2) Our expert author is Frederik H. Verbrugge @FH_Verbrugge Cardiology & ICU @HeartBrussels @UZBrussel | Research @MayoClinicCV | Deputy Editor EHJ ACVC | Editorial Consultant JACC Heart Fail. We are honoured to have him join our august faculty–see https://t.co/M19rwNALA2! pic.twitter.com/G0NG7Ws54A— cardio-met (@cardiomet_CE) May 25, 2023
4) .@FH_Verbrugge will be discussing the Acetazolamide in Decompensated heart failure with Volume OveRload #ADVOR trial @JACCJournals.— cardio-met (@cardiomet_CE) May 25, 2023
🔓 https://t.co/oxY9RsQSQp@PieterMartensMD@WilfriedMullens pic.twitter.com/UmhfKSIbwy
6) Allocation to #acetazolamide clearly ⬆️:— cardio-met (@cardiomet_CE) May 25, 2023
✅total urine output (+12.6%)
In relative terms: effect on natriuresis > urine output, UO 🚫significant after 1st diuretic dose, natriuresis remained high!
*Normalized UO to 24 h for collection 1. pic.twitter.com/mfWLzJger2
8) Be wary: total #natriuresis & UNa are not the same!— cardio-met (@cardiomet_CE) May 25, 2023
Total natriuresis tracks well with UO
➡️Amount of extracellular volume (#ECV) DURABLY removed (150 mmol Na ~ 1 L ECV)
❗️Urine is usually HYPOTONIC (UNa <150 mmol/L)
➡️ Part of UO reflects #dehydration, not #decongestion pic.twitter.com/58fsntEY80
14) Now the intriguing part: Good natriuretic response (UNa ≥80 mmol/L):— cardio-met (@cardiomet_CE) May 25, 2023
➡️Similar outcome loop diuretic monotherapy & combination w/ acetazolamide
❗️ Many more patients w/ #acetazoalmide had UNa ≥80 mmol/L (NNT = only 7!)
Poor natriuretic response (UNa <80 mmol/L):
🪦 & 🏥 pic.twitter.com/9LhRizIv8E
16) My interpretation is that by the play of chance, patients in the #acetazolamide arm were probably slightly sicker.— cardio-met (@cardiomet_CE) May 25, 2023
This is illustrated as well by slightly higher baseline dose of loop #diuretics (80 vs. 60 mg furosemide equivalents).
18) Also read this other analysis from the #ADVOR, eloquently discussed by my friend & partner in crime@PieterMartensMD: https://t.co/XOnDtgvN14 …— cardio-met (@cardiomet_CE) May 25, 2023
It shows nicely that after 48 h treatment with monotherapy loop diuretics, almost every patient develops "contraction alkalosis"
20) This is a BIG difference with #thiazides, which have shown to break diuretic resistance, can wait until this occurs!— cardio-met (@cardiomet_CE) May 25, 2023
The effect of #acetazolamide resides in braking the neurohumoral system, so need to treat upfront rather than bail-out, which is how #ADVOR was set up!
22a) So let's see what you have learned!— cardio-met (@cardiomet_CE) May 25, 2023
❓Which of these was NOT an inclusion criterion for #ADVOR?
a. clinical signs of volume overload
b. NTpBNP or BNP elevated
c. treatment with an #SGLT2i
d. oral maintenance tx with 40mg furosemide PO QD or more for >1 month or longer
22c) In fact it's d, which is ALL of the above. Increased #natriuresis with #acetazolamide in #ADHF is strongly related to successful decongestion, with all that clinical impact listed in 22b.— cardio-met (@cardiomet_CE) May 25, 2023
💡 UNa may be an attractive measure of effective decongestion for future trials.
23) And you just earned 0.5h 🆓CE/#CME! Just point your 🖱️ to https://t.co/1AAlYf5O7R and claim your certificate. And FOLLOW US for more expert-led #MedEd on all the advances in the #cardiometabolic space. @FH_Verbrugge thanks you for joining us! pic.twitter.com/DcwCgjkxIB— cardio-met (@cardiomet_CE) May 25, 2023