1,721,153 research outputs found
Empagliflozin and renal sodium handling: an intriguing smart osmotic diuretic
No full textThis article refers to ‘Effects of empagliflozin on renal sodium and glucose handling in patients with acute heart failure’ by E.M. Boorsma et al., published in this issue on pages xxx.Mullens, W (corresponding author), Ziekenhuis Oost Limburg, Dept Cardiol, Schiepse Bos 6, B-3600 Genk, Belgium.
Univ Hasselt, Hasselt, Belgium.
[email protected]
Contemporary Diuretic Therapies for Acute Heart Failure: Time for a Desalination-Guided Approach?
No full textNovel and mechanistic insights into established heart failure therapies
No full textHeart failure is a prevalent condition associated with high morbidity and mortality. Despite
major advances the past decade in the treatment options for patients with HFrEF,
numbers of admission, re-admission and mortality remain high. Additional the degree of
function impairment in patients with heart failure encountered in clinical practice remains
high. Despite potential novel device-based and medication based therapeutic treatment
options on the horizon of heart failure, current established therapies could benefit from
optimization. Indeed, registry based analysis indicate a disappointingly low uptake of
numerous guideline directed medical therapies in patients with HFrEF. A better
comprehension of the established heart failure therapies could lead to a better
implementation in clinical practice and potentially a better clinical outcome. In this PhDthesis we gain novel and mechanistic insights into several established heart failure
therapies including CRT, sacubitril/valsartan and the use of interventions to manage
congestion and iron deficiency. Hopefully, such novel insights could lead to a better
allocation of therapies to the appropriate patient and could lead to more certainty
regarding the use of heart failure therapies.Hartfalen is een frequente medische aandoening geassocieerd met verminderde
inspanningstolerantie, afgenomen kwaliteit van leven, en verhoogd risico op hartfalen
hospitalisatie en mortaliteit. Ondanks dat het veld van hartfalen gekenmerkt is door velen
innovaties en er beloftevolle nieuwe medische therapieën in ontwikkeling zijn, blijft het
gebruikt van de huidige gevestigde behandeling bij patiënten met hartfalen en een
verminderde linker ventrikel ejectie fractie ondermaats. Observatiestudies tonen aan dat
het gebruikt van de gevestigde behandeling, die daadwerkelijk hebben bewezen de
morbiditeit en mortaliteit te reduceren, vaak onvoldoende toegepast worden. In deze
doctoraatsthesis geven we aandacht en nieuwe inzichten in de gevestigde hartfalen
therapieën met een speciale focus op CRT, sacubitril/valsartan en de interventies gebruikt
voor het behandelen van congestie en ijzertekort. Door het verwerven van nieuwe
inzichten hopen we op een beter en optimaal gebruik van het huidige armamentarium van
hartfalen therapieën om zo uiteindelijk tot een betere patiëntenzorg te komen.Pieter martens was supported by a grant of the Research Foundation-Flanders (FWO, 1127917N).
This research was also part of the Limburg Clinical Research Program UHasselt-ZOL-Jessa,
supported by the foundation Limburg Sterk Merk, Hasselt University, Ziekenhuis Oost-Limburg, and
Jessa Hospital
Novel and mechanistic insights into established heart failure therapies
No full textHeart failure is a prevalent condition associated with high morbidity and mortality. Despite
major advances the past decade in the treatment options for patients with HFrEF,
numbers of admission, re-admission and mortality remain high. Additional the degree of
function impairment in patients with heart failure encountered in clinical practice remains
high. Despite potential novel device-based and medication based therapeutic treatment
options on the horizon of heart failure, current established therapies could benefit from
optimization. Indeed, registry based analysis indicate a disappointingly low uptake of
numerous guideline directed medical therapies in patients with HFrEF. A better
comprehension of the established heart failure therapies could lead to a better
implementation in clinical practice and potentially a better clinical outcome. In this PhDthesis we gain novel and mechanistic insights into several established heart failure
therapies including CRT, sacubitril/valsartan and the use of interventions to manage
congestion and iron deficiency. Hopefully, such novel insights could lead to a better
allocation of therapies to the appropriate patient and could lead to more certainty
regarding the use of heart failure therapies.Hartfalen is een frequente medische aandoening geassocieerd met verminderde
inspanningstolerantie, afgenomen kwaliteit van leven, en verhoogd risico op hartfalen
hospitalisatie en mortaliteit. Ondanks dat het veld van hartfalen gekenmerkt is door velen
innovaties en er beloftevolle nieuwe medische therapieën in ontwikkeling zijn, blijft het
gebruikt van de huidige gevestigde behandeling bij patiënten met hartfalen en een
verminderde linker ventrikel ejectie fractie ondermaats. Observatiestudies tonen aan dat
het gebruikt van de gevestigde behandeling, die daadwerkelijk hebben bewezen de
morbiditeit en mortaliteit te reduceren, vaak onvoldoende toegepast worden. In deze
doctoraatsthesis geven we aandacht en nieuwe inzichten in de gevestigde hartfalen
therapieën met een speciale focus op CRT, sacubitril/valsartan en de interventies gebruikt
voor het behandelen van congestie en ijzertekort. Door het verwerven van nieuwe
inzichten hopen we op een beter en optimaal gebruik van het huidige armamentarium van
hartfalen therapieën om zo uiteindelijk tot een betere patiëntenzorg te komen.Pieter martens was supported by a grant of the Research Foundation-Flanders (FWO, 1127917N).
This research was also part of the Limburg Clinical Research Program UHasselt-ZOL-Jessa,
supported by the foundation Limburg Sterk Merk, Hasselt University, Ziekenhuis Oost-Limburg, and
Jessa Hospital
Reduced occurrence of appropriate therapy for ventricular arrhythmias after beta-blocker uptitration following implant of a primary prevention CRT-defibrillator
No full textBackground: Absence of beta-blocker use independently predicts appropriate therapy. Following cardiac resynchronisation therapy (CRT) implant, reverse remodelling and protection against bradycardia allows for beta-blocker dose uptitration. The differential dosing effects on the occurrence of a first episode of appropriate therapy in primary prevention CRT-defibrillator (CRT-D) patients remains unstudied. Methods and Results: Changes in beta-blocker dose following CRT-D in consecutive primary prevention patients implanted between 2008 and 2015 were retrospectively studied. Beta-blocker dose was expressed as percent of target dose. Uptitration of beta-blocker dose following implant was calculated as the change in percent of target dose between implant and 6-months follow-up. Results from a prospectively maintained database of all device analysis were used to determine the occurrence of appropriate therapy. A total of 162 patients (68 +/- 8 years) were studied. One hundred and ten (68%) patients underwent uptitration (mean 47 +/- 19% in target dose) and 52 (32%) remained on a stable beta-blocker dose. During 37 +/- 22 months follow-up, the cumulative percent of appropriate therapy was 31% in patient receiving no-uptitration versus 10% in the uptitrated patients (p < 0.001). After correction for known predictors of appropriate therapy, uptitration was independently associated with an OR = 0.263 (CI = 0.103-0.675; p = 0.001) for the occurrence of appropriate therapy. Every 1%-increase in target dose for beta-blocker associated with a significant lower risk for appropriate therapy, OR = 0.982 (CI = 0.965-0.999; p = 0.042). Conclusion: Following implantation of a primary prevention CRT-D, uptitration of beta-blockers associated with a reduced occurrence of a first episode of appropriate therapy for ventricular arrhythmias. An inverse dose-response effect was seen between beta-blocker dose and appropriate therapy.Martens, P (reprint author), Ziekenhuis Oost Limburg, Dept Cardiol, Schiepse Bos 6, B-3600 Genk, Belgium.
[email protected]
The reverse remodeling response to sacubitril/valsartan therapy in heart failure with reduced ejection fraction
No full textBackgroundMajor classes of medical therapy for heart failure with reduced ejection fraction (HFrEF) induce reverse remodeling. The revere remodeling response to sacubitril/valsartan remains unstudied. MethodsWe performed a single-center, prospective assessor-blinded study to determine the reverse remodeling response of sacubitril/valsartan therapy in HFrEF patients with a class I indication (New York heart Association [NYHA]-class II-IV, Left ventricular ejection fraction [LVEF] < 35%, optimal dose with Renin-Angiotensin-System-Blocker [RAS-blocker]). Doses of sacubitril/valsartan were optimized to individual tolerance. Echocardiographic images were assessed offline by 2 investigators blinded to both the clinical data and timing of echocardiograms. ResultsOne-hundred-twenty-five HFrEF patients (6610years) were prospectively included. The amount of RAS-blocker before and after switch to sacubitril/valsartan was similar(P=.290), indicating individual optimal dosing of sacubitril/valsartan. Over a median(IQR) follow-up of 118(77-160)days after initiation of sacubitril/valsartan, LVEF improved (29.6 +/- 6% vs 34.8 +/- 6%; P<.001) and Left ventricular end-systolic (LVESV) and end-diastolic volume (LVEDV) decreased (LVESV; 147 +/- 57mL vs 129 +/- 55mL; P<.001 and LVEDV; 206 +/- 71mL vs197 +/- 72mL; P=.027). Volumetric remodeling was associated with a reduction in the degree of mitral regurgitation (1.59 +/- 1.0 vs 1.11 +/- 0.8; P<.001; [scale from 0-4]). Metrics of diastolic function improved; including a drop in the E/A-wave ratio (1.75 +/- 1.13 vs 1.38 +/- 0.88; P=.002) and diastolic filling time (% of cycle length) prolonged (48 +/- 9% vs 52 +/- 1%; P=.005). The percent of patients with a restrictive mitral filling pattern dropped from 47% to 23% (P=.004). A dose-dependent effect was noted for changes in LVEF (P<.001) and LVESV (P=.031), with higher doses of sacubitril/valsartan leading to more reverse remodeling. ConclusionSwitching therapy in eligible HFrEF patients from a RAS-blocker to sacubitril/valsartan induces beneficial reverse remodeling of both metrics of systolic as diastolic function.Pieter Martens is supported by a doctoral fellowship by the Research Foundation - Flanders (FWO, grant-number: 1127917N). Pieter Martens, Pieter Vandervoort and Wilfried Mullens are researchers for the Limburg Clinical Research Program (LCRP) UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk (LSM), Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital
Using combinational diuretics across the spectrum of renal function
No full textThis article refers to 'Combining loop and thiazide diuret-ics for acute heart failure across the estimated glomeru-lar filtration rate spectrum: A post-hoc analysis of the CLOROTIC trial' by J.C. Trullàs et al., published in this issue on pages 1784-1793. Acute heart failure (AHF) remains one of the most frequent reasons for admissions in patients older than 65 years of age. Worsening of signs and symptoms of congestion are the main reasons why patients with acute heart failure seek urgent care. 1 Congestion is the end-product of an abnormal interaction between the compliance of-and the volume within-the cardiovascular system. Not all congestion is caused by an increase in extracellular volume, as decreases in compliance with fluid shifts resulting in an increased stressed blood volume can also lead to congestion. While vasodilatation might be the preferred medication for the latter, diuretics are predominantly recommended by guidelines to treat signs and symptoms of volume overload. 2 Given the central role of congestion in AHF, it is not surprising that loop diuret-ics are a cornerstone therapy used in AHF. In clinical practice, congestion can often persist despite the use of loop diuretics. Residual congestion at discharge is associated with poor clinical outcome. It is unclear if this congestion itself mediates the poor outcome, or whether other clinical factors (renal dysfunction, frailty, high comorbidity burden) generate an inability to attain decongestion and optimize guideline-directed medical therapy and also influence the poor outcome. Indeed, several recent trials have shown that despite a higher likelihood of attaining deconges-tion in AHF with reductions in length of stay by achieving faster and safe decongestion via cheap and easy to implement diuretic strategies, that this did not necessarily translate into improved longer-term survival. 3-5 Nevertheless, the short-term goal in a patient that seeks urgent care for volume overload is to get rid of the excessive volume as this is the principal complaint of those patients. Every physician intimately involved in patient care will recognize the importance of attaining this goal when the patient presents in one of the most vulnerable phases in their disease trajectory. Achieving this goal in a safe and efficient manner is an important basis for a healthy doctor-patient relationship, The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Heart Failure or of the European Society of Cardiology
Exploiting the Natriuretic Peptide Pathway to Preserve Glomerular Filtration in Heart Failure
No full textDr. Martens is supported by a doctoral fellowship by the Research Foundation-Flanders (Fonds Wetenschappelijk Onderzoek, grant number 1127917N). Drs. Martens and Mullens are researchers for the Limburg Clinical Research Program, UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk, Hasselt University, Ziekenhuis OostLimburg, and Jessa Hospital
Renal sodium avidity, the prevailing renal target in heart failure
No full textGraphical Abstract Summary findings (A) Pharmacological effect of loop diuretics in healthy individuals showing CPDSR and the breaking phenomenon. (B) Potential therapies targeting sodium avidity in AHF and CHF. (C) Theoretical effect of therapies used in AHF and CHF on renal sodium
excretion throughout the day.P.M. is supported by 1 year support from the Belgian American Educational Foundation (BAEF) and 1 year support from the Frans Van de Werf Fund. W.H.W.T is partially supported by grants from the National Institutes of Health (R01HL126827 and R01HL146754)
Contemporary choice of glucose lowering agents in heart failure patients with type 2 diabetes
No full textBackground: The choice of glucose lowering agent in heart failure (HF)-patients can have a strong effect on HF-related adverse events, with some classes increasing and other classes reducing the risk. Little data is available about the choice of glucose lowering agents in HF-patients with type-2-diabetes. Methods: We performed a cross-sectional single centre point analysis of all patients with both a diagnoses of HF and type-2-diabetes followed in a tertiary HF-clinic. Medical records were used to determine the choice of current glucose lowering agent. Data at the time of cross-sectional analysis was used to determine potential eligibility to a sodium-glucose-linked-transporter-2-inhibitor (SGLT2-inhibitor) based on the enrolment criteria of the EMPAREG-OUTCOME-trial. Results: A total of 571 HF-patients with diabetes were assessed on June the first 2017. The majority of patients were either managed with one or two glucose lowering agents (43% respectively 34%), with metformin (N = 391;61%), Insulin (N = 278;49%) and sulfonylurea (N = 259;45%) being the most frequently employed treatments. SGLT2-inhibitor use was low (N = 7;1%). According to trial criteria 184 patients (32%) qualified for an SGLT2-inhibitor. With main reasons for ineligibility being a HbA1C = 2 glucose lowering agents from a class other than SGLT-2-inhibiton. Conclusion: Despite potential eligibility, SGLT2-inhibition remains an underused glucose lowering agent in this contemporary HF-population. Additional research is necessary on optimising its implementation in clinical practice, which might include switching glucose lowering therapies in patients at HbA1C-target.Pieter Martens is supported by a doctoral fellowship by the Research Foundation – Flanders (FWO, grant-number: 1127917N). Pieter Martens, and Wilfried Mullens are researchers for the Limburg Clinical Research Program (LCRP) UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk (LSM), Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital.Martens, P (corresponding author), Ziekenhuis Oost Limburg, Dept Cardiol, Schiepse Bos 6, B-3600 Genk, Belgium.
[email protected]
- …
