Management of Decongestion in Acute Heart Failure: Time for a New Approach?
Tolvaptan and Acute Heart Failure
Keywords:
Tolvaptan, loop diuretic, congestion, acute heart failure
Abstract
As the primary cause of hospitalization in acute heart failure (AHF) patients, congestion was responsible for a higher risk of mortality, rehospitalization, and renal dysfunction in AHF patients. Although loop diuretic was routinely used as the mainstay of AHF therapy, it is still ineffective to obtain the euvolemic state in most hospitalized AHF patients. Therefore, a higher loop diuretic dose was often required to increase the decongestion effect. However, consequently, it can cause several detrimental complications, including renal dysfunction, neurohormonal activation, hyponatremia, hypokalaemia, and reduced blood pressure, which eventually result in poor prognosis. Hence, the new approach may be proposed to optimize decongestion in acute phase, including the use of arginine vasopressin V2 receptor antagonist – Tolvaptan. As an additive therapy to loop diuretic in AHF patients, it can be considered due to its several beneficial effects, including greater decongestion effect, lowered worsening renal function incidence, counteract neurohormonal activation, neutralized hyponatraemic state, no alteration of potassium metabolism, stabilize the blood pressure, and reduced requirement of a higher dose of loop diuretic to achieve an equal or even greater decongestion effect compared to a high dose of loop diuretic alone. Tolvaptan provided favourable outcomes in several specific populations and was considered safe with several mild adverse effects. Several guidelines across countries have approved the use of Tolvaptan in AHF patients with or without hyponatremia. The initial dose of Tolvaptan was 7.5 to 15 mg and can be titrated up to 30 mg. However, further studies were still required to determine the timing dose and optimal dose of Tolvaptan in general and elderly populations with AHF, respectively.
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References
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7. Waranugraha Y, Rohman MS, Anjarwani S. Hemodynamic Congestion at Hospital Discharge Predicts Rehospitalization during Short Term Follow Up in Acute Heart Failure Patients. Indonesian Journal of Cardiology [Internet]. 2019 Sep 11 [cited 2022 Jan 16];40(3). Available from: https://www.ijconline.id/index.php/ijc/article/view/805
8. Lala A, McNulty SE, Mentz RJ, Dunlay SM, Vader JM, AbouEzzeddine OF, et al. Relief and Recurrence of Congestion During and After Hospitalization for Acute Heart Failure. Circulation: Heart Failure [Internet]. 2015 Jul [cited 2022 Jan 15]; Available from: https://www.ahajournals.org/doi/abs/10.1161/CIRCHEARTFAILURE.114.001957
9. Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, et al. Diuretic Strategies in Patients with Acute Decompensated Heart Failure. New England Journal of Medicine. 2011 Mar 3;364(9):797–805.
10. Cooper HA, Dries DL, Davis CE, Shen YL, Domanski MJ. Diuretics and risk of arrhythmic death in patients with left ventricular dysfunction. Circulation. 1999 Sep 21;100(12):1311–5.
11. Arampatzis S, Funk GC, Leichtle AB, Fiedler GM, Schwarz C, Zimmermann H, et al. Impact of diuretic therapy-associated electrolyte disorders present on admission to the emergency department: a cross-sectional analysis. BMC Medicine. 2013 Mar 27;11(1):83.
12. Damman K, Valente MAE, Voors AA, O’Connor CM, van Veldhuisen DJ, Hillege HL. Renal impairment, worsening renal function, and outcome in patients with heart failure: an updated meta-analysis. Eur Heart J. 2014 Feb;35(7):455–69.
13. Butler J, Forman DE, Abraham WT, Gottlieb SS, Loh E, Massie BM, et al. Relationship between heart failure treatment and development of worsening renal function among hospitalized patients. Am Heart J. 2004 Feb;147(2):331–8.
14. Palazzuoli A, Ruocco G, Ronco C, McCullough PA. Loop diuretics in acute heart failure: beyond the decongestive relief for the kidney. Critical Care. 2015 Dec 1;19(1):296.
15. Metra M, Nodari S, Parrinello G, Bordonali T, Bugatti S, Danesi R, et al. Worsening renal function in patients hospitalised for acute heart failure: clinical implications and prognostic significance. Eur J Heart Fail. 2008 Feb;10(2):188–95.
16. Forman DE, Butler J, Wang Y, Abraham WT, O’Connor CM, Gottlieb SS, et al. Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. J Am Coll Cardiol. 2004 Jan 7;43(1):61–7.
17. Yamada T, Ueyama H, Chopra N, Yamaji T, Azushima K, Kobayashi R, et al. Systematic Review of the Association Between Worsening Renal Function and Mortality in Patients With Acute Decompensated Heart Failure. Kidney Int Rep. 2020 Jul 2;5(9):1486–94.
18. Aldahl M, Jensen ASC, Davidsen L, Eriksen MA, Møller Hansen S, Nielsen BJ, et al. Associations of serum potassium levels with mortality in chronic heart failure patients. European Heart Journal. 2017 Oct 7;38(38):2890–6.
19. Savarese G, Xu H, Trevisan M, Dahlström U, Rossignol P, Pitt B, et al. Incidence, Predictors, and Outcome Associations of Dyskalemia in Heart Failure With Preserved, Mid-Range, and Reduced Ejection Fraction. JACC Heart Fail. 2019 Jan;7(1):65–76.
20. Klein L, O’Connor CM, Leimberger JD, Gattis-Stough W, Piña IL, Felker GM, et al. Lower serum sodium is associated with increased short-term mortality in hospitalized patients with worsening heart failure: results from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study. Circulation. 2005 May 17;111(19):2454–60.
21. Philbin EF, Cotto M, Rocco TA, Jenkins PL. Association between diuretic use, clinical response, and death in acute heart failure. Am J Cardiol. 1997 Aug 15;80(4):519–22.
22. Peacock WF, Costanzo MR, De Marco T, Lopatin M, Wynne J, Mills RM, et al. Impact of intravenous loop diuretics on outcomes of patients hospitalized with acute decompensated heart failure: insights from the ADHERE registry. Cardiology. 2009;113(1):12–9.
23. Hasselblad V, Gattis Stough W, Shah MR, Lokhnygina Y, O’Connor CM, Califf RM, et al. Relation between dose of loop diuretics and outcomes in a heart failure population: results of the ESCAPE trial. Eur J Heart Fail. 2007 Oct;9(10):1064–9.
24. Miura M, Sugimura K, Sakata Y, Miyata S, Tadaki S, Yamauchi T, et al. Prognostic Impact of Loop Diuretics in Patients With Chronic Heart Failure – Effects of Addition of Renin-Angiotensin-Aldosterone System Inhibitors and β-Blockers –. Circulation Journal. 2016;80(6):1396–403.
25. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. European Heart Journal. 2021 Sep 21;42(36):3599–726.
26. Felker GM, Mentz RJ, Adams KF, Cole RT, Egnaczyk GF, Patel CB, et al. Tolvaptan in Patients Hospitalized With Acute Heart Failure. Circulation: Heart Failure. 2015 Sep;8(5):997–1005.
27. Tsutsui H, Isobe M, Ito H, Ito H, Okumura K, Ono M, et al. JCS 2017/JHFS 2017 Guideline on Diagnosis and Treatment of Acute and Chronic Heart Failure - Digest Version. Circ J. 2019 Sep 25;83(10):2084–184.
28. Phrommintikul A, Buakhamsri A, Janwanishstaporn S. Heart Failure Council of Thailand (HFCT) 2019 Heart Failure Guideline: Acute Heart Failure. J Med Assoc Thai. 2019;102:373-9.
29. Kim MS, Lee JH, Kim EJ, Park DG, Park SJ, Park JJ, et al. Korean Guidelines for Diagnosis and Management of Chronic Heart Failure. Korean Circ J. 2017 Sep;47(5):555–643.
30. Lee CR, Watkins ML, Patterson JH, Gattis W, O’connor CM, Gheorghiade M, et al. Vasopressin: a new target for the treatment of heart failure. Am Heart J. 2003 Jul;146(1):9–18.
31. Nielsen S, Kwon TH, Christensen BM, Promeneur D, Frøkiaer J, Marples D. Physiology and pathophysiology of renal aquaporins. J Am Soc Nephrol. 1999 Mar;10(3):647–63.
32. Izumi Y, Miura K, Iwao H. Therapeutic potential of vasopressin-receptor antagonists in heart failure. J Pharmacol Sci. 2014;124(1):1–6.
33. Luo X, Jin Q, Wu Y. Tolvaptan add-on therapy in patients with acute heart failure: A systematic review and meta-analysis. Pharmacol Res Perspect. 2020 Jun;8(3):e00614.
34. Feig PU. Cellular mechanism of action of loop diuretics: implications for drug effectiveness and adverse effects. Am J Cardiol. 1986 Jan 24;57(2):14A-19A.
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Published
2022-06-30
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How to Cite
Pramudyo, M. (2022). Management of Decongestion in Acute Heart Failure: Time for a New Approach?. Indonesian Journal of Cardiology, 43(2), 77-89. https://doi.org/10.30701/ijc.1381
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Review Article
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