-37. [PMID: 27017514 PMCID: PMC4988995 DOI: 10.1007/s00392-016-0979-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 03/14/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Serelaxin showed beneficial effects on clinical outcome and trajectories of renal markers in patients with acute heart failure. We aimed to study the interaction between renal function and the treatment effect of serelaxin. METHODS In the current post hoc analysis of the RELAX-AHF trial, we included all patients with available estimated glomerular filtration rate (eGFR) at baseline (n = 1132). Renal impairment was defined as an eGFR <60 ml/min/1.73 m(2) estimated by creatinine. RESULTS 817 (72.2 %) patients had a baseline eGFR <60 ml/min/1.73 m(2). In placebo-treated patients, baseline renal impairment was related to a higher 180 day cardiovascular (HR 3.12, 95 % CI 1.33-7.30) and all-cause mortality (HR 2.81, 95 % CI 1.34-5.89). However, in serelaxin-treated patients, the risk of cardiovascular and all-cause mortality was less pronounced (HR 1.19, 95 % CI 0.54 -2.64; p for interaction = 0.106, and HR 1.15 95 % CI 0.56-2.34 respectively; p for interaction = 0.088). In patients with renal impairment, treatment with serelaxin resulted in a more pronounced all-cause mortality reduction (HR 0.53, 95 % CI 0.34-0.83), compared with patients without renal impairment (HR 1.30, 95 % CI 0.51-3.29). CONCLUSION Renal dysfunction was associated with higher cardiovascular and all-cause mortality in placebo-treated patients, but not in serelaxin-treated patients. The observed reduction in (cardiovascular) mortality in RELAX-AHF was more pronounced in patients with renal dysfunction. These observations need to be confirmed in the ongoing RELAX-AHF-2 trial.
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Spot urine sodium excretion as prognostic marker in acutely decompensated heart failure: the spironolactone effect. Clin Res Cardiol 2015; 105:489-507. [PMID: 26615605 DOI: 10.1007/s00392-015-0945-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Loop diuretic resistance characterized by inefficient sodium excretion complicates many patients with acutely decompensated heart failure (ADHF). Mineralocorticoid receptor antagonists (MRAs) in natriuretic doses may improve spot urine sodium excretion and outcomes. OBJECTIVE Our primary aim was to assess the association of high-dose spironolactone with short-term spot urine sodium excretion, and our secondary aim was to determine if this higher short-term spot urine sodium excretion is associated with reduction in the composite clinical outcome (of cardiovascular mortality and/or ADHF hospitalization) event rate at 180 days. METHODS Single-centre, non-randomized, open-label study enrolling 100 patients with ADHF. Patients were treated with standard ADHF therapy alone (n = 50) or oral spironolactone 100 mg/day plus standard ADHF therapy (n = 50). Spot urine samples were collected at day 1 and day 3 of hospitalization. RESULTS Spironolactone group had significantly higher spot urine sodium levels compared to standard care group at day 3 (84.13 ± 28.71 mmol/L vs 70.74 ± 34.43 mmol/L, p = 0.04). The proportion of patients with spot urinary sodium <60 mmol/L was lower in spironolactone group at day 3 (18.8 vs 45.7, p = 0.01). In multivariate analysis, spironolactone was independently associated with increased spot urinary sodium and urinary sodium/potassium ratio of >2 at day 3 (both, p < 0.05). Higher spot urine sodium levels were associated with a lower event rate [HR for urinary sodium >100 mmol/L = 0.16 (0.06-0.42), p < 0.01, compared to <60], and provided a significant prognostic gain measured by net reclassification indexes. CONCLUSION Spot urinary sodium levels >60 mmol/L and urinary sodium/potassium ratio >2 measured at day 3 of hospitalization for ADHF are associated with improved mid-term outcomes. Spironolactone is associated with increased spot urinary sodium and sodium/potassium ratio >2.
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Effect of low-dose diuretics on the level of serum cystatin C and prognosis in patients with asymptomatic chronic heart failure. Exp Ther Med 2015; 10:2345-2350. [PMID: 26668639 DOI: 10.3892/etm.2015.2837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/14/2015] [Indexed: 12/19/2022] Open
Abstract
The aim of the present study was to investigate the effect of low-dose diuretics on the serum cystatin C (CysC) and serum creatinine (Scr) levels, and on the prognosis in patients with asymptomatic chronic heart failure (HF). A total of 66 asymptomatic chronic HF patients were divided into the observation and control groups (n=33 in each group). Patients in the control group were treated with a routine treatment, while the patients in the observation group were treated with the diuretic hydrochlorothiazide along with the same routine treatment as the control group. The left ventricular ejection fraction (LVEF), serum CysC levels, Scr levels, heart function, prognosis, adverse reactions and complications of the patients in the two groups were compared prior to and following treatment. The LVEF increased in the two groups following treatment, while the levels of serum CysC and Scr decreased. The LVEF in the observation group increased following treatment for 1, 3 and 6 months compared with the LVEF values in the control group. In addition, the levels of serum CysC and Scr in the observation group were found to be lower compared with those in the control group (P<0.05). The incidence of adverse prognosis following treatment for 6 months in the observation group was lower compared with that in the control group (P<0.05). The proportion of HF patients with New York Heart Association (NYHA) class I and II increased following treatment for 6 months in the two groups (P<0.05). However, in the observation group, a higher number of patients exhibited class I and II disease after treatment for 6 months compared with the number in the control group (P<0.05). Furthermore, no statistically significant difference was observed between adverse reactions and complications in the two groups (P>0.05). In conclusion, low-dose diuretics may effectively improve the cardiac and renal functions and prognosis in asymptomatic chronic HF patients, without increasing the incidence of side effects.
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Comparison Costs of ERCP and MRCP in Patients with Suspected Biliary Obstruction Based on a Randomized Trial. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:767-773. [PMID: 26409603 DOI: 10.1016/j.jval.2015.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/25/2015] [Accepted: 04/28/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND The optimal management of patients with suspected biliary obstruction remains unclear, and includes the possible performance of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). OBJECTIVES To complete a cost analysis based on a medical effectiveness randomized trial comparing an ERCP-first approach with an MRCP-first approach in patients with suspected bile duct obstruction. METHODS The management strategies were based on a medical effectiveness trial of 257 patients over a 12-month follow-up period. Direct and indirect costs were included, adopting a societal perspective. The cost values are expressed in 2012 Canadian dollars. RESULTS Total per-patient direct costs were Can$3547 for ERCP-first patients and Can$4013 for MRCP-first patients. Corresponding indirect costs were Can$732 and Can$694, respectively. Causes for differences in direct costs included a more frequent second procedure and a greater mean number of hospital days over the year in patients of the MRCP-first group. In contrast, it is the ERCP-first patients whose indirect costs were greater, principally due to more time away from activities of daily living. Choosing an ERCP-first strategy rather than an MRCP-first strategy saved on average Can$428 per patient over the 12-month follow-up duration; however, there existed a large amount of overlap when varying total cost estimates across a sensitivity analysis range based on observed resources utilization. CONCLUSIONS This cost analysis suggests only a small difference in total costs, favoring the ERCP-first group, and is principally attributable to procedures and hospitalizations with little impact from indirect cost measurements.
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A combined clinical and biomarker approach to predict diuretic response in acute heart failure. Clin Res Cardiol 2015; 105:145-53. [PMID: 26280875 PMCID: PMC4735256 DOI: 10.1007/s00392-015-0896-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/20/2015] [Indexed: 11/29/2022]
Abstract
Background Poor diuretic response in acute heart failure is related to poor clinical outcome. The underlying mechanisms and pathophysiology behind diuretic resistance are incompletely understood. We evaluated a combined approach using clinical characteristics and biomarkers to predict diuretic response in acute heart failure (AHF). Methods and results We investigated explanatory and predictive models for diuretic response—weight loss at day 4 per 40 mg of furosemide—in 974 patients with AHF included in the PROTECT trial. Biomarkers, addressing multiple pathophysiological pathways, were determined at baseline and after 24 h. An explanatory baseline biomarker model of a poor diuretic response included low potassium, chloride, hemoglobin, myeloperoxidase, and high blood urea nitrogen, albumin, triglycerides, ST2 and neutrophil gelatinase-associated lipocalin (r2 = 0.086). Diuretic response after 24 h (early diuretic response) was a strong predictor of diuretic response (β = 0.467, P < 0.001; r2 = 0.523). Addition of diuretic response after 24 h to biomarkers and clinical characteristics significantly improved the predictive model (r2 = 0.586, P < 0.001). Conclusions Biomarkers indicate that diuretic unresponsiveness is associated with an atherosclerotic profile with abnormal renal function and electrolytes. However, predicting diuretic response is difficult and biomarkers have limited additive value. Patients at risk of poor diuretic response can be identified by measuring early diuretic response after 24 h. Electronic supplementary material The online version of this article (doi:10.1007/s00392-015-0896-2) contains supplementary material, which is available to authorized users.
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Rationale and design of a randomized, controlled multicentre clinical trial to evaluate the effect of bromocriptine on left ventricular function in women with peripartum cardiomyopathy. Clin Res Cardiol 2015; 104:911-7. [PMID: 26026286 PMCID: PMC4623094 DOI: 10.1007/s00392-015-0869-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 05/13/2015] [Indexed: 01/01/2023]
Abstract
Background Peripartum cardiomyopathy (PPCM) is an idiopathic heart disease that develops in the last month of pregnancy and/or the first months following delivery in previously healthy women and may lead to acute heart failure. A cleaved fragment of the nursing hormone prolactin is considered essential in the pathophysiology of PPCM. To date, no specific therapy has been tested for PPCM in a randomized controlled trial of adequate size. Aims The purpose of this trial is to investigate the safety of the dopamin-D2-receptor agonist bromocriptine and its effects on left ventricular (LV) function in women with PPCM. Methods This is an 11 center German trial with a prospective randomized controlled open-label design. The trial enrolls females with newly diagnosed PPCM according to European Society of Cardiology criteria with a LV ejection fraction (LVEF) <35 %. Patients are randomized 1:1 to either best supportive care (BSC) including standard heart failure therapy plus 8 weeks of bromocriptine therapy (2.5 mg b.i.d. for 14 days and 2.5 mg q.d. from day 15 to 56) or to BSC plus 1 week of low-dose bromocriptine (2.5 mg q.d.) with anticoagulant therapy at a prophylactic dose administered during the period of bromocriptine treatment in both groups. The primary endpoint is change in LVEF from baseline to 6 months follow-up as assessed by cardiac magnetic resonance imaging (or echocardiography if CMR is not tolerated). The secondary endpoints are hospitalization for worsening heart failure, heart transplantation, and all-cause mortality during follow-up or a combination of these endpoints. A total of 60 patients will be recruited (including 6 potential dropouts) giving a power of 0.9 for an expected LVEF change of 10.8 % between treatment groups at 6 months. Perspective This trial will provide important knowledge on potential benefits and safety of prolonged inhibition of prolactin release with bromocriptine in addition to standard heart failure therapy in newly diagnosed PPCM. Trial registration: ClinicalTrials.gov Identifier: NCT00998556.
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Influence of spironolactone on matrix metalloproteinase-2 in acute decompensated heart failure. Arq Bras Cardiol 2015; 104:308-14. [PMID: 25993594 PMCID: PMC4415867 DOI: 10.5935/abc.20140205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 09/30/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Matrix metalloproteinases (MMPs) are a family of enzymes important for the resorption of extracellular matrices, control of vascular remodeling and repair. Increased activity of MMP2 has been demonstrated in heart failure, and in acutely decompensated heart failure (ADHF) a decrease in circulating MMPs has been demonstrated along with successful treatment. OBJECTIVE Our aim was to test the influence of spironolactone in MMP2 levels. METHODS Secondary analysis of a prospective, interventional study including 100 patients with ADHF. Fifty patients were non-randomly assigned to spironolactone (100 mg/day) plus standard ADHF therapy (spironolactone group) or standard ADHF therapy alone (control group). RESULTS Spironolactone group patients were younger and had lower creatinine and urea levels (all p < 0.05). Baseline MMP2, NT-pro BNP and weight did not differ between spironolactone and control groups. A trend towards a more pronounced decrease in MMP2 from baseline to day 3 was observed in the spironolactone group (-21 [-50 to 19] vs 1.5 [-26 to 38] ng/mL, p = 0.06). NT-pro BNP and weight also had a greater decrease in the spironolactone group. The proportion of patients with a decrease in MMP2 levels from baseline to day 3 was also likely to be greater in the spironolactone group (50% vs 66.7%), but without statistical significance. Correlations between MMP2, NT-pro BNP and weight variation were not statistically significant. CONCLUSION MMP2 levels are increased in ADHF. Patients treated with spironolactone may have a greater reduction in MMP2 levels.
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High-dose spironolactone changes renin and aldosterone levels in acutely decompensated heart failure. COR ET VASA 2014. [DOI: 10.1016/j.crvasa.2014.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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High-sensitivity troponin T: a biomarker for diuretic response in decompensated heart failure patients. Cardiol Res Pract 2014; 2014:269604. [PMID: 25247106 PMCID: PMC4163417 DOI: 10.1155/2014/269604] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/04/2014] [Indexed: 11/17/2022] Open
Abstract
Background. Patients presenting with acutely decompensated heart failure (ADHF) and positive circulating cardiac troponins were found to be a high-risk cohort. The advent of high-sensitive troponins resulted in a detection of positive troponins in a great proportion of heart failure patients. However, the pathophysiological significance of this phenomenon is not completely clear. Objectives. The aim of this study is to determine the early evolution and clinical significance of high-sensitivity troponin T (hsTnT) in ADHF. Methods. Retrospective, secondary analysis of a prospective study including 100 patients with ADHF. Results. Globally, high-sensitivity troponin T decreased from day 1 to day 3 (P = 0,039). However, in the subgroup of patients who remained decompensated no significant differences in hsTnT from day 1 to day 3 were observed (P = 0,955), whereas in successfully compensated patients a significant reduction in hsTnT levels was observed (P = 0,025). High-sensitivity troponin T decrease was correlated with NTproBNP reduction (P = 0,007). Patients with hsTnT increase had longer length of stay (P = 0,033). Conclusions. Episodes of ADHF are associated with transient increases in the blood levels of hsTnT that are reduced with effective acute episode treatment. The decrease in hsTnT can translate less myocardial damage along with favourable ADHF treatment.
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Clinical and echocardiographic correlates of serum copper and zinc in acute and chronic heart failure. Clin Res Cardiol 2014; 103:938-49. [PMID: 24908339 DOI: 10.1007/s00392-014-0735-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022]
Abstract
AIM Emerging evidence suggests a pathophysiological role of micronutrient dyshomeostasis in heart failure, including promotion of adverse remodeling and clinical deterioration. We sought to evaluate serum copper (Cu) and zinc (Zn) levels in acute (AHF) and chronic (CHF) heart failure. METHODS We studied 125 patients, 71 % male, aged 69 ± 11 years, 37 % with preserved left ventricular ejection fraction (LVEF ≥40 %) (HFPEF), including 81 with AHF and 44 with CHF; 21 healthy volunteers served as controls. Serum Cu and Zn levels were determined using air-acetylene flame atomic absorption spectrophotometry. RESULTS Serum Cu levels were significantly higher in AHF (p = 0.006) and CHF (p = 0.002) patients compared to controls after adjusting for age, gender and comorbidities, whereas they did not differ between AHF and CHF (p = 0.840). Additionally, serum Cu in patients with LVEF <40 % was significantly higher compared to both controls (p < 0.001) and HFPEF patients (p = 0.003). Serum Zn was significantly lower in AHF (p < 0.001) and CHF (p = 0.039) compared to control after adjusting for the above-mentioned variables. Moreover, serum Zn was significantly lower in AHF than in CHF (p = 0.015). In multiple linear regression, LVEF (p = 0.033) and E/e ratio (p = 0.006) were independent predictors of serum Cu in total heart failure population, while NYHA class (p < 0.001) and E/e ratio (p = 0.007) were independent predictors of serum Zn. CONCLUSION Serum Cu was increased both in AHF and CHF and correlated with LV systolic and diastolic function. Serum Zn, in contrast, was decreased both in AHF and CHF and independently predicted by clinical status and LV diastolic function.
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Anemia is associated with an increased central venous pressure and mortality in a broad spectrum of cardiovascular patients. Clin Res Cardiol 2014; 103:467-76. [PMID: 24504376 DOI: 10.1007/s00392-014-0673-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 01/21/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anemia is frequently observed in patients with cardiovascular disease. Multiple factors have been associated with anemia, but the role of hemodynamics is largely unknown. Therefore, we investigated the association between hemoglobin (Hb) levels, hemodynamics and outcome in a broad spectrum of cardiovascular patients. METHODS AND RESULTS A total of 2,009 patients who underwent right heart catheterization at the University Medical Center Groningen, the Netherlands, between 1989 and 2006 were identified and data were extracted from electronic databases. Anemia was defined by the WHO criteria (male, hemoglobin <13.0 g/dL; female, hemoglobin <12.0 g/dL). The associations between central venous pressure (CVP), cardiac index (CI), systemic vascular resistance (SVR), hemoglobin (Hb), anemia and all-cause mortality were assessed with linear, logistic and Cox-proportional hazards analysis. The mean age was 57 ± 15 years, 57 % were male, mean Hb was 13.2 ± 0.4 g/dL, and 27.4 % of the patients were anemic. Patients with anemia had higher CVP levels (7.0 ± 5.4 mmHg) compared to non-anemic patients (5.6 ± 4.1 mmHg; p < 0.001). CI was higher in anemic patients; 3.0 ± 2.9 vs. 2.9 ± 0.8 L/min/m(2) (p < 0.001), whereas SVR was lower (1,212 ± 479 vs. 1,356 ± 555 dyn s cm(-5), p < 0.001). CVP and CI were both independent predictors of anemia (OR 1.49; CI 1.24-1.81, p < 0.001 and OR 1.93; CI 1.54-2.42, p < 0.001, respectively). Hemoglobin and CVP were both independent predictors of survival. Independent of CI and renal function, patients with anemia and an elevated CVP had the worst prognosis (HR 2.17; 95 % CI 1.62-2.90; p < 0.001). CONCLUSION Anemia is common in cardiovascular patients and independently related to an elevated CVP and CI. Patients with anemia and an elevated CVP have the worst prognosis.
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