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Pubblicazioni recenti - cardiorenal
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Measures of Loop Diuretic Efficiency and Prognosis in Chronic Kidney Disease.
Cardiorenal Med2020 Oct;():1-13. doi: 10.1159/000509741.
Verbrugge Frederik Hendrik, Martens Pieter, Testani Jeffrey M, Tang W H Wilson, Kuypers Dirk, Bammens Bert,
Abstract
BACKGROUND:
The evolution and prognostic impact of loop diuretic efficiency according to chronic kidney disease (CKD) severity is unclear.
METHODS:
This retrospective cohort study includes 783 CKD patients on oral loop diuretic therapy with a 24-h urine collection available. Acute kidney injury and history of renal replacement therapy were exclusion criteria. Patients were stratified according to Kidney Disease Improving Global Outcomes (KDIGO) glomerular filtration rate class. Loop diuretic efficiency was calculated as urine output, natriuresis, and chloruresis, each adjusted for loop diuretic dose, and compared among strata. Risk for onset of dialysis and all-cause mortality was evaluated.
RESULTS:
Loop diuretic efficiency metrics decreased from KDIGO class IIIB to IV in furosemide users and from KDIGO class IV to V with all loop diuretics (p value <0.05 for all comparisons). The correlation between loop diuretic efficiency and creatinine clearance was moderate at best (Spearman's ? 0.298-0.436; p value <0.001 for all correlations). During median follow-up of 45 months, 457 patients died (58%) and 63 received kidney transplantation (8%), while dialysis was started before in 328 (42%). All loop diuretic efficiency metrics were significantly and independently associated with both the risk for dialysis and all-cause mortality. In KDIGO class IV/V patients, low loop diuretic efficiency (i.e., urine output adjusted for loop diuretic dose ?1,000 mL) shortened median time to dialysis with 24 months and median time to all-cause mortality with 23 months.
CONCLUSION:
Low loop diuretic efficiency is independently associated with a shorter time to dialysis initiation and a higher risk for all-cause mortality in CKD.
© 2020 S. Karger AG, Basel.
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Cardiorenal Syndrome in Type 2 Diabetes Mellitus - Rational Use of Sodium-glucose Cotransporter-2 Inhibitors.
Eur Endocrinol2020 Oct;16(2):113-121. doi: 10.17925/EE.2020.16.2.113.
Kalra Sanjay, Aydin Hasan, Sahay Manisha, Ghosh Sujoy, Ruder Sundeep, Tiwaskar Mangesh, Kilov Gary, Kishor Kamal, Nair Tiny, Makkar Vikas, Unnikrishnan Ambika Gopalakrishnan, Dhanda Dinesh, Gupta Nikhil, Srinivasan Bharath, Kumar Amit,
Abstract
Cardiorenal syndrome (CRS) in people with type 2 diabetes mellitus (T2DM) illustrates the bidirectional link between the heart and the kidneys, with acute or chronic dysfunction of one organ adversely impacting the function of the other. Of the five subtypes identified, type 1 and 2 CRS occur because of the adverse impact of cardiac conditions on the kidneys. Type 3 and 4 occur when renal conditions affect the heart, and in type 5, systemic conditions impact the heart and kidneys concurrently. The cardiovascular and renoprotective benefits evidenced with sodium-glucose cotransporter-2 (SGLT2) inhibitors make them a potential choice in the management of CRS. Cardiovascular protection is mediated by a reduction in cardiac workload, blood pressure, and body weight; with improvement in lipid profile, uric acid levels, and adaptive ketogenesis process. Renoprotection is facilitated by reduction in albuminuria and hypoxic stress, and restoration of tubuloglomerular feedback. The favourable effect on cardiovascular complications and death, as well as renal complications and progression to end-stage kidney disease, has been confirmed in clinical trials. Guidelines endorse first-line use of SGLT2 inhibitors after metformin in patients with T2DM with high cardiovascular risk, chronic kidney disease or both. Since most trials with SGLT2 inhibitors excluded subjects with acute illness, patients with CRS subtypes 1 and 3 have not been studied adequately, making SGLT2 initiation in clinical practice challenging. Ongoing trials may provide evidence for SGLT2 inhibitor use in CRS. This review aims to enhance understanding of CRS and provide guidance for judicious use of SGLT2 inhibitors in T2DM.
© Touch Medical Media 2020.
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Blood Urea Nitrogen to Creatinine Ratio and Long-Term Mortality in Patients with Acute Heart Failure: A Prospective Cohort Study and Meta-Analysis.
Cardiorenal Med2020 Oct;():1-14. doi: 10.1159/000509834.
Zhu Xu, Cheang Iokfai, Liao Shengen, Wang Kai, Yao Wenming, Yin Ting, Lu Xinyi, Zhou Yanli, Zhang Haifeng, Li Xinli,
Abstract
OBJECTIVE:
To further explore the relationship between the blood urea nitrogen to creatinine (BUN/Cr) ratio and the prognosis of patients with acute heart failure (AHF), a two-part study consisting of a prospective cohort study and meta-analysis were conducted.
METHODS:
A total of 509 hospitalized patients with AHF were enrolled and followed up. Cox proportional hazards regression was used to analyze the relationship between the BUN/Cr ratio and the long-term prognosis of patients with AHF. Meta-analysis was also conducted regarding the topic by searching PubMed and Embase for relevant studies published up to October 2019.
RESULTS:
During a median follow-up of 2.8 years, 197 (42.6%) deaths occurred. The cumulative survival rate of patients with a BUN/Cr ratio in the bottom quartile was significantly lower than in the other 3 groups (log-rank test: p = 0.003). In multivariate Cox regression models, the mortality rate of AHF patients with a BUN/Cr ratio in the bottom quartile was significantly higher than in the top quartile (adjusted HR 1.52; 95% CI 1.03-2.24). For the meta-analysis, we included 8 studies with 4,700 patients, consisting of 7 studies from the database and our cohort study. The pooled analysis showed that the highest BUN/Cr ratio category was associated with an 77% higher all-cause mortality than the lowest category (pooled HR 1.77; 95% CI 1.52-2.07).
CONCLUSIONS:
Elevated BUN/Cr ratio is associated with poor prognosis in patients with AFH and is an independent predictor of all-cause mortality.
© 2020 S. Karger AG, Basel.
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Impairment of right ventricular strain evaluated by cardiovascular magnetic resonance feature tracking in patients with interstitial lung disease.
Int J Cardiovasc Imaging2020 Oct;():. doi: 10.1007/s10554-020-02079-x.
Kamide Hiroyuki, Kato Shingo, Hayakawa Keigo, Fukui Kazuki, Kitamura Hideya, Ogura Takashi, Iwasawa Tae, Kimura Kazuo, Tamura Kouichi, Utsunomiya Daisuke,
Abstract
OBJECTIVES:
The aims of this study were to investigate the relationship between pulmonary hypertension (PH) and right ventricular (RV) strain, and to evaluate the prognostic value of RV strain by cardiac magnetic resonance (CMR) feature tracking for patients with interstitial lung disease (ILD).
METHODS:
A total of seventy ILD patients (mean age: 71?±?8 years, 39 [56%] males) who underwent CMR and right heart catheterization (RHC) were studied. Using a 1.5T magnetic resonance (MR) scanner, steady-state free precession cine MR images encompassing the RV were acquired in all patients and 20 control subjects. RV longitudinal strain were calculated with a feature tracking algorithm. PH was defined as a mean pulmonary artery pressure of more than 20 mmHg at rest and a pulmonary vascular resistance ?3 Woods unit.
RESULTS:
The RV longitudinal strain was significantly impaired in the ILD patients with PH (n=18) than ILD patients without PH (n=52) (-13.3?±?5.4% vs. -16.9±5.4%, p=0.048). The RV longitudinal strain differed significantly between the ILD patients without PH and the controls (n=20) (-16.9?±?5.4% vs. -20.8?±?6.2%, p=0.002). Five of 70 (7%) patients died within one-year after CMR scan. Area under receiver operating characteristics curve for predicting death was 0.900 (95%CI: 0.800 to 1.000) for RV strain, 0.643 (95%CI: 0.454 to 0.832) for RVEF.
CONCLUSIONS:
Presence of PH was associated with impairment of RV strain, and RV strain could predict short-term mortality in patients with ILD. RV strain by feature tracking might be useful as a non-invasive prognostic marker for patients with ILD.
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Prevalence, types, risk factors, and outcomes of cardiorenal syndrome in a rural population of central India: A cross-sectional study.
J Family Med Prim Care2020 Aug;9(8):4127-4133. doi: 10.4103/jfmpc.jfmpc_533_20.
Prothasis Maria, Varma Anuj, Gaidhane Shilpa, Kumar Sunil, Khatib Nazli, Zahiruddin Quazi S, Gaidhane Abhay,
Abstract
Background and Objectives:
Heart failure leading to renal dysfunction and vice-versa termed as Cardio-Renal Syndrome(CRS) has now been increasingly identified as a marker of higher morbidity and mortality. Till date, there is limited data available regarding clinical profile, associated risk factors and outcome of CRS in rural population of central India. This study was conducted to elucidate the prevalence, risk factors, and outcome of CRS and its types.
Methods:
This was a single-centric, cross-sectional study conducted amongst the patients admitted to medicine wards and ICCU from October 2017 to September 2019. Classification given by RONCO . in 2008 was used for classifying CRS patients into various types. Cross-sectional data was used to find the prevalence, risk factors and their inter-relationship with outcome and mortality. STATA software was used for statistical analysis.
Results:
Out of 96 CRS patients, 47(48.96%) were Type 1, 22 (22.92%) were type 2, 19(19.79%) were type 4 and 3 (3.13% ) were type 3, and 5 (5.21%) were of type 5. Most common risk factor was Hypertension (HTN) found in 46 (47.92%), followed closely by Coronary Artery Disease (CAD) and anaemia. Mortality was seen in 44(45.83%) of CRS patients and it was significantly high. High mortality was common in patients of types 3 and type 5 CRS. Risk factors like HTN, CAD, smoking, reduced glomerular filtration rate, low ejection fraction and sepsis were significantly associated with worse outcomes across all CRS sub-types.
Interpretation and Conclusions:
There is high mortality among CRS. Prevention or optimal management of HTN, CAD and sepsis is required to decrease mortality. There is need for more population based studies for confirming our study findings.
Copyright: © 2020 Journal of Family Medicine and Primary Care.
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The expanding role of SGLT2 inhibitors beyond glucose-lowering to cardiorenal protection.
Ann Med2020 Oct;():1-32. doi: 10.1080/07853890.2020.1841281.
Brown Emily, Wilding John Ph, Alam Uazman, Barber Thomas M, Karalliedde Janaka, Cuthbertson Daniel J,
Abstract
The kidney plays a major physiological role in glucose homeostasis but also contributes to the pathophysiology of type 2 diabetes (T2D), mediated by renal sodium glucose cotransporters (SGLTs). This recognition led to development of SGLT2 inhibitors that inhibit proximal renal tubular renal glucose and sodium reabsorption. The glucoretic and natriuretic effect of SGLT2 inhibitors is associated with reductions in HbA levels, body weight, systolic blood pressure and triglycerides. Major vascular complications of T2D include cardiovascular disease and chronic kidney disease (CKD). Results from several cardiovascular outcome trials (CVOTs) with these drugs have highlighted benefits in reducing major adverse cardiovascular events by 11%, reducing the risk of cardiovascular death or hospitalisation for heart failure (HF) by 23% and reducing risk of progression of renal disease by 45%. Their cardiorenal benefits are apparent across a range of eGFRs (within CKD1-3 groups) and the presence or absence of ischaemic heart disease, HF or T2D. In patients with HF with reduced ejection fraction (HFrEF), similar risk reductions in cardiovascular death and HF events are also seen; results from studies in patients with HF with preserved ejection fraction (HFpEF) are awaited. Cardiorenal benefits have been recently reported in patients with CKD, regardless of the presence or absence of T2D. Indications for use of SGLT2 inhibitors has extended beyond glucose-lowering to a central role in cardiorenal protection. This review will first explore the mechanisms by which glycaemic control, weight loss and cardiovascular risk factors are modulated therapeutically with SGLT2 inhibitors. Subsequently we outline putative mechanisms underpinning the cardiorenal benefits seen, including in HF and CKD, in the context of completed and ongoing clinical studies. Treatment strategies with SGLT2 inhibitors in individuals with CKD or HF, with and/or without T2D are increasingly appealing. Combination therapy with complementary therapeutic agents is also explored.
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May need more comprehensive approach to residual risks in well controlled hypertensive patients.
Hypertens Res2020 Oct;():. doi: 10.1038/s41440-020-00567-0.
Suzuki Toru, Kamimura Daisuke, Wakui Hiromichi, Tamura Kouichi,
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Molecular Mechanisms of SGLT2 Inhibitor on Cardiorenal Protection.
Int J Mol Sci2020 Oct;21(21):. doi: E7833.
Hou Yi-Chou, Zheng Cai-Mei, Yen Tzung-Hai, Lu Kuo-Cheng,
Abstract
The development of sodium-glucose transporter 2 inhibitor (SGLT2i) broadens the therapeutic strategies in treating diabetes mellitus. By inhibiting sodium and glucose reabsorption from the proximal tubules, the improvement in insulin resistance and natriuresis improved the cardiovascular mortality in diabetes mellitus (DM) patients. It has been known that SGLT2i also provided renoprotection by lowering the intraglomerular hypertension by modulating the pre- and post- glomerular vascular tone. The application of SGLT2i also provided metabolic and hemodynamic benefits in molecular aspects. The recent DAPA-CKD trial and EMPEROR-Reduced trial provided clinical evidence of renal and cardiac protection, even in non-DM patients. Therefore, the aim of the review is to clarify the hemodynamic and metabolic modulation of SGLT2i from the molecular mechanism.
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Correction to: Cardiorenal Protection With the Newer Antidiabetic Agents in Patients With Diabetes and Chronic Kidney Disease A Scientific Statement From the American Heart Association.
Circulation -
The Healthy, Aging, and Diseased Kidney: Relationship with Cardiovascular Disease.
J Am Geriatr Soc2020 Oct;():. doi: 10.1111/jgs.16866.
Morcos Ramez, Lazar Ira, Kucharik Michael, Lavin Arye, Fahmy Andrew, Chandrasekhar Sanjay, Ibrahim Amira, Neupane Aashish, Khalili Houman, Maini Brijeshwar, Ouslander Joseph G,
Abstract
The cardiovascular and renal systems share an intimate physiological relationship, wherein a perturbance in one system may have an adverse effect on the other. Since the burden of renal disease increases with age, there is a considerable interest in the pathophysiology of kidney disease in the geriatric patient population. This review will explore the physiological dynamics behind the increased susceptibility to kidney disease in this population. A better understanding of these pathophysiological changes may lead to improved prevention and management strategies.
© 2020 The American Geriatrics Society.
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Association of Volume Overload With Kidney Function Outcomes Among Patients With Heart Failure With Reduced Ejection Fraction.
Kidney Int Rep2020 Oct;5(10):1661-1669. doi: 10.1016/j.ekir.2020.07.015.
McCallum Wendy, Tighiouart Hocine, Testani Jeffrey M, Griffin Matthew, Konstam Marvin A, Udelson James E, Sarnak Mark J,
Abstract
Introduction:
In patients with heart failure with reduced ejection fraction (HFrEF), volume overload is associated with mortality. Few studies that have examined the relation between volume and long-term kidney function outcomes in HFrEF.
Methods:
Using data from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial, we used multivariable Cox regression models to evaluate the association between volume overload as evaluated by B-type natriuretic peptide (BNP) and N-terminal pro B-type natriuretic peptide (NT-proBNP), and a clinical congestion score (scale of 0-12) composed of pedal edema, jugular venous distension, rales, and orthopnea with the occurrence of estimated glomerular filtration rate (eGFR) decline by >40%, and incident chronic kidney disease (CKD) stage ?4 defined by eGFR of <30 ml/min per 1.73 m, over a median 10-month follow-up.
Results:
Among 3718 patients (mean eGFR 59 ± 22 ml/min per 1.73 m), 340 (9%) reached an eGFR decline >40% and 337 (10%) developed incident CKD stage ?4. In multivariable models, compared with those in the quartile of lowest NT-proBNP, those within the highest quartile had a significantly higher risk of eGFR decline by >40% (hazard ratio [HR] = 2.62 [95% confidence interval {CI} = 1.62, 4.23]) and incident CKD stage ?4 (HR = 2.66 [95% CI = 1.49, 4.77]), with similar trends for BNP. Similarly in multivariable models, patients in the quartile of highest congestion score had a 48% increased risk for eGFR decline by >40% (HR = 1.48 [95% CI = 1.07, 2.06]) and a 42% increased risk for CKD stage ?4 (HR = 1.42 [95% CI = 1.01, 1.99]), compared with the lowest quartile.
Conclusion:
Volume overload, as indicated both by elevated natriuretic peptides and clinical signs and symptoms, is associated with increased risk for clinically important kidney function outcomes in HFrEF.
© 2020 International Society of Nephrology. Published by Elsevier Inc.
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Impact of CKD Progression on Cardiovascular Disease Risk in a Contemporary UK Cohort of Individuals With Diabetes.
Kidney Int Rep2020 Oct;5(10):1651-1660. doi: 10.1016/j.ekir.2020.07.029.
Cabrera Claudia S, Lee Alison S, Olsson Marita, Schnecke Volker, Westman Klara, Lind Marcus, Greasley Peter J, Skrtic Stanko,
Abstract
Introduction:
It remains unclear whether an increased progression rate of chronic kidney disease (CKD) adds predictive information regarding cardiovascular disease (CVD) risk. The aim of this study was to evaluate the association between CKD progression, based on estimated glomerular filtration rate (eGFR) slope estimates and the risk for CVD.
Methods:
We compared the updated eGFR slope calculated over multiple overlapping 2-year periods and the updated mean eGFR. Incident CKD subjects were selected from a prevalent population with diabetes (T2DM). Subjects from the UK Clinical Practice Research Data Link GOLD (CPRD) were followed from CKD diagnosis ( = 30,222) until heart failure (HF), myocardial infarction (MI), ischemic stroke (IS), or a composite end point including all 3 event types (MACE plus), mortality, database dropout, or end of study follow-up.
Results:
Both the updated eGFR slope and updated mean eGFR were associated with MACE plus and HF. Updated eGFR slope decline of > -3 ml/min/1.73 m increased the risk for MACE plus (adjusted hazard ratio [HR] = 1.45; 95% confidence interval [CI], 1.26-1.67), HF (HR = 1.50; 95% CI, 1.27-1.76), and MI (HR = 1.39; 95% CI, 1.01-1.91).
Conclusions:
This study strongly supports current evidence that CKD is an independent risk factor for CVD. From a clinical perspective, both rate of progression and cumulative status of CKD describe distinct aspects of the cardiorenal risk among persons with diabetes. This evidence is essential to enable more timely and improved use of treatments in this population.
© 2020 International Society of Nephrology. Published by Elsevier Inc.
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Characterization of the Oxidative Stress in Renal Ischemia/Reperfusion-Induced Cardiorenal Syndrome Type 3.
Biomed Res Int2020 ;2020():1605358. doi: 10.1155/2020/1605358.
Caio-Silva Wellington, da Silva Dias Danielle, Junho Carolina Victoria Cruz, Panico Karine, Neres-Santos Raquel Silva, Pelegrino Milena Trevisan, Pieretti Joana Claudio, Seabra Amedea Barozzi, De Angelis Kátia, Carneiro-Ramos Marcela Sorelli,
Abstract
In kidney disease (KD), several factors released into the bloodstream can induce a series of changes in the heart, leading to a wide variety of clinical situations called cardiorenal syndrome (CRS). Reactive oxygen species (ROS) play an important role in the signaling and progression of systemic inflammatory conditions, as observed in KD. The aim of the present study was to characterize the redox balance in renal ischemia/reperfusion-induced cardiac remodeling. C57BL/6 male mice were subjected to occlusion of the left renal pedicle, unilateral, for 60?min, followed by reperfusion for 8 and 15 days, respectively. The following redox balance components were evaluated: catalase (CAT), superoxide dismutase (SOD), total antioxidant capacity (FRAP), NADPH oxidase (NOX), nitric oxide synthase (NOS), hydrogen peroxide (HO), and the tissue bioavailability of nitric oxide (NO) such as S-nitrosothiol (RSNO) and nitrite (NO). The results indicated a process of renoprotection in both kidneys, indicated by the reduction of cellular damage and some oxidant agents. We also observed an increase in the activity of antioxidant enzymes, such as SOD, and an increase in NO bioavailability. In the heart, we noticed an increase in the activity of NOX and NOS, together with increased cell damage on day 8, followed by a reduction in protein damage on day 15. The present study concludes that the kidneys and heart undergo distinct processes of damage and repair at the analyzed times, since the heart is a secondary target of ischemic kidney injury. These results are important for a better understanding of the cellular mechanisms involved in CRS.
Copyright © 2020 Wellington Caio-Silva et al.
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Steroidal and non-steroidal mineralocorticoid receptor antagonists in cardiorenal medicine.
Eur Heart J2020 Oct;():. doi: ehaa736.
Agarwal Rajiv, Kolkhof Peter, Bakris George, Bauersachs Johann, Haller Hermann, Wada Takashi, Zannad Faiez,
Abstract
This review covers the last 80?years of remarkable progress in the development of mineralocorticoid receptor (MR) antagonists (MRAs) from synthesis of the first mineralocorticoid to trials of nonsteroidal MRAs. The MR is a nuclear receptor expressed in many tissues/cell types including the kidney, heart, immune cells, and fibroblasts. The MR directly affects target gene expression-primarily fluid, electrolyte and haemodynamic homeostasis, and also, but less appreciated, tissue remodelling. Pathophysiological overactivation of the MR leads to inflammation and fibrosis in cardiorenal disease. We discuss the mechanisms of action of nonsteroidal MRAs and how they differ from steroidal MRAs. Nonsteroidal MRAs have demonstrated important differences in their distribution, binding mode to the MR and subsequent gene expression. For example, the novel nonsteroidal MRA finerenone has a balanced distribution between the heart and kidney compared with spironolactone, which is preferentially concentrated in the kidneys. Compared with eplerenone, equinatriuretic doses of finerenone show more potent anti-inflammatory and anti-fibrotic effects on the kidney in rodent models. Overall, nonsteroidal MRAs appear to demonstrate a better benefit-risk ratio than steroidal MRAs, where risk is measured as the propensity for hyperkalaemia. Among patients with Type 2 diabetes, several Phase II studies of finerenone show promising results, supporting benefits on the heart and kidneys. Furthermore, finerenone significantly reduced the combined primary endpoint (chronic kidney disease progression, kidney failure, or kidney death) vs. placebo when added to the standard of care in a large Phase III trial.
© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.
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Worldwide inertia to the use of cardiorenal protective glucose-lowering drugs (SGLT2i and GLP-1 RA) in high-risk patients with type 2 diabetes.
Cardiovasc Diabetol2020 Oct;19(1):185. doi: 10.1186/s12933-020-01154-w.
Schernthaner Guntram, Shehadeh Naim, Ametov Alexander S, Bazarova Anna V, Ebrahimi Fahim, Fasching Peter, Jane? Andrej, Kempler Péter, Konr?de Ilze, Lali? Neboj?a M, Mankovsky Boris, Martinka Emil, Raheli? Dario, Serafinceanu Cristian, ?krha Jan, Tankova Tsvetalina, Visockien? ?ydr?n?,
Abstract
The disclosure of proven cardiorenal benefits with certain antidiabetic agents was supposed to herald a new era in the management of type 2 diabetes (T2D), especially for the many patients with T2D who are at high risk for cardiovascular and renal events. However, as the evidence in favour of various sodium-glucose transporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) accumulates, prescriptions of these agents continue to stagnate, even among eligible, at-risk patients. By contrast, dipeptidyl peptidase-4 inhibitors (DPP-4i) DPP-4i remain more widely used than SGLT2i and GLP-1 RA in these patients, despite a similar cost to SGLT2i and a large body of evidence showing no clear benefit on cardiorenal outcomes. We are a group of diabetologists united by a shared concern that clinical inertia is preventing these patients from receiving life-saving treatments, as well as placing them at greater risk of hospitalisation for heart failure and progression of renal disease. We propose a manifesto for change, in order to increase uptake of SGLT2i and GLP-1 RA in appropriate patients as a matter of urgency, especially those who could be readily switched from an agent without proven cardiorenal benefit. Central to our manifesto is a shift from linear treatment algorithms based on HbA1c target setting to parallel, independent considerations of atherosclerotic cardiovascular disease, heart failure and renal risks, in accordance with newly updated guidelines. Finally, we call upon all colleagues to play their part in implementing our manifesto at a local level, ensuring that patients do not pay a heavy price for continued clinical inertia in T2D.
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Impact of Myocardial Bridge on Life-Threatening Ventricular Arrhythmia in Patients With Implantable Cardioverter Defibrillator.
J Am Heart Assoc2020 Oct;():e017455. doi: 10.1161/JAHA.120.017455.
Okada Kozo, Hibi Kiyoshi, Ogino Yutaka, Maejima Nobuhiko, Kikuchi Shinnosuke, Kirigaya Hidekuni, Kirigaya Jin, Sato Ryosuke, Nakahashi Hidefumi, Minamimoto Yugo, Kimura Yuichiro, Akiyama Eiichi, Matsuzawa Yasushi, Iwahashi Noriaki, Kosuge Masami, Ebina Toshiaki, Tamura Kouichi, Kimura Kazuo,
Abstract
Background Myocardial bridge (MB), common anatomic variant, is generally considered benign, while previous studies have shown associations between MB and various cardiovascular pathologies. This study aimed to investigate for the first time possible impact of MB on long-term outcomes in patients with implantable cardioverter defibrillator, focusing on life-threatening ventricular arrhythmia (LTVA). Methods and Results This retrospective analysis included 140 patients with implantable cardioverter defibrillator implantation for primary (n=23) or secondary (n=117) prevention of sudden cardiac death. Angiographically apparent MB was identified on coronary angiography as systolic milking appearance with significant arterial compression. The primary end point was the first episode(s) of LTVA defined as appropriate implantable cardioverter defibrillator treatments (antitachyarrhythmia pacing and/or shock) or sudden cardiac death, assessed for a median of 4.5 (2.2-7.1) years. During the follow-up period, LTVA occurred in 37.9% of patients. Angiographically apparent MB was present in 22.1% of patients; this group showed younger age, lower rates of coronary risk factors and ischemic cardiomyopathy, higher prevalence of vasospastic angina and greater left ventricular ejection fraction compared with those without. Despite its lower risk profiles above, Kaplan-Meier analysis revealed significantly lower event-free rates in patients with versus without angiographically apparent MB. In multivariate analysis, presence of angiographically apparent MB was independently associated with LTVA (hazard ratio, 4.24; 95% CI, 2.39-7.55; <0.0001). Conclusions Angiographically apparent MB was the independent determinant of LTVA in patients with implantable cardioverter defibrillator. Although further studies will need to confirm our findings, assessment of MB appears to enhance identification of high-risk patients who may benefit from closer follow-up and targeted therapies.
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COVID-19-Associated Systemic Thromboembolism: A Case Report and Review of the Literature.
Cardiorenal Med2020 Oct;():1-8. doi: 10.1159/000511800.
Mahajan Pranav, Dass Bhagwan, Radhakrishnan Nila, McCullough Peter A,
Abstract
INTRODUCTION:
Coronavirus disease 2019 (COVID-19) is a pandemic that has affected >188 countries, involved >24 million people, and caused >840,000 deaths. COVID-19, in its severe form, presents as acute respiratory distress syndrome (ARDS), shock, and multiorgan failure. Thrombotic microangiopathy of the lungs and kidneys has been observed in these patients. Elevated D-dimer levels have been observed in people with serious COVID-19 illness, and this could be helpful in guiding treatment with anticoagulation in these patients.
OBJECTIVE:
To analyze the role of anticoagulation as a treatment modality for COVID-19.
METHODS:
We present the unique case of a COVID-19 patient who developed sepsis, ARDS, acute kidney injury, and deep-vein thrombosis (DVT), who was deteriorating clinically. She was treated with anticoagulation.
RESULTS:
There was rapid recovery after treatment with systemic anticoagulation.
CONCLUSIONS:
Systemic anticoagulation could prove to be essential in the treatment of CO-VID-19. Further studies are required to assess its role in improving long-term morbidity and mortality in these patients.
© 2020 The Author(s) Published by S. Karger AG, Basel.
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Predicted Cardiac Hemodynamic Consequences of the Renal Actions of SGLT2i in the DAPA-HF Study Population: A Mathematical Modeling Analysis.
J Clin Pharmacol2020 Oct;():. doi: 10.1002/jcph.1769.
Yu Hongtao, Tang Weifeng, Greasley Peter J, Penland Robert C, Boulton David W, Hallow K Melissa,
Abstract
The Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) study demonstrated that dapagliflozin, a sodium-glucose cotransporter-2 inhibitor (SGLT2i), reduced heart failure hospitalization and cardiovascular death in patients with heart failure with reduced ejection fraction (HF-rEF), with and without type 2 diabetes mellitus. Multiple potential mechanisms have been proposed to explain this benefit, which may be multifactorial. This study aimed to quantify the contribution of the known natriuretic/diuretic effects of SGLT2is to changes in cardiac hemodynamics, remodeling, and fluid homeostasis in the setting of HF-rEF. An integrated cardiorenal mathematical model was used to simulate inhibition of SGLT2 and its consequences on cardiac hemodynamics in a virtual population of HF-rEF patients generated by varying model parameters over physiologically plausible ranges and matching to baseline characteristics of individual DAPA-HF trial patients. Cardiovascular responses to placebo and SGLT2i over time were then simulated. The baseline characteristics of the HF-rEF virtual population and DAPA-HF were in good agreement. SGLT2i-induced diuresis and natriuresis that reduced blood volume and interstitial fluid volume, relative to placebo within 14 days. This resulted in decreased left ventricular end-diastolic volume and pressure, indicating reduced cardiac preload. Thereafter, blood volume and interstitial fluid volume again began to accumulate, but pressures and volumes remained shifted lower relative to placebo. After 1 year, left ventricle mass was lower and ejection fraction was higher than placebo. These simulations considered only hemodynamic consequences of the natriuretic/diuretic effects of SGLT2i, as other mechanisms may contribute additional benefits besides those predictions.
© 2020, The American College of Clinical Pharmacology.
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The influence of long-term administration of SGLT2 inhibitors on blood pressure at the office and at home in patients with type 2 diabetes mellitus and chronic kidney disease.
J Clin Hypertens (Greenwich)2020 Oct;():. doi: 10.1111/jch.14084.
Furuki Takayuki, Kobayashi Kazuo, Toyoda Masao, Hatori Nobuo, Sakai Hiroyuki, Sato Kazuyoshi, Miyakawa Masaaki, Tamura Kouichi, Kanamori Akira,
Abstract
The decrease in blood pressure is thought to play an important role for the renoprotective effects of sodium-glucose cotransporter 2 inhibitors in patients with diabetes mellitus. However, their influence on blood pressure at home has not been well studied. The aim of this study is to clarify how long-term use of sodium-glucose cotransporter 2 inhibitors influence on blood pressure both at the office and at home, and the kidney function. We retrospectively analyzed 102 patients with type 2 diabetes mellitus and chronic kidney disease to whom sodium-glucose cotransporter 2 inhibitors were administered for more than 1 year, and whose blood pressure were monitored both at the office and at home. The blood pressure at the office and at home significantly decreased, and there was a significant positive correlation between both blood pressure values. Controlled, white-coat, and sustained hypertension were observed in 9.8%, 14.7%, and 55.9% of the patients at the beginning of the treatment, which changed to 16.7%, 15.7%, and 48.0% at the time of the survey, however, the ratio of masked hypertension was not changed (19.6%). The cutoff value of mean arterial pressure at home after treatment for the improvement of urine albumin to creatinine ratio was 92.0 mm Hg, with 54.1% of sensitivity and 60.0% of specificity. Sodium-glucose cotransporter 2 inhibitors can be useful for the strict management of blood pressures both at the office and at home. The decrease in blood pressure at home by this treatment might be related to the improvement of diabetic nephropathy.
© 2020 Wiley Periodicals LLC.
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Value of Plasma NGAL and Creatinine on First Day of Admission in the Diagnosis of Cardiorenal Syndrome Type 1.
Cardiol Res Pract2020 ;2020():2789410. doi: 10.1155/2020/2789410.
Phan Thai Hao, Hoang Bui Bao, Hoang Anh Tien, Huynh Van Minh,
Abstract
Background:
The presence of acute kidney injury in the setting of acute heart failure (AHF) or acute decompensated heart failure (ADHF) is a very common occurrence and was termed cardiorenal syndrome 1 (CRS1). Neutrophil gelatinase-associated lipocalin (NGAL) in the blood and urine is one of the earliest biomarkers of acute kidney injury due to ischemia or renal toxicity. This study was aimed to evaluate the diagnostic efficacy of plasma NGAL in the diagnosis of CRS1.
Methods:
There were 139 patients with AHF or ADHF in the department of Cardiovascular Resuscitation and Interventional Cardiology at Ho Chi Minh City 115 People Hospital from September 2018 to March 2019. This was a prospective cohort study.
Results:
There were 48 cases (rate 34.5%) with CRS1, mean age was 66.12?±?15.77 and men accounted for 50.4%. There were no significant differences of vital signs at admission, diagnosis, and EF-based heart failure between CRS1 and non-CRS1 groups. The urea, creatinine on first day (creatinine D1) and third day (creatinine D3), NT-proBNP, and NGAL levels were higher in the CRS1 group than the non-CRS1 group, < 0.05. The optimal cutoff plasma NGAL for diagnosing CRS1 was >353.23?ng/ml, area under curve (AUC) 0.732 (95% CI 0.65-0.80, < 0.001), sensitivity 74.47%, specificity 68.48%, positive predictive value 54.7%, and negative predictive value 84%. Multivariable logistic regression analysis eGFR remained the strongest independent predictor of CRS1. Building the optimal regression model (without eGFRCKDEPID1) by the BMA (Bayesian model average) method with two variables NGAL and Creatinine D1, we had the equation: odds ratio?=?e while y?=?-2.39?+?0.0037?×?NGAL?+?0.17?×?Creatinine D1. The nomogram (without eGFR) was designed to predict the likelihood of CRS1 with AUC 0.79.
Conclusions:
The combination of plasma NGAL and creatinine D1 on the first day at admission had a high accuracy of predictive model for CRS1.
Copyright © 2020 Hao Phan Thai et al.
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