The prevalence of RAASi uptitration limiting hyperkalemia and the suitability of potassium binders among patients suffering from heart failure with reduced ejection fraction

Background

The use of the renin-angiotensin-aldosteron-system inhibitor (RAASi) regime is crucial to reduce the mortality and morbidity of heart failure with reduced ejection fraction (HFrEF). However, it is well known that among real life circumstances it is challenging to reach the guideline-recommended target doses (TDs) of RAASi-s, due to the occurrence of side effects (e.g. hyperkalemia). Based on the ESC expert consensus document, it is recommended to reduce the RAASi dosages or discontinue the therapy when significant hyperkalemia (HK) occurs (serum potassium >5.0 mmol/l or >6.0 mmol/l, respectively). Within the last years, trials of patiromer and zirconium cyclosilicate demonstrated dose-dependent effect of these drugs enhancing potassium level lowering. The ongoing DIAMOND study examining the effect of patiromer among patients with previous HK (se potassium >5mmol/l) in the effect of RAASi-s in HFrEF hopefully will answer the question whether the use of a potassium binder and in its effect the use of TD-s of RAASi translates to significant mortality benefit in HFrEF.

Aim

To assess the prevalence of RAASi uptitration limiting HK and to assess the potential suitability of potassium binders among HFrEF patients followed-up regularly at a heart failure outpatient clinic (HFOC).

Methods

Data of 557 consecutive HFrEF patients (NYHA: 3.1±0.8; LVEF: 27.4±6.6%; age: 61.2±13.0 years; male: 76.3%; ischemic: 47.2%; atrial fibrillation: 27.3%; diabetes: 35.7%; hypertension: 72.7%, systolic blood pressure: 124.3±24.3mmHg, eGFR: 65.6±23.6 ml/min/1.73m2) was analyzed. At baseline ACEi/ARBs in 33.6%, BBs in 40.9%, MRAs in 37.9% of the total cohort (TC) were used.

Results

After therapy optimization (TO) ACEis/ARBs were applied in 97.5% and TD (equivalent to at least 10 mg of enalapril b.i.d.) was reached in 59.4% of the TC. BBs in 90.7%, TDs of BBs in 48.3%, MRAs in 64.3%, TDs of MRAs in 24.6% of the TC were applied. In 100 patients (17.9%) the TDs of ACEi/ARBs and MRAs were reached simultaneously. Among those 457 patients not reaching the TD of ACEi/ARBs and/or the TD of MRAs the occurrence of HK (se potassium >5 mmol/l) was quite frequent (45.3%, 207 patients), the prevalence of HK with the need of permanent dose reduction of RAASi regime (se potassium>5.5 mmol/l) was 10.5% (48 patients) and the prevalence of HK resulting permanent discontinuation of RAASi (se potassium >6.0 mmol/l) was 2.8% (13 patient) during the TO.

Conclusions

The current ESC guidelines recommend the use of TDs or maximal tolerated doses of RAASi-s in HFrEF. In a real-world patient cohort when every effort was made to reach the TDs, the TD of ACEi/ARBs and the TD of MRAs was reachable only in 17.9% of patients due the side effects observed during the TO. The occurrence of HK preventing to reach the TD, resulting down-titration or temporary/permanent discontinuation of RAASi-s and representing potential suitability for potassium binders is significant among optimally treated HFrEF patients.

Funding Acknowledgement

Type of funding source: None

P1663The impact of highest doses of ACEi/ARB therapy on mortality of patients suffering from heart failure with reduced ejection fraction: a long-term follow-up, propensity-matched cohort study

Aim

To assess the effect of TD1 of ACEi/ARB on mortality of HFrEF patients followed at a heart failure outpatient clinic (HFOC).

Methods

Data of 579 consecutive HFrEF patients, who hadn't been treated with an ACEi/ARB or were receiving ≤50% of doses equivalent with 20mg enalapril daily (TD2) at the time of initiation of care (NYHA: 3.1±0.8; LVEF: 27.5±6.6%; age: 61.1±13.0 years; male: 76.1%; ischemic: 46.8%; atrial fibrillation: 27.6%; diabetes: 34.9%; hypertension: 72.5%), followed at our HFOC was analysed. After therapy optimization (TO) ACEis/ARBs were applied in 96.5% and at least TD2 was reached in 55.9% of the total cohort, while TD1 of an ACEi/ARB was applied in 111 patients (19.2% of total cohort). BBs in 88.4%, target doses of BBs in 46.8%, MRAs in 57.0% of total cohort were used. To adjust for possible confounders, patients were matched based on the ACEi/ARB doses reached during TO applying propensity score matching (PSM) using the nearest neighbor matching (caliper: 0.2). All-cause mortality (ACM) was assessed using the Kaplan-Meier method and compared with the Cox proportional hazard model.

Results

After 7.1±4.7 years follow-up ACM of patients treated with TD1 of ACEis/ARBs was significantly lower than those treated with lower doses in the total cohort (HR=0.67; 95% CI=0.50–0.89; p=0.005). Applying multivariate Cox regression analysis the use of TD1 of an ACEi/ARB didn't remain independent predictor of survival; creatinine, NYHA f.c., age, sex, ischemic etiology were proved to be significant predictor of mortality. After PSM the survival of patients receiving TD1 of an ACEi/ARB didn't differ from those treated with lower doses (HR=0.84; 95% CI=0.61–1.14; p=0.27).

Conclusions

The current ESC guidelines recommend the use of target doses or maximal tolerated doses of ACEis or ARBs in HFrEF. In a real-world patient cohort whom all the effort was made to reach the target doses, ACM of patients treated with TD1 of an ACEi/ARB was significantly lower than those treated with lower doses, however this result wasn't independent from the patient characteristics. Beside that, after PSM the survival of patients treated with TD1 or with lower doses of an ACEi/ARB did not differ significantly.

[Three cases of tuberculosis complicating acute respiratory distress syndrome]

In this report, we describe three patients with pulmonary tuberculosis with acute respiratory failure with an extensive tuberculous consolidation in bilateral lung fields. Disseminated intravascular coagulation (DIC) was present in one patient and miliary tuberculosis in two patients. They all developed acute respiratory distress syndrome (ARDS), nessecitating management by mechanical ventilation with a combination therapy of antituberculous agents and methylprednisolone (m-PSL) pulse therapy. Only one patient survived in whom the PaO2/FiO2 ratio recovered rapidly after the initiation of therapy. Two patients whose systemic condition upon admission was critically ill eventually died of hepatic failure and bacterial pneumonia, even though ARDS and pulmonary tuberculosis were successfully treated. Prognosis of pulmonary tuberculosis complicating ARDS and DIC is poor, and these patients need systemic intensive treatment, in which m-PSL therapy may be beneficial.

Differential regulation by anti-tumor-promoting 12-deoxyphorbol-13-phenylacetate reveals distinct roles of the classical and novel protein kinase C isozymes in biological responses of primary mouse keratinocytes

12-Deoxyphorbol-13-phenylacetate (dPP) is the prototype for a new class of phorbol derivatives that function as protein kinase C (PKC) activators with potent anti-tumor-promoting activity. To explore the mechanism of action of dPP, we have conducted detailed analyses of the translocation and down-regulation patterns of individual PKC isozymes in mouse primary keratinocytes upon dPP treatment. PKC-alpha, -delta, and -epsilon were very quickly (within 2-5 min) translocated from the soluble fraction to the Triton X-100-soluble particulate fraction. PKC-delta and -epsilon were translocated with 2 orders of magnitude higher potency than was PKC-alpha. After translocation, PKC-alpha, -delta, -eta, and -epsilon were down-regulated; the down-regulation of PKC-epsilon contrasts with its retention after phorbol-12-myristate-13-acetate or bryostatin treatment. As was the case with translocation, dPP down-regulated the novel PKC isozymes (delta, epsilon, and eta) with 2 orders of magnitude higher potency (ED50, about 1-2 nM), compared with PKC-alpha (ED50, about 100 nM). dPP induced transglutaminase activity, ornithine decarboxylase activity, and cornification with potencies similar to that for PKC-alpha translocation. On the other hand, dPP caused inhibition of EGF binding with a potency similar to that for the translocation of the novel PKC isozymes. Although the generality of its selectivity in different cell types remains to be determined, at least in keratinocytes dPP is a powerful tool for dissecting the involvement of the classical and novel PKC isozymes in biological responses. The unique regulatory pattern of PKC-epsilon could contribute to the anti-tumor-promoting activity of dPP.

Transformation of NIH3T3 cells with ras oncogenes abrogates the retinoic acid induction of tissue transglutaminase

Retinoic acid greatly increases enzyme activity and mRNA expression of the tissue-type transglutaminase enzyme in NIH3T3 cells. This response is blocked in cells transformed with activated H-ras, K-ras or N-ras oncogenes, but not in pSVneo vector transfected cells. Lack of induction by RA of the tissue-type TGase in these ras-transformed fibroblasts suggests intersecting pathways between retinoid action and the ras oncogene.