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Doses of diuretics commonly used to treat heart failure (with and without a preserved ejection fraction, chronic and acute)
Source publication
ESC Committee for Practice Guidelines (CPG): Jeroen J. Bax (CPG Chairperson) (The Netherlands), Helmut Baumgartner (Germany), Claudio Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK), Robert Fagard (Belgium), Christian Funck-Brentano (France), David Hasdai (Israel), Arno Hoes (The Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti...
Citations
... Observed baseline differences in indication may have also contributed to the higher risk of the composite renal outcome observed in the dual therapy arm, since dual blockade was indicated for treatment of progressive proteinuric CKD for much of the time period of this study. [30][31][32] Our results from benchmarking against the trial were consistent with ONTARGET findings where confounding by indication was not present due to randomisation. ...
We aimed to explore whether the ONTARGET trial results, which led to an end of recommendations of dual angiotensin-converting enzyme inhibitor (ACEi) and angiotensin receptor blocker (ARB) use, extended to patients with chronic kidney disease (CKD) who were underrepresented in the trial.
We selected people prescribed an ACEi and/or an ARB in the UK Clinical Practice Research Datalink Aurum during 1/1/2001-31/7/2019. We specified an operational definition of dual users and applied ONTARGET eligibility criteria. We used propensity-score-weighted Cox-proportional hazards models to compare dual therapy to ACEi for the primary composite trial outcome (cardiovascular death, myocardial infarction, stroke, or hospitalisation for heart failure), as well as a primary composite renal outcome (≥50% reduction in GFR or end-stage kidney disease), and other secondary outcomes, including hyperkalaemia. Conditional on successfully benchmarking results against the ONTARGET trial, we explored treatment effect heterogeneity by CKD at baseline.
In the propensity-score-weighted trial-eligible analysis cohort (n=412 406), for dual therapy vs ACEi we observed hazard ratio (HR) 0.98 (95% CI: 0.93, 1.03), for the primary composite outcome, consistent with the trial results (ONTARGET HR 0.99, 95% CI: 0.92, 1.07). Dual therapy use was associated with an increased risk of the primary renal composite outcome, HR 1.25 (95% CI: 1.15, 1.36) vs ONTARGET HR 1.24 (1.01, 1.51) and hyperkalaemia, HR 1.15 (95% CI: 1.09, 1.22) in the trial eligible cohort, consistent with ONTARGET. The presence of CKD at baseline had minimal impact on results.
... The intention of the guidelines committee was not to abruptly introduce new clinical entities with specific therapeutic and morphological backgrounds, but rather to encourage dedicated research into the "underlying characteristics, pathological aspects, and therapeutic features of the patient population". According to the 2021 ESC guidelines [3], the diagnosis of HFmrEF is based on the presence of clinical symptoms and signs [13,14], alongside an LVEF ranging from 41 to 49%. Additional criteria such as structural and functional cardiac abnormalities (LV hypertrophy and/or enlarged LV and/or diastolic dysfunction) and elevated natriuretic peptides further support the diagnosis of HFmrEF. ...
Heart failure (HF) presents a significant global health challenge recognised by frequent hospitalisation and high mortality rates. The assessment of left ventricular (LV) ejection fraction (EF) plays a crucial role in diagnosing and predicting outcomes in HF, leading to its classification into preserved (HFpEF), reduced (HFrEF), and mildly reduced (HFmrEF) EF. HFmrEF shares features of both HFrEF and HFpEF but also exhibits distinct characteristics. Despite advancements, managing HFmrEF remains challenging due to its diverse presentation. Large-scale studies are needed to identify the predictors of clinical outcomes and treatment responses. Utilising biomarkers for phenotyping holds the potential for discovering new treatment targets. Given the uncertainty surrounding optimal management, individualised approaches are imperative for HFmrEF patients. This chapter examines HFmrEF, discusses the rationale for its re-classification, and elucidates HFmrEF’s key attributes. Furthermore, it provides a comprehensive review of current treatment strategies for HFmrEF patients.
... Effectively managing CHF involves essential self-care practices such as medication adherence, limitations on salt and fluid intake, symptom monitoring, regular check-ups, and regular physical activity. These strategies are crucial for enhancing QOL and reducing the risk of readmission due to decompensation episodes [18][19][20]. However, engaging in CHF self-care activities, such as taking note of food items or seeking professional help, can have the effect of causing the individual to establish a psychological connection to the tangible and potentially distressing consequences associated with CHF, thereby evoking thoughts about the illness and eliciting reactions to its potential dangers. ...
Background
Chronic heart failure (CHF) poses a significant burden on both patients and their family caregivers (FCs), as it is associated with psychological distress and impaired quality of life (QOL). Acceptance and Commitment Therapy (ACT) supports QOL by focusing on value living and facilitates acceptance of psychological difficulties by cultivating psychological flexibility. A protocol is presented that evaluates the effectiveness of a dyad ACT-based intervention delivered via smartphone on QOL and other related health outcomes compared with CHF education only.
Methods
This is a single-center, two-armed, single-blinded (rater), randomized controlled trial (RCT). One hundred and sixty dyads of CHF patients and their primary FCs will be recruited from the Cardiology Department of a hospital in China. The dyads will be stratified block randomized to either the intervention group experiencing the ACT-based intervention or the control group receiving CHF education only. Both groups will meet two hours per week for four consecutive weeks in videoconferencing sessions over smartphone. The primary outcomes are the QOL of patients and their FCs. Secondary outcomes include psychological flexibility, psychological symptoms, self-care behavior, and other related outcomes. All outcomes will be measured by blinded outcome assessors at baseline, immediately post-intervention, and at the three-month follow-up. Multilevel modeling will be conducted to assess the effects of the intervention.
Discussion
This study is the first to adopt an ACT-based intervention for CHF patient-caregiver dyads delivered in groups via smartphone. If effective and feasible, the intervention strategy and deliverable approach could be incorporated into clinical policies and guidelines to support families with CHF without geographic and time constraints.
Trial registration
ClinicalTrials.gov Identifier: NCT04917159 . Registered on 08 June 2021.
... However, diagnosing HFpEF proves challenging and varies across studies, posing a significant issue in clinical trials. [17][18][19] Symptoms such as fatigue or dyspnea in patients with preserved LVEF may not solely originate from HFpEF, with some patients exhibiting co-morbidities that drive symptoms and events, potentially limiting the benefits of HF treatment when cardiac event risk is low. [20][21][22][23] In our study, the mean age of patients with congestive heart failure (CHF) was 56.40±12.90 ...
... Echocardiography emerged as a valuable tool for assessing left ventricular function and guiding HF management. Its accuracy, accessibility, safety, and cost-effectiveness make it the preferred diagnostic approach, particularly in suspected HF cases, as recommended by the European Society of Cardiology guidelines 17 . ...
Objectives: Heart failure (HF) poses a significant global health burden, characterized by inadequate cardiac output and systemic organ dysfunction. This study aimed to compare in-hospital outcomes between patients with reduced (HFrEF) and preserved (HFpEF) ejection fraction presenting with congestive heart failure. Methodology: A cross-sectional, prospective study was conducted at the Department of Cardiology, National Institute of Cardiovascular Diseases, Karachi, Pakistan, from July 2022 to January 2023. Patients aged 35 to 80 years with congestive heart failure were included. Ejection fraction status, demographic data, and clinical parameters were assessed, with in-hospital mortality as the primary outcome. Results: Among 196 patients, 91 (46.4%) had HFrEF, and 105 (53.6%) had HFpEF. In-hospital mortality occurred in 23 (11.7%) patients. Mortality rates were significantly higher in HFrEF patients compared to HFpEF patients (17.6% vs. 6.7%, p=0.018). Age (>60 years) and diabetes mellitus were significantly associated with in-hospital mortality (p=0.001 and p=0.036, respectively). Conclusion: This study highlights significantly higher in-hospital mortality rates in patients with reduced ejection fraction compared to preserved ejection fraction, underscoring the importance of considering ejection fraction status in assessing prognosis and guiding management strategies for patients with congestive heart failure.
... The most often mentioned prevalence estimate for the adult population at large is 2% (1-3%), and 5-9% selectively in those aged 65 years and over. 8,9 AHF is a new onset or worsening of heart failure signs and symptoms and is the most common cause of unplanned hospitalization in patients 65 years of age. 10 Therefore, it is particularly important to effectively identify the occurrence of MACE at 30 days when the elderly acute heart failure patients with preserved ejection fraction discharge, which can provide effective treatment for the patients for improving prognosis. To our knowledge, Hb reflects the level of malnutrition and inflammation in the body, which is a marker of the severity of heart failure and is an important predictor of the prognosis of heart failure. ...
Purpose
To investigate the predictive value of hemoglobin (Hb) to red blood cell distribution width (RDW) (Hb/RDW) ratio in combination with serum sodium for major adverse cardiovascular events (MACE) in elderly acute heart failure patients with preserved ejection fraction at 30 days after discharge.
Methods
130 elderly acute heart failure patients with preserved ejection fraction were enrolled and followed up at 30 days after discharge. They were classified into the MACE group (n=11) and none-MACE group (n=119). On the day of admission, clinical baseline characteristics were measured and results from laboratory tests were gathered. The correlation and predictive value of Hb/RDW and serum sodium with the occurrence of MACE at 30 days after discharge in acute heart failure patients with preserved ejection fraction in the elderly were analyzed.
Results
Spearman correlation analysis showed that the occurrence of MACE was negatively correlated with Hb/RDW, serum sodium (r=−0.209, r=0.291, p<0.05) and Hb/RDW (OR=0.484, 95% CI:0.254, 0.922), serum sodium (OR=0.779, 95% CI:0.646,0.939) were independent risk factors (p<0.05) analyzed by multifactorial logistic. Receiver operating characteristic curves (ROC) analysis showed that the area under the curve (AUC) for the prediction of MACE by Hb/RDW was 0.73, with an optimal threshold of 9.28, sensitivity 81.80%, specificity 70.60%, positive predictive value (PPV) 20.50%, negative predictive value (NPV) 97.70%; the AUC of serum sodium for predicting the occurrence of MACE was 0.76, with an optimal threshold of 140.35 mmol/L, sensitivity 90.90%, specificity 57.10%, PPV 16.40%, NPV 98.60%; and the AUC of Hb/RDW combined serum sodium to predict the occurrence of MACE was 0.83, with sensitivity 90.90%, specificity 78.20%, PPV 27.80% and NPV 98.90%.
Conclusion
Hb/RDW and serum sodium had negative correlation with MACE and were independent risk factors of 30-day MACE; Hb/RDW combined with serum sodium can predict 30-day MACE occurrence in elderly acute heart failure patients with preserved ejection fraction.
... In the same year, a modification of the AHF categories derived from the Forrester classification for heart failure after myocardial infarction was proposed, which is based on the presence or absence of tissue congestion and perfusion [4]. The heart failure guide from 2012 proposed the classification of AHF based on the level of systolic blood pressure (SBP) at the initial presentation of the patient [5,6]. All of the aforementioned divisions of AHF were analyzed within the ESC Heart Failure Long-Term (HF-LT) registry and the study published by Chioncel et al. ...
Although acute heart failure (AHF) is a common disease associated with significant symptoms, morbidity and mortality, the diagnosis, risk stratification and treatment of patients with hypertensive acute heart failure (H-AHF) still remain a challenge in modern medicine. Despite great progress in diagnostic and therapeutic modalities, this disease is still accompanied by a high rate of both in-hospital (from 3.8% to 11%) and one-year (from 20% to 36%) mortality. Considering the high rate of rehospitalization (22% to 30% in the first three months), the treatment of this disease represents a major financial blow to the health system of each country. This disease is characterized by heterogeneity in precipitating factors, clinical presentation, therapeutic modalities and prognosis. Since heart decompensation usually occurs quickly (within a few hours) in patients with H-AHF, establishing a rapid diagnosis is of vital importance. In addition to establishing the diagnosis of heart failure itself, it is necessary to see the underlying cause that led to it, especially if it is de novo heart failure. Given that hypertension is a precipitating factor of AHF and in up to 11% of AHF patients, strict control of arterial blood pressure is necessary until target values are reached in order to prevent the occurrence of H-AHF, which is still accompanied by a high rate of both early and long-term mortality.
... Decompensated HF (DHF) occurs when a heart with existing HF is unable to meet the physiological needs of the body. HF has a high prevalence and incidence worldwide, with an incidence of 10% in the population over the age of 70 [2]. A study conducted in 2012 showed that 21.5% of hospital admissions for cardiovascular disease in Brazil were due to HF. ...
... In the absence of hypotension, intravenous nitrates may be given as an adjunctive to diuretic agents in patients with decompensated heart failure (54,55). Intravenous nitrate is administered to relieve the symptoms of acute heart failure when systolic blood pressure is above 110 mmHg in the absence of severe aortic or mitral stenosis (22,56). The infusion is usually set to start at low rate then can be up-titrated according to clinical status and blood pressure measurements (22). ...
Patients at each shock stage may behave and present differently with a spectrum of shock severity and adverse outcomes. Shock severity, shock aetiology, and several factors should be integrated in management decision-making. Although the contemporary shock stages classification provided a standardized shock severity assessment, individual agents or management strategy has not yet been studied in the context of each shock stage. The pre-shock state may comprise a wide range of presentations. Nitrate therapy has potential benefit in myocardial infarction and acute heart failure. Herein, this review aims to discuss the potential use of nitrate therapy in the context of the pre-shock state or stage B of the contemporary shock classification given its various presentations.
... kjronline.org dysfunction, which is defined by abnormal LVEF, can be measured using any modality; however, LVEF abnormality should be shown either by two independent imaging modalities or on two distinct occasions using the same technique (preferably echocardiography or CMR) [9]. Cine imaging can be used to assess segmental wall-motion abnormalities in the LV or in LV dilatation and LVEF. ...
Dilated cardiomyopathy (DCM) is one of the most common types of non-ischemic cardiomyopathy. DCM is characterized by left ventricle (LV) dilatation and systolic dysfunction without coronary artery disease or abnormal loading conditions. DCM is not a single disease entity and has a complex historical background of revisions and updates to its definition because of its diverse etiology and clinical manifestations. In cases of LV dilatation and dysfunction, conditions with phenotypic overlap should be excluded before establishing a DCM diagnosis. The differential diagnoses of DCM include ischemic cardiomyopathy, valvular heart disease, burned-out hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, and non-compaction. Cardiac magnetic resonance (CMR) imaging is helpful for evaluating DCM because it provides precise measurements of cardiac size, function, mass, and tissue characterization. Comprehensive analyses using various sequences, including cine imaging, late gadolinium enhancement imaging, and T1 and T2 mapping, may help establish differential diagnoses, etiological work-up, disease stratification, prognostic determination, and follow-up procedures in patients with DCM phenotypes. This article aimed to review the utilities and limitations of CMR in the diagnosis and assessment of DCM.
... The action of MRAs in preventing aldosterone through competitive association with mineralocorticoid receptors is proving to be an effective complementary drug to ACEi for patients with HF, thus making MRAs one of the four classes of drugs used in the treatment of heart failure (26). MRAs also reduce NP levels and LA volume in patients with HF and have mild diuretic properties, the addition of MRAs can help with diuresis in addition to the Effect of MRAs on major adverse cardiovascular events, all-cause mortality, cardiovascular death, myocardial infarction, stroke, hyperkalemia and gynecomastia over 2.1 years. ...
Aims
Recent studies have shown that mineralocorticoid receptor antagonists (MRAs) can decrease mortality in patients with heart failure; however, the application of MRAs in current clinical practice is limited because of adverse effects such as hyperkalemia that occur with treatment. Therefore, this meta-analysis used the number needed to treat (NNT) to assess the efficacy and safety of MRAs in patients with chronic heart failure.
Methods
We meta-analysed randomized controlled trials (RCTs) which contrasted the impacts of MRAs with placebo. As of March 2023, all articles are published in English. The primary outcome was major adverse cardiovascular events (MACE), and secondary outcomes included all-cause mortality, cardiovascular death, myocardial infarction (MI), stroke, and adverse events.
Results
We incorporated seven studies with a total of 9,056 patients, 4,512 of whom received MRAs and 4,544 of whom received a placebo, with a mean follow-up period of 2.1 years. MACE, all-cause mortality, and cardiovascular mortality were all reduced by MRAs, with corresponding numbers needed to treat for benefit (NNTB) of 37, 28, and 34; as well as no impact on MI or stroke. MRAs increased the incidence of hyperkalemia and gynecomastia, with the corresponding mean number needed to treat for harm (NNTH) of 18 and 52.
Conclusions
This study showed that enabling one patient with HF to avoid MACE required treating 37 patients with MRAs for 2.1 years. MRAs reduce MACE, all-cause mortality, and cardiovascular death; however, they increase the risk of hyperkalemia and gynecomastia.
