Medical Therapy for Acute Decompensated Heart Failure: What Recent Clinical Trials Have Taught Us About Diuretics and Vasodilators

Is addition of vasodilators to loop diuretics of value in the care of hospitalized acute heart failure patients? Real-world evidence from a retrospective analysis of a large United States hospital database

BACKGROUND

Current guidelines recommend the use of intravenous (IV) vasodilators in addition to IV loop diuretics for the treatment of acute heart failure (AHF) patients without hypotension. The evidence basis for these recommendations is limited.

METHODS AND RESULTS

Hospital billing records for 82,808 AHF patients in the United States were analyzed. Patients receiving IV loop diuretics alone were paired with patients receiving IV loop diuretics + IV nitrates or IV nesiritide with the use of propensity score matching, excluding those with hypotension and/or evidence of cardiogenic shock, myocardial infarction, or acute coronary syndrome. Compared with paired patients receiving IV loop diuretics alone, in-hospital mortality was similar among IV loop diuretics + IV nitrates patients (n = 4,401; 1.9% vs 2.0%; P = .88) and marginally higher for IV loop diuretics + IV nesiritide patients (n = 2,254; 2.2% vs 3.1%; P = .05). Compared with paired IV loop diuretics patients, IV loop diuretics + IV nitrates or IV nesiritide had longer lengths of stay (+1.6 and +2.1 days; P < .01) and 57% higher costs (P < .01).

CONCLUSIONS

Among hospitalized AHF patients, the addition of IV vasodilators to IV loop diuretics did not lower inpatient mortality or rehospitalization rates compared with loop diuretics alone, and was associated with longer lengths of stay and higher hospitalization costs. Although the lack of complete clinical, socioeconomic, and post-discharge data may have confounded these results, this analysis questions whether currently available IV vasodilators can improve outcomes in hospitalized AHF patients.

Tolvaptan attenuates left ventricular fibrosis after acute myocardial infarction in rats

Tolvaptan, a non-peptide V2-receptor antagonist, is a newly developed diuretic agent. Recently, we reported that tolvaptan has diuretic as well as anti-inflammatory and anti-fibrotic actions in chronic heart failure. In this study, we investigated whether tolvaptan has a cardioprotective effect in acute heart failure after myocardial infarction (MI). After MI induction, rats were randomized into 6 groups as follows: vehicle group, group treated with 15 mg∙kg⁻¹∙day⁻¹ furosemide, 2 groups treated with 3 or 10 mg∙kg⁻¹∙day⁻¹ tolvaptan, and 2 groups treated with 15 mg∙kg⁻¹∙day⁻¹ furosemide combined with 3 or 10 mg∙kg⁻¹∙day⁻¹ tolvaptan. Each agent was administered for 2 weeks, and blood pressure levels and infarct sizes were similar in all MI groups. Lower left ventricular end-systolic volumes and greater improvement of left ventricular ejection fraction were observed in the tolvaptan-treated groups compared with the vehicle group. In contrast, furosemide alone did not improve them. Sirius red staining revealed that tolvaptan significantly repressed MI-induced interstitial fibrosis in the left ventricle. MI-induced mRNA expressions related to cardiac load, inflammation, and fibrosis were significantly attenuated in the combination group. The combination treatment also repressed MI-induced mineralocorticoid receptor expression. Tolvaptan, or combination of furosemide and tolvaptan, may improve cardiac function in acute MI.

Adenosine A1 modulators: a patent update (2008 to present)

INTRODUCTION

In 2008, we published our review titled 'Therapeutic potential of A1 adenosine receptor ligands - a survey of recent patent literature' that reported the compounds active on A1 adenosine receptors (ARs) and the applications of A1 AR ligands patented in the period 2005 - 2008.

AREAS COVERED

This article is a discussion of the patents about the same subjects, issued in the period 2008 to present. It is organized similarly to the first one, with a section about new compounds, subdivided on the basis of their functional activity (agonists, antagonists and allosteric modulators) and a section regarding new therapeutic applications.

EXPERT OPINION

The main novelty is represented by the patenting of A1 AR ligands with dual selectivity which may show, in some conditions, better efficacy and fewer side effects. Moreover, while the way to arrive into the market appears full of obstacles for selective A1 ligands that need systemic administration for long-term therapy, better chances are foreseen in applications requiring topical administration.