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Medical Management of Heart Failure With Reduced Ejection Fraction in Patients With Advanced Renal Disease.
Hein, AM, Scialla, JJ, Edmonston, D, Cooper, LB, DeVore, AD, Mentz, RJ
JACC. Heart failure. 2019;(5):371-382
Abstract
Large randomized clinical trials (RCT) supporting guidelines for the management of heart failure with reduced ejection fraction (HFrEF) have typically excluded patients with advanced chronic kidney disease (CKD). Patients with concomitant advanced CKD and HFrEF experience poor cardiovascular outcomes and mortality relative to either disease in isolation and have been shown to consistently receive lower rates of HFrEF guideline-directed medical therapy (GDMT). This review evaluated recent evidence for the use of GDMT in patients with HFrEF and advanced CKD approaching dialysis from RCTs and observational cohorts. The authors also discuss the limitations and challenges inherent in the evidence for GDMT in this population, and offer guidance to clinicians for proper clinical use and future research directions.
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Sickle Cell Nephropathy in the Pediatric Population.
Olaniran, KO, Eneanya, ND, Nigwekar, SU, Vela-Parada, XF, Achebe, MM, Sharma, A, Thadhani, RI
Blood purification. 2019;(1-3):205-213
Abstract
BACKGROUND Compared to the past, patients with sickle cell disease (SCD) currently live longer due to improvements in diagnosis and comprehensive care. Due to these advances, long-term chronic complications pose a greater challenge in the management of patients with SCD. In particular, sickle cell nephropathy (SCN) is associated with significant morbidity and mortality across all age groups. Furthermore, SCN is an understudied condition with relatively few symptoms and therefore requires close surveillance. In this review, we sought to explore the epidemiology, natural history, and treatment options for SCN with an emphasis on the pediatric population. SUMMARY SCN invariably begins in childhood with evidence of structural changes detected as early as infancy. These indolent changes can progress undetected to advanced chronic kidney disease by late adolescence or early adulthood. The risk factors for progression are not well defined, but significant albuminuria (which is also the most common presentation in childhood) is a key factor in progression. One of the main challenges in understanding SCN in children is the poor correlation between estimated and measured glomerular filtration rates. Another challenge is the lack of large-scale longitudinal studies that track the clinical outcomes of pediatric patients over time. Several studies aim to identify early biomarkers of SCN in children, as albuminuria presents only following significant chronic damage. The utility of angiotensin converting enzyme inhibitors and hydroxyurea in treating albuminuria is addressed here as well as novel treatments that may be of benefit.
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The Preventive Role of Angiotensin Converting Enzyme Inhibitors/Angiotensin-II Receptor Blockers and β-Adrenergic Blockers in Anthracycline- and Trastuzumab-Induced Cardiotoxicity.
Blanter, JB, Frishman, WH
Cardiology in review. 2019;(5):256-259
Abstract
Anthracycline (doxorubicin) and trastuzumab treatments for cancer patients have been known to cause cardiotoxicity. The current recommendations for prevention of cardiac events from cancer chemotherapies are largely based on opinion. The American Society of Clinical Oncology recommends active screening and prevention of modifiable cardiovascular risk factors. The risk factors are defined as tobacco use, high blood pressure, high cholesterol, alcohol use, obesity, and physical inactivity. Beta-adrenergic blockers and angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) have been the mainstay of treatment for heart failure patients with reduced left ventricular ejection fraction for many years. This review analyzed the use of beta-adrenergic blockers and ACE inhibitors/ARBs as protection against cardiomyopathy caused by anthracyclines and trastuzumab. Although many more studies are warranted, it was concluded that the addition of a beta-blocker early in the treatment of cancer patients who are undergoing anthracycline or trastuzumab treatment can have beneficial effects in preserving left ventricular ejection fraction and preventing chemotherapy-induced cardiotoxicity. The effects are more apparent in the short term. More studies of the long-term effects are warranted, as are the additive effects of using a beta-blocker and ACE inhibitor/ARB together to prevent chemotherapy-induced cardiotoxicity.
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ACE inhibitors and ARBs: Managing potassium and renal function.
Momoniat, T, Ilyas, D, Bhandari, S
Cleveland Clinic journal of medicine. 2019;(9):601-607
Abstract
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are used primarily to treat hypertension and are also useful for conditions such as heart failure and chronic kidney disease, independent of their effect on blood pressure. This article reviews the indications for ACE inhibitors and ARBs and offers advice for managing their adverse effects, particularly declining renal function and hyperkalemia.
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ACE-inhibitor/calcium antagonist combination: is this the first-choice therapy in arterial hypertension?
Taddei, S
Minerva medica. 2019;(6):546-554
Abstract
The 2018 ESH/ESC guidelines indicate that the first-choice therapy in the majority of hypertensive patients should be a fixed combination of a drug that blocks the renin-angiotensin-aldosterone system and a calcium antagonist or a diuretic. Evidence from the meta-analysis of controlled clinical trials, however, indicates that the classes of drugs that block the renin-angiotensin-aldosterone system should not be considered equivalent as ACE inhibitors have been clearly shown to outperform AT-1 antagonists in preventing myocardial infarction and total mortality. Moreover, studies such as ASCOT and ACCOMPLISH demonstrate a superiority of the ACE-inhibitor/calcium antagonist association over beta-blocker/diuretic associations and especially towards the ACE-inhibitor/diuretic combination, whereas there is no scientific evidence of efficacy with respect to cardiovascular events on the part of AT-1 antagonist/calcium antagonist combinations. Drugs such as ramipril and amlodipine are undoubtedly the reference molecules within their respective classes as numerous controlled clinical studies have demonstrated their effectiveness on cardiovascular events. It is therefore obvious that the availability of a fixed combination with both molecules is a great opportunity for the therapy of the hypertensive patient, considering also the availability of studies that demonstrate its effectiveness on intermediate endpoints associated with high tolerability. So, in accordance with the 2018 ESH/ESC guidelines, the fixed combination ramipril/amlodipine represents a first choice therapy for hypertension.
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The Use of Renin-Angiotensin System Inhibitors in Patients With Chronic Kidney Disease.
Leon, SJ, Tangri, N
The Canadian journal of cardiology. 2019;(9):1220-1227
Abstract
Chronic kidney disease (CKD) is a growing public health issue worldwide. It is acknowledged that CKD is associated with increased risk of cardiovascular disease, which is the leading cause of morbidity and mortality in this population. The role of the renin-angiotensin-aldosterone system in the pathophysiology of hypertension, and cardiovascular and kidney diseases is well known and the renin-angiotensin-aldosterone system is a major regulator of blood pressure through its effect on body fluids and electrolyte homeostasis. For 2 decades, renin-angiotensin system inhibitors have been the mainstay of treatment for CKD. Clinical trials have shown that prescription of monotherapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers reduces albuminuria and slows the progression of nephropathy in patients with diabetes. In clinical practice guidelines, renin-angiotensin system inhibitors are recommended as the antihypertensive drug of choice in patients with CKD with or without diabetes. Moreover, renin-angiotensin system inhibitors have been shown to offer cardiovascular protection beyond those resulting after blood pressure control. However, the benefits of renin-angiotensin system inhibitor prescriptions for patients with advanced CKD remain controversial. Patients with advanced CKD or who undergo dialysis are under-represented in clinical trials, and studies in this population are urgently needed.
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Angiotensin Receptor Blockers Versus Angiotensin Converting Enzyme Inhibitors for the Treatment of Arterial Hypertension and the Role of Olmesartan.
Omboni, S, Volpe, M
Advances in therapy. 2019;(2):278-297
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Abstract
Blood pressure lowering by all classes of antihypertensive drugs is accompanied by significant reductions of stroke and major cardiovascular (CV) events. Drugs acting on the renin-angiotensin-aldosterone system, such as angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), showed similar benefit on major CV events to other antihypertensive medications. In real-world practice, ARBs reduced by 10% the incidence of CV mortality, non-fatal myocardial infarction, non-fatal stroke and provided superior protection against CV events than ACEIs in high-risk patients. Despite similar antihypertensive properties and a favourable safety profile for both ACEIs and ARBs, evidence indicates that patients treated with ARBs have lower rates of withdrawal for adverse events and greater persistence to therapy than those treated with ACEIs. Among ARBs, olmesartan is one of the latest generation compounds introduced in clinical practice for treating hypertension: head-to-head comparative trials suggest that the efficacy of olmesartan is superior to that of commonly prescribed ACEIs (ramipril and perindopril). The drug, administered as a monotherapy or in combination with a dihydropyridine calcium channel blocker or a thiazide diuretic, has proved to be effective in maintaining blood pressure stability over 24 h, with a favourable safety profile and low discontinuation rates. These properties are pivotal for considering olmesartan as a useful antihypertensive agent especially for high-risk patients (e.g. elderly, diabetics, patients with metabolic syndrome).Funding: Article preparation and open access fee were funded by Menarini International Operations Luxembourg S.A. (M.I.O.L.).
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Hyperkalemia in ambulant postcardiac surgery patients during combined therapy with angiotensin-converting enzyme inhibitor, spironolactone, and diet rich in potassium: A report of two cases and review of literature.
Dixit, A, Majumdar, G, Tewari, P
Annals of cardiac anaesthesia. 2019;(2):162-168
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Abstract
INTRODUCTION Potassium is the most abundant cation in intracellular compartment. A deficiency or excess of its serum concentration can be deleterious to the one suffering from a cardiac ailment. Post cardiac surgery patients are often on multiple drugs like angiotensin receptor blockers (ARBs), angiotensin converting enzyme inhibitors (ACEI), diuretics including potassium sparing diuretics which are known to predispose for hyperkalemia. We report two postoperative cases who developed life threatening hyperkalemia despite normal renal function due to a combination of factors like treatment with ACEI, potassium sparing diuretics, high dietary intake of potassium and we also discuss renal handling of potassium in this review of literature. METHODOLOGY We present a case series of two cases of cardiac surgery, who presented in the emergency department with hyperkalemia, managed conservatively and detailed history revealed that patient were also on very high nutritional potassium. RESULT Both the patients responded to conservative management and there was no recurrence of such episodes once the dose of diuretics was adjusted and diet modification advised. CONCLUSION In India, many patients are from a low socioeconomic background and often resort to cheap and filling food items like bananas. This dietary factor should be kept in mind while prescribing patients with these medications and adequate counseling regarding diet should be done.
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Initiation, Continuation, Switching, and Withdrawal of Heart Failure Medical Therapies During Hospitalization.
Bhagat, AA, Greene, SJ, Vaduganathan, M, Fonarow, GC, Butler, J
JACC. Heart failure. 2019;(1):1-12
Abstract
Patients with worsening heart failure with reduced ejection fraction (HFrEF) spend a large proportion of time in the hospital and other health care facilities. The benefits of guideline-directed medical therapy (GDMT) in the outpatient setting have been shown in large randomized controlled trials. However, the decision to initiate, continue, switch, or withdraw HFrEF medications in the inpatient setting is often based on multiple factors and subject to significant variability across providers. Based on available data, in well-selected, treatment-naïve patients who are hemodynamically stable and clinically euvolemic after stabilization during hospitalization for HF, elements of GDMT can be safely initiated. Inpatient continuation of GDMT for HFrEF appears safe and well-tolerated in most hemodynamically stable patients. Hospitalization is also a potential time for switching from an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker to sacubitril/valsartan therapy in eligible patients, and is the subject of ongoing study. Therapy withdrawal or need for dose reduction is rarely required, but if needed identifies a particularly at-risk group of patients with progressive HF. If recurrent intolerance to neurohormonal blockers is observed, these patients should be evaluated for advanced HF therapies. There is an enduring need for using the teachable moment of HFrEF hospitalization for optimal initiation, continuation, and switching of GDMT to improve post-discharge patient outcomes and the quality of chronic HFrEF care.
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Angiotensin-Converting Enzyme Inhibitors vs. Angiotensin Receptor Blockers for the Treatment of Hypertension in Adults With Type 2 Diabetes: Why We Favour Angiotensin Receptor Blockers.
Mavrakanas, TA, Lipman, ML
Canadian journal of diabetes. 2018;(2):118-123
Abstract
Cardiovascular disease is the principal cause of morbidity and mortality in patients with diabetes mellitus. The incidence or progression of kidney disease is also common in these patients. Several clinical trials have established the efficacy of angiotensin receptor blockers for the prevention of adverse cardiovascular and renal outcomes in this population and are summarized in this review article. Head-to-head comparison of angiotensin receptor blockers with angiotensin-converting enzyme inhibitors has shown similar cardioprotective and renoprotective properties of both medication classes. However, angiotensin receptor blockers have an improved safety profile with fewer episodes of cough and angioedema and may be the agent of choice in patients with diabetes and hypertension. Novel therapeutic strategies, such as those that include a mineralocorticoid receptor blocker or a selective sodium-glucose cotransporter type 2 inhibitor, may further protect patients with diabetes from cardiovascular and renal complications.