Clinical question: Does acetazolamide enhance loop diuretic effect in patients with acute decompensated heart failure (ADHF) and how does this combination affect renal function?
Background: Nearly 50% of patients with heart failure also have chronic kidney disease (CKD) (eGFR <60 mL/min/1.73 m²). CKD is associated with an impaired response to diuretics, making it difficult to achieve decongestion in these patients. As many as 20% to 40% of patients with ADHF experience worsening renal function during treatment with loop diuretics. Few trials have evaluated diuretic strategies specifically for patients with impaired renal function. The ADVOR trial investigated whether adding intravenous acetazolamide to standardized intravenous loop diuretics can improve diuretic efficacy in patients with ADHF and volume overload.
Study design: This was a randomized, double-blinded, placebo-controlled trial of patients admitted for ADHF and on oral maintenance therapy with furosemide for at least one month
Setting: 30 acute care hospitals in Belgium
Synopsis: ADVOR is the largest randomized diuretic trial to date in patients with ADHF, investigating acetazolamide to improve decongestion on top of standardized loop diuretics. It found that an intravenous bolus of 500 mg of acetazolamide in combination with intravenous loop diuretic therapy significantly increased the rate of successful decongestion and reduced hospital stay, regardless of baseline renal function. Although there was a higher incidence of worsening renal function during treatment, this did not affect long-term renal function or clinical outcomes. The findings suggest that acetazolamide is particularly beneficial for patients with lower baseline renal function, enhancing natriuresis and diuresis. Overall, these insights could lead to more effective and nuanced approaches to the treatment of heart failure, particularly in patients with concurrent renal impairment.
Bottom line: Acetazolamide treatment is an effective strategy to enhance diuretic response and achieve better decongestion in heart failure management.
Citation: Meekers E, et al. Renal function and decongestion with acetazolamide in acute decompensated heart failure: the ADVOR trial. Eur Heart J. 2023;44(37):3672-82. doi: 10.1093/eurheartj/ehad557.
Dr. Feterik is an academic hospitalist in the section of hospital medicine at UPMC Presbyterian Hospital, an associate professor of medicine at the University of Pittsburgh School of Medicine, the medical director for enterprise interoperability, and the associate program director for UPMC Clinical Informatics Fellowship, all in Pittsburgh.