scholarly journals Use of sodium zirconium cyclosilicate for up-titration of renin–angiotensin–aldosterone system inhibitor therapy in patients with heart failure: a case series

2021 ◽  
Vol 5 (8) ◽  
Author(s):  
Rhys Williams ◽  
Alexander James ◽  
Moira Ashton ◽  
Sian Vaughan ◽  
Aaron Wong
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Case Series ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Additional Patient ◽  
Renin Angiotensin Aldosterone System ◽  
Renin Angiotensin ◽  
Sodium Zirconium ◽  
Sodium Zirconium Cyclosilicate

Abstract Background Patients often receive suboptimal dosing of renin–angiotensin–aldosterone system inhibitor (RAASi) therapy over concerns of hyperkalaemia. However, studies have shown associations between suboptimal dosing or interruptions to therapy and adverse clinical events. Therefore, effective treatments for hyperkalaemia that can enable optimal RAASi therapy are needed. This case series examines eight patients whose commencement on the novel potassium binder sodium zirconium cyclosilicate (SZC) allowed for the initiation and/or up-titration of RAASi therapy. Case summary Eight patients aged 64–87 years with heart failure (HF) with reduced ejection fraction all developed hyperkalaemia (serum potassium (sK+) >5.0 mmol/L) while receiving RAASi therapy. Following initiation of SZC, all patients experienced eventual stabilization of sK+ levels. All patients were able to initiate, restart, or up-titrate RAASi therapy with five patients achieving optimal medical therapy. Left ventricular ejection fraction improved in four patients, two patients are now re-classified as New York Heart Association Class I, and an additional patient had improved exercise tolerance. Follow-up for Patient 8 is still ongoing. Discussion These real-world cases demonstrate that use of SZC to manage hyperkalaemia in patients with HF is feasible and allows optimization of RAASi therapy.

scholarly journals Clinical Implications of Sodium Zirconium Cyclosilicate Therapy in Patients with Systolic Heart Failure and Hyperkalemia

2021 ◽  
Vol 10 (23) ◽  
pp. 5523
Author(s):  
Teruhiko Imamura ◽  
Akira Oshima ◽  
Nikhil Narang ◽  
Koichiro Kinugawa
Keyword(s):  
Heart Failure ◽  
Left Ventricular Ejection Fraction ◽  
Ejection Fraction ◽  
Systolic Heart Failure ◽  
Left Ventricular ◽  
Ventricular Ejection ◽  
Left Ventricular Ejection ◽  
Renin Angiotensin Aldosterone System ◽  
Ventricular Ejection Fraction ◽  
Renin Angiotensin

Background: Sodium zirconium cyclosilicate (SZC), a newly introduced specific potassium binder, is introduced to treat hyperkalemia. However, the implications of SZC in up-titrating renin–angiotensin–aldosterone system inhibitors in patients with systolic heart failure remain unknown. Methods and Results: Patients with heart failure with left ventricular ejection fraction <50% and hyperkalemia who had completed 3-month SZC therapy were retrospectively included. Serum potassium levels, the dose of renin–angiotensin–aldosterone system inhibitors, and echocardiographic parameters during the 3-month SZC therapy as compared with the pretreatment 3-month period were investigated. A total of 24 patients (median 77 years old, 71% men, median left ventricular ejection fraction 41%) received a 3-month SZC therapy without any associated adverse events including hypokalemia. Compared with the pretreatment period, serum potassium levels decreased, doses of renin–angiotensin–aldosterone system inhibitors increased, and the left ventricular ejection fraction and plasma B-type natriuretic peptide levels improved following the 3-month SZC therapy (p < 0.05 for all). Conclusions: SZC may be a promising therapeutic option to improve hyperkalemia, indirectly allowing up-titration of renin–angiotensin–aldosterone system inhibitors and facilitating reverse remodeling in patients with heart failure with a left ventricular ejection fraction <50% and hyperkalemia.

Mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction

2020 ◽  
Vol 15 (9) ◽  
pp. 1-9
Author(s):  
Kate O'Donovan
Keyword(s):  
Heart Failure ◽  
Cardiac Output ◽  
Adverse Effects ◽  
Ejection Fraction ◽  
Mineralocorticoid Receptor ◽  
Left Ventricular ◽  
Mineralocorticoid Receptor Antagonists ◽  
Renin Angiotensin Aldosterone System ◽  
Renin Angiotensin ◽  
Reduced Ejection Fraction

Heart failure with reduced ejection fraction is associated with decreased functional capacity, poor quality of life and increased mortality risk. The neurohormonal compensatory response to a reduced cardiac output is mainly comprised of the sympathetic nervous system, natriuretic peptides and the renin–angiotensin–aldosterone system, which attempt to maintain peripheral perfusion. The renin–angiotensin–aldosterone system is an integral mechanism in increasing afterload by promoting angiotensin II-mediated vasoconstriction and increasing preload via the secretion of aldosterone which causes sodium and water retention. Albeit compensatory mechanisms attempt to increase cardiac output and perfusion, their effects are maladaptive as left ventricular function deteriorates in response to an increased afterload, preload and ventricular remodelling. In an attempt to interrupt this vicious circle, first-line pharmacological therapy in the treatment of heart failure is beta blockade and inhibition of the renin–angiotensin–aldosterone system. Integral to this treatment strategy are mineralocorticoid receptor antagonists, also known as aldosterone antagonists. This class of drug inhibits the action of aldosterone, decreases preload and reduces left ventricular workload, thus preserving ventricular function. This translates into reduced mortality incidence, decreased episodes of hospitalisations for cardiac causes and improvement in clinical signs and symptoms. Although patient benefits are explicit, adverse effects such as hyperkalaemia and renal impairment are associated with this therapy. Regular patient follow up and monitoring for potential adverse effects and drug interactions are essential to the success of the therapy.

P2611The prognostic value of serum magnesium levels in patients with heart failure with preserved left ventricular ejection fraction

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T Nishihara ◽  
D Sueta ◽  
E Yamamoto ◽  
K Fujisue ◽  
H Usuku ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Serum Magnesium ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Rank Test ◽  
Lower Serum ◽  
Ventricular Ejection Fraction ◽  
Renin Angiotensin ◽  
Net Reclassification Improvement

Abstract Background In heart failure (HF) patients, various factors, such as hyperactivity of the renin-angiotensin system, influence of drug therapy such as loop and thiazide diuretics, undernutrition and others, can causes hypokalemia and hypomagnesemia. Although serum magnesium (Mg) levels are closely associated with the prognosis of HF patients, the clinical significance of serum Mg levels in cardiovascular outcomes of HF with preserved ejection fraction (HFpEF) patients is not fully understood. Purpose We examined the relationship between serum Mg and future HF-related events in patients with HFpEF. Methods This study was a retrospective, single-center, observational study. We enrolled 452 consecutive HFpEF patients admitted to our university hospital between January 2007 and September 2013 and followed them for 4 years or until occurrence of HF-related events. We defined lower serum Mg as <2.0 mg/dL (=0.8 mmol/L) and higher serum Mg as ≥2.0 mg/dL based on recent clinical evidences and compared their clinical characteristics and prognosis. Results The mean serum Mg level was 2.12 mg/dL (median, 2.1 mg/dL; interquartile range, 2.0–2.28 mg/dL). The follow-up period was 0–50 months (median, 47.3 months) and 48 HF-related events (10.6%) were recorded. The frequency of HF-related events was significantly higher in the lower serum Mg group compared with the higher serum Mg group (n=16, 17.4% vs. n=32, 8.9%; P=0.018). There were no significant differences between groups in the use of all drugs (loop diuretics, mineralcorticoid receptor antagonists, renin-angiotensin-aldosterone system inhibitors, calcium channel blockers, β-blockers, statins and Mg preparations). The lower serum Mg group (n=92) showed significantly higher prevalence of diabetes mellitus (DM), uric acid levels and B-type natriuretic peptide (BNP)levels compared with the higher serum Mg group (n=360). Kaplan-Meier curve revealed a significantly higher probability of HF-related events in the lower serum Mg group compared with the higher serum Mg group (log-rank test, P=0.012, Figure). Multivariate Cox proportional hazard analysis revealed that the lower serum Mg group had significantly and independently higher probabilities of HF-related events compared with those in the higher serum Mg group (hazard ratio: 2.37, 95% confidence intervals: 1.27–4.41, P=0.007). We reclassified the risk of a HF-related events after adding the lower serum Mg to the prognostic factors (age, previous hospitalization for HF, DM, ln-BNP); the continuous net reclassification improvement was 29.0% (p=0.041). Conclusion We first demonstrated that serum Mg was significantly correlated with the occurrence of future HF-related events in HFpEF patients. Lower serum Mg is able to successfully predict future HF-related events, and management of serum Mg in HFpEF patients is thus important. Acknowledgement/Funding None

scholarly journals Sacubitril/Valsartan Initiation Among Veterans Who Are Renin‐Angiotensin‐Aldosterone System Inhibitor Naïve With Heart Failure and Reduced Ejection Fraction

2021 ◽  
Author(s):  
April F. Mohanty ◽  
Emily B. Levitan ◽  
Jordan B. King ◽  
John A. Dodson ◽  
Orly Vardeny ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Drug Administration ◽  
Food And Drug Administration ◽  
Left Ventricular Ejection ◽  
Renin Angiotensin Aldosterone System ◽  
Renin Angiotensin ◽  
Reduced Ejection Fraction ◽  
Daily Dose

Background Sacubitril/valsartan, a first‐in‐class angiotensin receptor neprilysin inhibitor, received US Food and Drug Administration approval in 2015 for heart failure with reduced ejection fraction (HFrEF). Our objective was to describe the sacubitril/valsartan initiation rate, associated characteristics, and 6‐month follow‐up dosing among veterans with HFrEF who are renin‐angiotensin‐aldosterone system inhibitor (RAASi) naïve. Methods and Results Retrospective cohort study of veterans with HFrEF who are RAASi naïve defined as left ventricular ejection fraction (LVEF) ≤40%; ≥1 in/outpatient heart failure visit, first RAASi (sacubitril/valsartan, angiotensin‐converting enzyme inhibitor [ACEI]), or angiotensin‐II receptor blocker [ARB]) fill from July 2015 to June 2019. Characteristics associated with sacubitril/valsartan initiation were identified using Poisson regression models. From July 2015 to June 2019, we identified 3458 sacubitril/valsartan and 29 367 ACEI or ARB initiators among veterans with HFrEF who are RAASi naïve. Sacubitril/valsartan initiation increased from 0% to 26.5%. Sacubitril/valsartan (versus ACEI or ARB) initiators were less likely to have histories of stroke, myocardial infarction, or hypertension and more likely to be older and have diabetes mellitus and lower LVEF. At 6‐month follow‐up, the prevalence of ≥50% target daily dose for sacubitril/valsartan, ACEI, and ARB initiators was 23.5%, 43.2%, and 47.1%, respectively. Conclusions Sacubitril/valsartan initiation for HFrEF in the Veterans Administration increased in the 4 years immediately following Food and Drug Administration approval. Sacubitril/valsartan (versus ACEI or ARB) initiators had fewer baseline cardiovascular comorbidities and the lowest proportion on ≥50% target daily dose at 6‐month follow‐up. Identifying the reasons for lower follow‐up dosing of sacubitril/valsartan could support guideline recommendations and quality improvement strategies for patients with HFrEF.

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