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Targeting Hyponatremia and Hemodynamics in Acute Decompensated Heart Failure: Is There a Role for Vasopressin Antagonists?

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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.

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  1. Tufts University School of Medicine, Baystate Medical Center, S-4665, Cardiology, 759 Chestnut Street, Springfield, MA, 01199, USA

    Gregory Valania, Manmeet Singh & Mara T. Slawsky

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  1. Gregory Valania
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  2. Manmeet Singh
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  3. Mara T. Slawsky
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Correspondence to Mara T. Slawsky.

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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

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