1
|
Kittipibul V, Cox ZL, Chesdachai S, Fiuzat M, Lindenfeld J, Mentz RJ. Genitourinary Tract Infections in Patients Taking SGLT2 Inhibitors: JACC Review Topic of the Week. J Am Coll Cardiol 2024; 83:1568-1578. [PMID: 38631776 DOI: 10.1016/j.jacc.2024.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 04/19/2024]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) have been shown to reduce adverse cardiovascular events in patients with type 2 diabetes mellitus, all-cause mortality, and heart failure hospitalization in patients with heart failure, as well as adverse renal outcomes. However, concerns regarding the heightened risk of genitourinary (GU) infections, particularly urinary tract infections, remain a significant barrier to their wider adoption. Addressing these misconceptions using existing evidence is needed to ensure proper risk-benefit assessment and optimal utilization of this efficacious therapy. This review aims to provide a balanced perspective on the evidence-based cardiovascular and renal benefits of SGLT2is and the associated risk of GU infections. We also summarize and propose clinical practice considerations for SGLT2i-associated GU infections focusing on patients with cardiovascular disease.
Collapse
Affiliation(s)
- Veraprapas Kittipibul
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/vkittipibul
| | - Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee, USA; Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Supavit Chesdachai
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert J Mentz
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| |
Collapse
|
2
|
Cox ZL, Collins SP, Hernandez GA, McRae AT, Davidson BT, Adams K, Aaron M, Cunningham L, Jenkins CA, Lindsell CJ, Harrell FE, Kampe C, Miller KF, Stubblefield WB, Lindenfeld J. Efficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure. J Am Coll Cardiol 2024; 83:1295-1306. [PMID: 38569758 DOI: 10.1016/j.jacc.2024.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The primary goals during acute heart failure (AHF) hospitalization are decongestion and guideline-directed medical therapy (GDMT) optimization. Unlike diuretics or other GDMT, early dapagliflozin initiation could achieve both AHF goals. OBJECTIVES The authors aimed to assess the diuretic efficacy and safety of early dapagliflozin initiation in AHF. METHODS In a multicenter, open-label study, 240 patients were randomized within 24 hours of hospital presentation for hypervolemic AHF to dapagliflozin 10 mg once daily or structured usual care with protocolized diuretic titration until day 5 or hospital discharge. The primary outcome, diuretic efficiency expressed as cumulative weight change per cumulative loop diuretic dose, was compared across treatment assignment using a proportional odds model adjusted for baseline weight. Secondary and safety outcomes were adjudicated by a blinded committee. RESULTS For diuretic efficiency, there was no difference between dapagliflozin and usual care (OR: 0.65; 95% CI: 0.41-1.02; P = 0.06). Dapagliflozin was associated with reduced loop diuretic doses (560 mg [Q1-Q3: 260-1,150 mg] vs 800 mg [Q1-Q3: 380-1,715 mg]; P = 0.006) and fewer intravenous diuretic up-titrations (P ≤ 0.05) to achieve equivalent weight loss as usual care. Early dapagliflozin initiation did not increase diabetic, renal, or cardiovascular safety events. Dapagliflozin was associated with improved median 24-hour natriuresis (P = 0.03) and urine output (P = 0.005), expediting hospital discharge over the study period. CONCLUSIONS Early dapagliflozin during AHF hospitalization is safe and fulfills a component of GDMT optimization. Dapagliflozin was not associated with a statistically significant reduction in weight-based diuretic efficiency but was associated with evidence for enhanced diuresis among patients with AHF. (Efficacy and Safety of Dapagliflozin in Acute Heart Failure [DICTATE-AHF]; NCT04298229).
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee, USA; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, Tennessee, USA
| | - Gabriel A Hernandez
- Division of Cardiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - A Thomas McRae
- TriStar Centennial Medical Center, Nashville, Tennessee, USA
| | - Beth T Davidson
- TriStar Centennial Medical Center, Nashville, Tennessee, USA
| | - Kirkwood Adams
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Mark Aaron
- Department of Cardiac Sciences, Saint Thomas West Hospital, Nashville, Tennessee, USA
| | - Luke Cunningham
- Department of Cardiology, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christina Kampe
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
3
|
Rao VS, Ivey-Miranda JB, Cox ZL, Moreno-Villagomez J, Ramos-Mastache D, Neville D, Balkcom N, Asher JL, Bellumkonda L, Bigvava T, Shaburishvili T, Bartunek J, Wilson FP, Finkelstein F, Maulion C, Turner JM, Testani JM. Serial direct sodium removal in patients with heart failure and diuretic resistance. Eur J Heart Fail 2024. [PMID: 38556717 DOI: 10.1002/ejhf.3196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 04/02/2024] Open
Abstract
AIMS Loop diuretics may exacerbate cardiorenal syndrome (CRS) in heart failure (HF). Direct sodium removal (DSR) using the peritoneal membrane, in conjunction with complete diuretic withdrawal, may improve CRS and diuretic resistance. METHODS AND RESULTS Patients with HF requiring high-dose loop diuretics were enrolled in two prospective, single-arm studies: RED DESERT (n = 8 euvolaemic patients), and SAHARA (n = 10 hypervolaemic patients). Loop diuretics were withdrawn, and serial DSR was utilized to achieve and maintain euvolaemia. At baseline, participants required a median 240 mg (interquartile range [IQR] 200-400) oral furosemide equivalents/day, which was withdrawn in all participants during DSR (median time of DSR 4 weeks [IQR 4-6]). Diuretic response (queried by formal 40 mg intravenous furosemide challenge and 6 h urine sodium quantification) increased substantially from baseline (81 ± 37 mmol) to end of DSR (223 ± 71 mmol, p < 0.001). Median time to re-initiate diuretics was 87 days, and the median re-initiation dose was 8% (IQR 6-10%) of baseline. At 1 year, diuretic dose remained substantially below baseline (30 [IQR 7.5-40] mg furosemide equivalents/day). Multiple dimensions of kidney function such as filtration, uraemic toxin excretion, kidney injury, and electrolyte handling improved (p < 0.05 for all). HF-related biomarkers including N-terminal pro-B-type natriuretic peptide, carbohydrate antigen-125, soluble ST2, interleukin-6, and growth differentiation factor-15 (p < 0.003 for all) also improved. CONCLUSIONS In patients with HF and diuretic resistance, serial DSR therapy with loop diuretic withdrawal was feasible and associated with substantial and persistent improvement in diuretic resistance and several cardiorenal parameters. If replicated in randomized controlled studies, DSR may represent a novel therapy for diuretic resistance and CRS. CLINICAL TRIAL REGISTRATION RED DESERT (NCT04116034), SAHARA (NCT04882358).
Collapse
Affiliation(s)
- Veena S Rao
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Juan B Ivey-Miranda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, USA
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Julieta Moreno-Villagomez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Daniela Ramos-Mastache
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Daniel Neville
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Natasha Balkcom
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer L Asher
- Division of Comparative Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | | | | | - F Perry Wilson
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT, USA
| | - Fredrick Finkelstein
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher Maulion
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jeffrey M Turner
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jeffrey M Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
4
|
Cox ZL, Testani JM. The salt paradox in heart failure. Eur J Heart Fail 2024. [PMID: 38467462 DOI: 10.1002/ejhf.3194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/13/2024] Open
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, USA
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
5
|
Cox ZL, Dalia T, Goyal A, Fritzlen J, Gupta B, Shah Z, Sauer AJ, Haglund NA. Novel Nebulized Milrinone Formulation for the Treatment of Acute Heart Failure Requiring Inotropic Therapy: A Phase 1 Study. J Card Fail 2024; 30:329-336. [PMID: 37871843 DOI: 10.1016/j.cardfail.2023.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Nonintravenous inotropic-delivery options are needed for patients with inotropic-dependent heart failure (HF) to reduce the costs, infections and thrombotic risks associated with chronic central venous catheters and home infusion services. METHODS We developed a novel, concentrated formulation of nebulized milrinone for inhalation and evaluated the feasibility, safety and pharmacokinetic profile in a prospective, single-arm, phase I clinical trial. We enrolled 10 patients with stage D HF requiring inotropic therapy during a hospital admission for acute HF. Milrinone 60 mg/4 mL was inhaled via nebulization 3 times daily for 48 hours. The coprimary outcomes were adverse events and pharmacokinetic profiles of inhaled milrinone. Acute changes in hemodynamic parameters were secondary outcomes. RESULTS A concentrated nebulized milrinone formulation was well tolerated, without hypotensive events, arrhythmias or inhalation-related adverse events requiring discontinuation. Nebulized milrinone produced serum concentrations in the goal therapeutic range with a median plasma milrinone trough concentration of 39 (17-66) ng/mL and a median peak concentration of 207 (134-293) ng/mL. There were no serious adverse events. From baseline to 24 hours, mean pulmonary artery saturation increased (60% ± 7%-65 ± 5%; P = 0.001), and mean cardiac index increased (2.0 ± 0.5 mL/min/1.73m2-2.5 ± 0.1 mL/min/1.73m2; P = 0.001) with nebulized milrinone. CONCLUSIONS In a proof-of-concept study, a concentrated, nebulized milrinone formulation for inhalation was safe and produced therapeutic serum milrinone concentrations. Nebulized milrinone was associated with improved hemodynamic parameters of cardiac output in a population with advanced HF. These promising results require further investigation in a longer-term trial in patients with inotrope-dependent advanced HF.
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice and Pharmaceutical Science, Lipscomb University College of Pharmacy, Nashville, TN; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN.
| | - Tarun Dalia
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Amandeep Goyal
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - John Fritzlen
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Bhanu Gupta
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Zubair Shah
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Andrew J Sauer
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Nicholas A Haglund
- Minneapolis Heart Institute, Allina Health at Abbott Northwestern Hospital, Minneapolis, MN
| |
Collapse
|
6
|
Rao VS, Ivey-Miranda JB, Cox ZL, Moreno-Villagomez J, Maulion C, Bellumkonda L, Chang J, Field MP, Wiederin DR, Butler J, Collins SP, Turner JM, Wilson FP, Inzucchi SE, Wilcox CS, Ellison DH, Testani JM. Empagliflozin in Heart Failure: Regional Nephron Sodium Handling Effects. J Am Soc Nephrol 2024; 35:189-201. [PMID: 38073038 PMCID: PMC10843196 DOI: 10.1681/asn.0000000000000269] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 10/25/2023] [Indexed: 02/02/2024] Open
Abstract
SIGNIFICANCE STATEMENT The effect of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on regional tubular sodium handling is poorly understood in humans. In this study, empagliflozin substantially decreased lithium reabsorption in the proximal tubule (PT) (a marker of proximal tubular sodium reabsorption), a magnitude out of proportion to that expected with only inhibition of sodium-glucose cotransporter-2. This finding was not driven by an "osmotic diuretic" effect; however, several parameters changed in a manner consistent with inhibition of the sodium-hydrogen exchanger 3. The large changes in proximal tubular handling were acutely buffered by increased reabsorption in both the loop of Henle and the distal nephron, resulting in the observed modest acute natriuresis with these agents. After 14 days of empagliflozin, natriuresis waned due to increased reabsorption in the PT and/or loop of Henle. These findings confirm in humans that SGLT2i have complex and important effects on renal tubular solute handling. BACKGROUND The effect of SGLT2i on regional tubular sodium handling is poorly understood in humans but may be important for the cardiorenal benefits. METHODS This study used a previously reported randomized, placebo-controlled crossover study of empagliflozin 10 mg daily in patients with diabetes and heart failure. Sodium handling in the PT, loop of Henle (loop), and distal nephron was assessed at baseline and day 14 using fractional excretion of lithium (FELi), capturing PT/loop sodium reabsorption. Assessments were made with and without antagonism of sodium reabsorption through the loop using bumetanide. RESULTS Empagliflozin resulted in a large decrease in sodium reabsorption in the PT (increase in FELi=7.5%±10.6%, P = 0.001), with several observations suggesting inhibition of PT sodium hydrogen exchanger 3. In the absence of renal compensation, this would be expected to result in approximately 40 g of sodium excretion/24 hours with normal kidney function. However, rapid tubular compensation occurred with increased sodium reabsorption both in the loop ( P < 0.001) and distal nephron ( P < 0.001). Inhibition of sodium-glucose cotransporter-2 did not attenuate over 14 days of empagliflozin ( P = 0.14). However, there were significant reductions in FELi ( P = 0.009), fractional excretion of sodium ( P = 0.004), and absolute fractional distal sodium reabsorption ( P = 0.036), indicating that chronic adaptation to SGLT2i results primarily from increased reabsorption in the loop and/or PT. CONCLUSIONS Empagliflozin caused substantial redistribution of intrarenal sodium delivery and reabsorption, providing mechanistic substrate to explain some of the benefits of this class. Importantly, the large increase in sodium exit from the PT was balanced by distal compensation, consistent with SGLT2i excellent safety profile. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER ClinicalTrials.gov ( NCT03027960 ).
Collapse
Affiliation(s)
- Veena S. Rao
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Juan B. Ivey-Miranda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Zachary L. Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Julieta Moreno-Villagomez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Christopher Maulion
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - John Chang
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | | | | | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas
| | - Sean P. Collins
- Department of Emergency Medicine, Geriatric Research, Education and Clinical Center (GRECC), Vanderbilt University Medical Center and Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Jeffrey M. Turner
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - F. Perry Wilson
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Silvio E. Inzucchi
- Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher S. Wilcox
- Division of Nephrology and Hypertension Center, Georgetown University, Washington, DC
| | - David H. Ellison
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, Oregon
| | - Jeffrey M. Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
7
|
Rao VS, Ivey-Miranda JB, Cox ZL, Moreno-Villagomez J, Testani JM. Association of Urine Galectin-3 With Cardiorenal Outcomes in Patients With Heart Failure. J Card Fail 2024; 30:340-346. [PMID: 37301248 PMCID: PMC10947725 DOI: 10.1016/j.cardfail.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Approaches to distinguishing pathological cardiorenal dysfunction in heart failure (HF) from functional/hemodynamically mediated changes in serum creatinine are needed. We investigated urine galectin-3 as a candidate biomarker of renal fibrosis and a prognostic indicator of cardiorenal dysfunction phenotypes. METHODS We measured urine galectin-3 in 2 contemporary HF cohorts: the Yale Transitional Care Clinic (YTCC) cohort (n = 132) and the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial (n = 434). We assessed the association of urine galectin-3 with all-cause mortality in both cohorts and the association with an established marker of renal tissue fibrosis, urinary amino-terminal propeptide of type III procollagen (PIIINP) in TOPCAT. RESULTS In the YTCC cohort, there was significant effect modification between higher urine galectin-3 and lower estimated glomerular filtration rates (eGFRs) (Pinteraction = 0.046), such that low eGFR levels had minimal prognostic importance if urine galectin-3 levels were low, but they were important and indicated high risk if urine galectin-3 levels were high. Similar observations were noted in the TOPCAT study (Pinteraction = 0.002). In TOPCAT, urine galectin-3 also positively correlated with urine PIIINP at both baseline (r = 0.43; P < 0.001) and at 12 months (r = 0.42; P < 0.001). CONCLUSIONS Urine galectin-3 levels correlated with an established biomarker of renal fibrosis in 2 cohorts and was able to differentiate high- vs low-risk phenotypes of chronic kidney disease in HF. These proof-of-concept results indicate that additional biomarker research to differentiate cardiorenal phenotypes is warranted.
Collapse
Affiliation(s)
- Veena S Rao
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Juan B Ivey-Miranda
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA; Heart Failure and Heart Transplant Clinic, Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, USA; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julieta Moreno-Villagomez
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jeffrey M Testani
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.
| |
Collapse
|
8
|
Cox ZL, Siddiqi HK, Stevenson LW, Bales B, Han JH, Hart K, Imhoff B, Ivey-Miranda JB, Jenkins CA, Lindenfeld J, Shotwell MS, Miller KF, Ooi H, Rao VS, Schlendorf K, Self WH, Siew ED, Storrow A, Walsh R, Wrenn JO, Testani JM, Collins SP. Randomized controlled trial of urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE): Rationale and design. Am Heart J 2023; 265:121-131. [PMID: 37544492 PMCID: PMC10592235 DOI: 10.1016/j.ahj.2023.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
Diuresis to achieve decongestion is a central aim of therapy in patients hospitalized for acute decompensated heart failure (ADHF). While multiple clinical trials have investigated initial diuretic strategies for a designated period of time, there is a paucity of evidence to guide diuretic titration strategies continued until decongestion is achieved. The use of urine chemistries (urine sodium and creatinine) in a natriuretic response prediction equation accurately estimates natriuresis in response to diuretic dosing, but a randomized clinical trial is needed to compare a urine chemistry-guided diuresis strategy with a strategy of usual care. The urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE) trial is designed to test the hypothesis that protocolized diuretic therapy guided by spot urine chemistry through completion of intravenous diuresis will be superior to usual care and improve outcomes over the 14 days following randomization. ESCALATE will randomize and obtain complete data on 450 patients with acute heart failure to a diuretic strategy guided by urine chemistry or a usual care strategy. Key inclusion criteria include an objective measure of hypervolemia with at least 10 pounds of estimated excess volume, and key exclusion criteria include significant valvular stenosis, hypotension, and a chronic need for dialysis. Our primary outcome is days of benefit over the 14 days after randomization. Days of benefit combines patient symptoms captured by global clinical status with clinical state quantifying the need for hospitalization and intravenous diuresis. CLINICAL TRIAL REGISTRATION: NCT04481919.
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, Nashville, TN; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN.
| | - Hasan K Siddiqi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lynne W Stevenson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Brian Bales
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, TN
| | - Kimberly Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Brant Imhoff
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Henry Ooi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, TN
| | - Veena S Rao
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Kelly Schlendorf
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Edward D Siew
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alan Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan Walsh
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jesse O Wrenn
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey M Testani
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, TN
| |
Collapse
|
9
|
Beargie SM, Tolbert L, Tunney RK, Cox ZL, Gong W, Zalawadiya S. Serial evaluation of loop diuretic efficiency following left ventricular assist device implantation. Int J Artif Organs 2023; 46:555-561. [PMID: 37646461 DOI: 10.1177/03913988231193446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
More than 50% of heart failure (HF) patients require diuretic therapy after left ventricular assist device (LVAD). Although few data related to diuretic response (DR) exist in stage D patients, tubular sodium reabsorption may be clinically prognostic independent of estimated glomerular filtration rate (eGFR) and proteinuria within this cohort. We aimed to characterize DR serially before and after LVAD implantation in a stage D population. We conducted a prospective, observational cohort study of HF patients receiving diuretics with plans to undergo LVAD implantation. We measured urine sodium (UNa) and creatinine (UCr) at three points after diuretic therapy: pre-LVAD, post-LVAD prior to discharge, and as an outpatient. Prior to LVAD, patients (N = 19) had an average eGFR of 54.0 ± 18.0 mL/min/1.73 m2, spot UNa of 74.8 ± 28.0 mmol/L, and fractional excretion of sodium (FENa) of 3.1 ± 2.7%. Pre-LVAD, eGFR did not correlate with spot UNa nor FENa (p > 0.05 for both). LVAD implantation did not improve DR post-LVAD (mean change FENa per 40 mg IV furosemide 0.5 ± 1.0%; p = 0.84), and 90% of patients required loop diuretics at 90 days post-surgery. Improved hemodynamics following LVAD may not improve DR or tubular function; larger studies are needed to confirm our results and assess the utility of DR to predict post-LVAD outcomes.
Collapse
Affiliation(s)
- Sarah M Beargie
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Lindsey Tolbert
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert K Tunney
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zachary L Cox
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
- Lipscomb University College of Pharmacy, Nashville, TN, USA
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandip Zalawadiya
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
10
|
Hahn RT, Brener MI, Cox ZL, Pinney S, Lindenfeld J. Tricuspid Regurgitation Management for Heart Failure. JACC Heart Fail 2023; 11:1084-1102. [PMID: 37611990 DOI: 10.1016/j.jchf.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/25/2023]
Abstract
There is growing evidence that severe tricuspid regurgitation (TR) impacts clinical outcomes in a variety of cardiovascular disease states. The late presentation of patients with advanced TR highlights the underappreciation of the disease, as well as the pitfalls of current guideline-directed medical management. Given the high in-hospital mortality associated with isolated tricuspid valve surgery, transcatheter options continue to be explored with the hope of improved survival and reduced heart failure hospitalizations. In this review, we explore the physiology of TR, discuss the etiologic classes of TR, and explore the transcatheter options for treatment and who might benefit from device therapy.
Collapse
Affiliation(s)
- Rebecca T Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
| | - Michael I Brener
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Zachary L Cox
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Lipscomb University College of Pharmacy, Nashville, Tennessee, USA
| | - Sean Pinney
- Department of Medicine, Icahn School of Medicine, Mount Sinai Morningside, New York, New York, USA
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
11
|
Biegus J, Zymliński R, Testani J, Fudim M, Cox ZL, Guzik M, Iwanek G, Hurkacz M, Raj D, Marciniak D, Ponikowska B, Ponikowski P. The blunted loop diuretic response in acute heart failure is driven by reduced tubular responsiveness rather than insufficient tubular delivery. The role of furosemide urine excretion on diuretic and natriuretic response in acute heart failure. Eur J Heart Fail 2023; 25:1323-1333. [PMID: 37042083 DOI: 10.1002/ejhf.2852] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/01/2023] [Accepted: 04/07/2023] [Indexed: 04/13/2023] Open
Abstract
AIMS Diuretic response in heart failure is blunted when compared to healthy individuals, but the pathophysiology underlying this phenomenon is unclear. We aimed to investigate whether the diuretic resistance mechanism is related to insufficient furosemide tubular delivery or low tubular responsiveness. METHODS AND RESULTS We conducted a prospective, observational study of 50 patients with acute heart failure patients divided into two groups based on previous furosemide use (furosemide naïve: n = 28 [56%] and chronic furosemide users: n = 22 [44%]). Each patient received a protocol-derived, standardized furosemide dose based on body weight. We measured diuretic response and urine furosemide concentrations. The furosemide naïve group had significantly higher urine volumes and natriuresis when compared to chronic users at all timepoints (all p < 0.05). Urine furosemide delivery was similar in furosemide naïve versus chronic users after accounting for differences in estimated glomerular filtration rate (28.02 [21.03-35.89] vs. 29.70 [18.19-34.71] mg, p = 0.87). However, the tubular response to delivered diuretic was dramatically higher in naïve versus chronic users, that is the urine volume per 1 μg/ml of urine furosemide at 2 h was 148.6 ± 136.1 versus 50.6 ± 56.1 ml (p = 0.005). CONCLUSIONS Patients naïve to furosemide have significantly better diuresis and natriuresis when compared to chronic furosemide users. The blunted diuretic response in patients with chronic loop diuretic exposure is driven by decreased tubular responsiveness rather than insufficient furosemide tubular delivery.
Collapse
Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Robert Zymliński
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | | | - Marat Fudim
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Zachary L Cox
- Lipscomb University College of Pharmacy, Nashville, TN, USA
| | - Mateusz Guzik
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Gracjan Iwanek
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Magdalena Hurkacz
- Department of Clinical Pharmacology, Wroclaw Medical University, Wroclaw, Poland
| | - Danuta Raj
- Department of Pharmacognosy and Herbal Medicines, Wroclaw Medical University, Wroclaw, Poland
| | - Dominik Marciniak
- Department of Drugs Form Technology, Faculty of Pharmacy, Medical University, Wroclaw, Poland
| | - Barbara Ponikowska
- Student Scientific Organization, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| |
Collapse
|
12
|
Cox ZL, Testani JM. "Pouring Salt in the Wound": Sodium Restriction in Acute Heart Failure. J Card Fail 2023; 29:997-999. [PMID: 37236502 DOI: 10.1016/j.cardfail.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT.
| |
Collapse
|
13
|
Cox ZL, Zalawadiya SK, Simonato M, Redfors B, Zhou Z, Kotinkaduwa L, Zile MR, Udelson JE, Lim DS, Grayburn PA, Mack MJ, Abraham WT, Stone GW, Lindenfeld J. Guideline-Directed Medical Therapy Tolerability in Patients With Heart Failure and Mitral Regurgitation: The COAPT Trial. JACC Heart Fail 2023:S2213-1779(23)00139-7. [PMID: 37115135 DOI: 10.1016/j.jchf.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial, a central committee of heart failure (HF) specialists optimized guideline-directed medical therapies (GDMT) and documented medication and goal dose intolerances before patient enrollment. OBJECTIVES The authors sought to assess the rates, reasons, and predictors of GDMT intolerance in the COAPT trial. METHODS Baseline use, dose, and intolerances of angiotensin-converting enzyme inhibitors (ACEIs) angiotensin II receptor blockers (ARBs), angiotensin receptor neprilysin inhibitors (ARNIs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) were analyzed in patients with left ventricular ejection fraction (LVEF) ≤40%, in whom maximally tolerated doses of these agents as assessed by an independent HF specialist were required before enrollment. RESULTS A total of 464 patients had LVEF ≤40% and complete medication information. At baseline, 38.8%, 39.4%, and 19.8% of patients tolerated 3, 2, and 1 GDMT classes, respectively (any dose); only 1.9% could not tolerate any GDMT. Beta-blockers were the most frequently tolerated GDMT (93.1%), followed by ACEIs/ARBs/ARNIs (68.5%), and then MRAs (55.0%). Intolerances differed by GDMT class, but hypotension and kidney dysfunction were most common. Goal doses were uncommonly achieved for beta-blockers (32.3%) and ACEIs/ARBs/ARNIs (10.2%) due to intolerances limiting titration. Only 2.2% of patients tolerated goal doses of all 3 GDMT classes. CONCLUSIONS In a contemporary trial population with HF, severe mitral regurgitation, and systematic HF specialist-directed GDMT optimization, most patients had medical intolerances prohibiting 1 or more GDMT classes and achieving goal doses. The specific intolerances noted and methods used for GDMT optimization provide important lessons for the implementation of GDMT optimization in future clinical trials. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] [COAPT]; NCT01626079).
Collapse
Affiliation(s)
- Zachary L Cox
- Lipscomb University College of Pharmacy, Nashville, Tennessee, USA; Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Sandip K Zalawadiya
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matheus Simonato
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Bjorn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Laboratory, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Zhipeng Zhou
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Lak Kotinkaduwa
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Michael R Zile
- Medical University of South Carolina, RJH Department of Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | - James E Udelson
- Division of Cardiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - D Scott Lim
- Division of Cardiology, University of Virginia, Charlottesville, Virginia, USA
| | | | - Michael J Mack
- Department of Cardiovascular Surgery, Baylor Scott and White Health, Plano, Texas, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - JoAnn Lindenfeld
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
14
|
Eder M, Griffin M, Moreno-Villagomez J, Bellumkonda L, Maulion C, Asher J, Wilson FP, Cox ZL, Ivey-Miranda JB, Rao VS, Butler J, Borlaug BA, McCallum W, Ramos-Mastache D, Testani JM. The importance of forward flow and venous congestion in diuretic response in acute heart failure: Insights from the ESCAPE trial. Int J Cardiol 2023; 381:57-61. [PMID: 37023862 DOI: 10.1016/j.ijcard.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023]
Abstract
AIMS Previous studies have suggested venous congestion as a stronger mediator of negative cardio-renal interactions than low cardiac output, with neither factor having a dominant role. While the influence of these parameters on glomerular filtration have been described, the impact on diuretic responsiveness is unclear. The goal of this analysis was to understand the hemodynamic correlates of diuretic response in hospitalized patients with heart failure. METHODS AND RESULTS We analyzed patients from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) dataset. Diuretic efficiency (DE) was defined as the average daily net fluid output per doubling of the peak loop diuretic dose. We evaluated a pulmonary artery catheter hemodynamic-guided cohort (n = 190) and a transthoracic echocardiogram (TTE) cohort (n = 324) where DE was evaluated with hemodynamic and TTE parameters. Metrics of "forward flow" such as cardiac index, mean arterial pressure and left ventricular ejection fraction were not associated with DE (p > 0.2 for all). Worse baseline venous congestion was paradoxically associated with better DE as assessed by right atrial pressure (RAP), right atrial area (RAA), and right ventricular systolic and diastolic area (p < 0.05 for all). Renal perfusion pressure (capturing both congestion and forward flow) was not associated with diuretic response (p = 0.84). CONCLUSIONS Worse venous congestion was weakly associated with better loop diuretic response. Metrics of "forward flow" did not demonstrate any correlation with diuretic response. These observations raise questions about the concept of central hemodynamic perturbations as the primary drivers of diuretic resistance on a population level in HF.
Collapse
Affiliation(s)
- Maxwell Eder
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Matthew Griffin
- Department of Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA, United States of America
| | - Julieta Moreno-Villagomez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America; Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Lavanya Bellumkonda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Jennifer Asher
- Department of Comparative Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Francis P Wilson
- Clinical and translational research accelerator, Yale University School of Medicine, New Haven, CT, United States of America
| | - Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, United States of America
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America; Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, , United States of America
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Wendy McCallum
- Division of Nephrology, Tufts medical Center, Boston, MA, United States of America
| | - Daniela Ramos-Mastache
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States of America.
| |
Collapse
|
15
|
Ivey-Miranda JB, Rao VS, Cox ZL, Moreno-Villagomez J, Mahoney D, Maulion C, Bellumkonda L, Turner JM, Collins S, Wilson FP, Krumholz HM, Testani JM. In-Hospital Observation on Oral Diuretics After Treatment for Acute Decompensated Heart Failure: Evaluating the Utility. Circ Heart Fail 2023; 16:e010206. [PMID: 36896716 PMCID: PMC10186250 DOI: 10.1161/circheartfailure.122.010206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/12/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Following treatment for acute decompensated heart failure, in-hospital observation on oral diuretics (OOD) is recommended, assuming it provides actionable information on discharge diuretic dosing and thus reduces readmissions. METHODS In the Mechanisms of Diuretic Resistance (MDR) cohort, we analyzed in-hospital measures of diuretic response, provider's decisions, and diuretic response ≈30 days postdischarge. In a Yale multicenter cohort, we assessed if in-hospital OOD was associated with 30-day readmission risk. The main objective of this study was to evaluate the utility of in-hospital OOD. RESULTS Of the 468 patients in the MDR cohort, 57% (N=265) underwent in-hospital OOD. During the OOD, weight change and net fluid balance correlated poorly with each other (r=0.36). Discharge diuretic dosing was similar between patients who had increased, stable, or decreased weight (decreased discharge dose from OOD dose in 77% versus 72% versus 70%, respectively), net fluid status (decreased discharge dose from OOD dose in 100% versus 69% versus 74%, respectively), and urine output (decreased discharge dose from OOD dose in 69% versus 79% versus 72%, respectively) during the 24-hour OOD period (P>0.27 for all). In participants returning at 30 days for formal quantification of outpatient diuretic response (n=98), outpatient and inpatient OOD natriuresis was poorly correlated (r=0.26). In the Yale multicenter cohort (n=18 454 hospitalizations), OOD occurred in 55% and was not associated with 30-day hospital readmission (hazard ratio, 0.98 [95% CI, 0.93-1.05]; P=0.51). CONCLUSIONS In-hospital OOD did not provide actionable information on diuretic response, was not associated with outpatient dose selection, did not predict subsequent outpatient diuretic response, and was not associated with lower readmission rate. Additional research is needed to replicate these findings and understand if these resources could be better allocated elsewhere. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02546583.
Collapse
Affiliation(s)
- Juan B. Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
- Hospital de Cardiología, Instituto Mexicano del Seguro Social, Mexico City, México
| | - Veena S. Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Zachary L. Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN
| | - Julieta Moreno-Villagomez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
- Universidad Nacional Autónoma de México, México City, México
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Lavanya Bellumkonda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Jeffrey M. Turner
- Department of Medicine, Division of Nephrology, Yale University School of Medicine, New Haven CT
| | - Sean Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - F. Perry Wilson
- Clinical and translational research accelerator, Yale University School of Medicine, New Haven, CT
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation. Yale-New Haven Hospital, New Haven, CT
| | - Jeffrey M. Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
16
|
Natov PS, Ivey-Miranda JB, Cox ZL, Moreno-Villagomez J, Maulion C, Bellumkonda L, Shlipak MG, Estrella MM, Borlaug BA, Rao VS, Testani JM. Improvement in Renal Function During the Treatment of Acute Decompensated Heart Failure: Relationship With Markers of Renal Tubular Injury and Prognostic Importance. Circ Heart Fail 2023; 16:e009776. [PMID: 36700431 PMCID: PMC10150783 DOI: 10.1161/circheartfailure.122.009776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/28/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Improvement in renal function (IRF) in acute decompensated heart failure is associated with adverse outcomes. The mechanisms driving this paradox remain undefined. METHODS Using the ROSE-AHF study (Renal Optimization Strategies Evaluation-Acute Heart Failure), 277 patients were grouped according to renal function, with IRF defined by a ≥20% increase (N=75), worsening renal function by a ≥20% decline (N=53), and stable renal function (SRF) by a <20% change (N=149) in estimated glomerular filtration rate between baseline and 72 hours. Three well-validated renal tubular injury markers, NGAL (neutrophil gelatinase-associated lipocalin), NAG (N-acetyl-β-d-glucosaminidase), and KIM-1 (kidney injury molecule 1), were evaluated at baseline and 72 hours. Patients were also classified by the pattern of change in these markers. RESULTS Patients with IRF had the lowest admission estimated glomerular filtration rate (IRF, 37 [28 to 51] mL/min per 1.73 m2; worsening renal function, 43 [35 to 55] mL/min per 1.73 m2; and SRF, 43 [32 to 55] mL/min per 1.73 m2; Ptrend=0.032) but greater cumulative urine output (IRF, 8780 [7025 to 11 208] mL; worsening renal function, 7860 [5555 to 9765] mL; and SRF, 8150 [6325 to 10 456] mL; Ptrend=0.024) and weight loss (IRF, -9.0 [-12.4 to -5.3] lb; worsening renal function, -5.1 [-8.1 to -1.3] lb; and SRF, -7.1 [-11.9 to -3.2] lb; Ptrend<0.001) despite similar diuretic doses (Ptrend=0.16). There were no differences in the relative change in NGAL, NAG, or KIM-1 between renal function groups (Ptrend>0.19 for all). Patients with IRF had worse survival than patients with SRF (27% versus 54%; hazard ratio, 1.98 [1.10-3.58]; P=0.024). CONCLUSIONS IRF during decongestive therapy for acute decompensated heart failure was not associated with improved markers of renal tubular injury and was associated with worsened survival, likely driven by the presence of greater underlying cardiorenal dysfunction and more severe congestion.
Collapse
Affiliation(s)
- Peter S Natov
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
- Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, Nashville, TN
| | - Julieta Moreno-Villagomez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Lavanya Bellumkonda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco VA Medical Center, and Division of Nephrology, Department of Medicine and University of California, San Francisco, San Francisco, CA
| | - Michelle M Estrella
- Kidney Health Research Collaborative, San Francisco VA Medical Center, and Division of Nephrology, Department of Medicine and University of California, San Francisco, San Francisco, CA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| |
Collapse
|
17
|
Cox ZL, Lindenfeld J. STRONG start for implementation of guideline-directed medical therapies. Lancet 2022; 400:1901-1903. [PMID: 36463894 DOI: 10.1016/s0140-6736(22)02372-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, Nashville, TN, USA; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| |
Collapse
|
18
|
Newman JD, Schlendorf KH, Cox ZL, Zalawadiya SK, Powers AC, Niswender KD, Shah RV, Lindenfeld J. Post-transplant diabetes mellitus following heart transplantation. J Heart Lung Transplant 2022; 41:1537-1546. [DOI: 10.1016/j.healun.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/22/2022] [Accepted: 07/13/2022] [Indexed: 10/31/2022] Open
|
19
|
Maulion C, Chen S, Rao VS, Ivey-Miranda JB, Cox ZL, Mahoney D, Coca SG, Negoianu D, Asher JL, Turner JM, Inker LA, Wilson FP, Testani JM. Hemoconcentration of Creatinine Minimally Contributes to Changes in Creatinine during the Treatment of Decompensated Heart Failure. Kidney360 2022; 3:1003-1010. [PMID: 35845336 PMCID: PMC9255871 DOI: 10.34067/kid.0007582021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/21/2022] [Indexed: 01/10/2023]
Abstract
Background Worsening serum creatinine is common during treatment of acute decompensated heart failure (ADHF). A possible contributor to creatinine increase is diuresis-induced changes in volume of distribution (VD) of creatinine as total body water (TBW) contracts around a fixed mass of creatinine. Our objective was to better understand the filtration and nonfiltration factors driving change in creatinine during ADHF. Methods Participants in the ROSE-AHF trial with baseline to 72-hour serum creatinine; net fluid output; and urinary KIM-1, NGAL, and NAG were included (n=270). Changes in VD were calculated by accounting for measured input and outputs from weight-based calculated TBW. Changes in observed creatinine (Crobserved) were compared with predicted changes in creatinine after accounting for alterations in VD and non-steady state conditions using a kinetic GFR equation (Cr72HR Kinetic). Results When considering only change in VD, the median diuresis to elicit a ≥0.3 mg/dl rise in creatinine was -7526 ml (IQR, -5932 to -9149). After accounting for stable creatinine filtration during diuresis, a change in VD alone was insufficient to elicit a ≥0.3 mg/dl rise in creatinine. Larger estimated decreases in VD were paradoxically associated with improvement in Crobserved (r=-0.18, P=0.003). Overall, -3% of the change in eCr72HR Kinetic was attributable to the change in VD. A ≥0.3 mg/dl rise in eCr72HR Kinetic was not associated with worsening of KIM-1, NGAL, NAG, or postdischarge survival (P>0.05 for all). Conclusions During ADHF therapy, increases in serum creatinine are driven predominantly by changes in filtration, with minimal contribution from change in VD.
Collapse
Affiliation(s)
- Christopher Maulion
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Sheldon Chen
- Division of Nephrology, Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Veena S. Rao
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Juan B. Ivey-Miranda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Heart Failure, Cardiology Hospital, XXI Century National Medical Center, Mexican Social Security Institute, Mexico City, Mexico
| | - Zachary L. Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
| | - Devin Mahoney
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Steven G. Coca
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dan Negoianu
- Division of Renal Electrolyte and Hypertension, Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer L. Asher
- Department of Comparative Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey M. Turner
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lesley A. Inker
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - F. Perry Wilson
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey M. Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
20
|
Cox ZL, Rao VS, Testani JM. Classic and Novel Mechanisms of Diuretic Resistance in Cardiorenal Syndrome. Kidney360 2022; 3:954-967. [PMID: 36128483 PMCID: PMC9438407 DOI: 10.34067/kid.0006372021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/23/2022] [Indexed: 01/10/2023]
Abstract
Despite the incompletely understood multiple etiologies and underlying mechanisms, cardiorenal syndrome is characterized by decreased glomerular filtration and sodium avidity. The underlying level of renal sodium avidity is of primary importance in driving a congested heart failure phenotype and ultimately determining the response to diuretic therapy. Historically, mechanisms of kidney sodium avidity and resultant diuretic resistance were primarily extrapolated to cardiorenal syndrome from non-heart failure populations. Yet, the mechanisms appear to differ between these populations. Recent literature in acute decompensated heart failure has refuted several classically accepted diuretic resistance mechanisms and reshaped how we conceptualize diuretic resistance mechanisms in cardiorenal syndrome. Herein, we propose an anatomically based categorization of diuretic resistance mechanisms to establish the relative importance of specific transporters and translate findings toward therapeutic strategies. Within this categorical structure, we discuss classic and novel mechanisms of diuretic resistance.
Collapse
Affiliation(s)
- Zachary L. Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee,Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Veena S. Rao
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey M. Testani
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
21
|
Hardison E, Cox ZL, Heckman K, Kelly PA, Lindenfeld J. A case report of ivabradine used for heart rate control of atrial fibrillation in acute decompensated heart failure. Eur Heart J Case Rep 2022; 6:ytac077. [PMID: 35233502 PMCID: PMC8877172 DOI: 10.1093/ehjcr/ytac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/06/2021] [Accepted: 02/09/2022] [Indexed: 11/20/2022]
Abstract
Background Achieving pharmacologic rate control in patients with atrial fibrillation (AF) with rapid ventricular response (RVR) can be tricky when the patient’s underlying cardiac function is decreased. We present a case illustrating how ivabradine can be useful in this clinical scenario. Case summary A 95-year-old woman with a history of systolic heart failure (HF) presented with acute decompensated HF in AF with RVR. Beta blockade and calcium channel blockade were avoided given her cardiac history, and diuresis with high doses of furosemide was ineffective. Her ventricular response slowed with ivabradine, allowing for rapid decongestion and a safe discharge home. Discussion Ivabradine acts on the If current of cardiac pacemaker cells to slow heart rate (HR), and it currently carries a class IIa recommendation to reduce the risk of HF hospitalization and cardiac death in patients with left ventricular ejection fraction ≤35% and a symptomatic HR ≥70 b.p.m. Although current recommendations are for patients in sinus rhythm, ivabradine has a theoretical benefit in patients with AF given its mechanism of action. Because it does not negatively affect inotropy or blood pressure, ivabradine was used in our patient with a good clinical outcome. Our case provides an example of ivabradine’s usefulness in patients with AF in RVR with a history of depressed systolic function.
Collapse
Affiliation(s)
- Edward Hardison
- Department of Internal Medicine and Pediatrics, Vanderbilt University Medical Center and Monroe Carrell Jr. Children’s Hospital at Vanderbilt, One Hundred Oaks, 719 Thompson Ln, Suite 20400, Nashville, TN 37204, USA
| | - Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, 1 University Park Dr, Nashville, TN 37204, USA
| | - Katherine Heckman
- Department of Internal Medicine, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN 37232, USA
| | - Patricia A Kelly
- Missoula Cardiology, 2419 Mullan Road, Suite A, Missoula, MT 59808, USA
| | - JoAnn Lindenfeld
- Department of Cardiovascular Medicine, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN 37232, USA
| |
Collapse
|
22
|
Cox ZL, Nandkeolyar S, Johnson AJ, Lindenfeld J, Rali AS. In-hospital Initiation and Up-titration of Guideline-directed Medical Therapies for Heart Failure with Reduced Ejection Fraction. Card Fail Rev 2022; 8:e21. [PMID: 35815257 PMCID: PMC9253962 DOI: 10.15420/cfr.2022.08] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/16/2022] [Indexed: 11/04/2022] Open
Abstract
Implementation of guideline-directed medical therapy for patients with heart failure is suboptimal. The use of guideline-directed medical therapy improves minimally after heart failure hospitalisation, despite this event clearly indicating increased risk of further hospitalisation and death. In-hospital initiation and titration of guideline-directed medical therapies is one potential strategy to fill these gaps in care, both in the acute vulnerable period after hospital discharge and in the long term. The purpose of this article is to review the knowledge gaps in best practices of in-hospital initiation and up-titration of guideline-directed medical therapies, the benefits and risks of in-hospital initiation and post-discharge focused titration of guideline-directed medical therapies, the recent literature evaluating these practices, and propose strategies to apply these principles to the care of patients with heart failure with reduced ejection fraction.
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of PharmacyNashville, TN, US
- Department of Pharmacy, Vanderbilt University Medical CenterNashville, TN, US
| | - Shuktika Nandkeolyar
- Division of Cardiovascular Medicine, Vanderbilt University Medical CenterNashville, TN, US
| | - Andrew J Johnson
- Department of Pharmacy, Vanderbilt University Medical CenterNashville, TN, US
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University Medical CenterNashville, TN, US
| | - Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical CenterNashville, TN, US
| |
Collapse
|
23
|
Ivey-Miranda JB, Wetterling F, Gaul R, Sheridan S, Asher JL, Rao VS, Maulion C, Mahoney D, Mebazaa A, Gray AP, Burkhoff D, Cowie MR, Cox ZL, Butler J, Fudim M, McDonald K, Damman K, Borlaug BA, Testani JM. Changes in inferior vena cava area represent a more sensitive metric than change in filling pressures during experimental manipulation of intravascular volume and tone. Eur J Heart Fail 2021; 24:455-462. [PMID: 34837447 PMCID: PMC9306514 DOI: 10.1002/ejhf.2395] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/30/2021] [Accepted: 11/16/2021] [Indexed: 12/05/2022] Open
Abstract
Aims Remote monitoring of pulmonary artery pressure has reduced heart failure (HF) hospitalizations in chronic HF as elevation of pulmonary artery pressure provides information that can guide treatment. The venous system is characterized by high capacitance, thus substantial increases in intravascular volume can occur before filling pressures increase. The inferior vena cava (IVC) is a highly compliant venous conduit and thus a candidate for early detection of change in intravascular volume. We aimed to compare IVC cross‐sectional area using a novel sensor with cardiac filling pressures during experimental manipulation of volume status, vascular tone, and cardiac function. Methods and results Experiments were conducted in sheep to manipulate volume status (colloid infusion), vascular tone (nitroglycerin infusion) and cardiac function (rapid cardiac pacing). A wireless implantable IVC sensor was validated ex‐vivo and in‐vivo, and then used to measure the cross‐sectional area of the IVC. Right‐ and left‐sided cardiac filling pressures were obtained via right heart catheterization. The IVC sensor provided highly accurate and precise measurements of cross‐sectional area in ex‐vivo and in‐vivo validation. IVC area changes were more sensitive than the corresponding changes in cardiac filling pressures during colloid infusion (p < 0.001), vasodilatation (p < 0.001) and cardiac dysfunction induced by rapid pacing (p ≤ 0.02). Conclusions Inferior vena cava area can be remotely and accurately measured in real time with a wireless implantable sensor. Changes in IVC area are more sensitive than corresponding changes in filling pressures following experimental volume loading and fluid redistribution. Additional research is warranted to understand if remote monitoring of the IVC may have advantages over pressure‐based monitors in HF.
Collapse
Affiliation(s)
- Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT, USA.,Hospital de Cardiología, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | | | | | - Jennifer L Asher
- Department of Comparative Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Alexandre Mebazaa
- Université de Paris, Inserm 942 MASCOT, Department of Anesthesia and Critical Care, Hôpital Lariboisière, DMU Parabol, APHP Nord, Paris, France
| | - Alastair P Gray
- . Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Martin R Cowie
- School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Zachary L Cox
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | | | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
24
|
Rao VN, Murray E, Butler J, Cooper LB, Cox ZL, Fiuzat M, Green JB, Lindenfeld J, McGuire DK, Nassif ME, O'Brien C, Pagidipati N, Sharma K, Vaduganathan M, Vardeny O, Fonarow GC, Mentz RJ, Greene SJ. In-Hospital Initiation of Sodium-Glucose Cotransporter-2 Inhibitors for Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2021; 78:2004-2012. [PMID: 34763778 PMCID: PMC9766421 DOI: 10.1016/j.jacc.2021.08.064] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 12/11/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitor therapy is well suited for initiation during the heart failure hospitalization, owing to clinical benefits that accrue rapidly within days to weeks, a strong safety and tolerability profile, minimal to no effects on blood pressure, and no excess risk of adverse kidney events. There is no evidence to suggest that deferring initiation to the outpatient setting accomplishes anything beneficial. Instead, there is compelling evidence that deferring in-hospital initiation exposes patients to excess risk of early postdischarge clinical worsening and death. Lessons from other heart failure with reduced ejection fraction therapies highlight that deferring initiation of guideline-recommended medications to the U.S. outpatient setting carries a >75% chance they will not be initiated within the next year. Recognizing that 1 in 4 patients hospitalized for worsening heart failure die or are readmitted within 30 days, clinicians should embrace the in-hospital period as an optimal time to initiate sodium-glucose cotransporter-2 inhibitor therapy and treat this population with the urgency it deserves.
Collapse
Affiliation(s)
- Vishal N Rao
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Evan Murray
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Lauren B Cooper
- Department of Cardiology, North Shore University Hospital, Manhasset, New York, USA
| | - Zachary L Cox
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville Tennessee, USA
| | - Mona Fiuzat
- Duke Clinical Research Institute, Durham, North Carolina, USA; Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer B Green
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Endocrinology, Duke University School of Medicine, Durham, North Carolina, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Cara O'Brien
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Neha Pagidipati
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Muthiah Vaduganathan
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Orly Vardeny
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, and University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| |
Collapse
|
25
|
Ivey-Miranda JB, Stewart B, Cox ZL, McCallum W, Maulion C, Gleason O, Meegan G, Amatruda JG, Moreno-Villagomez J, Mahoney D, Turner JM, Wilson FP, Estrella MM, Shlipak MG, Rao VS, Testani JM. FGF-23 (Fibroblast Growth Factor-23) and Cardiorenal Interactions. Circ Heart Fail 2021; 14:e008385. [PMID: 34689571 DOI: 10.1161/circheartfailure.121.008385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Animal models implicate FGF-23 (fibroblast growth factor-23) as a direct contributor to adverse cardiorenal interactions such as sodium avidity, diuretic resistance, and neurohormonal activation, but this has not been conclusively demonstrated in humans. Therefore, we aimed to evaluate whether FGF-23 is associated with parameters of cardiorenal dysfunction in humans with heart failure, independent of confounding factors. METHODS One hundred ninety-nine outpatients with heart failure undergoing diuretic treatment at the Yale Transitional Care Center were enrolled and underwent blood collection, and urine sampling before and after diuretics. RESULTS FGF-23 was associated with several metrics of disease severity such as higher home loop diuretic dose and NT-proBNP (N-terminal pro-B-type natriuretic peptide), and lower estimated glomerular filtration rate, serum chloride, and serum albumin. Multivariable analysis demonstrated no statistically significant association between FGF-23 and sodium avidity measured by fractional excretion of sodium, or proximal or distal tubular sodium reabsorption, either before diuretic administration or at peak diuresis (P≥0.11 for all). Likewise, FGF-23 was not independently associated with parameters of diuretic resistance (diuretic excretion, cumulative urine and sodium output, and loop diuretic efficiency [P≥0.33 for all]) or neurohormonal activation (plasma or urine renin [P≥0.36 for all]). Moreover, the upper boundary of the 95% CI of all the partial correlations were ≤0.30, supporting the lack of meaningful correlations. FGF-23 was not associated with mortality in multivariable analysis (P=0.44). CONCLUSIONS FGF-23 was not meaningfully associated with any cardiorenal parameter in patients with heart failure. While our methods cannot rule out a small effect, FGF-23 is unlikely to be a primary driver of cardiorenal interactions.
Collapse
Affiliation(s)
- Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine (J.B.I.-M., B.S., C.M., O.G., G.M., J.M.-V., D.M., V.S.R., J.M.T.), Yale University School of Medicine, New Haven, CT.,Department of Heart Failure, Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City (J.B.I.-M.)
| | - Brendan Stewart
- Department of Internal Medicine, Section of Cardiovascular Medicine (J.B.I.-M., B.S., C.M., O.G., G.M., J.M.-V., D.M., V.S.R., J.M.T.), Yale University School of Medicine, New Haven, CT
| | - Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, Nashville, TN (Z.L.C.)
| | - Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, MA (W.M.)
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiovascular Medicine (J.B.I.-M., B.S., C.M., O.G., G.M., J.M.-V., D.M., V.S.R., J.M.T.), Yale University School of Medicine, New Haven, CT
| | - Olyvia Gleason
- Department of Internal Medicine, Section of Cardiovascular Medicine (J.B.I.-M., B.S., C.M., O.G., G.M., J.M.-V., D.M., V.S.R., J.M.T.), Yale University School of Medicine, New Haven, CT
| | - Grace Meegan
- Department of Internal Medicine, Section of Cardiovascular Medicine (J.B.I.-M., B.S., C.M., O.G., G.M., J.M.-V., D.M., V.S.R., J.M.T.), Yale University School of Medicine, New Haven, CT
| | - Jonathan G Amatruda
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco (J.G.A., M.M.E., M.G.S.)
| | - Julieta Moreno-Villagomez
- Department of Internal Medicine, Section of Cardiovascular Medicine (J.B.I.-M., B.S., C.M., O.G., G.M., J.M.-V., D.M., V.S.R., J.M.T.), Yale University School of Medicine, New Haven, CT.,Neuroscience Project, Faculty of Higher Studies Iztacala, National Autonomous University of Mexico, Mexico City (J.M.-V.)
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiovascular Medicine (J.B.I.-M., B.S., C.M., O.G., G.M., J.M.-V., D.M., V.S.R., J.M.T.), Yale University School of Medicine, New Haven, CT
| | - Jeffrey M Turner
- Department of Internal Medicine, Division of Nephrology (J.M.T.), Yale University School of Medicine, New Haven, CT
| | - F Perry Wilson
- Clinical and Translational Research Accelerator (F.P.W.), Yale University School of Medicine, New Haven, CT
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco (J.G.A., M.M.E., M.G.S.)
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco (J.G.A., M.M.E., M.G.S.)
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine (J.B.I.-M., B.S., C.M., O.G., G.M., J.M.-V., D.M., V.S.R., J.M.T.), Yale University School of Medicine, New Haven, CT
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine (J.B.I.-M., B.S., C.M., O.G., G.M., J.M.-V., D.M., V.S.R., J.M.T.), Yale University School of Medicine, New Haven, CT
| |
Collapse
|
26
|
Rao VS, Maulion C, Asher JL, Ivey-Miranda JB, Cox ZL, Moreno-Villagomez J, Mahoney D, Turner JM, Wilson FP, Wilcox CS, Testani JM. Renal negative pressure treatment as a novel therapy for heart failure-induced renal dysfunction. Am J Physiol Regul Integr Comp Physiol 2021; 321:R588-R594. [PMID: 34405731 DOI: 10.1152/ajpregu.00115.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Congestion is the primary pathophysiological lesion in most heart failure (HF) hospitalizations. Renal congestion increases renal tubular pressure, reducing glomerular filtration rate (GFR) and diuresis. Because each nephron is a fluid-filled column, renal negative pressure therapy (rNPT) applied to the urinary collecting system should reduce tubular pressure, potentially improving kidney function. We evaluated the renal response to rNPT in congestive HF. Ten anesthetized ∼80-kg pigs underwent instrumentation with bilateral renal pelvic JuxtaFlow catheters. GFR was determined by iothalamate clearance (mGFR) and renal plasma flow (RPF) by para-aminohippurate clearance. Each animal served as its own control with randomization of left versus right kidney to -30 mmHg rNPT or no rNPT. mGFR and RPF were measured simultaneously from the rNPT and no rNPT kidney. Congestive HF was induced via cardiac tamponade maintaining central venous pressure at 20-22.5 mmHg throughout the experiment. Before HF induction, rNPT increased natriuresis, diuresis, and mGFR compared with the control kidney (P < 0.001 for all). Natriuresis, diuresis, and mGFR decreased following HF (P < 0.001 for all) but were higher in rNPT kidney versus control (P < 0.001 for all). RPF decreased during HF (P < 0.001) without significant differences between rNPT treatments. During HF, the rNPT kidney had similar diuresis and natriuresis (P > 0.5 for both) and higher fractional excretion of sodium (P = 0.001) compared with the non-rNPT kidney in the no HF period. In conclusion, rNPT resulted in significantly increased diuresis, natriuresis, and mGFR, with or without experimental HF. rNPT improved key renal parameters of the congested cardiorenal phenotype.
Collapse
Affiliation(s)
- Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer L Asher
- Department of Comparative Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.,Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee.,Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Julieta Moreno-Villagomez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.,Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey M Turner
- Department of Medicine, Division of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - F Perry Wilson
- Clinical and translational research accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher S Wilcox
- Division of Nephrology and Hypertension Center, Georgetown University, Washington, District of Columbia
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
27
|
Cox ZL, Rao VS, Ivey-Miranda JB, Moreno-Villagomez J, Mahoney D, Ponikowski P, Biegus J, Turner JM, Maulion C, Bellumkonda L, Asher JL, Parise H, Wilson PF, Ellison DH, Wilcox CS, Testani JM. Compensatory post-diuretic renal sodium reabsorption is not a dominant mechanism of diuretic resistance in acute heart failure. Eur Heart J 2021; 42:4468-4477. [PMID: 34529781 DOI: 10.1093/eurheartj/ehab620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/02/2021] [Accepted: 08/27/2021] [Indexed: 01/12/2023] Open
Abstract
AIMS In healthy volunteers, the kidney deploys compensatory post-diuretic sodium reabsorption (CPDSR) following loop diuretic-induced natriuresis, minimizing sodium excretion and producing a neutral sodium balance. CPDSR is extrapolated to non-euvolemic populations as a diuretic resistance mechanism; however, its importance in acute decompensated heart failure (ADHF) is unknown. METHODS AND RESULTS Patients with ADHF in the Mechanisms of Diuretic Resistance cohort receiving intravenous loop diuretics (462 administrations in 285 patients) underwent supervised urine collections entailing an immediate pre-diuretic spot urine sample, then 6-h (diuretic-induced natriuresis period) and 18-h (post-diuretic period) urine collections. The average spot urine sodium concentration immediately prior to diuretic administration [median 15 h (13-17) after last diuretic] was 64 ± 33 mmol/L with only 4% of patients having low (<20 mmol/L) urine sodium consistent with CPDSR. Paradoxically, greater 6-h diuretic-induced natriuresis was associated with larger 18-h post-diuretic spontaneous natriuresis (r = 0.7, P < 0.001). Higher pre-diuretic urine sodium to creatinine ratio (r = 0.37, P < 0.001) was the strongest predictor of post-diuretic spontaneous natriuresis. In a subgroup of patients (n = 43) randomized to protocol-driven intensified diuretic therapies, the mean diuretic-induced natriuresis increased three-fold. In contrast to the substantial decrease in spontaneous natriuresis predicted by CPDSR, no change in post-diuretic spontaneous natriuresis was observed (P = 0.47). CONCLUSION On a population level, CPDSR was not an important driver of diuretic resistance in hypervolemic ADHF. Contrary to CPDSR, a greater diuretic-induced natriuresis predicted a larger post-diuretic spontaneous natriuresis. Basal sodium avidity, rather than diuretic-induced CPDSR, appears to be the predominant determinate of both diuretic-induced and post-diuretic natriuresis in hypervolemic ADHF.
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, 1 University Park Drive, Nashville, TN 37204, USA.,Department of Pharmacy, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA.,Hospital de Cardiologia, Instituto Mexicano del Seguro Social, 330 Cuauhtemoc Avenue. Cuauhtemoc, Mexico City 06720, Mexico
| | - Julieta Moreno-Villagomez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA.,Universidad Nacional Autónoma de México, Avenida Insurgentes Sur, Mexico City 3000, Mexico
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Rektorat, wybrzeże Ludwika Pasteura 1, Wroclaw 50-367, Poland
| | - Jan Biegus
- Clinical Military Hospital, Weigla 5, Wroclaw 50-981, Poland
| | - Jeffrey M Turner
- Department of Medicine, Division of Nephrology, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Lavanya Bellumkonda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Jennifer L Asher
- Department of Comparative Medicine, Yale University School of Medicine, 310 Cedar Street, New Haven, CT 06520, USA
| | - Helen Parise
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Perry F Wilson
- Clinical and Translational Research Accelerator, Yale University School of Medicine, 60 Temple Street, New Haven, CT 06520, USA
| | - David H Ellison
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University and the Veterans Affairs Portland Health Care System, 3181 S.W. Sam Jackson Park Road Portland, OR 97239, USA
| | - Christopher S Wilcox
- Division of Nephrology and Hypertension and Hypertension Center, Georgetown University, 3800 Reservoir Road, N.W., Washington, DC 20007, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| |
Collapse
|
28
|
Cox ZL, Sarrell BA, Cella MK, Tucker B, Arroyo JP, Umanath K, Tidwell W, Guide A, Testani JM, Lewis JB, Dwyer JP. Multinephron Segment Diuretic Therapy to Overcome Diuretic Resistance in Acute Heart Failure: A Single-Center Experience. J Card Fail 2021; 28:21-31. [PMID: 34403831 DOI: 10.1016/j.cardfail.2021.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The concept of multinephron segment diuretic therapy (MSDT) has been recommended in severe diuretic resistance with only expert opinion and case-level evidence. The purpose of this study was to investigate the safety and efficacy of MSDT, combining 4 diuretic classes, in acute heart failure (AHF) complicated by diuretic resistance. METHODS AND RESULTS A retrospective analysis was conducted in patients hospitalized with AHF at a single medical center who received MSDT, including concomitant carbonic anhydrase inhibitor, loop, thiazide, and mineralocorticoid receptor antagonist diuretics. Subjects served as their own controls with efficacy evaluated as urine output and weight change before and after MSDT. Serum chemistries, renal replacement therapies, and in-hospital mortality were evaluated for safety. Patients with severe diuretic resistance before MSDT were analyzed as a subcohort. A total of 167 patients with AHF and diuretic resistance received MSDT. MSDT was associated with increased median 24-hour urine output in the first day of therapy compared with the previous day (2.16 L [0.95-4.14 L] to 3.08 L [1.74-4.86 L], P = .003) in the total cohort and in the Severe diuretic resistance cohort (0.91 L [0.43-1.43 L] to 2.08 L [1.13-3.96 L], P < .001). The median cumulative weight loss at day 7 or discharge was -7.4 kg (-15.3 to -3.4 kg) (P = .02). Neither serum sodium, chloride, potassium, bicarbonate, or creatinine changed significantly relative to baseline (P > .05 for all). CONCLUSIONS In an AHF cohort with diuretic resistance, MSDT was associated with increased diuresis without changes in serum chemistries or kidney function. Prospective studies of MSDT in AHF and diuretic resistance are warranted.
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Bonnie Ann Sarrell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary Katherine Cella
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
| | - Brent Tucker
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
| | - Juan P Arroyo
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kausik Umanath
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan; Division of Nephrology and Hypertension, Wayne State University, Detroit, Michigan
| | - William Tidwell
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Guide
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey M Testani
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Julia B Lewis
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamie P Dwyer
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
29
|
Li DL, Cox ZL, Richardson TD, Kanagasundram AN, Saavedra PJ, Shen ST, Montgomery JA, Murray KT, Roden DM, Stevenson WG. Quinidine in the Management of Recurrent Ventricular Arrhythmias: A Reappraisal. JACC Clin Electrophysiol 2021; 7:1254-1263. [PMID: 34217656 DOI: 10.1016/j.jacep.2021.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study aimed to review the utility of quinidine in patients presenting with recurrent sustained ventricular arrhythmia (VA) and limited antiarrhythmic drug (AAD) options. BACKGROUND Therapeutic options are often limited in patients with structural heart disease and recurrent VAs. Quinidine has an established role in rare arrhythmic syndromes, but its potential use in other difficult VAs has not been assessed in the present era. METHODS We performed a retrospective analysis of 37 patients who had in-hospital quinidine initiation after multiple other therapies failed for VA suppression at our tertiary referral center. Clinical data and outcomes were obtained from the medical record. RESULTS Of 30 patients with in-hospital quantifiable VA episodes, quinidine reduced acute VA from a median of 3 episodes (interquartile range [IQR]: 2 to 7.5) to 0 (IQR: 0 to 0.5) during medians of 3 days before and 4 days after quinidine initiation (p < 0.001). VA events decreased from a median of 10.5 episodes per day (IQR: 5 to 15) to 0.5 episodes (IQR: 0 to 4) after quinidine initiation in the 12 patients presenting with electrical storm (p = 0.004). Among the 24 patients discharged on quinidine, 13 (54.2%) had VA recurrence during a median of 138 days. Adverse effects in 9 of the 37 patients (24.3%) led to drug discontinuation, most commonly gastrointestinal intolerance. CONCLUSIONS In patients with recurrent VAs and structural heart disease who have limited treatment options, quinidine can be useful, particularly as a short-term therapy.
Collapse
Affiliation(s)
- Dan L Li
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zachary L Cox
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Lipscomb University College of Pharmacy, Nashville, Tennessee, USA
| | - Travis D Richardson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Arvindh N Kanagasundram
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pablo J Saavedra
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sharon T Shen
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jay A Montgomery
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katherine T Murray
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dan M Roden
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William G Stevenson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| |
Collapse
|
30
|
Turner JM, Cox ZL, Testani JM. Improving renal function during diuresis: useful information or just noise? Eur J Heart Fail 2021; 23:1131-1133. [PMID: 34117684 DOI: 10.1002/ejhf.2267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 06/10/2021] [Indexed: 11/08/2022] Open
Affiliation(s)
- Jeffrey M Turner
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiology, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
31
|
Rao VS, Ivey-Miranda JB, Cox ZL, Testani JM. Reply: Protocolized Diuretic Approach Using the Natriuretic Equation: Careful Patient Selection Is Needed. J Am Coll Cardiol 2021; 77:2758-2759. [PMID: 34045035 DOI: 10.1016/j.jacc.2021.03.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
|
32
|
Parker R, Henslee A, Cox ZL. A Clinical Conundrum: The Pharmacist's Role in Evaluating Comorbid Urinary incontinence and Heart Failure. Sr Care Pharm 2021; 36:142-146. [PMID: 33662237 DOI: 10.4140/tcp.n.2021.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Heart failure (HF) is a complex disease to manage, and treatment strategies for older adults are complicated by the presence of comorbidities such as urinary incontinence (UI). There is a therapeutic competition that exists in the treatment of patients with both HF and UI, as many of the agents indicated for control of HF may directly exacerbate UI. A reported 80% of adults with HF are older than 65 years of age, and 50% of HF patients have UI. The prevalence of conflicting therapeutic objectives in older patients presents an opportunity for intervention by senior care pharmacists. Pharmacists are equipped to optimize medication outcomes through the provision of appropriate prescribing and deprescribing recommendations, when necessary. This provides an opportunity for shared decision making to improve patient-centered outcomes and goals of care within this population.
Collapse
Affiliation(s)
- Robin Parker
- 1Lipscomb University, College of Pharmacy, Nashville, Tennessee
| | - Aaron Henslee
- 1Lipscomb University, College of Pharmacy, Nashville, Tennessee
| | - Zachary L Cox
- 1Lipscomb University, College of Pharmacy, Nashville, Tennessee
| |
Collapse
|
33
|
Cox ZL, Collins SP, Aaron M, Hernandez GA, III ATM, Davidson BT, Fowler M, Lindsell CJ, Jr FEH, Jenkins CA, Kampe C, Miller KF, Stubblefield WB, Lindenfeld J. Efficacy and safety of dapagliflozin in acute heart failure: Rationale and design of the DICTATE-AHF trial. Am Heart J 2021; 232:116-124. [PMID: 33144086 DOI: 10.1016/j.ahj.2020.10.071] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/27/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, reduces cardiovascular death and worsening heart failure in patients with chronic heart failure and reduced ejection fraction. Early initiation during an acute heart failure (AHF) hospitalization may facilitate decongestion, improve natriuresis, and facilitate safe transition to a beneficial outpatient therapy for both diabetes and heart failure. OBJECTIVE The objective is to assess the efficacy and safety of initiating dapagliflozin within the first 24 hours of hospitalization in patients with AHF compared to usual care. METHODS DICTATE-AHF is a prospective, multicenter, open-label, randomized trial enrolling a planned 240 patients in the United States. Patients with type 2 diabetes hospitalized with hypervolemic AHF and an estimated glomerular filtration rate of at least 30 mL/min/1.73m2 are eligible for participation. Patients are randomly assigned 1:1 to dapagliflozin 10 mg once daily or structured usual care until day 5 or hospital discharge. Both treatment arms receive protocolized diuretic and insulin therapies. The primary endpoint is diuretic response expressed as the cumulative change in weight per cumulative loop diuretic dose in 40 mg intravenous furosemide equivalents. Secondary and exploratory endpoints include inpatient worsening AHF, 30-day hospital readmission for AHF or diabetic reasons, change in NT-proBNP, and measures of natriuresis. Safety endpoints include the incidence of hyper/hypoglycemia, ketoacidosis, worsening kidney function, hypovolemic hypotension, and inpatient mortality. CONCLUSIONS The DICTATE-AHF trial will establish the efficacy and safety of early initiation of dapagliflozin during AHF across both AHF and diabetic outcomes in patients with diabetes.
Collapse
|
34
|
Rao VS, Ivey-Miranda JB, Cox ZL, Riello R, Griffin M, Fleming J, Soucier R, Sangkachand P, O'Brien M, LoRusso F, D'Ambrosi J, Churchwell K, Mahoney D, Bellumkonda L, Asher JL, Maulion C, Turner JM, Wilson FP, Collins SP, Testani JM. Natriuretic Equation to Predict Loop Diuretic Response in Patients With Heart Failure. J Am Coll Cardiol 2021; 77:695-708. [PMID: 33573739 DOI: 10.1016/j.jacc.2020.12.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Most acute decompensated heart failure admissions are driven by congestion. However, residual congestion is common and often driven by the lack of reliable tools to titrate diuretic therapy. The authors previously developed a natriuretic response prediction equation (NRPE), which predicts sodium output using a spot urine sample collected 2 h after loop diuretic administration. OBJECTIVES The purpose of this study was to validate the NRPE and describe proof-of-concept that the NRPE can be used to guide diuretic therapy. METHODS Two cohorts were assembled: 1) the Diagnosing and Targeting Mechanisms of Diuretic Resistance (MDR) cohort was used to validate the NRPE to predict 6-h sodium output after a loop diuretic, which was defined as poor (<50 mmol), suboptimal (<100 mmol), or excellent (>150 mmol); and 2) the Yale Diuretic Pathway (YDP) cohort, which used the NRPE to guide loop diuretic titration via a nurse-driven automated protocol. RESULTS Evaluating 638 loop diuretic administrations, the NRPE showed excellent discrimination with areas under the curve ≥0.90 to predict poor, suboptimal, and excellent natriuretic response, and outperformed clinically obtained net fluid loss (p < 0.05 for all cutpoints). In the YDP cohort (n = 161) using the NRPE to direct therapy mean daily urine output (1.8 ± 0.9 l vs. 3.0 ± 0.8 l), net fluid output (-1.1 ± 0.9 l vs. -2.1 ± 0.9 l), and weight loss (-0.3 ± 0.3 kg vs. -2.5 ± 0.3 kg) improved substantially following initiation of the YDP (p < 0.001 for all pre-post comparisons). CONCLUSIONS Natriuretic response can be rapidly and accurately predicted by the NRPE, and this information can be used to guide diuretic therapy during acute decompensated heart failure. Additional study of diuresis guided by the NRPE is warranted.
Collapse
Affiliation(s)
- Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Heart Failure, Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Zachary L Cox
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ralph Riello
- Heart and Vascular Center, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Matthew Griffin
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James Fleming
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Richard Soucier
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Prasama Sangkachand
- Heart and Vascular Center, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Margaret O'Brien
- Heart and Vascular Center, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Francine LoRusso
- Heart and Vascular Center, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Julie D'Ambrosi
- Heart and Vascular Center, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Keith Churchwell
- Heart and Vascular Center, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lavanya Bellumkonda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jennifer L Asher
- Department of Comparative Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey M Turner
- Department of Medicine, Division of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - F Perry Wilson
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
| |
Collapse
|
35
|
Burns H, Russell L, Cox ZL. Statin-induced rhabdomyolysis from azithromycin interaction in a patient with heterozygous SLCO1B1 polymorphism. J Clin Pharm Ther 2020; 46:853-855. [PMID: 33277702 DOI: 10.1111/jcpt.13327] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/29/2020] [Accepted: 11/16/2020] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Unlike other macrolide antibiotics, azithromycin is considered safe to co-prescribe with simvastatin. We aim to elucidate the mechanism of a rare azithromycin-simvastatin interaction. CASE DESCRIPTION We report a case of simvastatin-induced rhabdomyolysis caused by an azithromycin drug interaction in a patient with heterozygous SLCO1B1 loss-of-function polymorphism. We propose a dual-hit mechanism for this drug-drug-genome interaction. Azithromycin mildly inhibits simvastatin's CYP 3A4 hepatic metabolism, and the SLCO1B1 polymorphism reduces simvastatin hepatic uptake. The combination increases simvastatin serum concentrations significantly, inducing rhabdomyolysis. WHAT IS NEW AND CONCLUSION Patients with statin-induced myopathy associated with non-classic CYP inhibitors should be considered for genetic testing and alternative statins with less risk of future interactions.
Collapse
Affiliation(s)
- Hailey Burns
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, USA
| | - Landon Russell
- Department of Pharmacy, Deaconess Health System, Evansville, IN, USA
| | - Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, USA.,Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
36
|
Cox ZL, Fleming J, Ivey-Miranda J, Griffin M, Mahoney D, Jackson K, Hodson DZ, Thomas D, Gomez N, Rao VS, Testani JM. Mechanisms of Diuretic Resistance Study: design and rationale. ESC Heart Fail 2020; 7:4458-4464. [PMID: 32893505 PMCID: PMC7754741 DOI: 10.1002/ehf2.12949] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/08/2020] [Accepted: 07/14/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Diuretic resistance is a common complication impairing decongestion during hospitalization for acute decompensated heart failure (ADHF). The current understanding of diuretic resistance mechanisms in ADHF is based upon extrapolations from other disease states and healthy volunteers. However, accumulating evidence suggests that the dominant mechanisms in other populations have limited influence on diuretic response in ADHF. Additionally, the ability to rapidly and reliably diagnose diuretic resistance is inadequate using currently available tools. AIMS The Mechanisms of Diuretic Resistance (MDR) Study is designed to rigorously investigate the mechanisms of diuretic resistance and develop tools to rapidly predict diuretic response in a prospective cohort hospitalized with ADHF. METHODS Study assessments occur serially during the ADHF hospitalization and after discharge. Each assessment includes a supervised 6-hour urine collection with baseline blood and timed spot urine collections following loop diuretic administration. Patient characteristics, medications, physical exam findings, and both in-hospital and post-discharge HF outcomes are collected. Patients with diuretic resistance are eligible for a randomized sub-study comparing an increased loop diuretic dose with combination diuretic therapy of loop diuretic plus chlorothiazide. CONCLUSIONS The Mechanisms of Diuretic Resistance Study will establish a prospective patient cohort and biorepository to investigate the mechanisms of diuretic resistance and urine biomarkers to rapidly predict loop diuretic resistance.
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, USA.,Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James Fleming
- Yale University School of Medicine, New Haven, CT, USA
| | - Juan Ivey-Miranda
- Yale University School of Medicine, New Haven, CT, USA.,Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - Devin Mahoney
- Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Daniel Thomas
- Yale University School of Medicine, New Haven, CT, USA
| | - Nicole Gomez
- Yale University School of Medicine, New Haven, CT, USA
| | - Veena S Rao
- Yale University School of Medicine, New Haven, CT, USA
| | - Jeffrey M Testani
- Yale University School of Medicine, New Haven, CT, USA.,Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
37
|
Affiliation(s)
- Zachary L Cox
- Lipscomb University College of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Lynne Warner Stevenson
- Advanced Heart Disease, Division of Cardiology, Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| |
Collapse
|
38
|
Cox ZL, Lai P, Lindenfeld J. Decreases in acute heart failure hospitalizations during COVID-19. Eur J Heart Fail 2020; 22:1045-1046. [PMID: 32469132 PMCID: PMC7283634 DOI: 10.1002/ejhf.1921] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, USA.,Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pikki Lai
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
39
|
Gorodeski EZ, Goyal P, Cox ZL, Thibodeau JT, Reay RE, Rasmusson K, Rogers JG, Starling RC. Virtual Visits for Care of Patients with Heart Failure in the Era of COVID-19: A Statement from the Heart Failure Society of America. J Card Fail 2020; 26:448-456. [PMID: 32315732 PMCID: PMC7166039 DOI: 10.1016/j.cardfail.2020.04.008] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 12/15/2022]
Abstract
In response to the COVID-19 pandemic, US federal and state governments have implemented wide-ranging stay-at-home recommendations as a means to reduce spread of infection. As a consequence, many US healthcare systems and practices have curtailed ambulatory clinic visits—pillars of care for patients with heart failure (HF). In this context, synchronous audio/video interactions, also known as virtual visits (VVs), have emerged as an innovative and necessary alternative. This scientific statement outlines the benefits and challenges of VVs, enumerates changes in policy and reimbursement that have increased the feasibility of VVs during the COVID-19 era, describes platforms and models of care for VVs, and provides a vision for the future of VVs.
Collapse
Affiliation(s)
- Eiran Z Gorodeski
- Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland, OH.
| | | | - Zachary L Cox
- Lipscomb University College of Pharmacy and Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Kismet Rasmusson
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | |
Collapse
|
40
|
Felker GM, Ellison DH, Mullens W, Cox ZL, Testani JM. Diuretic Therapy for Patients With Heart Failure. J Am Coll Cardiol 2020; 75:1178-1195. [DOI: 10.1016/j.jacc.2019.12.059] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/15/2019] [Accepted: 12/02/2019] [Indexed: 12/12/2022]
|
41
|
Cox ZL, Sury K, Rao VS, Ivey-Miranda JB, Griffin M, Mahoney D, Gomez N, Fleming JH, Inker LA, Coca SG, Turner J, Wilson FP, Testani JM. Effect of Loop Diuretics on the Fractional Excretion of Urea in Decompensated Heart Failure. J Card Fail 2020; 26:402-409. [PMID: 32007554 DOI: 10.1016/j.cardfail.2020.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/30/2019] [Accepted: 01/27/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Fractional excretion of urea (FEUrea) is often used to understand the etiology of acute kidney injury (AKI) in patients receiving diuretics. Although FEUrea demonstrates diagnostic superiority over fractional excretion of sodium (FENa), clinicians often assume FEUrea is not affected by diuretics. OBJECTIVE To assess the intravenous loop diuretic effect on FEUrea. METHODS We analyzed a prospective cohort (n=297) hospitalized with hypervolemic heart failure at Yale New Haven Hospital System. FENa and FEUrea were calculated at baseline and serially after diuretics. The change in FEUrea at peak diuresis was compared with the pre-diuretic baseline. RESULTS Mean baseline FEUrea was 35.2% ± 10.5% and increased by a mean 5.6% ± 10.5% following 80 mg (40-160 mg) of furosemide equivalents (P < .001). The magnitude of change in FEUrea was clinically important as the distribution of change in FEUrea was similar to the overall distribution of baseline FEUrea. Change in FEUrea was related to the diuretic response (r = 0.61, P < .001), with a larger FEUrea increase in diuretic responders (8.8%, interquartile range [IQR]: 1.8-16.9) than non-responders (1.2%, IQR: -3.2 to 5.5; P < .001). Diuretic administration reclassified 27% of patients between low and high FEUrea groups across a 35% threshold. Neither change in FEUrea nor percentage reclassified out of a low FEUrea category differed between patients with and without AKI (P > .63 for both). CONCLUSIONS FEUrea is meaningfully affected by loop diuretics. The degree of change in FEUrea is highly variable between patients and commonly of a magnitude that could reclassify across categories of FEUrea.
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Krishna Sury
- Division of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Veena S Rao
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Juan B Ivey-Miranda
- Division of Cardiology, Hospital de Cardiologia Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Matthew Griffin
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Devin Mahoney
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole Gomez
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - James H Fleming
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lesley A Inker
- Department of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Steven G Coca
- Department of Nephrology, Mount Sinai, New York City, New York
| | - Jeff Turner
- Division of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - F Perry Wilson
- Division of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey M Testani
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
| |
Collapse
|
42
|
Cox ZL, Lai P, Lewis CM, Lindenfeld J. Change in admission blood glucose from chronic glycemic status in acute heart failure hospitalization and 30-day outcomes: A retrospective analysis. Int J Cardiol 2020; 299:180-185. [DOI: 10.1016/j.ijcard.2019.07.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/13/2019] [Accepted: 07/22/2019] [Indexed: 11/17/2022]
|
43
|
Cox ZL, Hung R, Lenihan DJ, Testani JM. Diuretic Strategies for Loop Diuretic Resistance in Acute Heart Failure: The 3T Trial. JACC Heart Fail 2019; 8:157-168. [PMID: 31838029 DOI: 10.1016/j.jchf.2019.09.012] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This study compared combination diuretic strategies in acute heart failure (AHF) complicated by diuretic resistance (DR). BACKGROUND Combination diuretic regimens to overcome loop DR are commonly used but with limited evidence. METHODS This study was a randomized, double-blinded trial in 60 patients hospitalized with AHF and intravenous (IV) loop DR. Patients were randomized to oral metolazone, IV chlorothiazide, or tolvaptan therapy. All patients received concomitant high-dose IV infusions of furosemide. The primary outcome was 48-h weight loss. RESULTS The cohort exhibited DR prior to enrollment, producing 1,188 ± 476 ml of urine in 12 h during high-dose loop diuretic therapy (IV furosemide: 612 ± 439 mg/day). All 3 interventions significantly improved diuretic efficacy (p < 0.001). Compared to metolazone (4.6 ± 2.7 kg), neither IV chlorothiazide (5.8 ± 2.7 kg; 1.2 kg [95% confidence interval (CI)]: -2.9 to 0.6; p = 0.292) nor tolvaptan (4.1 ± 3.3 kg; 0.5 kg [95% CI: -1.5 to 2.4; p = 0.456) resulted in more weight loss at 48 h. Median (interquartile range [IQR]) cumulative urine output increased significantly and did not differ among those receiving metolazone (7.78 [IQR: 6.59 to 10.10] l) and chlorothiazide (8.77 [IQR: 7.37 to 10.86] l; p = 0.245) or tolvaptan (9.70 [IQR: 6.36 to 13.81] l; p = 0.160). Serum sodium decreased less with tolvaptan than with metolazone (+4 ± 5 vs. -1 ± 3 mEq/l; p = 0.001), but 48-h spot urine sodium was lower with tolvaptan (58 ± 25 mmol/l) than with metolazone (104 ± 16 mmol/l; p = 0.002) and with chlorothiazide (117 ± 14 mmol/l; p < 0.001). CONCLUSIONS In this moderately sized DR trial, weight loss was excellent with the addition of metolazone, IV chlorothiazide, or tolvaptan to loop diuretics, without a detectable between-group difference. (Comparison of Oral or Intravenous Thiazides vs. tolvaptan in Diuretic Resistant Decompensated Heart Failure [3T]; NCT02606253).
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville Tennessee; Department of Pharmacy, Vanderbilt University Medical Center, Nashville Tennessee.
| | - Rebecca Hung
- Division of Cardiology, Vanderbilt University Medical Center, Nashville Tennessee
| | - Daniel J Lenihan
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey M Testani
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
44
|
|
45
|
Xiong L, Chinaeke EE, Lu K, Lenihan DJ, Merritt TE, Cox ZL. Evaluation of Severe Myalgia Induced by Continuous‐Infusion Bumetanide in Patients with Acute Heart Failure. Pharmacotherapy 2019; 39:854-860. [DOI: 10.1002/phar.2297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Lianjie Xiong
- Department of Clinical Sciences California Health Sciences University College of Pharmacy Clovis California
| | - Eric E. Chinaeke
- University of South Carolina College of Pharmacy Columbia South Carolina
| | - Kevin Lu
- University of South Carolina College of Pharmacy Columbia South Carolina
| | | | - Tyler E. Merritt
- Vanderbilt University Medical Center Department of Pharmaceutical Services Nashville Tennessee
| | - Zachary L. Cox
- Vanderbilt University Medical Center Department of Pharmaceutical Services Nashville Tennessee
- Lipscomb University College of Pharmacy Nashville Tennessee
| |
Collapse
|
46
|
Charokopos A, Griffin M, Rao VS, Inker L, Sury K, Asher J, Turner J, Mahoney D, Cox ZL, Wilson FP, Testani JM. Serum and Urine Albumin and Response to Loop Diuretics in Heart Failure. Clin J Am Soc Nephrol 2019; 14:712-718. [PMID: 31010938 PMCID: PMC6500945 DOI: 10.2215/cjn.11600918] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 03/16/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Diuretic resistance can limit successful decongestion of patients with heart failure. Because loop diuretics tightly bind albumin, low serum albumin and high urine albumin can theoretically limit diuretic delivery to the site of action. However, it is unknown if this represents a clinically relevant mechanism of diuretic resistance in human heart failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In total, 208 outpatients with heart failure at the Yale Transitional Care Center undergoing diuretic treatment were studied. Blood and urine chemistries were collected at baseline and 1.5 hours postdiuretic administration. Urine diuretic levels were normalized to urine creatinine and adjusted for diuretic dose administered, and diuretic efficiency was calculated as sodium output per doubling of the loop diuretic dose. Findings were validated in an inpatient heart failure cohort (n=60). RESULTS Serum albumin levels in the outpatient cohort ranged from 2.4 to 4.9 g/dl, with a median of 3.7 g/dl (interquartile range, 3.5-4.1). Serum albumin had no association with urinary diuretic delivery (r=-0.05; P=0.52), but higher levels weakly correlated with better diuretic efficiency (r=0.17; P=0.02). However, serum albumin inversely correlated with systemic inflammation as assessed by plasma IL-6 (r=-0.35; P<0.001), and controlling for IL-6 eliminated the diuretic efficiency-serum albumin association (r=0.12; P=0.12). In the inpatient cohort, there was no association between serum albumin and urinary diuretic excretion (r=0.15; P=0.32) or diuretic efficiency (r=-0.16; P=0.25). In the outpatient cohort, 39% of patients had microalbuminuria, and 18% had macroalbuminuria. There was no correlation between albuminuria and diuretic efficiency after adjusting for kidney function (r=-0.02; P=0.89). Results were similar in the inpatient cohort. CONCLUSIONS Serum albumin levels were not associated with urinary diuretic excretion, and urinary albumin levels were not associated with diuretic efficiency.
Collapse
Affiliation(s)
- Antonios Charokopos
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthew Griffin
- Department of Internal Medicine, Section of Cardiovascular Medicine
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine
| | - Lesley Inker
- Department of Nephrology, Tufts Medical Center, Boston, Massachusetts; and
| | - Krishna Sury
- Department of Internal Medicine, Section of Nephrology, and
| | - Jennifer Asher
- Department of Comparative Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey Turner
- Department of Internal Medicine, Section of Nephrology, and
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiovascular Medicine
| | - Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
| | - F Perry Wilson
- Department of Internal Medicine, Section of Nephrology, and
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine,
| |
Collapse
|
47
|
Lewis CM, Cox ZL, Lai P, Lindenfeld J, Collins S. Real-time Application of an Inpatient Heart Failure Mortality Model to Predict 30-Day Mortality. J Card Fail 2018. [DOI: 10.1016/j.cardfail.2018.07.401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
48
|
Cox ZL, Lai P, Lewis CM, Lindenfeld J, Collins SP, Lenihan DJ. Customizing national models for a medical center's population to rapidly identify patients at high risk of 30-day all-cause hospital readmission following a heart failure hospitalization. Heart Lung 2018; 47:290-296. [DOI: 10.1016/j.hrtlng.2018.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 05/11/2018] [Indexed: 10/14/2022]
|
49
|
Lewis CM, Cox ZL, Lai P, Zhang AX, Lenihan DJ. Comparison of Heart Failure Patients Younger and Older Than 65 Years of Age: Is There a Difference? J Card Fail 2017. [DOI: 10.1016/j.cardfail.2017.07.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
50
|
Cox ZL, Lai P, Lewis CM, Lenihan DJ. Limits of the Obesity Paradox: Obese Patients with Heart Failure are at Higher Risk of Hospitalization. J Card Fail 2017. [DOI: 10.1016/j.cardfail.2017.07.324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|