Improved decongestion with the addition of acetazolamide to intravenous loop diuretics for acute heart failure

Reference

Mullens W, Dauw J, Martens P, et al, for the ADVOR Study Group. Acetazolamide in acute decompensated heart failure with volume overload. N Engl J Med 2022;387:1185-1195.

Synopsis

These investigators randomized hospitalized adults with acute decompensated heart failure (one clinical sign of volume overload plus elevated NT-pro-BNP or BNP) to receive intravenous acetazolamide 500 mg daily (n = 259) or matching placebo (n = 260) for 3 days. All patients also received standardized intravenous loop diuretic therapy at double the dose of their oral maintenance therapy. Those taking maintenance acetazolamide or sodium-glucose cotransporter 2 (SLGT-2) inhibitors were excluded. Trial participants had a mean age of 78 years, two-thirds were men, and 99% were white. Additionally, 87% were classified as New York Heart Association class III or IV. The primary outcome was successful decongestion, defined as the absence of signs of volume overload within 3 days of randomization without a need for escalation of decongestive therapy. Overall, more patients in the acetazolamide group than in the placebo group achieved the primary outcome (42.2% vs 30.5%; relative risk [RR] 1.46; 95% CI 1.17 - 1.82). This was consistent across all subgroups, except for a smaller benefit seen in patients receiving a higher dose of maintenance diuretics compared with those receiving a lower dose. Further, the acetazolamide group had a shorter hospital stay (8.8 vs 9.9 days; RR 0.89; 0.81 - 0.98) and a higher incidence of successful decongestion at discharge (62.5% vs 78.8%; RR 1.27; 1.13 - 1.43). Adverse events were similar in the 2 groups and there were no differences detected in death or rehospitalization at 3 months.