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Curso de Atualização em Medicina Cardiovascular 2019
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07. Syncope and Bradycardia
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Neurohormonal antagonist therapies, renal function and kalaemia: a trade-off to consider when treating heart failure patients
Session:
Posters 4 - Écran 9 - Insuficiência Cardíaca
Speaker:
Rafael Santos
Congress:
CPC 2019
Topic:
D. Heart Failure
Theme:
10. Chronic Heart Failure
Subtheme:
10.6 Chronic Heart Failure - Clinical
Session Type:
Posters
FP Number:
---
Authors:
Rafael Santos; João Pedro Ribeiro Agostinho; Tiago Graça Rodrigues; Afonso Nunes Ferreira; Joana Rigueira; Inês Aguiar Ricardo; Nelson P. Cunha; Maria Mónica Mendes Pedro; Fátima Veiga; Susana Longo; Fausto José Pinto; Dulce Brito
Abstract
<p><strong>Introduction</strong>: The heart failure (HF) with reduced ejection fraction (rEF) therapeutic algorithm encompasses three pharmacological classes that interact with homeostatic renal mechanisms and with potassium (K) excretion. The known effects of sacubitril/valsartan (S/V) on renal function and K levels accrue form the PARADIGM-HF Trial results but there is a lack of every-day clinical practice derived evidence.</p> <p><strong>Objectives</strong>: To evaluate the impact of S/V initiation therapy on renal function, serum K levels and concomitant K-retaining drugs in patients (pts) with HFrEF.</p> <p><strong>Methods</strong>: Single-centre, prospective study of pts medicated with S/V. Estimated glomerular filtration rate (eGFR) calculated by the CKD-EPI formula, serum creatinine (sCr) and K were recorded before S/V initiation and after the up-titration (to maximal individualized tolerated doses) period. Concomitant therapy with mineralocorticoid receptor antagonists (MRAs) and their respective doses was recorded. The effect of S/V introduction on laboratorial data and changes in MRA doses were evaluated by Wilcoxon test.</p> <p><strong>Results</strong>: S/V was prescribed to 102 pts. The mean sCr value was 1.24±0.5 mg/dL, corresponding to an average eGFR of 67.5±23.4 ml/min/1.73. There was no significant change in mean sCr (1.26±0.46, P=NS) or eGFR (62.6±22.5 ml/min/1.73; P=NS) after S/V initiation. Eleven pts (10.8%) had an increase of sCr >0.3mg/dL, which, however, did not led to the interruption or reduction of S/V dose. In 8 pts (7.8%) the drug was started off-label in pts with eGFR < 30ml/min/1.73 but >20ml/ min/1.73: in 7 of these pts, a sCr reduction was observed after S/V initiation (this reduction was >0.3 mg/dL in 3 pts).</p> <p>The mean baseline K value was 4.5±0.6 mmol/L and there was seen a statistically but not clinically significant increase (4.66±0.5mmol/L; P= 0.034) after S/V introduction. Hyperkalaemia with K >5.5mmol/L was observed in 6 pts (5.9%).</p> <p> In 18 pts (17.6%) S/V was started in the presence of K between 5 and 5.5mmol/L. In this sub-population, 10 pts (9.8%) had K reduction after starting the drug, 1 pt maintained the exact same level of K, and 4 pts (3.9%) had a rise of 0.1 to 0.2mmol/L. Only 1 pt required S/V dose reduction (basal K: 5.5mmol/L, maximum K: 6.2mmol/L).</p> <p>There was a need for MRA dose reduction in 5 pts (4.9%), and even interruption in 3 pts (2.9%) in order to reduce K levels. It is also worth noting that in 35 pts (34%) S/V was started without prior MRA prescription.</p> <p><strong>Conclusion</strong>: In this study population the initiation of S/V did not affect negatively renal function and its introduction in pts with eGFR between 20 and 30ml/min/1.73 was found to be safe. Hyperkalaemia was a frequent problem, but did not led to S/V discontinuation. It was observed that sometimes physicians choose to reduce MRA dose in order to maintain S/V therapy and consequently take the possible clinical benefit from both drugs.</p> <p> </p> <p> </p>
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