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Urinary sodium-guided precision management for heart failure
No full textIn patients with heart failure, neurohumoral activation leads to increased renal sodium avidity across the entire renal tubules, resulting in a positive sodium and water balance, leading to decompensated heart failure requiring intravenous diuretics. As the dose of diuretic therapy required to achieve euvolemia is difficult to estimate due to considerable intra- and interindividual differences, the
European Society of Cardiology recommends assessment of the diuretic response
within hours either via evaluation of the urinary sodium concentration or via
urinary volume after initial diuretic administration. All diuretic agents enhance
sodium excretion to a different extent depending on their side of action across the renal tubules, and renal adaptation mechanisms due to neurohumoral stimulation. Impaired sodium excretion, even in the presence of fluid loss, is associated with worse clinical outcomes. Therefore, assessing urinary sodium excretion is considered a good and direct marker of the diuretic efficacy. Such natriuresisguided protocols have been tested prospectively by the Pragmatic Urinary
Sodium-based algoritHm in Acute Heart Failure and the Efficacy of a Standardized
Diuretic Protocol in Acute Heart Failure study, both demonstrating increased natriuresis and diuresis. Moreover, the Readily Available Urinary Sodium Analysis in Patients with Acute Decompensated Heart Failure study has demonstrated that a nurse-led natriuresis-guided protocol is feasible through the use of a point-ofcare urinary sodium sensor, allowing an immediately readable urinary sodium result, enabling fast changes in diuretic therapy. This review summarizes the
rationale, current evidence and gaps supporting the role of the urinary sodium concentration in patients with acute decompensated heart failure
Spot Urinary Sodium Measurements: the Future Direction of the Treatment and Follow-up of Patients with Heart Failure
No full textPurpose of Review Heart failure is characterized by episodes of congestion with need for hospitalization. The current metrics lack the accuracy to predict and prevent episodes of congestion and to guide diuretic titration to reach euvolemia in case of decompensation. This article aims to provide answers to the role of urinary sodium measurements in acute and chronic heart failure. Recent Findings In acute heart failure, urinary sodium concentrations at the moment of admission and after diuretic administration are correlated with short- and long-term outcome. As this is a reflection of the degree of sodium retention, it can be used as a guide in the diuretic titration. In chronic heart failure, it might be used to predict and consequently prevent episodes of decompensation. Summary Urinary sodium measurements hold great promises to be a novel diagnostic and therapeutic parameter in patients with acute and chronic heart failure. However, more research is needed
When is the time right? Dancing on the tightrope: referral for upgrade to cardiac resynchronization therapy
No full textExtraforaminale lumbale discushernia
No full textDe anatomische opbouw van de wervelzuil maakt dat de spinale zenuwwortel die doorheen de paramediane ruimte loopt, verschilt van deze die door de extraforaminale ruimte loopt. Een extraforaminale discushernia geeft aldus compressie van een andere zenuwwortel dan een klassieke hernia op hetzelfde niveau. De prevalentie bedraagt ongeveer 1,78-6,1% van alle lumbale discushernia’s. Het voornaamste symptoom is radiculaire pijn. Daarnaast zijn lage rugpijn en sensomotorische uitvalsverschijnselen eveneens veelvoorkomend. Klinisch onderzoek omvat de „straight leg raising-test” (SLR), de omgekeerde SLR-test, de evaluatie van de reflexen, sensorimotorische uitval en radiculaire uitstralende pijn. In vergelijking met de klassieke discushernia blijkt de pijnbeleving meer uitgesproken te zijn. De MRI is de gouden standaard binnen de medische beeldvorming. De eerstelijnsbehandeling is conservatief (niet-steroïdale anti-inflammatoire geneesmiddelen (NSAID’s), steroïden, bedrust, …). Bij falen van deze therapie of bij duidelijke sensorimotorische uitval kan men opteren voor heelkunde. Epidurale corticoïdinjectie kan de pijn significant verlichten. De literatuurstudie en het patiëntendossieronderzoek tonen een gelijke leeftijdsverdeling. In beide studies bedroeg de prevalentie van radiculaire pijn 100%. Er werd minder vaak rugpijn opgetekend in het dossieronderzoek. De succesratio van het operatief ingrijpen (68% tot 79%) in de studie benadert de cijfers uit de literatuur. De chirurgische uitkomst is niet gerelateerd aan het niveau van de hernia.Dit werk is tot stand gekomen dankzij prof. dr.
Frank Weyns, dr. Thomas Daenekindt en dr. Eveleen Buelens. We danken prof. dr. Weyns hierbij
voor het aanbieden van dit boeiende onderwerp,
het toereiken van informatie en het kritisch evalueren van de tekst. Eveneens willen we de afdeling
neurochirurgie van het ZOL campus St. Jan danken
voor hun hulp bij het uitwerken van het patiëntenonderzoek
Renal and cardiac effects of salt loading in ambulatory heart failure patients
No full text73 p < 0.01) and, moreover, we also documented a higher sacubitril/valsartan prescription (67% vs 55%; p = 0.06) instead of lower loop diuretics use (47% vs 35%, p = 0.05). Mineralocorticoid receptor antagonist (77% vs 83%; p = 0.19) and beta blockers (94% in both groups) therapy did not change. With a total median follow-up of 19 months (Q1-Q3: 9-36), Kaplan-Meier mortality analysis was represented in Figure 1. Conclusions: In our centers, since SGLT2-i approval for HFrEF, there exists a fast joining of SGLT2-i to HFrEF therapy. It could help us to accomplish lower rates of loop diuretics prescription enabling a better titration of drugs with proven positive impact in remodelling and morbimortality. These results support in real-world the provider role of SGLT2-i, explaining a higher increase of left ventricular ejection fraction in post SGLT2-i group, with a non-statistically significant trend to lower mortality probably due to a small follow-up. Follow-up clinical visit Figure 1. Funding Acknowledgements: Type of funding sources: None. Background: Patients with hypotension have consistently been excluded from heart failure (HF) randomized controlled trials. This group of HF patients is largely unstudied. We aimed to characterize HF patients with hypotension. Methods: We retrospectively studied adult outpatients with systolic dysfunction followed in our HF clinic from January 2012 to December 2020. Patients without blood pressure measurement on the index visit (first medical visit) were excluded. We defined hypotension as systolic blood pressure (SBP) of less than 100 mmHg. The endpoint under analysis was all-cause mortality. Patients were followed until January 2023. Patients with hypotension were compared with the remaining. A Cox-regression analysis was used to assess the prognostic impact of hypotension and to study the prognostic impact of evidence-based therapy separately in HF patients with SPB < 100mmHg and those with SPB ≥ 100mmHg. Adjustments were made considering potential confounders. Results: We studied 1206 chronic ambulatory HF patients, 64.9% male, mean age 71 years, 47.4% with severe systolic dysfunction. Regarding the medication in use, 91.4% were on beta blockers (BB), 82.8% were on renin angiotensin system inhibitors (RASi), including angiotensin converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor neprilysin inhibitors; 29.6% were on min-eralocorticoid receptor antagonists (MRA). A total of 157 patients (13.0%) presented SBP < 100mmHg on the index visit. Hypotensive patients more often presented atrial fibrillation and severe systolic dysfunction; they had lower haemoglobin values and higher brain natriuretic peptide (BNP) levels. Patients with hypotension were less medicated with RASi (70.7% vs 84.6%, p < 0.001) but more with MRA (39.6% vs 28.1%, p = 0.004) and diuretics (86.6% vs 78.6%, p = 0.02). There were no differences regarding BB use between both groups. During a median follow-up of 47 (27-85) months 645 (53.5%) patients died, 61.1% in those with hypotension and 52.3% in the remaining, p = 0.04. The use of RASi in hypotensive patients was associated with better survival (HR = 0.42 (0.26-0.69)) as in those with SPB ≥ 100mmHg (HR = 0.64 (0.51-0.80)). Contrarily to patients with SPB ≥ 100mmHg, in those with hypotension, BB use was not associated with survival benefit (HR = 0.61 (0.46-0.81) and 0.98 (0.48-1.97), respectively). MRA use showed no prognostic impact in either group. Conclusions: Hypotension was associated with poor prognosis in HF patients. In HF patients with SBP < 100mmHg, BB and MRA use did not impact prognosis, however, RASi use portended a survival benefit. Despite their exclusion from most HF therapy trials, hypotensive patients might benefit from RASi drugs. Renal and cardiac effects of salt loading in ambulatory heart failure patients Funding Acknowledgements: Type of funding sources: Public grant(s)-National budget only. Main funding source(s): Hartfalenfonds ZOL-UHasselt Limburg Sterk Merk Background: Current guidelines recommend to limit sodium intake in heart failure (HF) patients. However, stringent sodium restriction can increase neurohormonal activation, decrease quality of life and was not advantageous in recent trials. In addition, recent studies suggest that the skin can function as a sodium buffer. Purpose: To study effects and handling of an increased salt load in patients with HF and reduced ejection fraction. Methods: Eighteen patients with HF and left ventricular ejection fraction < 40% and 10 age-and sex-matched healthy volunteers without cardiovascular disease were included. HF patients with severe right ventricular dysfunction, eGFR < 30 mL/min/1.73 m 2 or severe valvular dysfunction were excluded. After 2 weeks of run-in, all study participants received 3 grams of sodium chloride (capsules of 1 g three times daily) on top of their usual diet for 4 weeks. Patients were evaluated at inclusion, at 2 weeks (end of run-in), 4 weeks (2 weeks of sodium chloride intake) and 6 weeks (4 weeks of sodium chloride intake). At each evaluation, clinical parameters, Everest congestion score, lab, echocardiography, 24-hour urine collection and bio-impedance measurements of total body water were performed. Blood volume and plasma volume were assessed using a radio-labeled red blood cells dilution technique before salt loading (at 2 weeks) and and the end of the study (at 6 weeks). At the same time points, a skin biopsy was taken at the lower leg to assess skin sodium content and glycosaminoglycan content. Results: Mean age was 66 ± 8 years, 2 (11.1%) were female, median LVEF was 35 (31-39) %, median eGFR was 68 (51-74) mL/min/1.73 m 2 and median NT-proBNP was 431 (275-961) ng/L at baseline and all patients were optimally treated medically. Salt loading did not influence weight, blood pressure, congestion score or NT-proBNP (Figure 1). There was no significant change in total body water (from 46.87 L to 44.41 L; p = 0.780), plasma volume (2735 mL vs. 2904 mL; p = 0.231) and total blood volume (4748 mL vs. 4885 mL; p = 0.327). Renal sodium excretion increased from 150 ± 55 mmol/24h to 173 ± 58 mmol/24h (p = 0.024), while plasma renin decreased from 286 (25-550) í µí¼ U/L to 88 (19-362) í µí¼ U/L (p = 0.002) (Figure 2). Salt loading did not significantly influence LVEF (from 35% to 35%; p = 0.801), leftType of funding sources: Public grant(s) – Nationalbudget only. Main funding source(s): Hartfalenfonds ZOL-UHasselt Limburg SterkMer
Renal and cardiac effects of salt loading in ambulatory heart failure patients
No full text73 p < 0.01) and, moreover, we also documented a higher sacubitril/valsartan prescription (67% vs 55%; p = 0.06) instead of lower loop diuretics use (47% vs 35%, p = 0.05). Mineralocorticoid receptor antagonist (77% vs 83%; p = 0.19) and beta blockers (94% in both groups) therapy did not change. With a total median follow-up of 19 months (Q1-Q3: 9-36), Kaplan-Meier mortality analysis was represented in Figure 1. Conclusions: In our centers, since SGLT2-i approval for HFrEF, there exists a fast joining of SGLT2-i to HFrEF therapy. It could help us to accomplish lower rates of loop diuretics prescription enabling a better titration of drugs with proven positive impact in remodelling and morbimortality. These results support in real-world the provider role of SGLT2-i, explaining a higher increase of left ventricular ejection fraction in post SGLT2-i group, with a non-statistically significant trend to lower mortality probably due to a small follow-up. Follow-up clinical visit Figure 1. Funding Acknowledgements: Type of funding sources: None. Background: Patients with hypotension have consistently been excluded from heart failure (HF) randomized controlled trials. This group of HF patients is largely unstudied. We aimed to characterize HF patients with hypotension. Methods: We retrospectively studied adult outpatients with systolic dysfunction followed in our HF clinic from January 2012 to December 2020. Patients without blood pressure measurement on the index visit (first medical visit) were excluded. We defined hypotension as systolic blood pressure (SBP) of less than 100 mmHg. The endpoint under analysis was all-cause mortality. Patients were followed until January 2023. Patients with hypotension were compared with the remaining. A Cox-regression analysis was used to assess the prognostic impact of hypotension and to study the prognostic impact of evidence-based therapy separately in HF patients with SPB < 100mmHg and those with SPB ≥ 100mmHg. Adjustments were made considering potential confounders. Results: We studied 1206 chronic ambulatory HF patients, 64.9% male, mean age 71 years, 47.4% with severe systolic dysfunction. Regarding the medication in use, 91.4% were on beta blockers (BB), 82.8% were on renin angiotensin system inhibitors (RASi), including angiotensin converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor neprilysin inhibitors; 29.6% were on min-eralocorticoid receptor antagonists (MRA). A total of 157 patients (13.0%) presented SBP < 100mmHg on the index visit. Hypotensive patients more often presented atrial fibrillation and severe systolic dysfunction; they had lower haemoglobin values and higher brain natriuretic peptide (BNP) levels. Patients with hypotension were less medicated with RASi (70.7% vs 84.6%, p < 0.001) but more with MRA (39.6% vs 28.1%, p = 0.004) and diuretics (86.6% vs 78.6%, p = 0.02). There were no differences regarding BB use between both groups. During a median follow-up of 47 (27-85) months 645 (53.5%) patients died, 61.1% in those with hypotension and 52.3% in the remaining, p = 0.04. The use of RASi in hypotensive patients was associated with better survival (HR = 0.42 (0.26-0.69)) as in those with SPB ≥ 100mmHg (HR = 0.64 (0.51-0.80)). Contrarily to patients with SPB ≥ 100mmHg, in those with hypotension, BB use was not associated with survival benefit (HR = 0.61 (0.46-0.81) and 0.98 (0.48-1.97), respectively). MRA use showed no prognostic impact in either group. Conclusions: Hypotension was associated with poor prognosis in HF patients. In HF patients with SBP < 100mmHg, BB and MRA use did not impact prognosis, however, RASi use portended a survival benefit. Despite their exclusion from most HF therapy trials, hypotensive patients might benefit from RASi drugs. Renal and cardiac effects of salt loading in ambulatory heart failure patients Funding Acknowledgements: Type of funding sources: Public grant(s)-National budget only. Main funding source(s): Hartfalenfonds ZOL-UHasselt Limburg Sterk Merk Background: Current guidelines recommend to limit sodium intake in heart failure (HF) patients. However, stringent sodium restriction can increase neurohormonal activation, decrease quality of life and was not advantageous in recent trials. In addition, recent studies suggest that the skin can function as a sodium buffer. Purpose: To study effects and handling of an increased salt load in patients with HF and reduced ejection fraction. Methods: Eighteen patients with HF and left ventricular ejection fraction < 40% and 10 age-and sex-matched healthy volunteers without cardiovascular disease were included. HF patients with severe right ventricular dysfunction, eGFR < 30 mL/min/1.73 m 2 or severe valvular dysfunction were excluded. After 2 weeks of run-in, all study participants received 3 grams of sodium chloride (capsules of 1 g three times daily) on top of their usual diet for 4 weeks. Patients were evaluated at inclusion, at 2 weeks (end of run-in), 4 weeks (2 weeks of sodium chloride intake) and 6 weeks (4 weeks of sodium chloride intake). At each evaluation, clinical parameters, Everest congestion score, lab, echocardiography, 24-hour urine collection and bio-impedance measurements of total body water were performed. Blood volume and plasma volume were assessed using a radio-labeled red blood cells dilution technique before salt loading (at 2 weeks) and and the end of the study (at 6 weeks). At the same time points, a skin biopsy was taken at the lower leg to assess skin sodium content and glycosaminoglycan content. Results: Mean age was 66 ± 8 years, 2 (11.1%) were female, median LVEF was 35 (31-39) %, median eGFR was 68 (51-74) mL/min/1.73 m 2 and median NT-proBNP was 431 (275-961) ng/L at baseline and all patients were optimally treated medically. Salt loading did not influence weight, blood pressure, congestion score or NT-proBNP (Figure 1). There was no significant change in total body water (from 46.87 L to 44.41 L; p = 0.780), plasma volume (2735 mL vs. 2904 mL; p = 0.231) and total blood volume (4748 mL vs. 4885 mL; p = 0.327). Renal sodium excretion increased from 150 ± 55 mmol/24h to 173 ± 58 mmol/24h (p = 0.024), while plasma renin decreased from 286 (25-550) í µí¼ U/L to 88 (19-362) í µí¼ U/L (p = 0.002) (Figure 2). Salt loading did not significantly influence LVEF (from 35% to 35%; p = 0.801), leftType of funding sources: Public grant(s) – Nationalbudget only. Main funding source(s): Hartfalenfonds ZOL-UHasselt Limburg SterkMer
Empagliflozin in heart failure with preserved ejection fraction: from randomized trials to real-world evidence
No full textBackground : The EMPEROR-Preserved clinical trial established empagliflozin as an effective therapy in heart failure with preserved ejection fraction (HFpEF), yet real-world validation in elderly, comorbid populations remain limited. We aimed to evaluate the clinical profile, tolerability, and outcomes of empagliflozin in a large Belgian HFpEF cohort. Methods : This retrospective, single-centre observational study of consecutive HFpEF patients (LVEF >50%) initiated on empagliflozin (10 mg daily) between April 2023 and April 2024. Baseline characteristics, clinical parameters, laboratory values, and outcomes were collected from electronic health records. Results : Of 798 screened patients, 577 were included (median age 82 years, 58% female). Atrial fibrillation (67%) and hypertension (78%) were highly prevalent. Empagliflozin use was associated with significant improvements in NYHA functional class (NYHA II: 56% to 77%, p < 0.001) and reduction in peripheral oedema (26% to 9%, p < 0.001). Modest reductions were observed in systolic blood pressure (131 to 130 mmHg, p = 0.017), heart rate (71 to 68 bpm, p = 0.004), body weight (76 to 75 kg, p < 0.001), and BMI (27.7 to 27.2 kg/m2, p < 0.001). Haemoglobin levels increased (p = 0.002), while renal function declined modestly without clinical sequelae. Treatment discontinuation occurred in 2.8% of patients, mainly due to genitourinary infections. During a median follow-up period of 16 months, the all-cause mortality rate was 6.9%. Conclusion : In real-world elderly and comorbid HFpEF population, empagliflozin was well tolerated and associated with improvements in congestion and functional status, supporting the external validity of randomised trial findings.Funding
Sebastiaan Dhont is supported as predoctoral fundamental research fellow by the Fund for Scientific Research Flanders (FWO 11PGA24N)
MADIT-ICD benefit score aids in selecting implantable cardioverter-defibrillator in cardiac resynchronisation therapy
No full textNurse-led diuretic titration via a point-of-care urinary sodium sensor in patients with acute decompensated heart failure (EASY-HF): A single-centre, randomized, open-label study
No full textAims Early evaluation of the natriuretic response is recommended to guide diuretic therapy in acute decompensated heart failure (ADHF). However, its implementation in daily practice is hampered by implementation barriers and increased time constraints. The Readily Available Urinary Sodium Analysis in Patients with Acute Decompensated Heart Failure (EASY-HF) study assessed the feasibility, efficacy and safety of a nurse-led urinary sodium-based diuretic titration protocol with the use of a point-of-care urinary sodium sensor. Methods and results The EASY-HF study was a single-centre, randomized, open-label study comparing diuretic management at the treating physician's discretion as standard of care (SOC) with a nurse-led natriuresis-guided protocol in patients with ADHF. The LAQUAtwin Sodium Meter (HORIBA) was used as point-of-care sensor to measure urine sodium concentration. The primary endpoint was natriuresis after 48 h. Secondary endpoints included safety profile and user-friendliness of both the protocol and the point-of-care sensor. Sixty patients were randomized towards SOC (n = 30) versus protocolized care (n = 30). The mean age was 80 +/- 8 years, 25% were women and median N-terminal pro-B-type natriuretic peptide was 4667 (2667-7709) ng/L. Natriuresis after 48 h was significantly higher in the protocolized versus SOC group (820 +/- 279 vs. 657 +/- 273 mmol; p = 0.027). Pre-defined safety endpoints were similar among both groups. The sensor-based protocol was evaluated as easy to use by the nursing staff, and preferred over urinary collections. Conclusion A nurse-led diuretic titration protocol via a point-of-care urinary sodium sensor was feasible, safe and resulted in an increased natriuresis in ADHF compared to SOC.This study was supported by an FWO research grant (1SF6824N). Conflict of interest: none declared
Sodium loading in ambulatory patients with heart failure with reduced ejection fraction: Mechanistic insights into sodium handling
No full textAims Sodium restriction was not associated with improved outcomes in heart failure patients in recent trials. The skin might act as a sodium buffer, potentially explaining tolerance to fluctuations in sodium intake without volume overload, but this is insufficiently understood. Therefore, we studied the handling of an increased sodium load in patients with heart failure with reduced ejection fraction (HFrEF).Methods and results Twenty-one ambulatory, stable HFrEF patients and 10 healthy controls underwent a 2-week run-in phase, followed by a 4-week period of daily 1.2 g (51 mmol) sodium intake increment. Clinical, echocardiographic, 24-h urine collection, and bioelectrical impedance data were collected every 2 weeks. Blood volume, skin sodium content, and skin glycosaminoglycan content were assessed before and after sodium loading. Sodium loading did not significantly affect weight, blood pressure, congestion score, N-terminal pro-brain natriuretic peptide, echocardiographic indices of congestion, or total body water in HFrEF (all p > 0.09). There was no change in total blood volume (4748 ml vs. 4885 ml; p = 0.327). Natriuresis increased from 150 mmol/24 h to 173 mmol/24 h (p = 0.024), while plasma renin decreased from 286 to 88 mu U/L (p = 0.002). There were no significant changes in skin sodium content, total glycosaminoglycan content, or sulfated glycosaminoglycan content (all p > 0.265). Healthy controls had no change in volume status, but a higher increase in natriuresis without any change in renin.Conclusions Selected HFrEF patients can tolerate sodium loading, with increased renal sodium excretion and decreased neurohormonal activation. [GRAPHICS]Jeroen Dauw, Evelyne Meekers, Sebastiaan Dhont and Wilfried Mullens are researchers for the Limburg Clinical Research Center (LCRC) UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk (LSM), province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg, and Jessa Hospital
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