scholarly journals A propitious time for initiating clinical trials in patients with heart failure with reduced ejection fraction and an estimated glomerular filtration rate <30 mL/min with an mineralocorticoid receptor antagonist and a K+binder: ‘the forbidden fruit’

2016 ◽  
Vol 37 (41) ◽  
pp. 3130-3134 ◽  
Author(s):  
Murray Epstein ◽  
Bertram C. Pitt
Keyword(s):  
Heart Failure ◽  
Clinical Trials ◽  
Glomerular Filtration Rate ◽  
Ejection Fraction ◽  
Mineralocorticoid Receptor ◽  
Filtration Rate ◽  
Estimated Glomerular Filtration Rate ◽  
Mineralocorticoid Receptor Antagonist ◽  
Reduced Ejection Fraction ◽  
Patients With Heart Failure

scholarly journals Estimated Glomerular Filtration Rate Is Associated With an Increased Risk of Death in Heart Failure Patients With Preserved Ejection Fraction

2021 ◽  
Vol 8 ◽  
Author(s):  
Zhuo Chen ◽  
Qian Lin ◽  
Jingen Li ◽  
Xinyi Wang ◽  
Jianqing Ju ◽  
...  
Keyword(s):  
Heart Failure ◽  
Glomerular Filtration Rate ◽  
Ejection Fraction ◽  
Glomerular Filtration ◽  
Filtration Rate ◽  
Estimated Glomerular Filtration Rate ◽  
Cardiovascular Death ◽  
Preserved Ejection Fraction ◽  
Increased Risk ◽  
Patients With Heart Failure

Background: Renal dysfunction is associated with adverse cardiovascular outcomes in patients with heart failure (HF), but its impact on patients with heart failure with preserved ejection fraction (HFpEF) remains unclear.Methods: 3,392 subjects of the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial were assigned to two groups by estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m2 or 30–59 ml/min/1.73 m2. The outcomes, including all-cause death, cardiovascular death and HF hospitalization, were examined by multivariable cox models.Results: Over a median follow-up of 3.4 ± 1.7 years, a total of 524 all-cause deaths, 334 cardiovascular deaths and 440 HF hospitalizations occurred. Compared with patients with eGFR ≥ 60 ml/min/1.73 m2, those with eGFR 30–59 ml/min/1.73 m2 were associated with an increased risk of the all-cause death [adjusted hazard ratio (HR), 1.47; 95% confidence interval (CI), 1.24–1.76; P &lt; 0.001], cardiovascular death (adjusted HR, 1.53; 95% CI: 1.23–1.91; p &lt; 0.001), and HF hospitalization (adjusted HR: 1.21; 95% CI: 1.00–1.47; p = 0.049) after multivariable adjustment for potential confounders.Conclusions: eGFR 30–59 ml/min/1.73 m2 was related to an increased risk of all-cause death, cardiovascular death and HF hospitalization in HFpEF patients.

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.

scholarly journals Treatment of Atrial Fibrillation in Patients with Co-existing Heart Failure and Reduced Ejection Fraction: Time to Revisit the Management Guidelines?

2018 ◽  
Vol 7 (2) ◽  
pp. 91 ◽  
Author(s):  
Alex Baher ◽  
Nassir F Marrouche ◽  
◽  
◽  
◽  
...  
Keyword(s):  
Heart Failure ◽  
Clinical Trials ◽  
Catheter Ablation ◽  
Ejection Fraction ◽  
Rhythm Control ◽  
Pharmacological Interventions ◽  
Reduced Ejection Fraction ◽  
Increased Risk ◽  
Patients With Heart Failure ◽  
Heart Failure Hospitalisation

AF in patients with heart failure and reduced ejection fraction (HFrEF) is common and is associated with an increased risk of stroke, heart failure hospitalisation and all-cause mortality. Rhythm control of AF in this population has been traditionally limited to the use of antiarrhythmic drugs. Clinical trials assessing superiority of pharmacological rhythm control over rate control have been largely disappointing. Catheter ablation has emerged as a viable alternative to pharmacological rhythm control in symptomatic AF and has enjoyed significant technological advancements over the past decade. Recent clinical trials have suggested that catheter ablation is superior to pharmacological interventions in patients with co-existing AF and HFrEF. In this article, we will review the therapeutic options for AF in patients with HFrEF in the context of the latest clinical trials beyond the current established guidelines.

scholarly journals Changes of myocardial fibrosis markers with the use of beta-blockers and mineralocorticoid receptor antagonists in patients with heart failure with mid-range ejection fraction of ischemic origin

2021 ◽  
Vol 20 (7) ◽  
pp. 3068
Author(s):  
O. A. Osipova ◽  
E. V. Gosteva ◽  
T. P. Golivets ◽  
O. N. Belousova ◽  
O. A. Zemlyansky ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Myocardial Fibrosis ◽  
Mineralocorticoid Receptor ◽  
Nyha Class ◽  
Class Ii ◽  
Class I ◽  
Enzyme Linked Immunosorbent Assay ◽  
Mineralocorticoid Receptor Antagonist ◽  
Patients With Heart Failure

Aim. To compare the effect of 12-month pharmacotherapy with a betablocker (BB) (bisoprolol and nebivolol) and a combination of BB with a mineralocorticoid receptor antagonist (bisoprolol+eplerenone, nebivolol+eplerenone) on following fibrosis markers: matrix metalloproteinases 1 and 9 (MMP-1, MMP-9) and tissue inhibitor of MMP-1 (TIMP-1) in patients with heart failure with mid-range ejection fraction (HFmrEF) of ischemic origin.Material and methods. The study included 135 patients, including 40 (29,6%) women and 95 (70,4%) men aged 45-60 years (mean age, 53,1±5,7 years). Patients were randomized into subgroups based on pharmacotherapy with BB (bisoprolol or nebivolol) and their combination with eplerenone. The enzyme-linked immunosorbent assay was used to determine the level of MMP-1, MMP-9, TIMP-1 (ng/ml) using the commercial test system “MMP-1 ELISA”, “MMP-9 ELISA”, “Human TIMP-1 ELISA” (“Bender Medsystems “, Austria).Results. In patients with HFmrEF of ischemic origin, there were following downward changes in serum level of myocardial fibrosis markers, depending on the therapy: bisoprolol  — MMP-1 decreased by 35% (p<0,01), MMP-9  — by 56,3% (p<0,001), TIMP-1  — by 17,9% (p<0,01); nebivolol  — MMP-1 decreased by 45% (p<0,001), MMP-9  — by 57,1% (p<0,001), TIMP-1  — by 30,1% (p<0,01); combination of bisoprolol with eplerenone  — MMP-1 decreased by 43% (p<0,001), MMP-9  — by 51,2% (p<0,001), TIMP-1  — by 25,1% (p<0,01); combination of nebivolol with eplerenone  — MMP-1 decreased by 53% (p<0,001), MMP-9 — by 64,3% (p<0,001), TIMP-1 — by 39% (p<0,01). In patients with NYHA class I HFmrEF after 12-month therapy, the decrease in MMP-1 level was 39,9% (p<0,01), MMP-9  — 57,5% (p<0,001). In class II, the decrease in MMP-1 level was 47% (p<0,001), MMP-9 — 49,7% (p<0,001). A significant decrease in TIMP-1 level was revealed in patients with class I by 29% (p<0,01), in patients with class II by 27,1% (p<0,01) compared with the initial data.Conclusion. A significant decrease in the levels of myocardial fibrosis markers (MMP-1, MMP-9, TIMP-1) was demonstrated in patients with HFmrEF of ischemic origin receiving long-term pharmacotherapy. The most pronounced effect was determined in patients with NYHA class I HF.

scholarly journals Penggunaan Mineralocorticoid Receptor Antagonist pada Heart Failure Reduced Ejection Fraction

e-CliniC ◽  
2021 ◽  
Vol 9 (2) ◽  
pp. 379
Author(s):  
David H. P. Sihombing ◽  
Natalia C. I. Polii ◽  
Agnes L. Panda
Keyword(s):  
Heart Failure ◽  
Literature Review ◽  
Ejection Fraction ◽  
Brain Natriuretic Peptide ◽  
Receptor Antagonist ◽  
Mineralocorticoid Receptor ◽  
Evaluation Study ◽  
Mineralocorticoid Receptor Antagonist ◽  
Reduced Ejection Fraction ◽  
European Society Of Cardiology

Abstract: Heart failure reduction ejection fraction (HFrEF) is heart failure associated with decreased ejection fraction. It is characterized by abnormalities in cellular calcium regulation and changes in calcium kinetics that cause contraction changes in the myocardium. According to the European Society of Cardiology, mineralocorticoid receptor antagonist (MRA) is used as an adjunct drug when the first-line drugs are not sufficient to treat heart failure. This class of drugs has been shown to be very effective in use in HFrEF patients as shown in The Randomized Aldactone Evaluation Study (RALES), therefore, its use has been approved by the Food and Drug Administration (FDA). This study was aimed to analyze the effectiveness of MRA on HfrEF. This was a literature review study. The results showed that the use of MRA had significant benefits in reducing morbidity, mortality, and re-hospitalization in HFrEF patients. Improvements shown by the use of MRA included increased level of brain natriuretic peptide (BNP), improved NYHA classification, and decreased patient weight. A side effect that needs to be considered was hyperkalemia, whereas hypotensive effect was not of great concern because MRA was rarely reported to cause hypotension even when the initial systolic blood pressure is low. In conclusion, mineralocorticoid receptor antagonist is useful to improve the outome of HFrEF patients.Keywords: heart failure, heart failure reduced ejection fraction (HFrEF), mineralocorticoid receptor antagonist (MRA) Abstrak: Heart Failure reduced Ejection Fraction (HFrEF) merupakan gagal jantung disertai penurunan fraksi ejeksi. Kondisi ini ditandai dengan adanya kelainan regulasi kalsium seluler dan perubahan kinetika kalsium yang menyebabkan terjadinya perubahan kontraksi miokardium. Menurut European Society of Cardiology, mineralocorticoid receptor antagonist (MRA) digunakan sebagai obat tambahan bila obat lini pertama tidak cukup untuk mengatasi gagal jantung. Obat golongan ini terbukti sangat efektif digunakan pada pasien HFrEF sebagaimana yang ditunjukkan pada penelitian The Randomized Aldactone Evaluation Study (RALES), sehingga penggunaannya telah disetujui oleh Food and Drugs Administration (FDA). Penelitian ini bertujuan untuk menganalisis efektifitas penggunaan MRA pada pasien HFrEF. Jenis penelitian ialah literature review. Hasil penelitian memperlihatkan bahwa penggunaan MRA memiliki manfaat yang bermakna untuk menurunkan morbiditas, mortalitas, dan rawat inap ulang pada pasien HFrEF. Perbaikan yang ditunjukkan oleh penggunaan MRA antara lain peningkatan kadar Brain Natriuretic Peptide (BNP), perbaikan klasifikasi NYHA, dan penurunan berat badan pasien. Efek samping yang perlu menjadi pertimbangan ialah hiperkalemia, sedangkan efek hipotensi tidak terlalu dikhawatirkan karena MRA dilaporkan jarang menyebabkan hipotensi bahkan ketika tekanan darah sistolik awal rendah. Simpulan penelitian ini ialah mineralocorticoid receptor antagonist bermanfaat untuk memperbaiki luaran pada pasien HFrEF.Kata kunci: gagal jantung, heart failure reduced ejection fraction (HFrEF), mineralocorticoid, receptor antagonist (MRA)

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