- 1 Clinical Question
- 2 Bottom Line
- 3 Major Points
- 4 Guidelines
- 5 Design
- 6 Population
- 7 Interventions
- 8 Outcomes
- 9 Criticisms
- 10 Funding
- 11 Further Reading
In patients with HFrEF on standard therapy, does 60 days of tolvaptan reduce mortality or rehospitalization rates when compared to placebo?
In patients with HFrEF on standard therapy, tolvaptan has no effect on either all-cause mortality or a composite of CV mortality or HF rehospitalization when given for 60 days following an acute HF episode.
Diuretics are central to the management of hospitalizations for acute decompensated heart failure (ADHF) and are widely used as maintenance medications for outpatients with HFrEF. Hyponatremia is a poor prognosticator in HF, and the V2 receptor has previously been associated with the deleterious neurohormonal pathways in HFrEF; antagonism of these receptors has been hypothesized to prevent progression of the disease. Tolvaptan, a V2 antagonist, has been thought to play a dual role in both loss of free water through aquaresis and in the prevention of HF progression.
The 2007 Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan-Outcomes (EVEREST-Outcomes) trial randomized 4,133 patients admitted with ADHF to tolvaptan or placebo for at least 60 days. With a median follow-up of 9.9 months, there was no difference in all-cause mortality (25.9% vs. 26.3%) or the composite of CV mortality or HF rehospitalizations (42.0% vs. 40.2%). The related EVEREST-Symptoms (2007) demonstrated improvement in short-term HF symptoms without increasing adverse events.
AHA/ACCF Heart Failure Guidelines (2013, adapted)
- In hospitalized patients with HF or other causes of volume overload with persistent severe hyponatremia at risk for cognitive symptoms despite water restriction and OMT, a vasopressin antagonist may be considered in the short term to improve serum sodium concentration (class IIb, level B)
- Multicenter, double-blind, placebo controlled trial
- Tolvaptan (n=2,072)
- Placebo (n=2,061)
- Setting: 359 centers in North America, South America, and Europe
- Enrollment: 2003-2006
- Median follow-up: 9.9 months
- Analysis: Intention-to-treat
- Primary outcomes:
- All-cause mortality
- CV death or rehospitalization
- Age ≥18 years, with LVEF ≤40% with volume expansion findings
- NYHA class III or IV symptoms
- Acute-on-chronic HF admission
- Cardiac surgery in prior 60 days
- Cardiac mechanical support
- Biventricular PPM in prior 60 days
- Expected survival <6 months
- MI at time of hospitalization
- Uncorrected cardiac valvular disease
- Refractory end-stage HF
- Hemofiltration or dialysis
- Supine SBP <90 mmHg
- Creatinine >3.5 mg/dL
- K >5.5 mEq/L
- Hgb <9 g/dL
From the tolvaptan group.
- Demographics: Age 65.9 years, male 73.4%, white race 85.3%, black race 7.8%
- Health data: SBP 120.8 mmHg, EF 27.5%
- PMH: Ischemic HF 65.1%, HTN 70.8%, DM 39.8%, a fib 43.6%, CKD 26.5%, mitral valvular disease 31.2%
- Previous HF hospitalization: 79.2%
- NYHA class: III 60.1%, IV 39.5%
- Medications: ACE-inhibitors or ARBs 84.3%, beta-blocker 70.8%, diuretics 97.1%, aldosterone antagonists 53.6%
- Symptoms/signs: Dyspnea 90.9%, orthopnea 53.5%, rales 81.0%, pedal edema 79.3%, JVD ≥10 cm 27.0%
- Randomization to tolvaptan 30 mg by mouth daily or placebo for at least 60 days
- Physician-directed "standard" heart failure treatment with medications including diuretics, ACE-inhibitors/ARBs, aldosterone antagonists, hydralazine, and or nitrates
Comparisons are tolvaptan vs. placebo..
- All-cause mortality
- 25.9% vs. 26.3% (HR 0.98; 95% CI 0.87-1.11; superiority P=0.68; non-inferiority P<0.001)
- Composite CV mortality or HF hospitalization
- 42.0% vs. 40.2% (HR 1.04; 95% CI 0.95-1.14; P=0.55)
- Composite CV mortality or CV hospitalization
- 48.5% vs. 46.4% (P=0.52)
- CV mortality
- 20.3% vs. 19.8% (P=0.67)
- Worsening HF
- 36.5% vs. 35.8% (P=0.62)
- Improvement in dyspnea score at one day
- 74.3% vs. 68.0% (P<0.001)
- -1.76 vs. -0.97 kg (P<0.001)
- 73.8% vs. 70.5% (P=0.003)
- Change in serum sodium at 7 days or discharge
- 5.49 mEq/L vs. 1.85 mEq/L (P<0.001)
- Change in KCCQ score 1 week after discharge
- +19.90 vs. +18.52 (P=0.39)
There were no differences in the primary outcome when stratified by sex, race, age, region, etiology of HF, dyspnea, severity of congestion, EF, SBP, NYHA class, sodium level, BUN, creatinine, AVP, BNP, beta-blocker use, ACE inhibitor/ARB use, or aldosterone antagonist use.
- 22% vs. 21%
- Renal failure
- 6.4% vs. 6.8% (P=0.66)
- 11.3% vs. 11.0% (P=0.77)
- 8.0% vs. 9.8% (P=0.05)
- Thirst: 16% vs. 2.1% (P<0.001)
- Dry mouth: 8.4% vs. 2.1% (P<0.001)
- High rate of discontinuation of the study drug
- Dose of therapy was not titrated
Otsuka, the maker of Samsca, the brand name of tolvaptan
- Yancy CW. "Climbing the mountain of acute decompensated heart failure." JAMA. 2007;297(12):1374-1376.
- Gheorghiade M, et al. "Short-term clinical effects of tolvaptan, an oral vasopressin antagonist, in patients hospitalized for heart failure." JAMA. 2007;297(12):1332-1343.
- Torres VE, et al. "Tolvaptan in patients with autosomal dominant polycystic kidney disease." N Eng J Med. 2012;367(25):2407-2418.
- FDA Safety Announcement. "FDA Drug Safety Communication: FDA limits duration and usage of Samsca (tolvaptan) due to possible liver injury leading to organ transplant or death." Released 2013-04-30. Accessed 2013-06-05.
- Yancy CW, et al. "2013 ACCF/AHA guideline for the management of heart failure." Circulation. 2013;128:e240-e327.