ESC Heart Failure, Journal Year: 2024, Volume and Issue: 11(4), P. 1816 - 1818

Published: June 24, 2024

Congestion is a major clinical sign of acute heart failure (AHF), and loop diuretics remain the first-line treatment option for decongestion in phase disease.1 Even though facilitate water sodium excretion and, therefore, enable more effective decongestion, we need to keep mind that there are several drawbacks related their use. First all, due mode action, remove through sodium-related mechanisms, which long run may lead depletion. Although it has never been demonstrated, at least part ominous signs failure—hyponatremia hypochloremia—may be chronic exposure diuretics.2-4 On other hand, because needed an adequate diuretic response (to diuretics), same time, from body, sort vicious circle created hinders run. In this mechanism (sodium depletion), probably indirectly activate renin-angiotensin-aldosterone (RAA) system, meant homeostasis our body. addition, were shown directly excite RAA system by blocking macula densa thus promoting renin release. Furthermore, excessive (diuretic mediated) loss counterbalanced with thirst, another created.5 Some premises exist effect most drugs (especially SGLT-2) gets blunted time once some adaptive mechanisms come into play.6, 7 This why advanced HF patients (patients who take longer periods time) higher doses drugs.8 The also highly neurohormonal drive, can identify disrupted pathophysiology worse outcomes.9-11 Several studies have demonstrated association between dose outcomes, but casual-effect manner as data retrospective analyses or registries.12, 13 Unfortunately, moment, lack objective measures allow us adjust patients. Thus, all modifications (up- down-titrations) made based on physician's subjective decisions, bias. Finally, no evidence supports notion improve outcomes HF. recently, novel hypotheses about different ways decongest AHF effectiveness, such using SGLT-2 inhibitors, ARNI, optimizing guideline-directed medical therapy (GDMT), STRONG-HF trial.14-16 Taking consideration those aspects, not surprising growing interest de-escalation congestion residual (in particular) associated outcomes. But again, direct causality cannot derived observations observational studies. It is, very likely much difficult sicker patients, creates unfavourable Diuretic responsiveness efficiency net results advancement disease blunt rather than drug characteristics themselves. Both these aspects studied recent paper published ESC Heart Failure.17 Croset et al. down-titration discharge hospital safe patients.17 authors retrospectively analysed cohort mostly (80%) preserved ejection fraction hospitalized single centre. admission recorded compared. led identification two profiles: down titration stable/up-titration during hospitalization. Importantly, both profiles comparison status, defined score biomarkers. There important takes paper. Firstly, was increased risk composite endpoint (time all-cause death and/or rehospitalization) whole population. clinically relevant information clinicians reluctant down-titrate only fear potential side effects, namely, fluid retention subsequent decompensation. However, authors, case cohort. Secondly, approximately one out eight had down-titrated account well-described pharmacological inertia, circumstances (patient degree congestion), 'natural' reluctance optimize hospitalization, reported number quite high. We must hospitalization great (but usually unused misused) opportunity modify pharmacotherapy patients.18, 19 Thirdly, stress group started high median 100 mg discharged 50 mg. increase/stable up-titration 40 80 differences changes seem significant perspective. they Lastly, caveat emphasized. subgroup lower clinical/laboratory congestion. crucial key understanding presented results. study endpoints congestion, BNP (>985 pg/mL), elevated Ca125 (>120 U/mL) admission. confirms individualized management, long-term success. presents clear message, consider its limitations. single-centre analysis type analysis. underpowered detect small groups, follow-up might reveal additional information. To conclude, real unmet markers guide dosing (both down- up-titration) use natriuretic-guided first step therapy, still way go. Moreover, prognostic spot urine discharge, makes even complicated.20 subpopulation safe, deterioration. prospective randomized would provide definitive

Language: Английский