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Serum sodium levels and blood pressure monitoring in heart failure: Added diagnostic and prognostic value
Natremia e medição de pressão arterial na insuficiência cardíaca: mais-valia diagnóstica e prognóstica
José Braz Nogueira
Faculdade de Medicina, Universidade de Lisboa, Centro Cardiovascular da Universidade de Lisboa, Lisboa, Portugal
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(2) the Watchman 14F double curve sheath is advanced over an Amplatzer stiff wire positioned in the left superior pulmonary vein; (3) the left atrial appendage is measured by angiography (3a) and TEE (3b); (4) the Watchman is implanted guided by fluoroscopy (4a) and good apposition and absence of leaks and complications are confirmed by TEE (4b); (5) the Watchman 14F double curve sheath is exchanged for a 24F MitraClip guide catheter, over an Amplatzer support wire; (6) the clip delivery system is directed to the mid scallops of the anterior and posterior mitral valve leaflets, and guided by three-dimensional TEE, the clip is positioned above the origin of the mitral regurgitation (MR) jet; (7) leaflet insertion, MR reduction, and absence of significant mitral valve stenosis are confirmed by TEE (7a and 7b); (8) additional clips are deployed if necessary.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Rita G. 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"apellidos" => "Pinto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255117304456" "doi" => "10.1016/j.repc.2016.11.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117304456?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302040?idApp=UINPBA00004E" "url" => "/21742049/0000003600000078/v1_201707290050/S2174204917302040/v1_201707290050/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204917302039" "issn" => "21742049" "doi" => "10.1016/j.repce.2016.11.014" "estado" => "S300" "fechaPublicacion" => "2017-07-01" "aid" => "1026" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2017;36:513-20" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2732 "formatos" => array:3 [ "EPUB" => 159 "HTML" => 2227 "PDF" => 346 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Ambulatory blood pressure monitoring in heart failure and serum sodium levels" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "513" "paginaFinal" => "520" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Monitorização ambulatória da pressão arterial na insuficiência cardíaca atendendo aos níveis de sódio sérico" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2161 "Ancho" => 2996 "Tamanyo" => 253507 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Boxplots showing differences in 24-h SBP (mean 24-hour systolic blood pressure), dSBP (mean daytime systolic blood pressure), fall in SBP (systolic blood pressure) and fall in DBP (diastolic blood pressure), by groups of serum sodium level.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Carlos Arévalo-Lorido, Juana Carretero-Gómez, Luis Manzano Espinosa, Javier Sobrino-Martínez, José Luis Arias-Jiménez, Francesc Formiga, Antoni Castro-Salomó, Miguel Camafort Babkowski" "autores" => array:8 [ 0 => array:2 [ "nombre" => "José Carlos" "apellidos" => "Arévalo-Lorido" ] 1 => array:2 [ "nombre" => "Juana" "apellidos" => "Carretero-Gómez" ] 2 => array:2 [ "nombre" => "Luis" "apellidos" => "Manzano Espinosa" ] 3 => array:2 [ "nombre" => "Javier" "apellidos" => "Sobrino-Martínez" ] 4 => array:2 [ "nombre" => "José Luis" "apellidos" => "Arias-Jiménez" ] 5 => array:2 [ "nombre" => "Francesc" "apellidos" => "Formiga" ] 6 => array:2 [ "nombre" => "Antoni" "apellidos" => "Castro-Salomó" ] 7 => array:2 [ "nombre" => "Miguel" "apellidos" => "Camafort Babkowski" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255117304432" "doi" => "10.1016/j.repc.2016.11.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117304432?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302039?idApp=UINPBA00004E" "url" => "/21742049/0000003600000078/v1_201707290050/S2174204917302039/v1_201707290050/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Serum sodium levels and blood pressure monitoring in heart failure: Added diagnostic and prognostic value" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "521" "paginaFinal" => "523" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "José Braz Nogueira" "autores" => array:1 [ 0 => array:3 [ "nombre" => "José" "apellidos" => "Braz Nogueira" "email" => array:1 [ 0 => "jnogueira@fm.ul.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Faculdade de Medicina, Universidade de Lisboa, Centro Cardiovascular da Universidade de Lisboa, Lisboa, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Natremia e medição de pressão arterial na insuficiência cardíaca: mais-valia diagnóstica e prognóstica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hyponatremia is the electrolyte abnormality most often encountered in patients admitted for heart failure (HF).<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1–3</span></a> Its prevalence ranges between 18 and 30%,<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4–8</span></a> although it is lower in stable HF outpatients (10-17%).<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">9–12</span></a> It also varies with the severity and duration of HF, the criteria used to define it, medication prescribed and drug doses, particularly of diuretics. Most studies define hyponatremia as Na <135 mEq/l, although some use quartiles, and a linear relation has been observed between risk of short- and long-term total mortality and in-hospital cardiovascular morbidity and mortality and sodium <140 mEq/l. Other studies have demonstrated a U-curve for values between 140 and 145 mEq/l.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4–12</span></a> The value of natremia as a risk indicator is thus evident even for values considered normal; for every 3 mEq/l fall in blood sodium the risk of in-hospital mortality rises by 19.5% in HF with systolic dysfunction and by 8.6% in HF with preserved systolic function, and mortality 60-90 days after discharge rises by 10-18%.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4,5</span></a> Pathophysiologically, hyponatremia is multifactorial, usually due to hypervolemia related to hyperactivity of the sympathetic and rein-angiontensin-aldosterone systems and their effects on the kidneys. This hyperactivity is in turn secondary to reduced cardiac output and consequent reduced stimulation of aortic and carotid baroreceptors, which also induces an excessive increase in non-osmotic secretion of vasopressin and hence fluid retention.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1–3</span></a> However, diuretic therapy can transform this to normovolemia or even hypovolemia.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1–3</span></a> Recent reports suggest that chronic inflammation mediated by interleukin-6 may play a part in this increased vasopressin secretion.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The relationship between blood pressure (BP) and HF, which may appear a simple one due to the known importance of high BP in the etiopathogenesis of HF, becomes more complex in light of the results of various studies that report worse prognosis in HF patients with lower office systolic BP, particularly below 120 mmHg, on admission, at discharge or even as outpatients, especially if they have reduced ejection fraction (EF).<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">14–17</span></a> A meta-analysis of 10 studies including over 8000 patients with stable chronic HF showed a reduction in mortality of 13% for every 10 mmHg higher systolic BP on admission.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> However, some authors describe a U-shaped curve for long-term mortality with values between 120 and 139 mmHg, with slight differences between reduced and preserved EF.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Most studies on the prognostic value of blood sodium levels in HF have shown that hyponatremia is associated with significantly lower office BP, which is also independently associated with higher risk.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4–12</span></a> The few studies on the prognostic value of ambulatory BP monitoring (ABPM) in HF show that non-dipper profiles (inverted dipper or riser) are more common in these patients, possibly related to increased sympathetic activity, and that these profiles are significantly associated with worse prognosis than for a dipper profile,<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">18–20</span></a> as has been shown in hypertensive patients and in population-based studies.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">21,22</span></a> However, to the best of my knowledge no studies have set out to relate natremia levels with BP values recorded by ABPM or with possible changes in circadian patterns.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study by Arévalo-Lorido et al.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> published in this issue of the <span class="elsevierStyleItalic">Journal</span> sets out to analyze precisely this relationship in 175 patients with stable HF, mostly of hypertensive etiology, assessed by ABPM. The authors found a significant correlation between serum sodium levels and systolic BP by ABPM in multivariate analysis, as well as a low prevalence of dipper pattern (20.5%), as has been reported both in patients hospitalized for acute HF and in those with stable chronic HF.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">18–20</span></a> Furthermore, although they did not specifically examine the subgroup with Na <135 mEq/l, the usual definition of hyponatremia, they found that in the lowest quartile (133-139 mEq/l), both mean 24-hour and mean daytime systolic BP levels by ABPM were consistently lower than in the other quartiles. It should be noted that there were no significant differences in drugs prescribed in the different quartiles, including diuretics. There was also a lower prevalence of dipper pattern and a higher proportion of risers in the lowest quartile. Although, as pointed out above, non-dipper profiles are common in HF with either reduced or preserved EF, the riser pattern has recently been particularly strongly associated with HF with preserved EF and with increased risk.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">19,20</span></a> In the present study, most patients in all quartiles of serum sodium levels had preserved EF, which may explain the high proportion of risers (38%), but this contrasts with the lower proportion seen in hypertension (5-19%).</p><p id="par0025" class="elsevierStylePara elsevierViewall">The authors point out certain limitations of their study, including the fact that they were unable to form a true hyponatremic group, i.e. with sodium level <135 mEq/l (although several studies have shown increased risk with levels below 140 mEq/l<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,9,10</span></a>), and that they could not analyze HF with reduced and preserved EF separately, due to the preponderance of the latter, which could have further clarified some of the inter-relationships that have recently been reported, especially the increased risk seen in HF patients with riser profile and with preserved (but not reduced) EF.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> Nevertheless, we consider their work to be original and of considerable interest, as it confirms the previously described association between low sodium levels and lower office BP in stable HF patients, only this time with 24-hour ABPM, with its added diagnostic and prognostic value. Furthermore, they raise the possibility that the changes in circadian profile found mostly in the lowest serum sodium quartile, particularly the lower prevalence of night-time dipping and the significantly higher proportion of riser profile, may improve risk stratification, higher risk being associated with lower sodium levels, as described in studies of both hospitalized<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4–8</span></a> and outpatient<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">9–12</span></a> HF populations. The study may also contribute toward a better understanding of the pathophysiology involved, with specific serum sodium levels being used as markers or risk factors for overall mortality and cardiovascular morbidity and mortality in HF, and possibly as therapeutic targets.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Braz Nogueira J. Natremia e medição de pressão arterial na insuficiência cardíaca: mais-valia diagnóstica e prognóstica. Rev Port Cardiol. 2017;36:521–523.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hyponatremia and heart failure – pathophysiology and implications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 6 | 18 |
| 2024 October | 58 | 25 | 83 |
| 2024 September | 61 | 24 | 85 |
| 2024 August | 69 | 24 | 93 |
| 2024 July | 58 | 33 | 91 |
| 2024 June | 46 | 30 | 76 |
| 2024 May | 56 | 21 | 77 |
| 2024 April | 63 | 31 | 94 |
| 2024 March | 87 | 23 | 110 |
| 2024 February | 86 | 19 | 105 |
| 2024 January | 76 | 35 | 111 |
| 2023 December | 47 | 33 | 80 |
| 2023 November | 97 | 25 | 122 |
| 2023 October | 58 | 21 | 79 |
| 2023 September | 45 | 23 | 68 |
| 2023 August | 53 | 15 | 68 |
| 2023 July | 56 | 10 | 66 |
| 2023 June | 40 | 15 | 55 |
| 2023 May | 54 | 27 | 81 |
| 2023 April | 48 | 10 | 58 |
| 2023 March | 77 | 30 | 107 |
| 2023 February | 62 | 25 | 87 |
| 2023 January | 35 | 25 | 60 |
| 2022 December | 53 | 25 | 78 |
| 2022 November | 63 | 33 | 96 |
| 2022 October | 36 | 35 | 71 |
| 2022 September | 43 | 47 | 90 |
| 2022 August | 38 | 30 | 68 |
| 2022 July | 40 | 43 | 83 |
| 2022 June | 36 | 37 | 73 |
| 2022 May | 18 | 25 | 43 |
| 2022 April | 27 | 33 | 60 |
| 2022 March | 34 | 36 | 70 |
| 2022 February | 27 | 36 | 63 |
| 2022 January | 36 | 19 | 55 |
| 2021 December | 27 | 25 | 52 |
| 2021 November | 30 | 33 | 63 |
| 2021 October | 41 | 42 | 83 |
| 2021 September | 22 | 32 | 54 |
| 2021 August | 23 | 25 | 48 |
| 2021 July | 20 | 27 | 47 |
| 2021 June | 20 | 20 | 40 |
| 2021 May | 25 | 34 | 59 |
| 2021 April | 52 | 31 | 83 |
| 2021 March | 36 | 21 | 57 |
| 2021 February | 65 | 18 | 83 |
| 2021 January | 47 | 13 | 60 |
| 2020 December | 49 | 12 | 61 |
| 2020 November | 26 | 18 | 44 |
| 2020 October | 26 | 16 | 42 |
| 2020 September | 49 | 12 | 61 |
| 2020 August | 38 | 8 | 46 |
| 2020 July | 73 | 13 | 86 |
| 2020 June | 59 | 8 | 67 |
| 2020 May | 46 | 5 | 51 |
| 2020 April | 32 | 15 | 47 |
| 2020 March | 27 | 18 | 45 |
| 2020 February | 89 | 38 | 127 |
| 2020 January | 28 | 8 | 36 |
| 2019 December | 23 | 3 | 26 |
| 2019 November | 20 | 9 | 29 |
| 2019 October | 45 | 6 | 51 |
| 2019 September | 7 | 11 | 18 |
| 2019 August | 26 | 7 | 33 |
| 2019 July | 27 | 9 | 36 |
| 2019 June | 22 | 16 | 38 |
| 2019 May | 24 | 12 | 36 |
| 2019 April | 17 | 10 | 27 |
| 2019 March | 32 | 12 | 44 |
| 2019 February | 45 | 9 | 54 |
| 2019 January | 19 | 6 | 25 |
| 2018 December | 42 | 12 | 54 |
| 2018 November | 115 | 11 | 126 |
| 2018 October | 242 | 19 | 261 |
| 2018 September | 73 | 11 | 84 |
| 2018 August | 43 | 8 | 51 |
| 2018 July | 56 | 3 | 59 |
| 2018 June | 90 | 5 | 95 |
| 2018 May | 65 | 9 | 74 |
| 2018 April | 78 | 13 | 91 |
| 2018 March | 93 | 7 | 100 |
| 2018 February | 61 | 6 | 67 |
| 2018 January | 37 | 14 | 51 |
| 2017 December | 109 | 9 | 118 |
| 2017 November | 64 | 28 | 92 |
| 2017 October | 59 | 27 | 86 |
| 2017 September | 52 | 35 | 87 |
| 2017 August | 105 | 39 | 144 |
| 2017 July | 22 | 12 | 34 |
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