Cardiology

McCullough, P.A. (2021). “Anemia of cardiorenal syndrome.” Kidney Int Suppl (2011) 11(1): 35-45.

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Cardiorenal syndrome includes a spectrum of disorders of the kidneys and heart in which loss of function in one organ contributes to reduced function in the other organ. Cardiorenal syndrome is frequently complicated by comorbid anemia, which leads to reciprocal and progressive cardiac and renal deterioration. The triad of heart failure, chronic kidney disease (CKD), and anemia is termed cardiorenal anemia syndrome (CRAS). There are currently no evidence-based recommendations for managing patients with CRAS; however, the treatment of these patients is multifactorial. Not only must the anemia be controlled, but heart failure and kidney injury must be addressed, in addition to other comorbidities. Intravenous iron and erythropoiesis-stimulating agents are the mainstays of treatment for anemia of CKD, addressing both iron and erythropoiesis deficiencies. Since erythropoiesis-stimulating agent therapy can be associated with adverse outcomes at higher doses in patients with CKD and is not used in routine practice in patients with heart failure, treatment options for managing anemia in patients with CRAS are limited. Several new therapies, particularly the hypoxia-inducible factor-prolyl hydroxylase inhibitors, are currently under clinical development. The hypoxia-inducible factor-prolyl hydroxylase inhibitors have shown promising results for treating anemia of CKD in clinical trials and may confer benefits in patients with CRAS, potentially addressing some of the limitations of erythropoiesis-stimulating agents. Updated clinical practice guidelines for the screening and management of anemia in cardiorenal syndrome, in light of potential new therapies and clinical evidence, would improve the clinical outcomes of patients with this complex syndrome.

Mack, M.J., Fullerton, D.A. and Fann, J.I. (2021). “The Answers You Get Depend On the Questions You Ask: Insights from the Recent EXCEL Trial Controversy.” Ann Thorac Surg Mar 6;S0003-4975(21)00447-1. [Epub ahead of print].

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The SYYNTAX authors found that the impact of these “enzyme-driven events” on time-to-event curves and the composite endpoints was greater in the surgical cohort. PMIs after PCI were associated with 10-year mortality regardless of definition, whereas their impact on mortality after CABG was limited to 1 year, leading to the conclusion that “the rates of PMI are highly dependent on their definition, which affects time-to-event curves, composite endpoints, and their lethal prognostic relevance”. This serves to stress the importance of engagement of all investigators during the design phase of a trial because of the importance of the decisions at that time in determining trial outcomes. [No abstract; excerpt from article].

Lo, K.B., Toroghi, H.M., Salacup, G., Jiang, J., Bhargav, R., Quintero, E., Balestrini, K., Shahzad, A., Mathew, R.O., McCullough, P.A. and Rangaswami, J. (2021). “Angiotensin converting enzyme inhibitors and angiotensin receptor blockers in acute heart failure: invasive hemodynamic parameters and clinical outcomes.” Rev Cardiovasc Med 22(1): 199-206.

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There are limited data regarding the use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs) in acute heart failure (AHF). The purpose is to determine the patterns of ACEi/ARB use at the time of admission and discharge in relation to invasive hemodynamic data, mortality, and heart failure (HF) readmissions. This is a retrospective single-center study in patients with AHF who underwent right heart catheterization between January 2010 and December 2016. Patients on dialysis, evidence of shock, or incomplete follow up were excluded. Multivariate logistic regression analysis was used to analyze the factors associated with continuation of ACEi/ARB use on discharge and its relation to mortality and HF readmissions. The final sample was 626 patients. Patients on ACEi/ARB on admission were most likely continued on discharge. The most common reasons for stopping ACEi/ARB were worsening renal function (WRF), hypotension, and hyperkalemia. Patients with ACEi/ARB use on admission had a significantly higher systemic vascular resistance (SVR) and mean arterial pressure (MAP), but lower cardiac index (CI). Patients with RA pressures above the median received less ACEi/ARB (P = 0.025) and had significantly higher inpatient mortality (P = 0.048). After multivariate logistic regression, ACEi/ARB use at admission was associated with less inpatient mortality; OR 0.32 95% CI (0.11 to 0.93), and this effect extended to the subgroup of patients with HFpEF. Patients discharged on ACEi/ARB had significantly less 6-month HF readmissions OR 0.69 95% CI (0.48 to 0.98). ACEi/ARB use on admission for AHF was associated with less inpatient mortality including in those with HFpEF.

Leon, M.B., Mack, M.J., Hahn, R.T., Thourani, V.H., Makkar, R., Kodali, S.K., Alu, M.C., Madhavan, M.V., Chau, K.H., Russo, M., Kapadia, S.R., Malaisrie, S.C., Cohen, D.J., Blanke, P., Leipsic, J.A., Williams, M.R., McCabe, J.M., Brown, D.L., Babaliaros, V., Goldman, S., Herrmann, H.C., Szeto, W.Y., Genereux, P., Pershad, A., Lu, M., Webb, J.G., Smith, C.R. and Pibarot, P. (2021). “Outcomes 2 Years After Transcatheter Aortic Valve Replacement in Patients at Low Surgical Risk.” J Am Coll Cardiol 77(9): 1149-1161.

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BACKGROUND: In low surgical risk patients with symptomatic severe aortic stenosis, the PARTNER 3 (Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis) trial demonstrated superiority of transcatheter aortic valve replacement (TAVR) versus surgery for the primary endpoint of death, stroke, or re-hospitalization at 1 year. OBJECTIVES: This study determined both clinical and echocardiographic outcomes between 1 and 2 years in the PARTNER 3 trial. METHODS: This study randomly assigned 1,000 patients (1:1) to transfemoral TAVR with the SAPIEN 3 valve versus surgery (mean Society of Thoracic Surgeons score: 1.9%; mean age: 73 years) with clinical and echocardiography follow-up at 30 days and at 1 and 2 years. This study assessed 2-year rates of the primary endpoint and several secondary endpoints (clinical, echocardiography, and quality-of-life measures) in this as-treated analysis. RESULTS: Primary endpoint follow-up at 2 years was available in 96.5% of patients. The 2-year primary endpoint was significantly reduced after TAVR versus surgery (11.5% vs. 17.4%; hazard ratio: 0.63; 95% confidence interval: 0.45 to 0.88; p = 0.007). Differences in death and stroke favoring TAVR at 1 year were not statistically significant at 2 years (death: TAVR 2.4% vs. surgery 3.2%; p = 0.47; stroke: TAVR 2.4% vs. surgery 3.6%; p = 0.28). Valve thrombosis at 2 years was increased after TAVR (2.6%; 13 events) compared with surgery (0.7%; 3 events; p = 0.02). Disease-specific health status continued to be better after TAVR versus surgery through 2 years. Echocardiographic findings, including hemodynamic valve deterioration and bioprosthetic valve failure, were similar for TAVR and surgery at 2 years. CONCLUSIONS: At 2 years, the primary endpoint remained significantly lower with TAVR versus surgery, but initial differences in death and stroke favoring TAVR were diminished and patients who underwent TAVR had increased valve thrombosis. (Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis [PARTNER 3]; NCT02675114).

Kalantar-Zadeh, K., McCullough, P.A., Agarwal, S.K., Beddhu, S., Boaz, M., Bruchfeld, A., Chauveau, P., Chen, J., de Sequera, P., Gedney, N., Golper, T.A., Gupta, M., Harris, T., Hartwell, L., Liakopoulos, V., Kopple, J.D., Kovesdy, C.P., Macdougall, I.C., Mann, J.F.E., Molony, D., Norris, K.C., Perlmutter, J., Rhee, C.M., Riella, L.V., Weisbord, S.D., Zoccali, C. and Goldsmith, D. (2021). “Nomenclature in nephrology: preserving ‘renal’ and ‘nephro’ in the glossary of kidney health and disease.” J Nephrol Mar 13. [Epub ahead of print].

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A recently published nomenclature by a “Kidney Disease Improving Global Outcomes” (KDIGO) Consensus Conference suggested that the word “kidney” should be used in medical writings instead of “renal” or “nephro” when referring to kidney disease and kidney health. Whereas the decade-old move to use “kidney” more frequently should be supported when communicating with the public-at-large, such as the World Kidney Day, or in English speaking countries in communications with patients, care-partners, and non-medical persons, our point of view is that “renal” or “nephro” should not be removed from scientific and technical writings. Instead, the terms can coexist and be used in their relevant contexts. Cardiologists use “heart” and “cardio” as appropriate such as “heart failure” and “cardiac care units” and have not replaced “cardiovascular” with “heartvessel”, for instance. Likewise, in nephrology, we consider that “chronic kidney disease” and “continuous renal replacement therapy” should coexist. We suggest that in scientific writings and technical communications, the words “renal” and “nephro” and their derivatives are more appropriate and should be freely used without any pressure by medical journals to compel patients, care-partners, healthcare providers, researchers and other stakeholders to change their selected words and terminologies. We call to embrace the terms “kidney”, “renal” and “nephro” as they are used in different contexts and ask that scientific and medical journals not impose terminology restrictions for kidney disease and kidney health. The choice should be at the discretion of the authors, in the different contexts including in scientific journals.