https://doi.org/10.55788/caab19d5
Results of the ADVOR (NCT03505788) trial were presented by Prof. Wilfried Mullens (Hospital Oost-Limburg, Belgium), who showed that acetazolamide added to standard-of-care improved decongestion rates by 12%. The results were simultaneously published in the New England Journal of Medicine [1,2].
Patients with acute decompensated HF were randomised to receive standard loop diuretics with addition of either acetazolamide (500 mg intravenously; n=259) or placebo (n=256). At randomisation, oral loop diuretics were stopped and all participants received high-dose intravenous loop diuretics. Participants had an average age of 78 years, the average ejection fraction (EF) was 43%, and all had at least 1 clinical sign of volume overload (i.e. ascites, pleural effusion, or oedema), elevated natriuretic peptide levels, and had been taking oral diuretics for at least 1 month.
Randomisation was stratified according to the left ventricular ejection fraction (LVEF ≤40% or >40%). The primary endpoint was successful decongestion, defined as no clinical signs of fluid overload within 3 days of randomisation, and without any escalation of decongestive therapy. Secondary endpoints were a composite of death from any cause, rehospitalisation for HF during 3 months of follow-up, and safety.
The primary endpoint was met; 42.2% of participants in the acetazolamide group versus 30.5% in the placebo group were successfully decongested within 3 days, with a relative risk (RR) of 1.46 (95% CI 1.17–1.82; P=0.0009, see Figure). At discharge, 78.8% of the acetazolamide group versus 62.5% of the placebo group had successful decongestion (RR 1.27; 95% CI 1.13–1.43; P=0.0001).
Figure: Results of ADVOR primary endpoint: successful decongestions within 3 days [1]
NNT, number needed to treat; RR, relative risk
The secondary endpoints revealed other benefits; participants in the acetazolamide arm stayed in hospital for shorter periods (average 8.8 days) compared with those in the placebo arm (average 9.9 days; P=0.02). However, there were no differences between the arms in the composite outcome of all-cause mortality and hospitalisation for HF within 3 months (HR 1.07; 95% CI 0.78–1.48). Safety signals were not different between the arms, and the incidence of renal decline, hypokalaemia, hypotension, and adverse events was similar between the 2 groups.
Prof. Mullens concluded: “ADVOR was a large, randomised, diuretic trial performed in patients with acute decompensated HF. Acetazolamide is easy to use, safe, effective, off-patent, and cheap. It is therefore expected that the results of ADVOR will lead to a paradigm shift in the way physicians worldwide treat acute decompensated HF."
- Mullens W, et al. ADVOR - Acetazolamide in acute heart failure. Hot Line Session 2, ESC Congress 2022, Barcelona, Spain, 26–29 August.
- Mullens W, et al. N Engl J Med. 2022 Aug 27. doi: 10.1056/NEJMoa2203094.
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Table of Contents: ESC 2022
Featured articles
ESC Clinical Practice Guidelines
Prevention of VT and sudden cardiac death: the new recommendations
New and first ESC cardio-oncology guideline
The 2022 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension
Cardiovascular assessment and management of patients undergoing non-cardiac surgery
Heart Failure
Old dogs, new tricks: Acetazolamide plus loop diuretics improves decongestion
No effect of neprilysin inhibition on cognition
Dapagliflozin DELIVERs for HFmrEF/HFpEF
Meta-analysis of DELIVER and EMPEROR-Preserved
Anticoagulation
Rheumatic heart disease-associated AF: standard-of-care holds ground
New anticoagulant safe and maybe effective: PACIFIC-AMI and PACIFIC-Stroke outcomes
AXIOMATIC-SSP: Reducing risk of ischaemic stroke with factor XIa inhibition?
Evolving evidence for P2Y12 inhibition in chronic coronary syndromes: PANTHER
Prevention
Danish study suggests starting CVD screening before age 70
Polypill SECUREs win in secondary prevention in elderly
Long-term therapy with evolocumab associated with lower CV mortality
ARBs + beta-blockers may delay Marfan syndrome aortic root replacement
ENTRIGUE: Subcutaneous pegozafermin in severe hypertriglyceridaemia
Artificial Intelligence & Digital Health – What Is New
First RCT evidence for use of AI in daily practice
AI-enhanced echography supports aortic stenosis patients
Ischaemia
Medical therapy versus PCI for ischaemic cardiomyopathy
Allopurinol disappoints in ALL-HEART
Conservative or invasive management for high-risk kidney disease patients with ischaemia?
Genotype-guided antiplatelet therapy in patients receiving PCI
Other HOTLINE Sessions
BOXing out oxygen and blood pressure targets
Coronary CT angiography diagnostics compared head-to-head
High-dose influenza vaccine: mortality benefit?
FFR-guided decision-making in patients with AMI and multivessel disease
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