Abstract
Current treatment of acute decompensated heart failure (ADHF) has not reduced the significant morbidity or mortality associated with this disease, and has promoted drug development aimed at neurohormonal targets. Hypervolemic hyponatremia, which is linked to the nonosmotic release of arginine vasopressin, is associated with a poor prognosis in patients with heart failure (HF). Vasopressin acts on V2 and V1a receptors to cause water retention and vasoconstriction, respectively. Clinical trials have demonstrated that vasopressin receptor antagonists (VRAs) are effective in treating hypervolemic hyponatremia in ADHF without a negative impact on renal function. The small hemodynamic benefit seen with VRA use appeared to result from V2-receptor antagonist–induced increase in urine output rather than from a vasodilatory drug effect. VRA use in ADHF trials was associated with minimal symptomatic improvement and no impact on morbidity or mortality. At present, clinical trial evidence does not support the routine use of VRAs in ADHF. Given the favorable renal profile of VRAs, studies on the possible benefit of VRAs in ADHF patients with renal insufficiency and diuretic resistance appear warranted.
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Abbreviations
- ACTIV in CHF:
-
Acute and Chronic Therapeutic Impact of a Vasopressin 2 Antagonist in Congestive Heart Failure
- OPTIME–CHF:
-
Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure
- ESCAPE:
-
Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness
- OPTIMIZE-HF:
-
Organized Program to Initiation Life-saving Treatment in Hospitalized Patients with Heart Failure
- ECLIPSE:
-
Effect of Tolvaptan on Hemodynamic Parameters in Subjects with Heart Failure
- EVEREST:
-
Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan
- THE BALANCE:
-
The Treatment of Hyponatremia Based on Lixivaptan in NYHA Class III/IV Cardiac Patient Evaluation.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance, •• Of major importance
Fang J, Mensah GA, Croft JB, Keenan NL: Heart failure-related hospitalization in the U.S., 1979 to 2004. J Am Coll Cardiol 2008, 52:428–434.
Lloyd-Jones D, Adams RJ, Brown TM, et al.: Heart disease and stroke statistics 2010 update: a report from the American Heart Association. Circulation 2010, 121:e46–e215.
Jessup M, Abraham WT, Casey DE, et al.: 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009, 119:1977–2016.
Gheorghiade M, Filippatos G, De Luca L, Burnett J: Congestion in acute heart failure syndromes: an essential target of evaluation and treatment. Am J Med 2006, 119(12 Suppl 1):S3–S10.
Fonarow GC, Adams KF Jr, Abraham WT, et al.: Risk stratification for in-hospital mortality in acutely decompensated heart failure. JAMA 2005, 293:572–580.
Gheorghiade M, Abraham WT, Albert NM, et al.: Systolic blood pressure at admission, clinical characteristics, and outcomes in patients hospitalized with acute heart failure. JAMA 2006, 296:2217–2226.
Francis GS, Siegel RM, Goldsmith SR, et al.: Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Activation of the neurohormonal axis. Ann Intern Med 1985, 103:1–6.
Cohn JN, Burke LP: Nitroprusside. Ann Intern Med 1979, 91:752–757.
Shin J, Dec GW: Ultrafiltration should not replace diuretics for the initial treatment of acute decompensated heart failure. Circ Heart Fail 2009, 2:505–511.
Goldsmith SR, Francis GS, Cowley AW Jr, et al.: Increased plasma arginine vasopressin levels in patients with congestive heart failure. J Am Coll Cardiol 1983, 1:1385–1390.
Gheorghiade M, Gattis WA, O’Connor CM, et al.: Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure. JAMA 2004, 291:1963–1971.
Klein L, O’Connor CM, Leimberger JD, 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, 111:2454–2460.
Gheorghiade M, Rossi JS, Cotts W, et al.: Characterization and prognostic value of persistent hyponatremia in patients with severe heart failure in the ESCAPE Trial. Arch Intern Med 2007, 167:1998–2005.
Gheorghiade M, Abraham WT, Albert NM, et al.: Relationship between admission serum sodium concentration and clinical outcomes in patients hospitalized for heart failure: an analysis from the OPTIMIZE-HF registry. Eur Heart J 2007, 28:980–988.
Chin MH, Goldman L: Correlates of major complications or death in patients admitted to the hospital with congestive heart failure. Arch Intern Med 1996, 156:1814–1820.
Lee DS, Austin PC, Rouleau JL, et al.: Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. JAMA 2003, 290:2581–2587.
Rossi J, Bayram M, Udelson JE, et al.: Improvement in hyponatremia during hospitalization for worsening heart failure is associated with improved outcomes: insights from the Acute and Chronic Therapeutic Impact of a Vasopressin Antagonist in Chronic Heart Failure (ACTIV in CHF) trial. Acute Card Care 2007, 9:82–86.
Lee WH, Packer M: Prognostic importance of serum sodium concentration and its modification by converting-enzyme inhibition in patients with severe chronic heart failure. Circulation 1986, 73:257–267.
Kearney MT, Fox KA, Lee AJ, et al.: Predicting death due to progressive heart failure in patients with mild-to-moderate chronic heart failure. J Am Coll Cardiol 2002, 40:1801–1808.
Felker MG, Leimberger JD, Califf RM, et al.: Risk stratification after hospitalization for decompensated heart failure. J Card Fail 2004, 10:460–466.
• Schrier RW: Decreased effective blood volume in edematous disorders: what does this mean? J Am Soc Nephrol 2007, 18:2028–2031. This article presents a unifying hypothesis to explain the sodium and water retention in edematous disorders as a compensatory response to arterial underfilling.
Schrier RW, Abraham WT: Hormones and hemodynamics in heart failure. N Engl J Med 1999, 341:577–585.
Lee CR, Watkins ML, Patterson JH, et al.: Vasopressin: a new target for the treatment of heart failure. Am Heart J 2003, 146:9–18.
Kumar S, Rubin S, Mather PJ, Whellan D: Hyponatremia and vasopressin antagonism in congestive heart failure. Clin Cardiol 2007, 30:546–551.
Szatalowicz VL, Arnold PE, Chaimovitz C, et al.: Radioimmunoassay of plasma arginine vasopressin in hyponatremic patients with congestive heart failure. N Engl J Med 1981, 305:263–266.
Francis GS, Benedict C, Johnson DE, et al.: Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure. Circulation 1990, 82:1724–1729.
Goldsmith SR, Francis GS, Cowley AW Jr, et al.: Hemodynamic effects of infused arginine vasopressin in congestive heart failure. J Am Coll Cardiol 1986, 8:779–783.
Creager MA, Faxon DP, Cutler SS, et al.: Contribution of vasopressin to vasoconstriction in patients with congestive heart failure: comparison with the renin-angiotensin system and the sympathetic nervous system. J Am Coll Cardiol 1986, 7:758–765.
Nakamura Y, Haneda T, Osaki J, et al.: Hypertrophic growth of cultured neonatal rat heart cells mediated by vasopressin V1a receptor. Eur J Pharmacol 2000, 391:39–48.
Xu DL, Martin PY, Ohara M, et al.: Upregulation of aquaporin-2 water channel expression in chronic heart failure rat. J Clin Invest 1997, 99:1500–1505.
Funayama H, Nakamura T, Saito T, et al.: Urinary excretion of aquaporin-2 water channel exaggerated dependent upon vasopressin in congestive heart failure. Kidney Int 2004, 66:1387–1392.
Finley JJ 4th, Konstam MA, Udelson JE: Arginine vasopressin antagonists for the treatment of heart failure and hyponatremia. Circulation 2008, 118:410–421. (Published erratum appears in Circulation 2009, 119:3552.)
Goldsmith SR: Current treatments and novel pharmacological treatments for hyponatremia in congestive heart failure. Am J Cardiol 2005, 95(suppl):14B–23B
Costello-Boerrigter LC, Smith WB, Boerrigter G, et al.: Vasopressin-2-receptor antagonism augments water excretion without changes in renal hemodynamics or sodium and potassium excretion in human heart failure. Am J Physiol Renal Physiol 2006, 290:F273–F278,
Udelson JE, Smith WB, Hendrix GH, et al.: Acute hemodynamic effects of conivaptan, a dual V1A and V2 vasopressin receptor antagonist, in patients with advanced heart failure. Circulation 2001, 104:2417–2723.
Goldsmith SR, Elkayam U, Haught WH, et al.: Efficacy and safety of the vasopressin V1A/V2-receptor antagonist conivaptan in acute decompensated heart failure: a dose-ranging pilot study. J Card Fail 2008, 14:641–647.
•• Udelson JE, Orlandi C, Ouyang J, et al.: Acute hemodynamic effects of tolvaptan, a vasopressin V-2 receptor blocker, in patients with symptomatic heart failure and systolic dysfunction: The ECLIPSE international, multicenter, randomized placebo controlled trial. J Am Coll Cardiol 2008, 52:1540–1545. According to this article, the improvement in cardiac filling pressures in patients treated with the V 2 -receptor blocker tolvaptan was similar to what had been observed in a prior hemodynamic study with the V 1 /V 2 -receptor blocker conivaptan. These findings suggested that the diuretic effect of vasopressin-receptor blockers was sufficient to account for the observed hemodynamic improvement in patients with heart failure.
•• Konstam MA, Gheorghiade M, Burnett JC Jr, et al.: Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST outcome trial. JAMA 2007, 297:1319–1331. According to this article, tolvaptan therapy initiated during hospitalization for ADHF had no effect on long-term mortality or rehospitalization for heart failure.
Abraham WT, Shamshirsaz AA, McFann K, et al.: Aquaretic effect of lixivaptan, an oral, non-peptide, selective V2 receptor vasopressin antagonist, in New York Heart Association functional class II and III chronic heart failure patients. J Am Coll Cardiol 2006, 47:1615–1621.
CardioKine Inc.: THE BALANCE Study: Treatment of hyponatremia based on Lixivaptan in NYHA class III/IV cardiac patient evaluation (NLM identifier: NCT00578695). Available at http://clinicaltrials.gov/ct2/show/NCT00578695. Accessed September 2010.
•• Gheorghiade M, Konstam MA, Burnett JC Jr, et al.: Short-term clinical effects of tolvaptan, an oral vasopressin antagonist, in patients hospitalized for heart failure: The EVEREST clinical status trials. JAMA 2007, 297:1332–1343. According to this article, the addition of tolvaptan to standard therapy in patients hospitalized for ADHF resulted in greater weight loss and significant improvement in dyspnea without adversely affecting renal function.
Gheorghiade M, Gottlieb SS, Udelson JE, et al.: Vasopressin V2 receptor blockade with tolvaptan versus fluid restriction in the treatment of hyponatremia. Am J Cardiol 2006, 97:1064–1067.
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Valania, G., Singh, M. & Slawsky, M.T. Targeting Hyponatremia and Hemodynamics in Acute Decompensated Heart Failure: Is There a Role for Vasopressin Antagonists?. Curr Heart Fail Rep 8, 198–205 (2011). https://doi.org/10.1007/s11897-010-0035-3
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DOI: https://doi.org/10.1007/s11897-010-0035-3