Prognostic impact of the acute reactiveness to intravenous administration of tolvaptan sodium phosphate in patients with acute decompensated heart failure.

Aims: Intravenous tolvaptan sodium phosphate (IV-tolvaptan) is a novel aquaretic agent for acute decompensated heart failure (ADHF). This study evaluated its short-term effects and prognostic implications in clinical practice.

Methods And Results: In this retrospective cohort of 169 consecutive ADHF patients receiving IV-tolvaptan for the first time (mean age 76.0 ± 12.7 years; 50.9% female), we measured hourly urine output over 6 h and assessed clinical and biochemical parameters at baseline and 24 h post-dose. The primary endpoint was a composite of all-cause mortality and heart failure rehospitalization. At 24 h, IV-tolvaptan significantly reduced body weight (mean difference: -1.1 ± 2.3 kg, < 0.001), NT-proBNP (median change: -1704 pg/mL; < 0.001), and urinary osmolality (mean change: -71.4 ± 169.4 mOsm/kg; = 0.015), while raising serum sodium (mean change: 1.7 ± 2.9 mEq/L; < 0.001). Six-hour urine output correlated with baseline estimated glomerular filtration rate (eGFR) ( = 0.34; < 0.001), urinary osmolality ( = 0.28; = 0.003), and the change in serum sodium ( = 0.21; = 0.005). In multivariable logistic regression, renal impairment (eGFR < 60 mL/min/1.73m) [odds ratio (OR) 0.2; 95% confidence interval (CI) 0.1-0.4; < 0.001] and higher furosemide doses (>20 mg) (OR 0.3; 95% CI 0.2-0.6; = 0.01) predicted reduced responsiveness, whereas first hospitalization (OR 2.2; 95% CI 1.1-4.5; = 0.04) and high urinary osmolality (OR 2.3; 95% CI 1.0-5.4; = 0.05) predicted favourable response. Kaplan-Meier analysis demonstrated a lower incidence of the primary endpoint in patients achieving ≥ 1000 mL urine output (log-rank = 0.032).

Conclusion: Intravenous tolvaptan sodium phosphate enhances decongestion and short-term outcomes in ADHF without worsening renal function. Early diuretic responsiveness is a robust prognostic marker.