Doses Of Furosemide Research Articles

Furosemide Responsiveness Predicts Acute Kidney Injury Progression After Cardiac Surgery

BackgroundAs patients with acute kidney injury (AKI) progress to a higher stage, the risk for poor outcomes dramatically rises. Early identification of patients at high risk for AKI progression remains a major challenge. This study aimed to evaluate the value of furosemide responsiveness (FR) for predicting AKI progression in patients with initial mild and moderate AKI after cardiac surgery. MethodsWe performed 2 separate exploratory analyses. The Zhongshan cohort was a single-center, prospective, observational cohort, whereas the Beth Israel Deaconess Medical Center cohort was a single-center, retrospective cohort. We calculated 2 FR parameters for each patient, namely the FR index and modified FR index, defined as 2-hour urine output divided by furosemide dose (FR index, mL/mg/2 h) and by furosemide dose and body weight (modified FR index, mL/[mg·kg]/2 h), respectively. The primary outcome was AKI progression within 7 days. ResultsAKI progression occurred in 80 (16.0%) and 359 (11.3%) patients in the Zhongshan and Beth Israel Deaconess Medical Center cohorts, respectively. All FR parameters (considered continuously or in quartiles) were inversely associated with risk of AKI progression in both cohorts (all adjusted P < .01). The addition of FR parameters significantly improved prediction for AKI progression based on baseline clinical models involving C-index, net reclassification improvement, and integrated discrimination improvement index in both cohorts (all P < .01). ConclusionsFR parameters were inversely associated with risk of AKI progression in patients with mild and moderate AKI after cardiac surgery. The addition of FR parameters significantly improved prediction for AKI progression based on baseline clinical models.

The Relationship between the MAGGIC Score and Cardiorenal Syndrome in Patients with Acute Decompensated Heart Failure with Reduced Ejection Fraction.

The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) is a scoring system that is easy to use in outpatient clinics or at the bedside, and was developed to predict the survival of heart failure patients after hospitalization. This study aims to evaluate the relationship between the MAGGIC score and cardiorenal syndrome (CRS) in patients with acute decompensated heart failure with reduced ejection fraction (HFrEF). This retrospective, single-center study, included 706 patients with New York Heart Association II-IV who were hospitalized and discharged for acute decompensated heart failure between 2016 and 2021. CRS type 1 was defined as acute worsening of cardiac function leading to renal dysfunction. Patients were divided into two groups: those with CRS and those without. The MAGGIC score of all patients was determined. The primary outcome was the occurrence of CRS. CRS developed in 132 patients. The MAGGIC score was higher in CRS (+) patients compared to CRS (-) patients (30.70 ± 8.09 vs. 23.96 ± 5.59, p < 0.001). After a multivariable analysis, MAGGIC score [odds ratio (OR): 3.92, p < 0.001], sodium (OR: 0.92, p = 0.003), N terminal pro B type natriuretic peptide (OR: 1.78, p = 0.009), hs troponin (OR: 1.28, p = 0.044), MRA (OR: 0.61, p = 0.019) and furosemide dose (OR: 1.03, p = 0.001) were found to be independent predictors of CRS development. The MAGGIC score was associated with CRS development (area under curve = 0.778). The MAGGIC score may be associated with CRS in HFrEF patients.

#6633 DIURETIC RESISTANCE PREDICTORS IN ACUTE DECOMPENSATED HEART FAILURE ADMISSIONS: A BROADER LOOK

Abstract Background and Aims Failing to relieve congestion portends a rise in mortality rate and length of stay in acute decompensated heart failure (ADHF) hospitalizations. That situation corresponds to diuretic resistance (RDIUR). We sought to evaluate clinical and biochemical predictors of RDIUR, including those non-conventional ones we noticed as relevant in prognosis in our clinical practice. Method We conducted an observational, analytical and cross-sectional study, with prospective and consecutive patient (P) data acquisition. We included P over 18 years-old, who were admitted to the Intensive Care Telemetry Unit in our Hospital in the period between July, 2011 and May, 2022 due to ADHF diagnosis. All P received diuretic IV therapy as part of pharmacological treatment. As mentioned in earlier presentations, urine output (UO) was registered in all P, and failure to achieve an UO ≥ 1.5 ml/kg/hour under a pre-established protocol that included and initial 100 mg of IV furosemide bolus followed by a 2 hours of a 5 mg/hour furosemide continuous infusion. Under failure to achieve the goal, furosemide dose was doubled for two additional hours. Failure to respond to this strategy was called “diuretic resistance”. P who received a heart transplant during index admission or those who were on chronic dialysis were excluded from this study. Clinical, epidemiological and biochemical variables were registered. Missing data was imputed by means of multiple regression with chained equations. We constructed a multivariate logistic regression, with selection of relevant predictors completed by resampling and regularization of a Lasso regression model. Statistical significance was considered with a 5% of alpha error. Analysis was conducted using R (R Core Team, 2021), with RStudio (RStudio Team, 2020) as Integrated Development Environment for R, and the tidymodels package (Silge and Kuhn, 2022). Results A total of 1359 P were included. RDIUR was observed in 177 P (13%). These P were younger (69 years old vs 72 p = 0.02), with a higher prevalence of diabetes (39.5% vs 28%; p = 0.002), admission creatinine levels (1.4 vs 1.1 mg/dl; p &amp;lt; 0.001), lower total T3 serum levels (0.56 ng/ml vs 0.7; p &amp;lt; 0.001), with higher incidence of cholestasis (61 vs 40%; p &amp;lt; 0.001), and anasarca as clinical phenotype of systemic congestion (17.5% vs 8.5% p &amp;lt; 0.001). In-hospital mortality was higher in P who developed RDIUR (32.8 vs 5.6%, p &amp;lt; 0.001), in the same way that inotropic support (62 vs 16, p &amp;lt; 0.001), worsening heart failure (48% vs 11; p &amp;lt; 0.001), and furosemide dose at 2nd admission day (175.4 vs 123.4 p &amp;lt; 0.001) were higher in these P. We found no differences in left ventricular ejection fraction (38 vs 41 p = 0.21), first day natriuresis (75.5 vs 78.4, p = 0.093), coronary etiology vs others (20% vs 22; p = 0.26) or one month readmission rate (33% vs 37; p = 0.27). In the adjusted model, inotropic support (OR 5.2; IC95% 3.4-8; p &amp;lt; 0.001), worsening heart failure (OR 3.4; IC95% 2.2-5.3; P &amp;lt; 0.001), furosemide dose at 2nd day (OR 1, IC95%1, P 0.001), admission creatininemia (OR 2.05; IC95% 1.7-2.6; p &amp;lt; 0.001), anasarca phenotype (OR 2.3; IC95 1.4-3.9; p = 0.002) and normal T3 levels (OR 0.05; IC95% 0.02-0.14; p &amp;lt; 0.001) were identified as independent predictors of RDIUR development. Model accuracy was 0.89 and ROC-AUC 0.87. In the same way, RDIUR (OR 2.57; IC95% 1.5-4.3; p &amp;lt; 0.001), worsening heart failure (OR 4.1 IC95% 2.4-7; p &amp;lt; 0.001), inotropic support (OR 3; IC95% 1.7-5.2; p &amp;lt; 0.001) and cholestasis (OR 3.1; IC95% 1.9-5.2; p &amp;lt; 0.001) were found as independent predictors of in-hospital mortality. Conclusion Diuretic resistance is a serious event in patients hospitalized for ADHF, and considerably associated with mortality. A decreased renal reserve, low T3 levels, and anasarca at admission were significantly associated with diuretic resistance development. Considering “new” biochemical predictors as admission T3 levels might add strength to this subset of patients, opposed to information displayed by “classical” event predictors in ADHF patients, as ventricular function or etiology of cardiac disease. Due to clinical potential implications these observational results should be confirmed under evidence based protocols.

#4949 COMBINED ORAL DIURETICS: A BETTER ALTERNATIVE FOR NEPHROTIC EDEMA THAN INTRAVENOUS FUROSEMIDE?

Abstract Background and Aims Edema is a serious complication of nephrotic syndrome and is the main reason why patients usually address to a doctor. There is no guideline on managing nephrotic edema. Besides non pharmacological interventions such as sodium and water restrictions, most doctors would choose high doses of intravenous furosemide as the first option, but still many patients fail to properly decrease their volume overload, as they become diuretic resistant. Amiloride, an ENaC mediated diuretic, is an optimistic management option, especially when used with other diuretics. The aim of the present study was to assess the non inferiority of the combined oral diuretics furosemide and the fixed combination of hydrochlorothiazide/amiloride diuretics with intravenous furosemide in diuretic resistant nephrotic edema. Method We conducted a prospective randomized trial in 22 patients with diuretic resistant nephrotic edema. Based on a computer-generated randomization we assigned patients to receive either intravenous furosemide (40 mg bolus and then continuous administration of 5 mg/h) or oral furosemide (40 mg/day) and hydrochlorothiazide/amiloride (50/5 mg/day). Clinical and laboratory measurements were performed daily, for five days (body weight, urinary output, blood pressure and hydration status by bioimpedance twice, creatinine, urea, albumin, hematocrit, Na, K, Ca, Mg, bicarbonate, pH). The primary outcome was weight and hydration status change from baseline to day 5. Secondary outcomes were safety outcomes (low blood pressure, severe dyselectrolytemia, acute kidney injury or aggravated hypervolemia). Results The patients were equally distributed between the two groups. Mean age was 47,77±15,97 (54,5% females and 45,5% males). Half of the patients had membranous nephropathy (45,5%), followed by minimal change disease (22,7%) and lupus nephritis (9,1%). 86,4% of patients had their first episode of nephrotic edema. The mean weight decrease was of significantly larger magnitude in the combined oral diuretics group compared with the intravenous furosemide group (-7,97±2,83 [SD] vs -4,5±2,6 [SD] kg; p = 0,018). Although the increase in 24-hour urine sodium excretion was higher in combined oral diuretics as compared to intravenous furosemide group, this increment was not statistically significant different (26,79±33,48 [SD] vs 16,04±42,81 mmol/24 h [SD]; p = 0,5). Mean values for changes in systolic and diastolic BP, 24-hour urine volume, hydration status measured by bioimpedance were not significantly different between the two groups. A total of 5 patients could not be followed through, 4 in the intravenous furosemide (two patients experienced low blood, one patient had no response to iv furosemide and one patient suffered from insomnia due to iv pump) and one patient in the oral combination of diuretics group had severe hyperkalemia (&amp;gt;6,5 mmol/l). Conclusion Combined oral diuretics with furosemide, amiloride and hydrochlorothiazide is more effective and safer than intravenous furosemide for the treatment of refractory nephrotic edema. These results make amiloride a promising diuretic and further trials with larger sample sizes and longer follow-up are needed in this regard.

Intravenous Furosemide in the Management of Transient Tachypnea of Newborn

Objective: To determine the mean length of hospital stay of term and late preterm infants with transient tachypnea of the newborn treated with intravenous Furosemide compared to the Control Group.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Combined Military Hospital, Kharian, from Apr to Oct 2016.&#x0D; Methodology: All term and late preterm infants with transient tachypnea of new-borns were included in the study. One Group was given IV Furosemide, and the other was taken as control. Two doses of Furosemide were administered IV at 1 mg/kg 12 hours apart. The Control Group were given normal saline 01 ml/kg as a placebo 12 hours apart. &#x0D; Results: It was found that the duration of tachypnea in the Study-Group was less than that of the Control-Group (49.4±7.4 h vs 76.7±4.5h, p-value &lt;0.001). The requirement of oxygen was less in the Treatment Group (53.7±6.6h) as compared to the Control-Group (84.5±4.2h) (p&lt;0.01). The duration of hospitalization in the Study-Group was 71.4±4.9 hours, and in the Control-Group was 100.0±3.7 hours (p-value &lt;0.001).&#x0D; Conclusion: Using intravenous Furosemide in neonates with transient tachypnea of newborns effectively reduces the hospital stay of term and late preterm patients. It reduced the tachypnea and, subsequently, the requirement for oxygen in patients with transient tachypnea in newborns.

Validation of the TRI-SCORE in patients undergoing surgery for isolated tricuspid regurgitation

IntroductionEstimation of peri-procedural risk in patients with tricuspid regurgitation (TR) undergoing isolated tricuspid valve surgery (ITVS) is of paramount importance. The TRI-SCORE is a new surgical risk scale specifically developed...

Prevalence and clinical profile of kidney disease in patients with chronic heart failure. Insights from the Spanish cardiorenal registry

Introduction and objectivesPatients with combined heart failure (HF) and chronic kidney disease (CKD) have been underrepresented in clinical trials. The prevalence of CKD in these patients and their clinical profile require constant evaluation. This study aimed to analyze the prevalence of CKD, its clinical profile, and patterns of use of evidence-based medical therapies in HF across CKD stages in a contemporary cohort of ambulatory patients with HF. MethodsFrom October 2021 to February 2022, the CARDIOREN registry included 1107 ambulatory HF patients from 13 HF clinics in Spain. ResultsThe median age was 75 years, 63% were male, and 48% had heart failure with reduced left ventricular ejection fraction (HFrEF). A total of 654 (59.1%) had an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, and 122 (11%) patients with eGFR ≥ 60 mL/min/1.73 m2 had a urine albumin-creatinin ratio ≥ 30 mg/g. The most important variables associated with lower eGFR were age (R2=61%) and furosemide dose (R2=21%). The proportion of patients receiving an angiotensin-converting enzyme inhibitor (ACEI)/ angiotensin II receptor blockers (ARB), an angiotensin receptor-neprilysin inhibitor (ARNi), a sodium-glucose cotransporter 2 inhibitor (SGLT2i), or a mineralocorticoid receptor antagonist (MRA) progressively decreased with lower eGFR categories. Notably, 32% of the patients with HFrEF and an eGFR <30 mL/min/1.73 m2 received the combination of ACEI/ARB/ARNi+beta-blockers+MRA+SGLT2i. ConclusionsIn this contemporary HF registry, 70% of patients had kidney disease. Although this population is less likely to receive evidence-based therapies, structured and specialized follow-up approaches within HF clinics may facilitate the adoption of these life-saving drugs.

P329 MANAGEMENT OF ADVANCED AND TERMINAL HEART FAILURE IN AN ELDERLY PATIENT WITH REDUCED EJECTION FRACTION

Abstract Heart failure (HF), despite new therapeutic strategies, remains a condition characterized by an inauspicious prognosis and poor quality of life. The management of advanced and then terminal SC proves to be a current challenge, especially in elderly patients. A.C, 87 years old is autonomous and cognitively intact (BADL preserved 5/6, MMSE 28/30). In June ‘21 femur fracture complicated by cerebral hemorrhage (no relics) and anterior STEMI (FE 25%). Not performed coronarography (contraindication to antiplatelet therapy). Discharged to NYHA II with ARNI, MRA and beta blocker. After 1 month hospitalized for HF in the course of AF, performed infusion of levosimendan. In September ‘21 taken over by our "HF clinic" with progressive titration of therapy and insertion of SGLT2–i. In January ‘22 due to precarious clinical compensation (NYHA III–IV) progressive increase in furosemide dosage and undertaken sequential nephron blockade with metolazone, with good response. Given advanced–HF situation, performed Levosimendan infusions under DH regimen (8 h; 0.05–&amp;gt;0.2 mcg/Kg/min; three times every 2 weeks) with clinical stabilization. In April, hospitalization for decompensation flare–up with worsening creatinine (0.8 &amp;gt;&amp;gt;&amp;gt;2 mg/dL). On discharge, given the precarious compensation, activated the "Hospital–Territory Rapid Intervention Group" with home diuretic infusions and stabilization of the clinical picture and subsequent new referral from the "heart failure clinic" with monthly FU. By November 2022, clinical (NYHA IV with diuretic resistance), cognitive and functional (MMSE 22/30, BADL preserved 2/6) worsening. Evaluated as an end–stage scenario (in the absence of further treatment options), family interview was performed, home nursing service activated for infusions of furosemide, and referred to the palliative care service to assist the patient in the terminal phase of illness at home (Fig. 1). Conclusion in order to ensure the best quality of life in the terminal phase of the disease, the management of advanced SC in the elderly patient must involve individualization of the care pathway, through multidimensional assessment of the patient and sharing of goals at the different stages: from intensive FU with optimization of therapy in the early stages to early activation of home and palliative care services in the more advanced stages.

P85 REAL WORLD EXPERIENCE ON THE USE OF SGLT2–I IN ELDERLY PATIENTS WITH HFREF

Abstract SGLT2–i have been shown to improve prognosis in patients with heart failure with reduced ejection fraction (HFrEF) in randomized clinical trials (RCTs). However, at the moment, we have little data on the use of these drugs in clinical practice, both in terms of safety and efficacy profile. Objectives To describe the characteristics of HFrEF outpatients who started SGLT2–i in clinical practice; evaluate tolerability and the effect on clinical and biohumoral parameters. Methods We prospectively analyzed patients who started SGLT2–i in our Heart Failure clinic. The baseline characteristics, the variations of bio–humoral and clinical parameters were recorded, as well as the onset of adverse effects leading to drug suspension after one month. Results We evaluated 37 patients, with a mean age of 77.7± 8.5 years (65% over 75). The baseline characteristics of the population compared to that of the treatment arms of the RCTs are shown in Fig.1. Most patients were in NYHA II (62%), with ischemic etiology (65%), with reduced EF (mean 34.7± 5.1%) and nearly half of the patients received ICD or CRT–D (43.2%). At the one month follow–up, there was a significant reduction in NYHA class (Fig. 2)and furosemide dose (36.3 vs 53.2 mg, p&amp;lt;0.001), without a significant change in NTproBNP values ​​(2499 vs 2431 pg /mL, p=0.804). Furthermore, there was a reduction in systolic blood pressure (115 vs 120 mmHg, p=0.029) with no significant increase in the incidence of orthostatic hypotension (27% vs 21%, p=0.48). In line with the trials, there was a slight, non–significant worsening of renal function (CKD–EPI 52.9 vs 55.9 mL/min, p=0.10). At one month, no patients experienced any adverse effects leading to SGLT2–i discontinuation. Conclusions In this preliminary analysis, after one month of SGLT2–i therapy in elderly patients, there was a clinical and hemodynamic improvement as demonstrated by the improvement of the NYHA class and the reduction of the diuretic therapy. SGLT2–i have been shown to be relatively safe, with no adverse effects and no increased risk of orthostatic hypotension or significant worsening of renal function.

P243 EXTRACORPOREAL CONTINUOUS VENO–VENOUS ULTRAFILTRATION IN PATIENTS WITH ACUTE HEART FAILURE REFRACTORY TO DIURETIC THERAPY: A SINGLE–CENTER PILOT EXPERIENCE

Abstract Introduction Congestive Acute Heart Failure (C–AHF) is characterized by extracellular fluid overload. Extensive use of loop diuretics may induce worsening renal function, electrolyte imbalance, symptomatic hypotension and diuretic resistance. Extracorporeal veno–venous ultrafiltration (UF) may represent a useful adjunctive therapy. Despite a few randomized clinical trials have been carried out, the results are controversial; aim of this study is to describe our pilot experience using UF. Methods We enrolled consecutive patients with C–AHF refractory to diuretic therapy treated with UF from January to December 2022; patients affected by concomitant acute coronary syndrome were excluded. UF was delivered using a modern device specifically designed for fluid removal in C–AHF patients through slow continuous UF (Fig.1). According to our protocol, the initial UF rate was based on baseline systolic arterial pressure (250cc/h if&amp;gt;120mmHg, 100–120cc/h if 100–120mmHg and &amp;lt;100cc/h if&amp;lt;100mmHg; contra–indicated if&amp;lt;90mmHg). Laboratories values, urinary output and fluid balance were monitored at baseline, after 6 hours (T6) and when UF was stopped (T0). Variables are expressed as medians with 25p–75p. Results Seven patients were enrolled in the study (5M;2F); in each a femoral central venous catheter (20cm/14G) was placed to perform UF. A standard anticoagulation regimen based on UFH bolus + infusion was adopted aiming to an ACT of 180–220. Median age and LVEF were respectively 40[20–50] and 79[73–85]; 3 patients were diabetics, 2 smokers and 4 hypertensive. Median rate of hospitalization in the previous 12 months was 1 [0–2]; domiciliary dosage of furosemide was 75mg [50–125]. Baseline, T6h and T0 creatinine values were respectively 1.2 [1.1–2], 1.3 [1.1–1.8] and 1.4 [1.1–1.9]. Heart rate and blood pressure were stable during the treatment. UF parameters in the patients of the study are summarized in Tab.1; congestion was resolved or improved in 6/7 patients, no severe complication (bleeding, AKI, death) occurred while 1 premature filter clot is reported. Conclusions Our initial experience with UF is promising. Modern heart failure specific devices appear safe, easy to use and require only minimal training. Compared to extensive i.v. diuretic use, predictable fluid removal through UF may be beneficial as it is characterized by higher excretion of sodium, limited neuro–hormonal activation, enhanced spontaneous diuresis and restoration of diuretic response.

P72 A CASE OF DRAMATIC HEART CHAMBERS REVERSE REMODELING AND DISEASE REGRESSION IN A PATIENT WITH HEART FAILURE AND END–STAGE RENAL FAILURE TREATED WITH SACUBITRIL/VALSARTAN AND SGLT2I: THE IMPORTANCE OF PUSHING THE BOUNDARIES

Abstract Background Heart failure (HF) therapy has been disrupted by the introduction of 2 new prognostic–relevant drugs: Sacubitril/Valsartan and SGLT2i. However, the amount of evidence for guideline–directed HF therapies in the context of chronic kidney disease (CKD) is relatively modest, especially in advanced stages (e.g., on haemodialysis). Aim of this report is to describe the feasibility and the efficacy of HF medical therapy in a patient with naive HFrEF and CKD on haemodialysis. Case report: A woman in her 40’s, with no cardiovascular history, affected by polycystic kidney disease end end–stage CKD placed on hemodialysis for the previous 9 months, underwent a echocardiography (TTE) in 09/2021, as part of investigations for kidney transplantation. The TTE showed a picture consistent with dilated cardiomyopathy with reduced EF, severe left atrium (LA) dilation and moderate–to–severe mitral regurgitation (MR). Thus, the patient was temporarily suspended from the transplant list. She was on chronic diuretic therapy with high dose of furosemide (250mg b.i.d.), with a residual diuresis of 400–500 mL per day. An elective coronary angiography showed normal coronary arteries. A Cardiac Magnetic Resonance (CMR) confirmed the diagnosis of DCM with severe dilation of the left ventricle (LV), reduced EF and severe MR. A cardiopulmonary exercise test (CPET) showed mild functional limitation with no pulmonary vascular limitation. After a multidisciplinary evaluation involving HF specialists and nephrologists, the recommended quadruple HF therapy was started and gradually up–titrated during the following 10 months. Neither the hemodialysis protocol nor the diuretic therapy was changed throughout this period. No adverse events were observed (e.g., increased sessions or dialysis schedule, hyperkalemia, hypotension). During this timeframe, the patients was asymptomatic and a progressive and sustained decrease in N–terminal pro B–type natriuretic peptide (NT–proBNP) from 26356 to 1556 ng/ml was observed. We documented a significant amelioration in CPET and other laboratory parameters (sST2), as well as a consistent reverse remodeling of the left heart chambers and a significant reduction in MR grade. Conclusions We described a case of significant left heart chambers reverse remodeling and disease regression in a patient with end–stage CKD presenting with HFrEF treated with off–label optimized HF medical therapy. Further studies on hemodialyzed HF patients will be needed.

P48 PATIENT SELECTION FOR TRANSCATHETER TRICUSPID ANNULOPLASTY: CASE PRESENTATION

Abstract Clinical case We describe the case of an 87–year–old woman, BSA 1.7 m2, affected by arterial hypertension, atrial fibrillation, COPD, stage III chronic renal failure. The patient underwent aortic valve replacement with a biological prosthesis. The patient had good quality of life. n the last year, the patient had had two hospitalizations for right heart failure, with a home dose of Furosemide of 250 mg/day. A transthoracic echocardiogram, performed in outpatient setting, showed massive tricuspid regurgitation (ERO 0.8 cm2), TAPSE 21 mm, S TDI 0.12 cmc/sec, LVEF 55%, sPAP 40 mmHg (RHC). The TRISCORE (specific risk score for tricuspid pathology) was equal to 8%, therefore at a high preoperative risk. The case was collectively discussed in the Heart Team and we decided for transcatheter treatment of the isolated tricuspid pathology. A transesophageal echocardiogram confirmed the severity of the tricuspid regurgitation, characterized by multiple jets of which the prevalent central and posteroseptal. The coaptation gap was 10 mm, with partial retraction of the septal flap. Therefore, the possibility of an edge–to–edge treatment was excluded and the screening for annuloplasty device evaluation (Cardioband) continued. Cardio–CT showed feasibility for Cardioband with adequate implant safety and distance from the right coronary artery. Therefore, a Cardioband (Edwards Lifesciences) was implanted in the tricuspid position. The procedural time was 220 minutes. The final result was tricuspid regurgitation less than grade 2 (R vol 30 mL/beat, EROA 0.2). The patient was discharged on the 4th postoperative day. At the 30–day follow–up, he was in NYHA class I–II, with a furosemide dose of 75 mg/day, in the absence of peripheral edema. Conclusions Patients with isolated tricuspid regurgitation are, in most cases, not treated due to the high postoperative surgical risk. In recent years, transcatheter technologies have been a valid solution in the event of inoperability. Where a treatment on the valve leaflets is not feasible, tricuspid annuloplasty represents a valid alternative.

P80 EFFICACY OF DAPAGLIFLOZIN IN EARLY IMPROVEMENT OF QUALITY OF LIFE IN OUTPATIENT WITH CHRONIC HEART FAILURE

Abstract Sodium glucose cotransporter–2 inhibitors reduce mortality and hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF). As a consequence, they are recommended by the European guidelines as mandatory pillar for HFrEF treatment with a strong recommendation (IA). In order to confirm the quality of life improvement shown in prespecified analysis of randomised controlled trial, we administered the Kansas City Cardiomyopathy Questionnaire (KCCQ–12) to 21 patients treated with Dapagliflozin 10mg in an outpatient setting of four Heart Failure Unit of Val Padana Hospitals. Among 21 HFrEF patients included in the analysis 11 have had coronary artery disease, 12 had hypertensive or dilatative cardiomyopathy etiology. The average age of our population was 73 yrs (54–89), 67% were male and 33% female, every patient were in NYHA II class and average BNP was 315 pg/mL. All the patients received Dapagliflozin for the entire observation period without any discontinuation for adverse event or intolerance. Every patient received KCCQ–12 questionnaire twice: at Time 0 when the first dose of Dapagliflozin was administered and after 3 months (Time 1) to verify the variation of the score. During the follow–up different therapy or dose regimen change has not occurred, as baseline therapies were already optimized. Only one patient changed furosemide dosage, reduce it from 75 to 50 mg/die without significant changes in body weight. After 3 months from the first administration of Dapagliflozin the KCCQ–12 summary score has increased by 10,27 points (from baseline avg value to 57,89 – 22% increase (Figure 1). Each of the single components of the score (physical limitation, symptoms frequency, QOL single score, social limitation) had increase in a consistent way from baseline values (Figure 2) In conclusion our data from an outpatient setting of real–world chronic HF population confirm the results of secondary analysis of the Trials and show that adding Dapagliflozin to the standard of care therapy leads to an early improvement in quality of life and physical limitations as quantified by KCCQ–12 questionnaire results. Furthomore, the KCCQ–12 seems to be a reliable and a useful health status instrument to evaluate the performance of HF outpatients, especially to test the benefits of new therapies.

P328 PROTOCOL OF REPEATED OUTPATIENT INFUSIONS OF LEVOSIMENDAN IN ELDERLY PATIENTS WITH ADVANCED HEART FAILURE: PRELIMINARY DATA FROM A REAL–WORLD EXPERIENCE

Abstract Background Intermittent infusions of Levosimendan (L) have been shown to reduce hospitalizations and improve quality of life in patients with advanced heart failure (HF). "Real–world" experience is currently insufficient, particularly in older patients. Purpose: Since November 2020 we treated elderly outpatients with advanced HF with repeated L infusions. Here, we present the preliminary analysis of the collected data. Methods The protocol involves three infusions of L given 14 days apart. The duration of each session was approximately 8 hours. The starting infusion rate is 0.05 μg/Kg/min, titrated every 30/60‘ to a maximum of 0.2 μg/Kg/min based on blood pressure, heart rate and rhythm recorded on telemetry. We evaluated patients by clinical, labatorily and echocardiographic at baseline and two weeks after the end of treatment. Results The treated population had a mean age of 79 years, a long history of disease (mean 12 years) and high comorbidities (mean Charlson Comorbidity Index of 6.8). As shown in Table 1, we compared our population with that of leading international trials on this type of treatment, and we found that our population was significantly older and more complex. Of the 19 patients enrolled, 15 completed the expected treatment of infusions while 4 were lost due to hospitalizations for cardiovascular causes and/or social issues. In the 50 infusions performed, we observed good tolerance to the therapy with a failure rate of 2 % and good safety profile in the absence of major adverse effects, particularly in terms of arrhythmias (Figure 1). At the end of the infusion cycles, there was significant improvement of clinical and hemodynamic parameters (Figure 2). Moreover, we found a decrease in systemic congestion in terms of VD–AD gradient reduction (p=0.031) associated with a downward trend in average daily furosemide dose, clinical congestion scores and mean NTproBNP value. Conclusions Our preliminary analysis seems to confirm the safety and tolerability of the developed treatment scheme. Further data are needed to confirm its efficacy in clinical, hemodynamic, and therapy effects.

P311 PULSED INFUSIONS OF LEVOSIMENDAN IN OUTPATIENTS WITH ADVANCED HEART FAILURE

Abstract Background Several non–randomized studies and small registries showed the efficacy of pulsed levosimendan infusion in relief of symptoms and preventing hospitalization in patients with advanced heart failure excluded by age or comorbidity from heart transplant program Aim of the study to describe the experience of pulsed levosimendan infusion in patient with advanced heart failure followed by the Division of Cardiology at "Villa Sofia" Hospital in Palermo Materials and methods we collected data of patient with adavced heart failure (NYHA III–IV) with reduced ejection fraction, who underwent pulsed levosimendan infusione at Division of Cardiology at "Villa Sofia" Hospital. Reduction of NYHA class, body weight and Nt–pBNP were examined as outcome indicators Results Between July 2021 an December 2022, fifhteen levosimendan infusion were made in five patient with advanced heart failure. Levodimendan was adminestered for a 24–hours infusion, as therapeutic day–hospital regimen. in the population of analysis, the following mean parameters were recorded at admission: NYHA class 3.2, furosemide dose 390mg, Nt–pBNP 10710pg/ml, body weight 72.8Kg, glomerualr filtration rate (GFR MDRD) 44ml/min. At discharge, the following mean parameters were recorded: NYHA class 2.1, Nt–pBNP 9225pg/ml, body weight 70.7Kg. One patient dead of sudden cardiac death during follow–up, one patient refused to continue treatment, the remaining three patient are still on treatment. Conclusions In our center experience, pulsed levosimendan infusion in patient with advanced heart failure determined an improvement of clinical and instrumental signs of congestion. Patients treated reported a subjective improvement of symptoms and of quality of life, also as a consequence of the reduction of the hospitalizations for heart failure. Although data ara scarce, they can be considered representative of a pilot experience of an integrated modality of assistance for patient with advanced heart failure, in which the sinergy between cardiology ward, a strict follow–up at the heart failure outpatient clinic are essential to obtain a good outcome in patient with such high complexity and frailty.

The blunted loop diuretic response in acute heart failure is driven by reduced tubular responsiveness rather than insufficient tubular delivery. The role of furosemide urine excretion on diuretic and natriuretic response in acute heart failure.

Diuretic response in heart failure is blunted when compared to healthy individuals, but the pathophysiology underlying this phenomenon is unclear. We aimed to investigate whether the diuretic resistance mechanism is related to insufficient furosemide tubular delivery or low tubular responsiveness. We conducted a prospective, observational study of 50 patients with acute heart failure patients divided into two groups based on previous furosemide use (furosemide naïve: n = 28 [56%] and chronic furosemide users: n = 22 [44%]). Each patient received a protocol-derived, standardized furosemide dose based on body weight. We measured diuretic response and urine furosemide concentrations. The furosemide naïve group had significantly higher urine volumes and natriuresis when compared to chronic users at all timepoints (all p < 0.05). Urine furosemide delivery was similar in furosemide naïve versus chronic users after accounting for differences in estimated glomerular filtration rate (28.02 [21.03-35.89] vs. 29.70 [18.19-34.71] mg, p = 0.87). However, the tubular response to delivered diuretic was dramatically higher in naïve versus chronic users, that is the urine volume per 1 μg/ml of urine furosemide at 2 h was 148.6 ± 136.1 versus 50.6 ± 56.1 ml (p = 0.005). Patients naïve to furosemide have significantly better diuresis and natriuresis when compared to chronic furosemide users. The blunted diuretic response in patients with chronic loop diuretic exposure is driven by decreased tubular responsiveness rather than insufficient furosemide tubular delivery.

Clinical Efficacy and Safety of Empagliflozin in Patients with Acute Heart Failure from the First Day of Hospitalization

Aim. Evaluation of the safety, clinical and hemodynamic effects of empagliflozin in patients with acute decompensated heart failure (ADHF) from the first day of hospitalization in the absence of signs of hemodynamic instability.Material and methods. A prospective, comparative, randomized study included 46 patients admitted to the hospital in connection with ADHF in the absence of signs of hemodynamic instability. Inclusion in the study and randomization to receive empagliflozin was carried out in the first 24 hours from the moment of admission to the hospital. The main group (n=23) from the first day of hospitalization and the entire subsequent follow-up period took empagliflozin at a daily dose of 10 and 25 mg (for patients with type 2 diabetes mellitus) in addition to basic therapy, the control group (n=23) received standard therapy without gliflozines. The observation period was 3 months and included 3 control points: 1st day of hospitalization, 7th-12th day, 3rd month of observation. Clinical, anamnestic and instrumental data were evaluated at all control points.Results. In the hospital period, by the 7th-12th day, only in the main group there was an improvement in all clinical indicators (p&lt;0.01), an increase in the rate of diuresis (p&gt;&lt;0.01), a decrease in the daily dose of the parenteral diuretic furosemide from 54 mg to 26 mg (p&gt;&lt;0.01). A decrease in systolic blood pressure (SBP) occurred in both groups (p&gt;&lt;0.01), but it was more pronounced in the comparison group [from 141 (110; 160) to 110 (90; 120) mm Hg) compared to the main group [from 140 (120; 160) to 120 (110; 130) mm Hg]. According to echocardiography data in the main group, there was a decrease in the indexed volume of the right atrium, the end-systolic volume of the left ventricle (LV ESV) and systolic pressure in the pulmonary artery, an increase in the LV ejection fraction (LV EF) (p&gt;&lt;0.05). In the comparison group, only an increase in LV ESV was noted (p=0.04). The index of the indexed volume of the left atrium did not show significant dynamics in the main group (p=0.79), but showed a significant decrease&gt;˂0.01), a decrease in the daily dose of the parenteral diuretic furosemide from 54 mg to 26 mg (p&lt;0.01). A decrease in systolic blood pressure (SBP) occurred in both groups (p&gt;˂0.01), but it was more pronounced in the comparison group [from 141 (110; 160) to 110 (90; 120) mm Hg) compared to the main group [from 140 (120; 160) to 120 (110; 130) mm Hg]. According to echocardiography data in the main group, there was a decrease in the indexed volume of the right atrium, the end-systolic volume of the left ventricle (LV ESV) and systolic pressure in the pulmonary artery, an increase in the LV ejection fraction (LV EF) (p˂0.05). In the comparison group, only an increase in LV ESV was noted (p=0.04). The index of the indexed volume of the left atrium did not show significant dynamics in the main group (p=0.79), but showed a significant decrease in the 2nd and 3rd control points compared to the control group (p=0.01 and p=0.02). Complications, against the background of taking empagliflozin, were not noted: there were no episodes of hypotension (SBP˂90 mm Hg), hypoglycemia, acute kidney injury.Conclusion. The results obtained indicate the safety of empagliflozin in patients with ADHF, regardless of the status of carbohydrate metabolism and LV EF, as well as taking into account the clinical (more intense positive dynamics of clinical symptoms of ADHF) and hemodynamic (smooth decrease in SBP, increased diuretic effect) effects of empagliflozin, this drug should be considered as an effective and safe supplement to the main therapy from the first day of hospitalization in patients with stable hemodynamic parameters.

Is furosemide a nephrotoxic for hospitalized patients?

Introduction: Acute kidney disease (AKI) is preventable in certain situations. Long-term and/or high dose furosemide may lead to acute kidney injury. Objectives: We aimed to find the risk of AKI among hospitalised patients who were exposed to furosemide. Patients and Methods: This is a retrospective cohort study of hospitalised patients who received furosemide therapy during the admission between 2019 and 2021. Exposure to furosemide was grouped into low dose (≤ 40 mg/d) or high dose (&gt;40 mg/d) and short-term use (≤ 72 hours) or long-term use (&gt;72 hours). Risk of acute kidney injury was calculated as odds ratios with a 95% confidence interval (CI). A P value &lt;0.05 was considered statistically significant. Results: Of 314 patients who received furosemide intravenously or orally, 197 patients (62.7%) had acute kidney injury. Of 197 patients with acute kidney injury, 110 patients (55.9%) received the dosage of &gt;40 mg/d and 121 patients (61.4%) were on furosemide for &gt;7 days (odds ratios [ORs]: 5.46, 95% CI: 3.17 to 9.39, P≤0.001 and ORs: 7.72, 95% CI: 4.4 to 13.52, P≤0.001). In comparison, the 87 (44.1%) patients who received ≤40 mg/d of furosemide had a lower incidence of AKI (ORs: 0.25, 95% CI: 0.13 to 0.48, P≤0.001) and only 21 of the patients (10.6%) who received furosemide for &lt; 7 days were found to have acute kidney injury (ORs: 0.08, 95% CI: 0.04 to 0.14, P≤0.001). The combined effect of high dose and long-term furosemide therapy is more consequential as we found that 100 (31.8%) patients who received furosemide &gt;40 mg for &gt;72 hours, 96 patients (30.6%) developed AKI (ORs: 26.8, 95% CI: 9.53 to 75.63, P≤0.001). Conclusion: Among hospitalised patients, exposure to high dose furosemide or prolonged use of furosemide is associated with AKI. The risk is more when high dose furosemide is administered for longer than 72 hours. Presence of underlying diabetes, hypertension, cardiac failure and chronic kidney disease, are also associated with furosemide -induced hospital-acquired acute kidney injury.

Acute kidney injury biomarker olfactomedin 4 predicts furosemide responsiveness.

Acute kidney injury (AKI) is associated with increased morbidity and mortality in critically ill patients. Olfactomedin 4 (OLFM4), a secreted glycoprotein expressed in neutrophils and stressed epithelial cells, is upregulated in loop of Henle (LOH) cells following AKI. We hypothesized that urine OLFM4 (uOLFM4) will increase in patients with AKI and may predict furosemide responsiveness. Urine from critically ill children was collected prospectively and tested for uOLFM4 concentrations with a Luminex immunoassay. Severe AKI was defined by KDIGO (stage 2/3) serum creatinine criteria. Furosemide responsiveness was defined as > 3mL/kg/h of urine output in the 4h after a 1mg/kg IV furosemide dose administered as part of standard of care. Fifty-seven patients contributed 178 urine samples. Irrespective of sepsis status or AKI cause, uOLFM4 concentrations were higher in patients with AKI (221ng/mL [IQR 93-425] vs. 36ng/mL [IQR 15-115], p = 0.007). uOLFM4 concentrations were higher in patients unresponsive to furosemide (230ng/mL [IQR 102-534] vs. 42ng/mL [IQR 21-161], p = 0.04). Area under the receiver operating curve for association with furosemide responsiveness was 0.75 (95% CI, 0.60-0.90). AKI is associated with increased uOLFM4. Higher uOLFM4 is associated with a lack of response to furosemide. Further testing is warranted to determine whether uOLFM4 could identify patients most likely to benefit from earlier escalation from diuretics to kidney replacement therapy to maintain fluid balance. A higher resolution version of the Graphical abstract is available as Supplementary information.

Perimenopozal dönemin kalp yetersizliği seyrine etkileri

Purpose: It is known that the decrease in estrogen level in women's life has negative effects on the cardiovascular system. In this study, it was aimed to elucidate the changes in the clinical status and treatment requirement of patients with heart failure (HF) during the menopausal transition period.&#x0D; Materials and Methods: A total of 26 patients followed up in the HF outpatient clinic between 2015–2020 were included in this retrospective, single-center study. Demographic data of the patients, New York Heart Association class, echocardiographic findings, routine biochemical parameters and HF signs, symptoms and therapies were examined. Data at the beginning of the menopause period and after 12 months were compared. &#x0D; Results: At the end of the 12-month follow-up, a statistically significant increase was found in the daily dose of furosemide (50.5 mg/day vs. 72.4 mg/day). While the mean heart rate of the patients was 80.4±20.1 beats/min at the beginning, it was 69.3±10.1 beats/min in the control visit. Echocardiographically measured left ventricular (LV) systolic diameters of the patients were significantly increased compared to baseline in the control visit (41.2±7.4 mm vs 45.8±7.0 mm,). &#x0D; Conclusion: The menopausal period caused an increase in the need for treatment in patients followed up with HF. Therefore, in evaluation of the patients with HF, it would be a useful approach to question the menopausal status in detail and to follow the patients more closely during the menopausal transition period.