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ΕΠΙΣΤΗΜΟΝΙΚΑ ΚΙ … ΑΛΛΑ”από τον Ομ. Καθηγητή, Ιωάννη Γουδέβενο, 13.01.2025 –Ανταγωνιστές Αλατοκορτικορεοειδών

Στο αεροδρόμιο περιμένοντας να επιβιβασθεί. H νεκροψία τίποτα!

Αντιδήμαρχος Δήμου Αγράφων

Βρέθηκε στο δωμάτιο της νεκρή το ΣΚ

Αυτού του είδους οι ειδήσεις πουλάνε στα ΜΚΔ αλλά ημάς  μας γεμίζουν αμηχανία, προβληματισμούς και μας προσγειώνουν ανώμαλα

ΚΑΡΔΙΑΚΗ ΑΝΕΠΆΡΚΕΙΑ: ICDs, CRTs,   MRAs .

Οι ICDs αμφισβητούνται στη πρωτογενή πρόληψη, οι CRT θα αντικατασταθούν από τους βηματοδότες του αριστερού συστήματος αγωγής  και για τους MRA που υποχρησιμοποιούνται στη ΚΑ   ανοίγουν νέοι ορίζοντες με την είσοδο του  Κerendia

 Στην Ελλάδα  τοποθετούνται  ετησίως 1.080 αυτόματοι απινιδωτές  και 600 αμφικοιλιακοί βηματοδότες

Περίπου 1/3 των ατόμων με ICD θα εκδηλώσει επεισόδια κοιλιακής ταχυκαρδίας και θα χορηγηθεί  shock στα 3 χρόνια από την εμφύτευση. Οι ασθενείς με υποτροπές αρρυθμιών έχουν φτωχή ποιότητα ζωής, πολλές νοσηλείες για ΚΑ και φτωχή επιβίωση. Εναλλακτική πρόταση στη διαφλέβια εμφύτευση αποτελεί η    εξωαγγειακή

    Yehya A, Lopez J, Sauer AJ, et al. Revisiting ICD Therapy for Primary Prevention in Patients With Heart Failure and Reduced Ejection Fraction. JACC Heart Fail 2024;Dec 4:[Epublished].

Key points:

1.The MADIT I and II trials demonstrated a survival benefit with primary prevention ICDs in patients post–MI with EF<35% and <30%, respectively, compared to medical therapy. However, trials examining the benefit of ICD in patients recovering from acute MI (AMI) have been negative.

2.Primary prevention of SCD in nonischemic cardiomyopathy (NICM) patients was shown in the SCD-HeFT trial that enrolled both patients with ICM and NICM, NYHA class II or III, and LVEF ≤35%. However, the recent DANISH trial showed no statistically significant reduction in mortality with ICDs in patients with NICM, but the incidence of SCD was lower in patients receiving an ICD. Secondary analysis of the study showed that ICD was associated with a reduction in all-cause mortality in patients <70 years old. Similarly, a meta-analysis of four trials suggested a 25% reduction in mortality in patients with NICM with an ICD.

3.Current guidelines provide the strongest recommendation (Class I) for ICD to patients with NICM or ICM with LVEF ≤35%, NYHA class II-III, on optimal GDMT, and life expectancy of ≥1 year.

4.ICDs are also recommended (Class I) in patients ≥40 days after an AMI with LVEF <30%, even in the absence of symptoms.

5.Patients with advanced HF with limited life expectancy, including NYHA class IV , who are not candidates for advanced therapies or have limited survival of <1 year, should not receive an ICD (Class III ).

6.In older patients, the benefits of an ICD may be diminished due to increased comorbidities and reduced life expectancy with an increased risk of device-associated complications. Similarly, data on patients needing an ICD who are on hemodialysis are sparse and current guidelines recommend against this. Similarly, patients with diabetes have a 2.6-fold increased risk for complications from an ICD. Shared decision making plays an important role in discussions with patients on ICDs.

7.Shared decision making for ICDs should highlight the survival benefit associated with them but also discuss possible complications associated with the device.

8.ICDs are underutilized in the general population and this disparity is more pronounced in women and. Reasons for these disparities include physician bias with trials enrolling predominantly male patients and disparities in access to high-quality care.

9.Pooled data from trials suggest that Black patients with NICM have a higher risk for ventricular and atrial arrhythmias with lower survival rates compared to Whites.

10.All components of contemporary GDMT  reduce mortality and improve morbidity. Therefore, if GDMT can be rapidly initiated and titrated, improvement in LVEF can lead to deferral of ICD implantation.

11.Etiology of cardiomyopathy impacts the risk for SCD as ARVC dysplasia  LMNA-associated disease, and channelopathies. In such populations, ICD indications differ by genetic etiology,  and family and clinical history. Additional considerations include scar burden on MRI (specifically mid-myocardial LGE ), and patients with extremely low LVEF and severe LV dilatation who may warrant earlier consideration for an ICD.

CRT cardiac resynchronization therapy

   H ιδέα υπήρχε από το 1990 αλλά το  2001 (ΜUSTIC trial)  η θεραπεία καρδιακού επανασυγχρονισμού αποτέλεσε επανάσταση  στη θεραπεία της HFrEF με ευρύ QRS . Όταν το πρωτακούσαμε δεν το πιστεύαμε αλλά πολύ σύντομα πεισθήκαμε όταν το είδαμε να “δουλεύει”.  H αχίλλειος πτέρνα της είναι ότι το 1/3 των ασθενών δεν αποκρίνεται(nonresponders). Η βηματοδότηση του δεματίου του HIS φαίνεται να αποτελέσει εναλλακτική/συμπληρωματική λύση.  Circulation. 2024;150:1563–1566

ΑΝΤΑΓΩΝΙΣΤΕΣ ΑΛΑΤΟΚΟΡΤΙΚΟΕΙΔΩΝ Mineralocorticoid Antagonism(ΜRAs)

Over 2 decades ago, spironolactone was demonstrated to substantially reduce the risk of all-cause mortality along with HF hospitalizations in patients with HFrEF(RALES trial). Under trial selection and protocol-directed monitoring, the median potassium (0.30 mmol/L) and creatinine levels (0.10 mg/dL) increased modestly with spironolactone relative to placebo. Serious hyperkalemia as an adverse event did not differ. However, after publication of the RALES trial, a series of reports suggested that as applied in clinical practice, rates of hyperkalemia and hyperk hospitalizations with MRAs were much higher than expected. Subsequent studies identified that patients frequently started doses of spironolactone without consideration of baseline kidney function, without subsequent laboratory monitoring, or when tested potassium levels were elevated without timely adjustment in dosing. As a result of these reports and the continued perception of hyperkalemia risk, MRAs have continued to be underused in eligible patients with HFrEF.

Aνασκόπηση για το ρόλο τους στη Καρδιακή ανεπάρκεια. Mineralocorticoid Antagonism in Heart Failure: Established and Emerging Therapeutic Role. J Am Coll Cardiol HF. 2024 Dec, 12 (12) 1979–1993

Οι τοξικές δράσεις της αλδοστερόνης είναι από παλιά γνωστές

Key points:  Eίναι γεγονός ότι πρόκειται για μια κύρια κατηγορία φαρμάκων που υπο χρησιμοποιείται  λόγω του φόβου της υπερκαλιαιμίας στη  ΚΑ. Πέρα απ αυτό ή είσοδος των μη στεροειδών  στην αγορά (με ήπια αντιυπερτασική δράση) έχει δημιουργήσει καινούργιο ενδιαφέρον . Large RCTs  in HFrEF have demonstrated reduction in CV mortality and HF hospitalizations with MRA. Steroidal MRAs (spironolactone and eplerenone) block other steroid receptors including androgen and progesterone receptors leading to gynecomastia, menstrual irregularities, and impotence in addition to hyperkalemia.

2.Contemporary HF guidelines recommend MRA in patients with HFrEF with NYHA  II-IV symptoms (Class 1)  if GFR  is >30 mL/min/1.73 m2 και  K  <5 mEq/L. Close monitoring of renal function and potassium level at 1 week, 4 weeks, and then every 6 months after initiating or up-titrating MRA is recommended.

3.For HF with mid-range EF (HFmrEF; EF 41-49%), guidelines recommend MRA in symptomatic patients as a Class 2b  to reduce hospitalization, especially among patients with  LVEF on the lower end of this spectrum.

4.The TOPCAT trial with spironolactone in HFmrEF  HFpEF  showed a reduction in HF hospitalizations (η μελέτη είχε πολλά προβλήματα) .

5.Nonsteroidal MRAs (finerenone, esaxerenone, and balcinrenone) offer potential advantages over steroidal MRAs including lower risk for hyperkalemia and lack of antiestrogen and antiprogesterone side effects.

6.Finerenone is currently FDA approved for CKD associated with type 2 DM based on trial FIDELIO-DKD showing reduction in a composite endpoint for kidney failure. HFrEF patients were excluded in this trial but finerenone also reduced risk for CV events (CV death, MI], and HF hospitalization) in this trial. In a similar cohort, the FIGARO-DKD trial showed reduced CV death, MI, HF hospitalization, and stroke with finerenone.

7.Phase 2 trial data suggest superiority of finerenone compared with eplerenone in chronic HFrEF and/or CKD with type 2 diabetes with a larger decrease in NT-proBNP level at day 90. A secondary analysis also showed a larger reduction in all-cause mortality, CV hospitalizations, and worsening HF leading to ED visits with finerenone compared with eplerenone. The incidence of hyperkalemia was not different between finerenone and eplerenone groups.

8.The FINEARTS-HF trial (κύριος ερευνητής Μάκης Φιλιππάτος) included HF patients with LVEF >40% randomized to finerenone and placebo(μέση ηλικία 72 έτη, 45% γυναίκες,  ΚΕ >40%(μέσο 53%), ΣΔ 40%, ΚΜ 38%). Ασθενείς με Κ +> 5.0 mmol/L and eGFR < 25 mL/min/1.73 m2 were excluded. Finerenone was superior to placebo in reducing the composite of CV death and total number of HF hospitalizations/ER visits, without any difference in CV death when considered alone.

9.Trials have demonstrated that esaxerenone is superior to placebo in patients with type 2 diabetes and CKD for renal protection and improves myocardial remodeling in HFpEF patients by decreasing BNP. A phase 2 trial comparing balcinrenone with dapagliflozin versus dapagliflozin alone in symptomatic HF patients with LVEF<60% and CKD showed that combination therapy was superior to dapagliflozin monotherapy in reducing urine-albumin-creatinine ratio at 12 weeks.

10. Although emerging trials are promising for nonsteroidal MRAs, real-world costs limit their use in contemporary practice. The authors suggest using steroidal MRA in treatment of cardiorenal disease due to cost-effectiveness until there are more data with head-to-head comparison of steroidal versus nonsteroidal MRA.

11.Future trials looking at efficacy of nonsteroidal MRA in combination with SGLT-2 inhibitors compared with standard care in hospitalized HF patients across the entire spectrum of EF are ongoing. This is in addition to another trial looking at nonsteroidal MRA in HFrEF patients with previous intolerance to steroidal MRA and other trials re-examining efficacy of spironolactone compared with placebo in HF patients with LVEF >40%.

. .. για να ικανοποιήσουμε και τον ναρκισσισμό μας. Στο   πρόσφατο καρδιο νεφρικό   τιμήθηκε ένας νεφρολόγος (Δ.  Βλαχάκος ) και ένας καρδιολόγος(ο υπογράφων). Στην απονομή επισήμανα  3 λόγους  που η τιμητική  βράβευση έχει αξία.  1. ΟΧΙ ΕΠΙΙΔΙΩΞΗ, 2. ΟΧΙ ΥΣΤΕΡΟΒΟΥΛΙΑ (υποχρεώσεις) 3.  Η ΒΡΑΒΕΥΣΗ ΝΑ ΓΙΝΕΤΑΙ ΑΠΟ ΣΥΝΑΔΕΛΦΟΥΣ

Και να θυμόμαστε : Watch how a man takes praise and there you have the measure of him  ή

Παρατήρησε τον τρόπο με τον οποίο κάποιος δέχεται τους επαίνους καi από εκεί  θα τον αποτιμήσεις.   Thomas Burke 1886-1945

Γουδέβενος Γιάννης  Γιάννινα

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