Aldosterone Antagonists Reduce the Risk of Cardiovascular Mortality in Dialysis Patients: A Meta-Analysis

Background and Purpose. Cardiovascular disease is the major cause of death in dialysis patients. Although aldosterone antagonists were considered a treatment for severe heart failure patients to reduce cardiac mortality, whether treating patients undergoing maintenance dialysis with aldosterone antagonists could reduce the risk of cardiocerebrovascular (CCV) remains unclear. We aim to systematically assess the efficacy and tolerability of the addition of aldosterone antagonists to conventional therapy in patients undergoing maintenance dialysis. Materials and Methods. We searched PubMed, EMBASE, the Cochrane Library, the Chinese Biomedical Literature Database (CBM), and the China National Knowledge Infrastructure (CNKI) for relevant articles. The primary endpoint of interest was CCV mortality. The secondary endpoints were all-cause mortality, left ventricular mass index (LVMI), and left ventricular ejection fraction (LVEF). Publication bias was evaluated using funnel plots and Egger's test. The meta-analysis was performed using Review Manager software version 5.3. Results. This analysis included 10 randomized controlled trials (RCTs) with 1172 total chronic dialysis patients. The use of aldosterone antagonists in the dialysis population resulted in a marked reduction in CCV mortality (RR 0.42, 95% CI 0.26-0.65, P=0.0002) and all-cause mortality (RR0.46, 95%CI 0.32-0.66, P<0.0001). The LVEF was improved by treatment with aldosterone antagonists (WMD 6.35%, P<0.00001). Moreover, aldosterone antagonists decreased the LVMI (WMD -8.69 g/m², P=0.0006), whereas aldosterone antagonists increased the occurrence of hyperkalemia (RR1.70, 95%CI 1-2.88, P=0.05) and gynecomastia (RR 8.01, 95% CI 2.44- 26.27, P=0.0006). Conclusions. Addition of aldosterone antagonists to conventional treatment in chronic dialysis patients may reduce CCV mortality, improve cardiac function, and simultaneously decrease LVMI.

Meta-analysis of the cardioprotective effect of sevoflurane versus propofol during cardiac surgery

BACKGROUND

To evaluate the cardioprotective effects of sevoflurane versus propofol anesthesia in patients undergoing cardiac surgery.

METHODS

Studies were retrieved through searching several databases. Study quality was evaluated by Jadad scale. Meta-analysis was performed with RevMan5.0 software. Publication bias was tested by funnel plot.

RESULTS

As a result, 15 studies were included. Compared with propofol, sevoflurane anesthesia significantly improved postoperative (WMD (weighted mean difference) = 0.62, 95% CI: 0.33 to 0.92; P < 0.0001) and postoperative 12 hour cardiac index (WMD = 0.18, 95% CI: 0.03 to 0.33; P = 0.02), postoperative cardiac output (WMD = 1.14, 95% CI: 0.74 to 1.54; P < 0.00001), and reduced postoperative 24 hour cardiac troponin I concentration (WMD = -0.86, 95% CI:-1.49 to -0.22; P = 0.008), postoperative inotropic drug usage (OR (odds ratio) = 0.31, 95% CI: 0.22 to 0.44; P < 0.00001), vasoconstrictor drug usage (OR = 0.30, 95% CI:0.21 to 0.43; P < 0.00001), ICU stay (WMD = -15.53, 95% CI: -24.29 to -6.58; P = 0.0007) and a trial fibrillation incidence (OR = 0.25, 95% CI: 0.07 to 0.85; P = 0.03). However, no significant differences were found in other indexes. Subgroup analysis indicated the similar results.

DISCUSSION

The sevoflurane-induced cTnI reduction is associated with lower incidence of late adverse cardiac events, accounting for its roles in cardiac protection. Several limitations existed such as the small sample size and the lack use of blind design.

CONCLUSIONS

Sevoflurane may exhibit a more favorable cardioprotective effect during cardiac surgery than propofol.

Effects of levosimendan in patients with left ventricular hypertrophy undergoing aortic valve replacement

BACKGROUND

Left ventricular hypertrophy is associated with adverse outcomes, including death, during cardiac surgery. This may be facilitated by an increased oxygen demand and diastolic dysfunction. Levosimendan augments haemodynamics without further oxygen consumption and improves echocardiographic indices of diastolic dysfunction. This study aimed to describe the haemodynamic effects of short-term pre- and intra-operative levosimendan infusion including advanced echocardiographic measures of diastolic and systolic heart function.

METHODS

The study was randomised, double-blinded and placebo-controlled performed at a single-centre university hospital. Patients with left ventricular hypertrophy and ejection fraction > 45% scheduled for single procedure aortic valve replacement were included and randomised to infusion of either levosimendan 0.1 μg/kg/min or placebo from 4 h before anaesthesia to the end of surgery. Outcome measures were echocardiographic indices of left ventricular diastolic function: E/e' (primary endpoint), e', e'/a' and indices of systolic function: longitudinal strain, ejection fraction and s'. Patients were followed until 6 months after surgery. In addition, invasive haemodynamic measures were obtained perioperatively.

RESULTS

The trial was prematurely terminated due to an overall high incidence of post-operative atrial fibrillation (15/20, P = 0.002) after inclusion of 20 patients. The relative decrease in perioperative cardiac index was lower (P = 0.016) in the levosimendan group. There was no difference in E/e', and similar results were found for all measures of systolic function.

CONCLUSION

Short-term levosimendan caused a transient relative increase in cardiac index, but no effect was seen on the first post-operative day and up to 6 months post-operatively with indices of systolic and diastolic heart function.

Preoperative left ventricular hypertrophy is associated with reduced patient survival after liver transplantation

Left ventricular hypertrophy (LVH) has been described in the context of cirrhotic cardiomyopathy. The influence of LVH on survival of liver transplant (LT) recipients has not been clarified. Therefore, we evaluated the effect of LVH on survival in LT recipients. In total, data from 352 LT patients were analyzed. LVH was diagnosed by echocardiographic measurement of left ventricular wall thickness before LT. Patients were followed up for a mean of 4.2 yr. LVH was diagnosed in 135 (38.4%) patients. Patients with LVH had significantly more frequently male gender (p = 0.046), diastolic dysfunction (p < 0.001), and hepatocellular carcinoma (HCC; p = 0.004). Furthermore, LVH patients were older (p < 0.001) and had a higher body mass index (BMI; p = 0.001). There was no difference in frequency of arterial hypertension, pre-transplant diabetes mellitus, or etiology of liver cirrhosis. Patients without LVH had a better survival (log rank: p = 0.05) compared with LVH patients. In a multivariate Cox regression LVH (p = 0.031), end-stage renal disease (ESRD; p = 0.003) and lack of arterial hypertension (p = 0.004) but not MELD score (p = 0.885) were associated with poorer survival.

CONCLUSION

LVH is frequently diagnosed in patients on the waiting list and influences survival after LT.