Association of congestion with worsening renal function in acute decompensated heart failure according to age

Latest pharmaceutical approaches across the spectrum of heart failure

Despite major advances in prevention and medical therapy, heart failure (HF) remains associated with high morbidity and mortality, especially in older and frailer patients. Therefore, a complete, guideline-based treatment is essential, even in HF patients with conditions traditionally associated with a problematic initiation and escalation of the medical HF therapy, such as chronic kidney disease and arterial hypotension, as the potential adverse effects are overcome by the overall decrease of the absolute risk. Furthermore, since the latest data suggest that the benefit of a combined medical therapy (MRA, ARNI, SGLT2i, beta-blocker) may extend up to a LVEF of 65%, further trials on these subgroups of patients (HFmrEF, HFpEF) are needed to re-evaluate the guideline-directed medical therapy across the HF spectrum. In particular, the use of SGLT2i was recently extended to HFpEF patients, as evidenced by the DELIVER and EMPEROR-preserved trials. Moreover, the indication for other conservative treatments in HF patients, such as the intravenous iron supplementation, was accordingly strengthened in the latest guidelines. Finally, the possible implementation of newer substances, such as finerenone, in guideline-directed medical practice for HF is anticipated with great interest.

Preliminary Report of Intravenous Tolvaptan Sodium Phosphate (Samtas®) Treatment in Decompensated Heart Failure

Background: Tolvaptan sodium phosphate (Samtas®; Otsuka Pharmaceutical, Tokyo, Japan) is a novel intravenous aquaretic diuretic aimed at individuals experiencing advanced congestion refractory to conventional diuretics and having difficulty with oral intake. Despite its potential, the true efficacy and practicality of this compound within real-world clinical settings remain obscure. Methods: A retrospective analysis of clinical data was conducted, examining trends among consecutive in-hospital patients diagnosed with congestive heart failure who underwent treatment with tolvaptan sodium phosphate at a prominent academic medical center between June 2022 and June 2023. Results: Twenty-one patients were enrolled (median age: 75 years, serum N-terminal pro B-type natriuretic peptide: 8941 pg/mL). Among them, 14 patients (67%) received non-invasive/invasive positive-pressure ventilation, and 17 patients (81%) concurrently received intravenous inotropes. Subsequent to the initiation of tolvaptan sodium phosphate treatment, a significant increase in urine volume was observed on the following day (p = 0.036). Urine osmolality decreased from 356 (318, 443) at baseline to 247 (176, 333) mOsm/kg after 4 h (p = 0.002). No occurrences of hypernatremia were recorded during the therapeutic period. Notably, two patients transitioned from tolvaptan sodium phosphate treatment to continuous hemodiafiltration due to insufficient efficacy. Conclusions: In routine clinical practice, intravenous tolvaptan sodium phosphate exhibits potential efficacy and practicability in the majority of congestive heart failure patients exhibiting refractory congestion, unstable hemodynamics, and challenges with oral intake.

Patient-Centered Heart Failure Therapy

Simultaneous initiation of quadruple therapy with angiotensin receptor-neprilysin inhibitor, beta-adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor aims at prompt improvement and prevention of readmission in patients hospitalized for heart failure with reduced ejection fraction. However, titration of quadruple therapy is time consuming. Lengthy up-titration of quadruple therapy may negate the benefit of early initiation. Quadruple therapy should start with a sodium glucose cotransporter 2 inhibition and a mineralocorticoid antagonist, as both enable safe decongestion and require minimal or no titration. Depending on the level of decongestion and clinical characteristics, patients receive an angiotensin receptor-neprilysin inhibitor or a beta-adrenergic receptor blocker to be titrated after hospital discharge. Outpatient addition of an angiotensin receptor-neprilysin inhibitor to a beta-adrenergic receptor blocker or vice versa completes the quadruple therapy scheme. By focusing on decongestion and matching intervention to patients' profile, the present therapeutic sequence allows rapid implementation of quadruple therapy at fully recommended doses.