Editorial Comment
Inotropes for the management of acute heart failure and their renal repercussions: Are they all the same?
Inotrópicos na abordagem da insuficiência cardíaca aguda e sua repercussão renal – serão todos iguais?
Inês Rangel
Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "627" "paginaFinal" => "628" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Inês Rangel" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Inês" "apellidos" => "Rangel" "email" => array:1 [ 0 => "inesrang@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Inotrópicos na abordagem da insuficiência cardíaca aguda e sua repercussão renal – serão todos iguais?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure (HF) is a clinical syndrome with a significant public health burden worldwide due to its high prevalence, morbidity and mortality. Its prevalence is predicted to increase by 25% by 2030.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In developed countries, acute HF is the leading cause of hospitalization in individuals aged over 65 years, and is a life-threatening condition that requires urgent assessment and treatment.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> In Portugal, HF is responsible for the highest in-hospital mortality of all cerebrovascular and cardiovascular diseases.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Since it is a systemic disease, HF can cause dysfunction in various organs, particularly the kidneys. The term cardiorenal syndrome (CRS) was coined to describe a range of clinical situations involving concomitant worsening of renal and cardiac function. Studies have established the prognostic implications of this syndrome, which is associated with longer hospital stay, higher in-hospital and post-discharge mortality, and higher rehospitalization rates.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">4–6</span></a> The conventional explanation for the worsening of renal function in HF – renal hypoperfusion due to low cardiac output or hypotension – has been shown to be inadequate, explaining only certain aspects of the syndrome.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Inotropic therapy is one of the most controversial subjects in the management of acute HF. Various studies have clearly demonstrated many uncertainties concerning the use of these drugs.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7–9</span></a> While they bring about hemodynamic improvement, they also increase myocardial oxygen demand, promote arrhythmias, and interact with proapoptotic mechanisms. The clinical impact of CRS in these patients led some authors to examine the potential beneficial effects of inotropes on renal function.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">10,11</span></a> Inotropes such as dobutamine and levosimendan improve cardiac output and thus renal perfusion. In addition, levosimendan also has a vasodilatory effect on the renal arteries and veins, which may explain its renoprotective effect.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In their study published in the current issue of the <span class="elsevierStyleItalic">Journal</span>, Madeira et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a> retrospectively assessed the incidence of CRS in 108 consecutive patients admitted for acute HF and requiring inotropes, dividing their sample into two groups according to the inotrope used (levosimendan vs. dobutamine), in order to determine the predictors of CRS.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The incidence of CRS was higher in the dobutamine group than in the levosimendan group (49% vs. 77%, p<0.01), and cystatin C level was the only predictor of the syndrome. In-hospital mortality was also higher in the dobutamine group (9% vs. 42%, p<0.01), and the presence of CRS and the inotrope used were independent predictors of in-hospital mortality. The authors also observed that recovery of renal function at discharge tended to be incomplete in patients treated with dobutamine, in contrast to patients selected for levosimendan perfusion, who had a complete recovery.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study is interesting and contributes to the scientific evidence, seeing that knowledge of how to manage acute HF with inotropes is limited and that the study population was of real-world acute HF patients.</p><p id="par0040" class="elsevierStylePara elsevierViewall">However, the fact that it was retrospective, and the heterogeneity of the study population, limit the applicability of the results and mean that firm conclusions cannot be drawn concerning the superiority of one inotrope or the other. The patients in the dobutamine group may have had a higher baseline risk and hence a worse initial prognosis, since they were older, with lower hemoglobin and systolic blood pressure on admission, and were more often treated with vasopressors, renal replacement therapy and mechanical ventilation.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Thus, although levosimendan is a promising drug for patients with acute HF and renal impairment, the challenge remains to explore in more detail the differences between the various inotropes available for treatment of acute HF and their potential beneficial effects.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" 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: Rangel I. Inotrópicos na abordagem da insuficiência cardíaca aguda e sua repercussão renal – serão todos iguais? Rev Port Cardiol. 2017;36:627–628.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Heart failure: preventing disease and death worldwide" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Ponikowski" 1 => "S.D. Anker" 2 => "K.F. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 4 | 12 |
| 2024 October | 34 | 27 | 61 |
| 2024 September | 55 | 24 | 79 |
| 2024 August | 47 | 25 | 72 |
| 2024 July | 36 | 27 | 63 |
| 2024 June | 39 | 22 | 61 |
| 2024 May | 45 | 25 | 70 |
| 2024 April | 44 | 26 | 70 |
| 2024 March | 39 | 19 | 58 |
| 2024 February | 22 | 22 | 44 |
| 2024 January | 26 | 22 | 48 |
| 2023 December | 20 | 23 | 43 |
| 2023 November | 27 | 28 | 55 |
| 2023 October | 27 | 11 | 38 |
| 2023 September | 18 | 17 | 35 |
| 2023 August | 33 | 19 | 52 |
| 2023 July | 43 | 10 | 53 |
| 2023 June | 24 | 11 | 35 |
| 2023 May | 52 | 24 | 76 |
| 2023 April | 33 | 10 | 43 |
| 2023 March | 72 | 24 | 96 |
| 2023 February | 59 | 12 | 71 |
| 2023 January | 32 | 14 | 46 |
| 2022 December | 34 | 19 | 53 |
| 2022 November | 71 | 27 | 98 |
| 2022 October | 31 | 23 | 54 |
| 2022 September | 23 | 25 | 48 |
| 2022 August | 46 | 24 | 70 |
| 2022 July | 39 | 41 | 80 |
| 2022 June | 33 | 36 | 69 |
| 2022 May | 27 | 33 | 60 |
| 2022 April | 29 | 35 | 64 |
| 2022 March | 32 | 38 | 70 |
| 2022 February | 28 | 34 | 62 |
| 2022 January | 35 | 19 | 54 |
| 2021 December | 25 | 35 | 60 |
| 2021 November | 33 | 43 | 76 |
| 2021 October | 35 | 42 | 77 |
| 2021 September | 20 | 29 | 49 |
| 2021 August | 38 | 32 | 70 |
| 2021 July | 20 | 12 | 32 |
| 2021 June | 26 | 17 | 43 |
| 2021 May | 28 | 42 | 70 |
| 2021 April | 52 | 37 | 89 |
| 2021 March | 41 | 17 | 58 |
| 2021 February | 54 | 19 | 73 |
| 2021 January | 20 | 12 | 32 |
| 2020 December | 28 | 12 | 40 |
| 2020 November | 21 | 18 | 39 |
| 2020 October | 14 | 10 | 24 |
| 2020 September | 41 | 18 | 59 |
| 2020 August | 18 | 8 | 26 |
| 2020 July | 51 | 10 | 61 |
| 2020 June | 30 | 9 | 39 |
| 2020 May | 37 | 8 | 45 |
| 2020 April | 36 | 13 | 49 |
| 2020 March | 25 | 6 | 31 |
| 2020 February | 41 | 27 | 68 |
| 2020 January | 24 | 6 | 30 |
| 2019 December | 27 | 1 | 28 |
| 2019 November | 30 | 7 | 37 |
| 2019 October | 41 | 6 | 47 |
| 2019 September | 16 | 8 | 24 |
| 2019 August | 30 | 7 | 37 |
| 2019 July | 29 | 10 | 39 |
| 2019 June | 23 | 7 | 30 |
| 2019 May | 43 | 6 | 49 |
| 2019 April | 32 | 15 | 47 |
| 2019 March | 118 | 9 | 127 |
| 2019 February | 87 | 10 | 97 |
| 2019 January | 123 | 5 | 128 |
| 2018 December | 129 | 9 | 138 |
| 2018 November | 110 | 6 | 116 |
| 2018 October | 157 | 16 | 173 |
| 2018 September | 49 | 14 | 63 |
| 2018 August | 35 | 9 | 44 |
| 2018 July | 19 | 8 | 27 |
| 2018 June | 46 | 10 | 56 |
| 2018 May | 53 | 14 | 67 |
| 2018 April | 42 | 11 | 53 |
| 2018 March | 96 | 13 | 109 |
| 2018 February | 28 | 6 | 34 |
| 2018 January | 28 | 8 | 36 |
| 2017 December | 53 | 31 | 84 |
| 2017 November | 74 | 26 | 100 |
| 2017 October | 73 | 24 | 97 |
| 2017 September | 51 | 27 | 78 |
| 2017 August | 3 | 5 | 8 |
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