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Prof. Andrew L Clark
Session number: 149
Session title: Dos and don'ts in the management of acute heart failure
Authors: Andrew Clark (Kingston-Upon-Hull, United Kingdom)
The packed session challenged the audience to reconsider much of what we think we know about the management of acute heart failure. Dr Ken McDonald (Dublin, IE) started by considering the role of salt and water restriction, pointing out that there is no evidence to support what is standard practice. Dr McDonald has demonstrated that fluid restriction is of no apparent benefit (JCF 2007;13:128) and recent work shows that salt and water restriction merely serves to make patients feel more thirsty without benefiting outcomes.
Dr Frank Peacock (Houston, US) discussed the use of nitrates. Guidelines differ in their recommendations, and he took grave exception to the recent NICE guidelines suggesting that nitrates should not be routinely offered to patients. He pointed out that the absence of randomised trials does not mean we should not use parachutes when jumping out of aeroplanes: similarly, the absence of randomised trials does not mean we should not treat the patient with acute pulmonary oedema and hypertension with intravenous nitrates. Part of the problem here is one of definition, and Dr Peacock made it clear that nitrates are not useful for patients whose dominant problem is fluid retention.
Dr Michael Felker (Durham, US) then made us consider diuretics. We all know that higher doses of diuretics are associated with worse outcomes, but of course, there is a major problem of confounding by indication. Those with worse heart failure have a worse prognosis – and are likely to be on higher diuretic doses. Congestion itself is profoundly associated with a worse prognosis, and strategies to reduce congestion more quickly may be beneficial. The ATHENA trial is examining the possible effects of giving high dose spironolactone to patients presenting with severe fluid retention, and other trials are testing the adjunctive use of early, short-term tolvaptan in congested patents.
Finally, Dr Adriaan Voors (Groningen, NL) continued the theme. Congestion is bad, reducing congestion is good, but may cause worsening renal function, and worsening renal function is associated with worse prognosis. However, there is evidence of publication bias in the renal function studies, and more careful analysis of the available data shows that the key issue is congestion. Using a measure of diuretic responsiveness measured as kg of weight loss per 40 mg furosemide used, those patients with greater responsiveness have better outcomes despite worsening renal function.