AUCTORES
Globalize your Research
Chat with us
Research Article | DOI: https://doi.org/10.31579/2641-0419/076
1Department of Medicine, Institute of Clinical Sciences in Lund, Lund University, Sweden.
2Department of Emergency and Internal medicine, Lund University Hospital of Skåne, Sweden.
*Corresponding Author: Isak Lindstedt, Department of Medicine Institute of Clinical Sciences in Lund Lund University, S22185 Lund, Sweden, Phone: + 46 734 386425
Citation: Lindstedt I., Edvinsson L., Marie-L. Edvinsson., (2020) High Dose Loop-Diuretic Treatment Results in Higher Mortality Rate in Elderly Heart Failure Patients (>80 years) versus Standardized Neuroendocrine Treatment. J. Clinical Cardiology and Cardiovascular Interventions, 3(8);Doi:10.31579/2641-0419/076
Copyright: © 2020 Isak Lindstedt, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 13 August 2020 | Accepted: 24 August 2020 | Published: 01 September 2020
Keywords: loop-diuretic; mortality; heart failure; neuroendocrine
Introduction
Most chronic heart failure (HF) patients receive therapy with non-potassium-sparing diuretics (loop diuretics), which are fundamental drugs used to prevent multi-organ failure and improve symptoms. The use of diuretics in HF is also associated with neuroendocrine activation, organ damage and increased mortality. However, there is a lack of studies in the very elderly over the age of eighty.
Methods
The study included 99 elderly patients with HF, mean age 81 years, which represented a cohort of patients gathered during recent years. They had been admitted to the internal medicine ward at Lund University Hospital and had been given the primary diagnosis of HF. The patients were divided into two groups based upon the dose of furosemide they had at discharge. Patients receiving less than 80 mg daily were allocated to the low-dose furosemide group (LD-group), 65 patients, and patients receiving 80 mg or more of furosemide, 34 patients, were allocated to the high-dose furosemide group (HD-group).
Results
The HD-group received a mean of 118 mg/day of furosemide and the LD-group received a mean of 39 mg/day of furosemide (p < 0.01). The main finding was that the HD-group had an increased 6 month mortality compared to the LD-group (p = 0.03). Also, both groups demonstrated significant decreases in mean NT-proBNP values from enrollment into the hospital compared to follow up (p < 0.01).
Conclusions
Elderly patients (>80 years of age) were enrolled into the hospital with the diagnosis of severe HF. During treatment they showed higher 6-month mortality when therapy was focused on high doses of furosemide as compared to low doses combined with neuroendocrine therapy. The use of non-potassium-sparing diuretics in the elderly is not unproblematic and this group of patients respond favourable to neuroendocrine treatment.
The prevalence of heart failure (HF) is approximately 1–2% of the adult population in developed countries, but over 10 % among people 70 years of age. The cause of HF is usually a myocardial abnormality. However, defects of the valves, pericardium, endocardium, heart rhythm and conduction can also be involved and more than one abnormality is often present [1]. Systolic and/or diastolic ventriculardysfunction and fluid overload are the main manifestations of HF. The pathophysiological cornerstones of HF are neurohormonal/neuroendocrine activation via the renin-angiotensin-aldosterone system and the sympathetic nervous system. The heart is also somewhat of an endocrine organ that releases natriuretic peptides, like NT-proBNP, that are possible to measure in the blood. [1,2] Furthermore, it is well established that HF is a disorder associated with severe adverse outcomes and a poor prognosis.[3] Most chronic HF patients receive therapy with non-potassium-sparing diuretics. [4] These loop diuretics are the fundamental drugs used to prevent multi-organ failure and improve symptoms in these patients. [5] However, Use of diuretics in HF is associated with further activation of neuroendocrine systems. [6] Diuretics can cause disease progression by increasing myocardial fibrosis [7,8] and worsen renal function [9]. Risks and benefits of loop diuretics have been reevaluated and questioned, particularly the dosage and administration procedure [10]. Several observational studies have shown that static drug exposure is associated with adverse outcomes. In trials examining the use of loop diuretics compared to the non-use of the same, the use of loop diuretics have been associated with poor outcomes such as increased death and rehospitalizations [11-14], For example, in one study on 1302 propensity-matched patients with a mean age of 71 years of age, all-cause mortality occurred in 173 patients not receiving diuretics and 208 patients receiving diuretics, hazard ratio (HR) = 1.36 (Confidence interval (CI) = 1.08-1.71)[13]. Also, in trails comparing the dose of the diuretic, high dose regimens have been associated with increased adverse outcomes compared to low dose regimens [15,18]. Furthermore, the use of potassium-sparing diuretics in patients with HF has been associated with a reduced risk of death compared to the use of non-potassium-sparing diuretics in such patients [19]. Even though the association between loop diuretics and outcome have been demonstrated in several observational studies, some have shown conflicting results [20-22]. There is the argument that the association is merely a marker of disease severity than the cause of it [16]. Most importantly, there is still a lack of studies among the very elderly HF patients over the age of eighty. We hypothesized that elderly HF patients, often frail and with many organs affected, receiving higher doses of furosemide would have a worse outcome than elderly HF patients receiving lower doses of furosemide in combination with neuroendocrine therapy.
Methods
The 99 patients with HF represented a cohort of patients gathered during recent years. They had been admitted to the internal medicine ward at Lund University Hospital and had been given the primary diagnosis of HF. The inclusion criteria was that NT-proBNP tests and blood pressure tests had to been taken at least twice during the hospital stay. The HF patients were divided into two groups based upon the dose of furosemide they had at discharge. Patients receiving less than 80 mg were allocated to the low-dose furosemide group, 65 patients, and patients receiving 80 mg or more, 34 patients, were allocated to the high-dose furosemide group. The cut-off dosage was not established arbitrarily, but was based on the information from previous studies [11,16]. In these trials meaningful comparisons were possible at this cut-off level with the power to detect a difference. We attained relevant information about the patients from their medical records. We obtained basic demographic information about age, gender, BMI, pulse, blood pressure, physical finds and laboratory data at admission. We recorded types of drugs and diagnoses at discharge, total number of drugs at discharge, and number of deaths within 6 months. Six month all-cause mortality was confirmed by reviewing the patients’ medical records and confirming which patients were alive and which were not 6 month after discharge from the hospital, also checking with the Swedish National Death Registry when needed.
Calculations for comparison between the two groups were done using the Student’s T-test for continuous variables and the Pearson’s Chi-square test for dichotomous variables. Paired Samples T-test was used when comparing in-group differences between two values. Statistical significance was set at p < 0.05. Statistics were performed using the IBM SPSS Statistics 25 program.
The final results can be seen in (Table 1, 2 and 3, and Figure 1. Table 1) shows basic demographic parameters. The two groups had the same mean age and gender distribution, but the HD-group had a higher BMI. Overall, the standard laboratory tests were similar in the two groups. In addition, the two groups had the same drug treatment when it came to anticoagulant therapy, mineralocorticoid antagonist therapy and beta-adrenoceptor blocker treatment. However, the HD-group had a higher mean number of total drugs and also had somewhat more treatment with angiotensin receptor blockers. On the other hand, the LD-group were treated to a greater extent with the standard of care medications for HF with neuroendocrine therapy, e.g. angiotensin converting enzyme inhibitors. The two groups had similar comorbidities, even though the HD-group had somewhat more chronic obstructive pulmonary disease and asthma. The HD-group had more physical signs of decompensation in the form of pulmonary and peripheral edema, yet the number of HF patients in NYHA IV were the same between the groups. The number of rehospitalizations within 30 days were also the same.
Table 2 presents the results of tests that were performed repeatedly. The mean NT-proBNP value at discharge from the hospital was significantly lower in the LD-group compared to the HD-group. Otherwise, the mean NT-proBNP values and blood pressure values were similar at the given time points.
Table 3 depicts the change within variables from enrollment to discharge, from discharge to follow up, and from enrollment to follow up within each study group. Even though the blood pressure values decreased from enrollment to discharge, there was not seen any significant difference in either study group. Overall, there were statistically significant decreases in NT-proBNP values from enrollment to discharge and from enrollment to follow up in both study groups.
In this study we had elderly patients with severe HF that received somewhat different modes of therapy; the HD-group received a mean dose of 118 mg/day of furosemide at discharge from the hospital and had higher 6 months mortality than patients from the LD-group that received a mean dose of 39 mg/day of furosemide, but were usually combined with neuroendocrine therapy. The results are important because this association between diuretic dose and mortality has not been studied extensively in patients over the age of 80. To the best of our knowledge, most studies up to date have included patients with a mean age between 50 and 79 years of age. This is central because it might be that the difference in mortality between low dose therapy and high dose therapy of loop diuretics is even more pronounced in the elderly population; patients who have more severe heart failure, greater tendency to congestion, numerous concomitant diseases, and are prone to side effects and interactions between drugs. For example, the trials and their respective study arms referenced to in this paper, had the following age demographics: mean age of 53 and 56 years [15]; mean age of 55 and 58 years [18]; mean age of 53 and 60 years [16]; mean age of 59, 61, 61, and 62 years [19]; mean age of 62.6 and 62.9 years [12]; mean age of 67, 69, and 72 years [11]; mean age of 69.8 and 70.9 years [14]; mean age of 71.5 and 71.6 years [13]; and, finally, mean age of 77.3, 78.4 and 78.7 years [17]. We had a mean age of 80.9 and 81.8 years.
The ways furosemide interacts with the cardiovascular system are still worth studying and the exact pathophysiological pathways through which it determines the prognosis of HF remain poorly investigated and understood. [18] Nonetheless, there are several probable pathophysiological effects of furosemide that could harm the human body. Furosemide acts on the Na+-K+-2Cl−cotransporter in the thick ascending limb of the loop of Henle. Its main function is to inhibit sodium and chloride reabsorption [23]. Frequently observed adverse drug reactions to furosemide is hypokalemia and/or hypomagnesemia[24]. These abnormalities could lead to potentially deleterious arrhythmogenic effects in elderly patients with chronic HF. [25] Furthermore, furosemide causes intravascular volume depletion. A decreased intravascular volume could lead to hypotension with the risk of orthostatic hypotension which is associated with increased mortality in elderly HF patients. [26] Also, intravascular volume depletion can cause a reduced glomerular filtration rate and renal dysfunction. It is well known that renal dysfunction predicts mortality in hospitalized patients with HF. [27]
There was a significant difference in mean creatinine values at baseline between the LD-group and the HD-group in our study (Table 1). However, there was no significant difference in eGFR nor in the number of HF patients with renal failure (data not shown) at baseline. Whether the increased 6 month mortality that we saw was a consequence of increased renal failure caused by higher doses of furosemide, or was merely a marker of greater sickness in the HD-group because of habitual renal failure independent of furosemide treatment, is unclear. In a similar line of thought, congestion seemed to be greater in the HD-group since they presented with significantly more symptomatic disease such as pulmonary and peripheral edema. Yet, the number of HF patients in NYHA IV, mean left ventricular ejection fraction, and mean NT-proBNP values at admittance were similar between the groups. It appears logical that the HF patients in the HD-group were treated with higher doses of furosemide by their general physician before hospitalization and/or by the hospital physician when confronted with more physical signs of HF. But we might speculate that this action also could be the very reason behind the higher mortality in the HD-group. Higher doses of furosemide might very well help alleviating the immediate symptoms of HF, but over time lead to diuretic resistance, electrolyte disturbances, intravascular volume depletion, renal dysfunction and death. On the other hand, there is still the possibility that the greater congestion seen in the HD-group was a sign of greater HF disease (and renal disease because of increased creatinine levels) in this group compared to the LD-group finally leading to greater death. [28]
There are many common causes of diuretic resistance such as incorrect diagnosis of the disease, nonadherence to recommended sodium and/or fluid restriction, nonadherence to the drug, the dose of the drug is too low or infrequent, or absorption of the drug is poor. [29] Furthermore, there are many renal issues involved in diuretic resistance best divided into reduced diuretic secretion or insufficient kidney response to the drug. Decreased kidney blood flow and/or decreased functional kidney mass hinders secretion and low glomerular filtration rate and/or activation of the renin-angiotensin system hampers the kidneys response to the drug. [29] The increased congestion in the HD-group could have contributed to the diuretic resistance by limiting absorption of furosemide e.g. because of mucosal edema of the intestine, decreased intestinal perfusion and reduced intestinal motility. [30] Indeed, there are many pharmacokinetic and pharmacodynamic considerations to take into account when evaluating loop diuretics in disease states such as HF and renal failure. [31]
Increased levels of NT-proBNP have been associated with increased mortality in HF patients [32] and, along the same lines, reductions in NT-proBNP have been associated with improved outcomes. [33] Considering this fact, we might have expected that meaningful decreases in NT-proBNP levels from admittance, through discharge from the hospital, to follow up would improve survival of the patients in the two groups. Both groups showed significant reductions in mean values of NT-proBNP from enrollment to follow up. Yet, there were more deaths in the HD-group than the LD-group. Interestingly, the reduction of the mean NT-proBNP value from discharge to follow up in the HD-group was significant, 1577 ng/L (p=0.04), while the reduction of the mean NT-proBNP value during the same time frame in the LD-group was meager, 94.7 ng/L (p=0.80). A substantial reduction in natriuretic peptides in the HD-group still led to increased mortality. This finding is novel and important since it suggests that the potential harmful effects of high dose furosemide overrides the known beneficial effects of decreasing natriuretic peptides. The use of therapy mainly focused on administration of high doses of loop diuretics with early diuretic effect (but in our patients this did not show up as reduction in body weight). The LD-group had the same entry conditions and there was no difference between the groups in NT-proBNP, neither at enrollment nor at follow-up (Table 2). However, the mortality rate was significantly higher in the HD-group versus the LD-group of diuretic based therapy (Figure 1). The reason might rely on the positive effect offered by treating the sympathetic over activity with a beta-adrenoceptor blocker, antagonizing the over activity of the renin-angiotensin-aldosterone pathway. The caveat is that neuroendocrine therapy works equally well in the elderly as in younger patients.
We have recently shown that elderly patients (84.6 years of age) with HF treated with intravenous bolus injections of furosemide had lower mortality than elderly heart failure patients (80.1 years of age) treated with continuous intravenous infusions of furosemide. [34] One logical reasons for this could be less persistent kidney damage caused by the diuretic when it was given intermittently, which also might have led to less neuroendocrine overdrive. On the contrary, in a randomized controlled trial in HF patients with acute decompensation and high risk of diuretic resistance, continuous infusion of furosemide was associated with better decongestion than intermittent bolus of furosemide [35]. Also, in the largest prospective randomized trial comparing the two modes of administration of furosemide in acute decompensated HF, the DOSE study, no significant differences were found between bolus and continuous therapy. [36] However, the patients included in both these trials were significantly younger than in our study, mean age about 60 and 66 years of age respectively, making a comparison more difficult. In the current study we showed that a low dose regimen of furosemide was superior to a high dose regimen in eighty year olds, putatively because of less diuretic resistance and less potential harmful pathophysiological effects. Based on these observations, we suggest that it might be more appropriate to treat HF patients in their eighties with intermittent and low doses of diuretics in order to improve outcome. In favor of this argument, a recent study have shown that diuretic withdrawal in stable outpatients with mild heart failure did not increase self-perception of dyspnea, the need for reuse of furosemide and heart failure related events were infrequent [37].
Limitations and future directions: This is a relatively small study and to the best of our knowledge the first study that has solely examined patients in their eighties. Larger studies in even older patients might give further insight. A randomized controlled trial would be optimal, but is not possible to undertake since HF patients are treated based on their need of symptom relief which may differ from patient to patient. Also, it would seem unethical to withhold diuretics for patients in need or add diuretics to patients that do not require them. We have shown that it is possible to improve the outcome of HF patients by standardizing the care of these patients when they are admitted to the hospital with increased congestive symptoms [38]. We now propose that a new improved standardized plan might be implemented based on intermittent and low dose diuretic treatment in acute HF.
Conclusions: We advocate careful use of loop diuretics, only to improve symptoms in the very elderly patients (>80 years), and to be used in a balanced way with neuroendocrine therapy modes. With angiotensin converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonist, and beta-adrenoceptor blockers in well titrated doses the circulation to vital organs such as the brain, the heart and the kidneys is maintained.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
