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HomeA Practitioner's Must ReadSystemic corticosteroids a potential treatment for HF – Spanish study

Systemic corticosteroids a potential treatment for HF – Spanish study

Intravenous corticosteroids didn’t hurt people with acute heart failure (HF), and could be a potential treatment for those with more inflammation, according to a hypothesis-generating study based on Spain’s Epidemiology of Acute Heart Failure in the Emergency Departments (EAHFE) registry.

Whereas acute HF patients receiving corticosteroid therapy in the emergency department (ED) saw no improvement in all-cause mortality at 30 days, there was a trend of more favourable point estimates for survival in those with elevated C-reactive protein (CRP) levels.

Medpage Today reports that potential for an association between corticosteroid therapy and better outcomes was observed among people with the most inflammation, defined as CRP >40 mg/L – findings that were nevertheless statistically non-significant based on the available data:

All-cause mortality at 30 days: 11.8% with corticosteroids vs 19.4% without (HR 0.56, 95% CI 0.20-1.55);

Post-discharge ED revisit at 30 days: 42.3% vs 43.8% (HR 0.92, 95% CI 0.52-1.62)
In-hospital all-cause mortality: 8.8% vs 13.4% (HR 0.61, 95% CI 0.17- 2.14).

“The present analysis suggests that corticosteroids might have the potential to improve outcomes in acute HF patients with inflammatory activation,” wrote study authors Dr Gad Cotter of Momentum Research in Chapel Hill, North Carolina, and colleagues in ESC Heart Failure.

Inflammation has been linked to HF, though anti-inflammatory therapies have failed in chronic HF, the researchers said, citing the failures of infliximab and etanercept in the older ATTACH and RENEWAL studies, respectively.

“Although corticosteroids have been classically viewed as anti-inflammatory agents, they can cause sodium and water retention, potentially leading to worsening of HF. However, it has been reported that the administration of corticosteroids to patients with severe acute HF produced a potent diuretic effect and improved fluid overload and renal function,” said the investigators.

“Added to previous studies of potentially improved diuresis, the [present] results suggest that future randomised trials on anti-inflammatory therapy are needed to assess potential benefit in patients with the highest degree of inflammation,” Cotter and co-authors said.

EAHFE was a registry that included 45 Spanish EDs from 2007 to 2018. For the present analysis, the investigators included 1,109 people (median age of 81.2, 45% of whom were men) with NT-proBNP >300 pg/mL and CRP >5 mg/L in the ED. The team excluded people taking chronic systemic corticosteroids and those who had had acute HF triggered by an infection.

Of the study cohort, 10.9% of patients received at least one IV bolus corticosteroid treatment.

This group tended to have higher systolic blood pressure, lower room air oxygen saturation, and were more likely to have cerebrovascular disease, peripheral artery disease, chronic obstructive pulmonary disease, and dementia. Their index acute HF episode was more commonly triggered by hypertensive crisis, compared with non-corticosteroid users.

The retrospective study was limited by the potential for confounding, a relatively small sample of corticosteroid users, and a lack of details regarding dose and duration of treatment in the database, Cotter and colleagues acknowledged.

Study details

Effect of systemic corticosteroid therapy for acute heart failure patients with elevated C-reactive protein

Òscar Miró, Koji Takagi, Beth Davison, Christopher Edwards, Yonathan Freund, Javier Jacob, Pere Llorens, Alexandre Mebazaa, Gad Cotter.

Published in ESC on 8 April 2022

Abstract

Aims
The current study explores whether degree of inflammation, reflected by C-reactive protein (CRP) level, modifies the effect of intravenous (IV) corticosteroid administered in the emergency department (ED) on clinical outcomes in patients with acute heart failure (AHF).

Methods and results
We selected patients diagnosed with AHF in the ED, with confirmed N-terminal pro-B-type natriuretic peptide > 300 pg/mL and CRP > 5 mg/L in the ED from the Epidemiology of Acute Heart Failure in the Emergency Departments (EAHFE) registry. In these 1109 patients, 121 were treated by corticosteroid. The corticosteroid therapy hazard ratio (HR) for 30 day all-cause mortality was 1.26 [95% confidence interval (CI) 0.75–2.09, P = 0.38]. Although not statistically significant, HRs tended to decrease with increasing CRP level, with point estimates favouring corticosteroid at CRP levels above 20. In patients with CRP > 40 mg/L, with adjusted HRs of 0.56 (95% CI 0.20–1.55, P = 0.27) for 30 day all-cause mortality, 0.92 (95% CI 0.52–1.62, P = 0.78) for 30 day post-discharge ED revisit, hospitalisation, or death, and adjusted odds ratio of 0.61 (95% CI 0.17–2.14, P = 0.44) for in-hospital all-cause mortality.

Conclusions
The present analysis suggests that corticosteroids might have the potential to improve outcomes in AHF patients with inflammatory activation. Larger, prospective studies of anti-inflammatory therapy should be considered to assess potential benefit in patients with the highest degree of inflammation.

 

Medpage Today article – Systemic Corticosteroids in Acute HF: Worth Another Look? (Open access)

 

ESC Heart Failure journal – Effect of systemic corticosteroid therapy for acute heart failure patients with elevated C-reactive protein (Open access)

 

See more from MedicalBrief archives:

 

Corticosteroids supported for pneumonia

 

Heart failure is associated with loss of important gut bacteria

 

Even low-dose steroid treatments substantially increase CVD risk

 

 

 

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