Cardiology

Packer, M. (2017). “Early worsening of renal function after treatment with antihyperglycemic drugs: A consistent finding in large-scale trials.” Am J Med: 2017 Nov [Epub ahead of print].

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Prolonged hyperglycemia in type 2 diabetes exerts adverse structural and functional effects on the kidney, and sustained lowering of blood glucose for a decade or longer has been shown to reduce the risk of progression to end-stage renal disease. 1 However, during the first months or years of treatment with an antihyperglycemic drug, patients may experience worsening of renal function regardless of the agent used to lower blood glucose. There is minimal recognition of this phenomenon in the medical literature. The most persuasive evidence supporting the occurrence of early worsening of renal function after initiation of treatment with antidiabetic drugs is derived from randomized controlled clinical trials with different antihyperglycemic agents. Sequential changes in estimated glomerular filtration rate (or in serum creatinine) have been reported in 5 large-scale trials completed since regulatory agencies issued a new guidance on diabetes in 2008. 2

Packer, M. (2017). “Early worsening of renal function after treatment with antihyperglycemic drugs: A consistent finding in large-scale trials.” Am J Med: 2017 Nov [Epub ahead of print].

Full text of this article.

Prolonged hyperglycemia in type 2 diabetes exerts adverse structural and functional effects on the kidney, and sustained lowering of blood glucose for a decade or longer has been shown to reduce the risk of progression to end-stage renal disease. 1 However, during the first months or years of treatment with an antihyperglycemic drug, patients may experience worsening of renal function regardless of the agent used to lower blood glucose. There is minimal recognition of this phenomenon in the medical literature. The most persuasive evidence supporting the occurrence of early worsening of renal function after initiation of treatment with antidiabetic drugs is derived from randomized controlled clinical trials with different antihyperglycemic agents. Sequential changes in estimated glomerular filtration rate (or in serum creatinine) have been reported in 5 large-scale trials completed since regulatory agencies issued a new guidance on diabetes in 2008. 2

VanWagner, L. B., M. E. Harinstein, J. R. Runo, C. Darling, M. Serper, S. Hall, J. A. Kobashigawa and L. L. Hammel (2017). “Multidisciplinary approach to cardiac and pulmonary vascular disease risk assessment in liver transplantation: An evaluation of the evidence and consensus recommendations.” Am J Transplant: 2017 Oct [Epub ahead of print].

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Liver transplant (LT) candidates today are older, have greater medical severity of illness, and have more cardiovascular comorbidities than ever before. In addition, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Cirrhotic cardiomyopathy, a condition characterized by increased cardiac output and a reduced ventricular response to stress, is present in up to 30% of patients with cirrhosis thus challenging perioperative management. Current noninvasive tests that assess for subclinical coronary and myocardial disease have low sensitivity, and altered hemodynamics during the LT surgery can unmask latent cardiovascular disease either intraoperatively or in the immediate postoperative period. Therefore, this review, assembled by a group of multidisciplinary experts in the field and endorsed by the American Society of Transplantation Liver and Intestine and Thoracic and Critical Care Communities of Practice, provides a critical assessment of the diagnosis of cardiac and pulmonary vascular disease and interventions aimed at managing these conditions in LT candidates. Key points and practice-based recommendations for the diagnosis and management of cardiac and pulmonary vascular disease in this population are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.

Joseph, S. M., J. L. Manghelli, J. M. Vader, T. Keeney, E. L. Novak, J. Felius, S. C. Martinez, M. E. Nassif, B. Lima, S. C. Silvestry and M. W. Rich (2017). “Prospective assessment of frailty using the fried criteria in patients undergoing left ventricular assist device therapy.” Am J Cardiol 120(8): 1349-1354.

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Frail patients are more prone to adverse events after cardiac surgery, particularly after implantation of left ventricular assist devices. Thus, frailty assessment may help identify patients unlikely to benefit from left ventricular assist device therapy. The purpose was to establish a suitable measure of frailty in adults with end-stage heart failure. In a prospective cohort of 75 patients (age 58 +/- 12 years) with end-stage heart failure, we assessed the association between frailty (5-component Fried criteria) and the composite primary outcome of inpatient mortality or prolonged length of stay, as well as extubation status, time on ventilator, discharge status, and long-term mortality. Fried frailty criteria were met in 44 (59%) patients, but there was no association with the primary outcome (p = 0.10). However, an abridged set of 3 criteria (exhaustion, inactivity, and grip strength) was predictive of the primary outcome (odds ratio 2.9, 95% confidence interval 1.1 to 7.4), and of time to extubation and time to discharge. In patients with advanced heart failure, the 5-component Fried criteria may not be optimally sensitive to clinical differences. In conclusion, an abridged set of 3 frailty criteria was predictive of the primary outcome and several secondary outcomes, and may therefore be a clinically useful tool in this population.

Afzal, A., R. C. Vallabhan and P. A. McCullough (2017). “Acute kidney injury in cardiogenic shock: In search of early detection and clinical certainty.” Eur J Heart Fail: 1-3.

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This study stands out as the rst study to prospectively eval-uate AKI in patients with CS by KDIGO guidelines, based notonly on creatinine, but also on cystatin C.5The AKI mortal-ity results in this study are internally consistent as patients pre-senting with A KI had lower ejection fractions, higher Sequen-tial Organ Failure Assessment scores, and a higher incidenceof respiratory failure requiring mechanical ventilation.7Rates ofrenal replacement therapy were 14%, yet the 90-day mortalityrate was 38% suggesting that the majority of deaths in the rst20 days reected the natural history of CS treated with stan-dard of care in the cardiac catheterization laboratory and coro-nary care unit and were not amenable to ultraltration for pul-monary oedema/anuria or haemodialtration for hyperkalaemia orazotaemia.