Diuretics/therapeutic use

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Editorial

Microalbuminuria and the Risk of Mortality in Patients with Acute Heart Failure

Heart failure (HF) is a chronic and progressive clinical syndrome resulting from structural or functional abnormalities of the heart. The most common symptoms and signs of HF are dyspnea, fatigue, pulmonary and peripheral congestion or edema and jugular vein distension. The prevalence of HF continuously increases due to improved treatment and reduced short-term mortality in patients with acute coronary syndromes, congenital heart disease, population aging and improved survival of patients with already developed heart failure by the widespread application of modern disease-modifying medications and devices.

Acute heart failure (AHF) is recognized when symptoms of HF appear in the patient without the history of previous HF (de novo HF) or when symptoms and signs are rapidly exacerbating in a patient with previously recognized HF (decompensated HF). Acute heart failure is the most common cause of unplanned hospital admissions in older patients. The pathophysiology of both conditions is similar, but de novo HF requires a more detailed diagnostic approach to find the underlying pathology. The initial treatment of AHF includes intravenous diuretics and short-acting vasodilators. The minority of patients with AHF present with cardiogenic shock associated with low blood pressure and severely compromised perfusion of peripheral tissues; the cardiogenic shock is associated with much higher mortality than AHF without shock. Whereas the treatment of chronic HF has substantially improved survival rates, the outcome of AHF is still poor, with high mortality and hospital readmission rates. Currently used therapy is directed to reduce the pre and afterload of the heart and does not target the specific underlying pathology in a given patient, which may explain unsatisfactory progress of clinical outcomes. Therefore, individualized therapy is highly appreciated, requiring establishing specific markers.^,

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IJCS

Original Article

Use of Diuretics is Associated with Higher Risk of Sarcopenia in Older Adults with Hypertension

Francisco de Assis Dias Martins Junior et al. Dahany Pamela Acta Mateo Fábio Junior de Miranda Silva Samara Silva de Moura … Emerson Cruz Oliveira Daniel Barbosa Coelho Eduardo Bearzoti Kelerson Mauro de Castro Pinto Lenice Kappes Becker

Abstract

Background:

Sarcopenia is a disease that involves skeletal muscle mass loss and is highly prevalent in the older adult population. Moreover, the incidence of sarcopenia is increased in patients with hypertension.

Objectives:

The study aimed to evaluate the association between the classes of the drugs used for arterial hypertension treatment and the presence or absence of sarcopenia.

Methods:

129 older adults with hypertension were evaluated by the researchers who registered the participants medication for arterial hypertension treatment. Sarcopenia level was measured by anthropometric parameters, muscular strength, and functional capacity. The data were analyzed by one-way ANOVA followed by post-hoc test and Fisher’s exact test; statistical significance was set at 0.05.

Results:

Age was not different between women with different levels of sarcopenia, but significant differences were observed between men with absent sarcopenia (66.8±4.2 years) and men with probable sarcopenia (77.0±10.2 years). Individuals with absent sarcopenia showed higher handgrip strength (men: 33.8±7.4, women: 23.2±4.6 Kgf) in comparison with those with sarcopenia (men with probable sarcopenia: 9.5±3.3 Kgf, women with probable, confirmed, and severe sarcopenia: 11.7±2.5, 12.2±3.0, 11.8±1.8 Kgf, respectively). The analysis showed an association between the type of medication and degree of sarcopenia; diuretics were significantly associated with probable sarcopenia, and angiotensin II receptor blockers (alone or in combination with diuretics) was associated with absence of sarcopenia.

Conclusion:

In conclusion, handgrip strength was a good method to diagnose sarcopenia, and diuretics were associated with increased risk of sarcopenia in older adults with hypertension.

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Editorial

New Perspectives in the Treatment of Hypertension

Heno F. Lopes

Arterial hypertension is by far the biggest risk factor for cardiovascular diseases. Thiocyanates, barbiturates, bromides and bismuth were tested in the treatment of arterial hypertension in the early 1940s. The use of these drugs was discontinued because they were proven ineffective and had several side effects. In the mid-1950s, ganglion blockers such as hexamethonium, pentolinium, mecamylamine and peripherally acting sympatholytic substances (guanethidine) were tested as treatment of arterial hypertension and were shown effective in reducing blood pressure, but little tolerated. New drugs were introduced to treat hypertension in the 1950s, including diuretics.

In 1956, in an observational study, Moser and Magaulay followed up 106 hypertensive patients who received rauwolfia, hydralazine, reserpine, mecamylamine and chlorothiazide as treatment for arterial hypertension, alone or in combination. The dose of chlorothiazide used in this study ranged from 0.5 to 1.5 grams and the combination of chlorothiazide resulted in better control of blood pressure. Since that observational study by Moser and Magaulay to the present day, several studies related to the pharmacological treatment of hypertension have been carried out. The first randomized, placebo-controlled study conducted on the treatment of arterial hypertension was the Veterans Administration (VA), published in 1967. It is worth noting that the study inclusion criterion for active versus placebo treatment was diastolic pressure between 115 and 129 mmHg. After the publication of the VA-I study in 1967 and the VA-II in 1970, several randomized controlled studies addressing the treatment of arterial hypertension were carried out. The initial focus of treatment for arterial hypertension was renal sodium excretion, as renal disorders were initially thought to be the main cause of hypertension. Subsequently, the pathophysiological mechanisms of hypertension were elucidated and the therapy was directed to the main pathophysiological mechanisms. The activation of the sympathetic nervous system as an important pathophysiological mechanism of hypertension had already been perceived in the 1950s, and various forms of sympathetic nervous system block and even sympathectomy were then attempted. Beginning in the 1980s, with the introduction of the microneurography and the norepinephrine spillover technique, the importance of activation of the sympathetic nervous system in the pathophysiology of hypertension was even more evident.^, Although poorly tolerated, central and peripheral adrenergic blockers have always been part of the treatment of arterial hypertension. The activation of the renin-angiotensin aldosterone system (RAS) and the altered natriuresis pressure curve are two other important mechanisms in the pathophysiology of arterial hypertension. Currently, the use of diuretics to correct the altered natriuresis pressure curve and inhibitors of the renin-angiotensin aldosterone system, which act at different sites, has been routine in the treatment of arterial hypertension.

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Original Article

Worsening Renal Function and Congestion in Patients with Acute Heart Failure: A Study with Bioelectrical Impedance Vector Analysis (BIVA) and Neutrophil Gelatinase-Associated Lipocalin (NGAL)

Humberto Villacorta et al. Aline Sterque Villacorta Leonardo Simões de Castro Villacorta Analucia Rampazzo Xavier … Salim Kanaan Felipe Mafort Rohen Leonardo Dinis Albuquerque Daniele Dantas Bastilho Cecília de Oliveira Cudischevitch

Abstract

Background:

Worsening renal function (WRF) is frequently observed in the setting of aggressive diuresis for the treatment of acute decompensated heart failure (ADHF) and is associated with poor outcomes in some studies.

Objective:

We sought to assess the relationship of WRF and congestion at discharge with events (cardiac death or heart failure hospitalization).

Methods:

Eighty patients with ADHF were studied. WRF was defined by an absolute increase in serum creatinine of ≥0.5 mg/dL from the values measured at the time of admission. B-type natriuretic peptide (BNP) and plasma neutrophil gelatinase-associated lipocalin (NGAL) were measured at admission and at discharge. Congestive state at discharge was assessed using bioelectrical impedance vector analysis (BIVA). Primary endpoint was time to first event defined as a combination of cardiac death or heart failure hospitalization. Receiver operating characteristic (ROC) curve analysis was used to determine the best hydration index cutoff to predict events. Kaplan-Meier event-free survival curves were constructed and compared using the log-rank test. Cox proportional hazards models were used to investigate the association with events. The criterion for determining statistical significance was p<0.05.

Results:

Mean age was 60.6±15 years, and 48 (60%) were male. Mean ejection fraction was 35.3±7.8%. WRF occurred in 37.5% of the sample. Baseline creatinine was associated with WRF (p<0.001), but neither admission BNP (p=0.35) nor admission NGAL (p=0.18) was predictor of WRF. Using Cox proportional hazard models, hydration index at discharge calculated with BIVA was significantly associated with events (HR 1.39, 95% CI 1.25-1.54, p<0.0001) but not WRF (HR 2.14, 95% CI 0.62-7.35, p=0.22).

Conclusion:

Persistent congestion at discharge was associated with worse outcomes. WRF seems to be related to hemodynamic changes during the decongestion process but not to kidney tubular injuries.

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Microalbuminuria and the Risk of Mortality in Patients with Acute Heart Failure

Use of Diuretics is Associated with Higher Risk of Sarcopenia in Older Adults with Hypertension

Abstract

Background:

Objectives:

Methods:

Results:

Conclusion:

New Perspectives in the Treatment of Hypertension

Worsening Renal Function and Congestion in Patients with Acute Heart Failure: A Study with Bioelectrical Impedance Vector Analysis (BIVA) and Neutrophil Gelatinase-Associated Lipocalin (NGAL)

Abstract

Background:

Objective:

Methods:

Results:

Conclusion:

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