RESUMO
BACKGROUND: High values of cardiac troponin in acute decompensated congestive heart failure (ADHF) identify patients at higher risk and worsened prognosis. A cardiac troponin increase during therapy indicates the need for more appropriate intervention, aimed at compensating cardiac disease and effectively minimizing myocardial wall stress and subsequent cytolysis. This study evaluated the effects of an intravenous high dose of furosemide with (group A) or without small volume hypertonic saline solution (HSS) (group B) on myocardial cytolysis in patients with ADHF. METHODS: A total of 248 consecutive patients with ADHF (148 men, mean age 74.9 ± 10.9 years) were randomly assigned to group A or B. Plasma levels of cardiac troponin-I, brain natriuretic peptide, glomerular filtration rate by Modification of Diet in Renal Disease formula, bioelectrical impedance analysis measurements, and delta pressure/delta time (dP/dt) rate were observed on admission and discharge for all patients. RESULTS: We observed a significant reduction of cardiac troponin in both groups and a significant improvement in renal function, hydration state, pulmonary capillary wedge pressure (P < .0001), end diastolic volume (P < .01), ejection fraction (P < .01), and dP/dt (P < .004) in group A. We also observed a significant reduction in body weight (64.4 vs 75.8 kg) (P < .001), cardiac troponin I (0.02 vs 0.31 ng/mL) (P < .0001) and brain natriuretic peptide (542 vs 1,284 pg/mL) (P < .0001), and hospitalization time (6.25 vs 10.2 days) (P < .0001) in the HSS group. CONCLUSIONS: These data demonstrate that intravenous high doses of furosemide do not increase myocardial injury and, in addition, when associated to HSS, significantly reduce cardiac troponin I release. This behavior is mirrored by the achievement of improved hemodynamic compensation at echocardiography and body hydration normalization.
Assuntos
Diuréticos/administração & dosagem , Furosemida/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Solução Salina Hipertônica/administração & dosagem , Troponina I/sangue , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Quimioterapia Combinada , Ecocardiografia Doppler em Cores , Impedância Elétrica , Feminino , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Peptídeo Natriurético Encefálico/efeitos dos fármacos , Potássio/sangue , Troponina I/efeitos dos fármacosRESUMO
The conflicting results of diuretic treatments in heart failure (HF) and the importance of Na management in the context of the cardiorenal syndrome and neurohormonal activation in HF have suggested novel and counterintuitive strategies, focused primarily on the use of vasopressin antagonists and hypertonic saline solution with high doses of loop diuretics and their neurohormonal interference. The emerging novel therapies involving direct inhibition of vasopressin receptors appear to show promising results. The use of hypertonic saline solution mixed with a high dose of loop diuretics produces, probably by indirect mechanisms, a reduction or inhibition of the activated neurohormonal systems in HF patients. This treatment opens a new window on the role of sodium management in these patients and on the relation between sodium and the kidney's role and function in heart failure. The authors review the current evidence for these therapies and suggest hypothetical bases for their efficacy.
Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/metabolismo , Natriurese/efeitos dos fármacos , Inibidores de Simportadores de Cloreto de Sódio e Potássio/uso terapêutico , Antagonistas dos Receptores de Hormônios Antidiuréticos , Insuficiência Cardíaca/fisiopatologia , Humanos , Antagonistas de Receptores Purinérgicos P1 , Sistema Renina-Angiotensina/efeitos dos fármacos , Solução Salina Hipertônica/farmacologia , Solução Salina Hipertônica/uso terapêutico , Inibidores de Simportadores de Cloreto de Sódio e Potássio/farmacologia , Sódio na Dieta/administração & dosagem , Sódio na Dieta/metabolismoRESUMO
Acute stent thrombosis is rare and it is usually related to complications during the procedure. Subacute thrombosis is far more common and is associated with a high incidence of acute myocardial infarction and death. Restoration of flow by thrombolysis, emergency bypass surgery or emergency percutaneous transluminal coronary angioplasty (PTCA) has had only limited success with respect to myocardial salvage. We report the case of a patient who suffered from recurrent subacute stent thrombosis, in whom administration of tirofiban at high-dose bolus in association with a half dose of recombinant tissue plasminogen activator succeeded in restoring normal myocardial flow and stable clinical condition.
Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Trombose Coronária/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Infarto do Miocárdio/terapia , Stents/efeitos adversos , Tirosina/análogos & derivados , Tirosina/administração & dosagem , Doença Aguda , Idoso , Angioplastia Coronária com Balão/métodos , Angiografia Coronária , Circulação Coronária/fisiologia , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/etiologia , Relação Dose-Resposta a Droga , Quimioterapia Combinada , Seguimentos , Humanos , Masculino , Infarto do Miocárdio/diagnóstico , Medição de Risco , Tirofibana , Grau de Desobstrução Vascular/fisiologiaRESUMO
OBJECTIVE: A randomised, double-blind study was performed to evaluate the effects of the combination of high-dose torasemide and hypertonic saline solution (HSS) infusion versus high-dose furosemide (frusemide) and HSS in the treatment of refractory New York Heart Association class IV congestive heart failure (CHF). MATERIALS AND METHODS: Eighty-four patients (55 males, 29 females) with refractory CHF, aged 55-84 years, with an ejection fraction <35%, serum creatinine <2 mg/dL, blood urea nitrogen =60 mg/dL, a reduced urinary volume and a low natriuresis, were randomised to two groups. Group 1 (27 males, 15 females) received an intravenous infusion of furosemide 500mg plus HSS (150mL of 1.4-4.6% sodium chloride) twice daily in 30 minutes. Group 2 (28 males, 14 females) received torasemide 200mg twice daily plus HSS during a period lasting 4-8 days. Physical examination, measurement of bodyweight, blood pressure, heart rate, evaluation of signs of CHF, and serum and urinary parameters were controlled daily during hospitalisation. Chest x-ray, ECG and echocardiogram were obtained at entry, during hospitalisation and at discharge. During the treatment and after discharge the daily dietary sodium intake was 120 mmol, with a fluid intake of 1.0-1.5L in both groups. Bodyweight and 24-hour urinary volume, serum and urinary laboratory parameters, until reaching a compensated state, were controlled daily, when intravenous furosemide and torasemide were replaced with oral furosemide administration only (250-500mg twice daily). After discharge the double-blind design was discontinued and the subsequent period was an open-label study with furosemide only; the patients were followed up as outpatients weekly for the first 3 months and subsequently once a month. RESULTS: Baseline clinical characteristics of patients were similar in both groups. A significant increase in daily diuresis and natriuresis was observed in both groups. No difference was observed in serum sodium or potassium. Bodyweight was reduced in both groups. Blood pressure values decreased, and heart rate was corrected to normal values in both groups. In the follow-up period (12 +/- 3.9 months), 17 patients were re-admitted to the hospital for heart failure. Thirteen patients died during follow-up. CONCLUSION: We conclude that high-dose torasemide is equivalent to high-dose furosemide in the treatment of refractory CHF.