1,721,458 research outputs found
Contemporary Diuretic Therapies for Acute Heart Failure: Time for a Desalination-Guided Approach?
No full textEmpagliflozin 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.
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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.
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Redefining Boundaries in Heart Failure Care The Potential and Pitfalls of Subcutaneous Furosemide
No full textSpot 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
Response by Dauw and Mullens to Letters Regarding Article, "Protocolized Natriuresis-Guided Decongestion Improves Diuretic Response: The Multicenter ENACT-HF Study"
No full textIn Response: We thank all our colleagues for their interest in our study. 1 Dr Albulushi questions how patient selection might affect the generalizability of our results. A detailed description of the inclusion and exclusion criteria has been published previously. 2 Our study had a pragmatic design with the goal of mimicking real-life practice as much as possible. In essence, almost all patients with fluid overload on a daily loop diuretic dose of ≥40 mg of furosemide or equivalent with elevated natriuretic peptides could be included. Only patients in shock or impending shock and patients with a potential need for renal replacement therapy were excluded. As a result, the patient population in our study is comparable to that of recent registries of acute heart failure. 3 Of note, comor-bidities were highly prevalent, and almost half of the patients had chronic kidney disease (defined as an estimated glomerular filtration rate <60 mL/min/1.73 m 2). Regarding arrhythmias, 54% of patients had a history of atrial fibrillation, and 45% were in atrial fibrillation at the time of admission. Therefore, our study population seems generalizable to real-world patients. Dr Albulushi was also interested in long-term data on readmission rates or mortality, but we did not collect data beyond discharge. Shahriar et al request more information on the diuretic response assessments after the first loop diuretic dose. Indeed, there were more patients with an insufficient urine output (UO; 19.6%) than an insufficient urinary sodium concentration (UNa; 12.6%) in the protocol arm. We performed additional analyses to provide more in-depth information: 36 (25.2%) patients had any sign of insufficient diuretic response. Of those, 8 (5.6%) only had UNa <50 mmol/L; 18 (12.6%) only had UO <100 mL/h, and 10 (7.0%) had both UNa <50 mmol/L and UO <100 mL/h. Thus, both measures can be incongruent and have additive value. Recent observational data in a small group of acute heart failure patients have already suggested that UNa and UO may differ. 4 When a threshold of UNa <70 mmol/L is applied, 60 (24.5%) patients in the standard of care group and 26 (18.3%) patients in the protocol group had an insufficient diuretic response. Potentially, a cutoff value of UNa <70 mmol/L might identify a larger group of patients with an insufficient diuretic response. A cutoff value of UNa <70 mmol/K was also used in the recent Pragmatic Urinary Sodium-Based Treatment Algorithm in Acute Heart Failure randomized trial. 5 In addition, the trial used a higher UO threshold with UO <150 mL/h. Again, the natriuresis-guided protocol performed better than the standard of care, but UNa and UO were not always congruent. ARTICLE INFORMATION Affiliation
When is the time right? Dancing on the tightrope: referral for upgrade to cardiac resynchronization therapy
No full textExploiting 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
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
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.
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