The addition of acetazolamide to standardized intravenous loop-diuretic therapy in patients with acute decompensated heart failure led to a higher incidence of successful decongestion, according to findings from the ADVOR trial presented Aug. 27 during ESC Congress 2022 in Barcelona, and simultaneously published in the New England Journal of Medicine.

The study out of Belgium randomized 519 patients with acute decompensated heart failure and clinical signs of volume overload to receive either intravenous acetazolamide (500 mg once daily; n=256) or placebo added to standardized intravenous loop diuretics (at a dose equivalent to twice the oral maintenance dose; n=259). The primary endpoint was successful decongestion within three days following randomization and without an indication for escalation of decongestive therapy. Secondary endpoints were a composite of death from any cause or rehospitalization for heart failure during three months of follow-up.

Results showed successful decongestion occurred in 108 patients (42.2%) in the acetazolamide group compared with 79 (30.5%) in the placebo group. Study investigators also found that "acetazolamide treatment was associated with higher cumulative urine output and natriuresis, findings consistent with better diuretic efficiency." Similar incidences of worsening kidney function, hypokalemia, hypotension, and adverse events were observed across both groups.

Wilfried Mullens, MD, who presented the results, said that some limitations to the study include the lack of non-white participants, which may limit the generalizability of the results to other racial or ethnic groups. Mullens and colleagues also said the results may not be applicable to patients with newly diagnosed heart failure, noting that all of the patients had a history of chronic heart failure and had been receiving long-term outpatient treatment with at least 40 mg of furosemide equivalent.

In a related editorial comment, G. Michael Felker, MD, FACC, calls the findings a "welcome addition" that "suggest the use of acetazolamide as a reasonable adjunct to achieving more rapid decongestion." However, he notes the exclusion of patients receiving SGLT2 inhibitors is a "critical limitation" of the trial that warrants future studies.

Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Statins, Acute Heart Failure

Keywords: ESC Congress, ESC22, Acetazolamide, Diuretics, Edema, Furosemide, Geriatrics, Heart Failure, Hypokalemia, Hypotension, Length of Stay, Natriuretic Peptides, Brain, Pleural Effusion, Torsemide, Ventricular Function, Left, ACC International

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