Management of Acute Decompensated Heart Failure in Hospitalized Patients
Journal of Clinical Outcomes Management. 2015 April;22(4)
References
) [5]. Finally, previous studies have suggested that the addition of low-dose dopamine to diuretic therapy may enhance decongestion and preserve renal function in ADHF [25–27]. Dopamine at low infusion doses (1–3 mcg/min) directly activates dopaminergic receptors in the kidney promoting renal vasodilatation. This vasodilatory effect augments renal blood flow leading to an increase in urine output. This theoretical effect, however, has not translated into improved clinical outcomes in patients with ADHF. The recent Renal Optimization Strategies Evaluation in Acute Heart Failure (ROSE-AHF) study randomized patients with ADHF and renal dysfunction to low-dose dopamine (2 mcg/kg/min) or placebo in addition to diuretic therapy. The study failed to demonstrate significant differences in urine output at 72 hours or improved renal function in patients randomized to dopamine compared to placebo [27].
Ultrafiltration
For patients with marked fluid overload who are unresponsive to diuretic therapy, peripheral ultrafiltration may be considered. Initial data demonstrated that early ultrafiltration effectively and safely reduced congestion in patients with ADHF with diuretic resistance and renal insufficiency. Length of stay was reduced, with 60% of discharges in 3 days or less and 1 readmission at 30 days. Neurohormonal activation, indicated by reduction in BNP level, was reduced without worsening glomerular filtration rate, hypotension or electrolyte abnormalities [28]. The UNLOAD trial confirmed these results and extended their findings to show that patients undergoing peripheral ultrafiltration had greater weight and net fluid loss at 48 hours and reduced rate of rehospitalization at 90 days when compared with IV diuretic therapy alone in ADHF patients. Interestingly, there was no difference in the dyspnea score at 48 hours and there was a trend toward worsening of renal function in the ultrafiltration group. The study was not powered to document a survival benefit [29]. However, the more recent Cardiorenal Rescue Study in ADHF (CARRESS-HF) trial involving patients with ADHF and worsening renal function showed that there was no difference in weight loss between patients randomized to ultrafiltration or a strategy of stepped pharmacologic therapy. Additionally, ultrafiltration was associated with a significant increase in creatinine at 96 hours and a higher rate of adverse events related to the procedure, driven by complications from intravenous catheter insertion. There was no difference between the 2 groups in death or rehospitalization for heart failure [30]. At present, ultrafiltration may be a reasonable option if all diuretic strategies are unsuccessful in relieving congestion [5].
Vasopressin-Receptor Antagonists
The vasopressin-receptor antagonists represent a relatively new class of medications that target the vasopressin receptors V 1a and V 2. Activation of the vasopressin V 2 receptors by arginine vasopressin in heart failure causes inappropriate free water retention contributing to the symptoms of congestion and hyponatremia [31]. Currently, the only 2 vasopressin-receptor antagonists available for clinical use are conivaptan (V 1a /V2 receptor antagonist) and tolvaptan (V 2 receptor antagonist). The effectiveness of tolvaptan was tested in a randomized study (EVEREST) in patients hospitalized with ADHF [32,33]. At 1 year there was no difference seen in the primary endpoints of all-cause mortality, death from cardiovascular causes, or first hospitalization for heart failure [32,33]. However, hyponatremia, when present, was improved in the tolvaptan group. Conivaptan has a similar hemodynamic profile compared to tolvaptan, but without improving signs and symptoms in hospitalized patients with ADHF [34]. Currently, vasopressin antagonists are recommended in the management of ADHF by professional guidelines as only a class IIb indication in hospitalized patients with volume overload and severe hyponatremia [5].
