scholarly journals Need to revisit heart failure treatment guidelines for hyperkalaemia management during the use of mineralocorticoid receptor antagonists

2018 ◽  
Vol 20 (9) ◽  
pp. 1247-1251 ◽  
Author(s):  
Javed Butler ◽  
Shilpa Vijayakumar ◽  
Bertram Pitt
Keyword(s):  
Heart Failure ◽  
Mineralocorticoid Receptor ◽  
Treatment Guidelines ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Heart Failure Treatment ◽  
Failure Treatment

Abstract 040: Mineralocorticoid Receptor Antagonists After Hospitalization of Patients With Heart Failure With a Reduced Ejection Fraction

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Matthew S Durstenfeld ◽  
Stuart D Katz ◽  
Hannah Park ◽  
Saul Blecker
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Mineralocorticoid Receptor ◽  
Secondary Diagnosis ◽  
Mineralocorticoid Receptor Antagonists ◽  
Principal Diagnosis ◽  
Receptor Antagonists ◽  
Reduced Ejection Fraction ◽  
Patients With Heart Failure ◽  
Before And After

Background: Mineralocorticoid receptor antagonists (MRAs) are an important component of guideline-directed therapy for patients with heart failure with a reduced ejection fraction (HFrEF) but are underutilized in clinical practice. Hospitalization is a quality-improvement opportunity to increase appropriate use of MRAs, particularly as this therapy is associated with reduced readmission following both hospitalizations with a principal and secondary diagnosis of heart failure. We studied MRA prescription for heart failure patients before and after hospitalization. Methods: We performed a retrospective cohort study of adults hospitalized within an academic tertiary-care hospital system in 2013-2015 with a principal or secondary discharge diagnosis of heart failure. We included patients with ejection fraction ≤35%, systolic blood pressure ≥100 mm Hg, estimated glomerular filtration rate >30 ml/min/1.73 m 2 , and potassium <5.0 mEq/L. We recorded MRA prescription before and after hospitalization. We used McNemar’s test to compare MRA prescription before and after hospitalization, with pre-specified principal and secondary diagnosis subgroups. We used the chi-square test to compare prescriptions between groups. Results: Among 1176 hospitalizations of patients who met the inclusion criteria, the mean age was 72.7±13.4 years and 366 (31%) were female. Of these patients, 303 (25.8%) were prescribed MRAs prior to hospitalization and 331 (28.2%) were prescribed them at discharge, a small but statistically significant increase (p=0.02). Among patients previously prescribed MRAs, 241 (79.5%) continued them at discharge. Among 873 patients not previously prescribed MRAs, 90 (10.3%) had MRAs initiated at discharge. Among 347 patients with a principal diagnosis of heart failure, 95 had MRAs continued, 27 had MRAs discontinued, and 39 had MRAs initiated, a non-significant increase of 12 patients (+3.6%, p=0.14). Among 829 patients with a secondary diagnosis, 146 had MRAs continued, 35 had MRAs discontinued, and 51 had MRAs initiated, a non-significant increase of 16 patients (+1.9%, p=0.08). More patients with a principal diagnosis received MRAs at discharge: 134/347 (38.6%) compared to 197/829 (23.7%) patients discharged with a secondary diagnosis of HFrEF, p<0.0001; similarly, patients with a principal diagnosis of HFrEF had higher rates of MRA initiation at discharge: 39/225 (17.3%) versus 51/648 (7.9%), p=0.0004. Conclusions: Over 70% of hospitalized HFrEF patients did not receive MRAs before or after hospitalization. Although more patients with a principal diagnosis than secondary diagnosis of heart failure received MRAs and had them initiated, over 80% of eligible patients not on MRAs were not initiated on them at discharge. Hospitalization remains an opportunity to identify patients indicated for MRAs and initiate guideline-directed heart failure pharmacotherapy.

Chronic heart failure: definitions, investigation, and management

2010 ◽  
pp. 2728-2728
Author(s):  
John G.F Cleland ◽  
Andrew L Clark
Keyword(s):  
Heart Failure ◽  
Heart Disease ◽  
Chronic Heart Failure ◽  
Ejection Fraction ◽  
Sinus Rhythm ◽  
Mineralocorticoid Receptor ◽  
Angiotensin Receptor ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
High Concentrations

Heart failure is a common clinical syndrome, often presenting with breathlessness, fatigue and peripheral oedema. It is predominantly a disease of older people. The prevalence is increasing, exceeding 2% of the adult population in developed countries. The pathophysiology of heart failure is complex. A common feature is salt and water retention, possibly triggered by a relative fall in renal perfusion pressure. Common aetiologies include ischaemic heart disease, hypertension, and valvular heart disease. The early diagnosis of heart failure relies on a low threshold of suspicion and screening of people at risk before the onset of obvious symptoms or signs. In patients with suspected heart failure, routine investigation with electrocardiography and blood tests for urea and electrolytes, haemoglobin and BNP/NT-proBNP are recommended. Low plasma concentrations of BNP/NT-proBNP exclude most forms of heart failure. Intermediate or high concentrations should prompt referral for echocardiography to identify possible causes of heart failure and the left ventricular ejection fraction (LVEF). Patients can be classified as reduced (<40%) LVEF (HFrEF), normal (>50%) LVEF (HFnEF), or borderline (40–50%) LVEF (HFbEF). Currently HFbEF and HFnEF are managed similarly by current guidelines. Treatable causes for heart failure (e.g. valvular disease, tachyarrhythmias, thyrotoxicosis, anaemia or hypertension) should be identified and corrected. Patients with heart failure will generally benefit from lifestyle advice (diet, exercise, vaccination). Pharmacological therapy is given to improve symptoms and prognosis. Diuretic therapy is the mainstay for control of congestion and symptoms; it may be life-saving for patients with acute heart failure but its effect on long-term prognosis is unknown. For patients with HFrEF, either angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers, or, more recently, angiotensin receptor neprilysin inhibitors, combined with β‎-blockers and mineralocorticoid receptor antagonists (triple therapy) provide both symptomatic and prognostic benefit. Ivabridine may be added for those in sinus rhythm where the heart rate remains above 70 bpm. Whether digoxin still has a role in contemporary management is uncertain. Cardiac resynchronization therapy is appropriate for symptomatic patients with HFrEF if they are in sinus rhythm and have a broad QRS (>140 ms). Implantable defibrillators provide additional prognostic benefit in selected patients with an ejection fraction below 35%. For patients with HFnEF, treatments directed at comorbid conditions (e.g. hypertension, atrial fibrillation) and congestion (e.g. diuretics and mineralocorticoid receptor antagonists) are appropriate but there is no robust evidence that any treatment can improve prognosis. Heart transplantation or assist devices may be options for highly selected patients with endstage heart failure; many others may benefit from palliative care services. Effective management of chronic heart failure requires a coordinated multidisciplinary team, including heart failure nurse specialists, primary care physicians, and cardiologists. New treatments have improved the prognosis of heart failure substantially over the past two decades. The annual mortality is now probably less than 5% for patients with HFrEF receiving good contemporary care whose symptoms are stable and controlled. For patients with recurrent or recalcitrant congestion requiring admission to hospital, the prognosis is much worse. In-patient mortality is about 5% for those aged less than 75 years but threefold higher for older patients; mortality in the year after discharge ranges from 20% to 40% depending on age.

Mineralocorticoid receptor antagonists

ESC CardioMed ◽  
2018 ◽  
pp. 167-173
Author(s):  
Faiez Zannad ◽  
João Pedro Ferreira
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Adverse Effects ◽  
Beneficial Effect ◽  
Mechanism Of Action ◽  
Mineralocorticoid Receptor ◽  
Post Myocardial Infarction ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Clinical Syndromes

Hypertension, post-myocardial infarction, and heart failure are the cardiovascular clinical syndromes where mineralocorticoid receptor antagonists (MRAs) have shown a beneficial effect. Most guidelines while recommending a MRA do not make a clear recommendation as to which MRA should be used, how doses should be titrated, or which monitorization is indicated. This chapter provides an appraisal of the different types of MRA drugs and their pharmacological differences with respect to mechanism of action, pharmacokinetics, monitoring, adverse effects, and drug interactions.

scholarly journals Molecular, Cellular, and Clinical Evidence That Sodium‐Glucose Cotransporter 2 Inhibitors Act as Neurohormonal Antagonists When Used for the Treatment of Chronic Heart Failure

2020 ◽  
Vol 9 (16) ◽  
Author(s):  
Milton Packer
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Mineralocorticoid Receptor ◽  
Sglt2 Inhibitors ◽  
Autophagic Flux ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Cellular Effects ◽  
Sodium Glucose Cotransporter ◽  
Β Blockers

Abstract Sodium‐glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure. Initially, these drugs were believed to have a profile similar to diuretics or hemodynamically active drugs, but they do not rapidly reduce natriuretic peptides or cardiac filling pressures, and they exert little early benefit on symptoms, exercise tolerance, quality of life, or signs of congestion. Clinically, the profile of SGLT2 inhibitors resembles that of neurohormonal antagonists, whose benefits emerge gradually during sustained therapy. In experimental models, SGLT2 inhibitors produce a characteristic pattern of cellular effects, which includes amelioration of oxidative stress, mitigation of mitochondrial dysfunction, attenuation of proinflammatory pathways, and a reduction in myocardial fibrosis. These cellular effects are similar to those produced by angiotensin converting enzyme inhibitors, β‐blockers, mineralocorticoid receptor antagonists, and neprilysin inhibitors. At a molecular level, SGLT2 inhibitors induce transcriptional reprogramming of cardiomyocytes that closely mimics that seen during nutrient deprivation. This shift in signaling activates the housekeeping pathway of autophagy, which clears the cytosol of dangerous cytosolic constituents that are responsible for cellular stress, thereby ameliorating the development of cardiomyopathy. Interestingly, similar changes in cellular signaling and autophagic flux have been seen with inhibitors of the renin‐angiotensin system, β‐blockers, mineralocorticoid receptor antagonists, and neprilysin inhibitors. The striking parallelism of these molecular, cellular, and clinical profiles supports the premise that SGLT2 inhibitors should be regarded as neurohormonal antagonists when prescribed for the treatment of heart failure with a reduced ejection fraction.

1136Prognostic impact of mineralocorticoid receptor antagonists in patients hospitalized for acute heart failure

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
H Yaku ◽  
T Kato ◽  
T Morimoto ◽  
Y Inuzuka ◽  
Y Tamaki ◽  
...  
Keyword(s):  
Heart Failure ◽  
Lower Risk ◽  
Mineralocorticoid Receptor ◽  
Primary Outcome ◽  
Outcome Measure ◽  
Primary Outcome Measure ◽  
Matched Cohort ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists

Abstract Background The favourable effect of mineralocorticoid receptor antagonists (MRAs) on mortality was established in patients with stable heart failure (HF) with reduced ejection fraction (EF). However, its prognostic effect of MRAs in acute decompensated heart failure (ADHF) including HF with preserved EF (HFpEF) was unclear. Purpose This study sought to investigate the long-term impact of MRA on the post-discharge outcomes in patients with ADHF. Methods From the consecutive 3717 patients hospitalized for ADHF and discharged alive in the KCHF registry, we developed the propensity score (PS) for MRA use and constructed the PS-matched cohort. We compared the effect of MRA use on the primary outcome measure of all-cause death or HF hospitalization. Results A total of 1678 patients (45%) received MRA at discharge from the index hospitalization. Median follow-up was 470 days with 96% 1-year follow-up rate. In the PS-matched cohort (N=1034 in each group), the cumulative 1-year incidence of the primary outcome measure was significantly lower in the MRA group than in the no MRA group (28.4% vs. 33.9%, P=0.003) (Figure 1). The cumulative 1-year incidence of HF hospitalization was significantly lower in the MRA group than in the no MRA group (18.7% vs. 24.8%, P<0.001), while there was no difference in mortality between the 2 groups (15.6% vs. 15.8%, P=0.85). There was no interaction between the effect of MRA and the 3 subgroups stratified by EF (EF <40%, EF 40–49%, EF ≥50%) (interaction P=0.12). Figure 1 Conclusion The use of MRA was associated with lower risk for the primary composite outcome of all-cause death or HF hospitalization in patients hospitalized for ADHF including HFpEF, which was mainly driven by the lower risk for HF hospitalization.

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