Efficacy and safety of our unique clinical pathway for acute care that specifies early introduction of tolvaptan in elderly patients with congestive heart failure: a 10-year study

Background For 10 years since August 2015, we have been using a unique clinical pathway (PATH), with some modifications, to shorten hospital stays through efficient acute care for patients with congestive heart failure (CHF). This pathway prescribes the administration of the potent diuretic tolvaptan immediately after admission. Early diuretic treatment results in early improvement of heart failure symptoms, enabling early mobilization and simplifying various medical procedures, such as oxygen inhalation, continuous intravenous infusion, and urinary catheterization. Early mobilization is particularly important for elderly patients, who are thought to have a high prevalence of frailty. However, in elderly patients with CHF, caution is required regarding the use of tolvaptan, a potent diuretic, as it may cause dehydration, resulting kidney damage, and its specific side effect, hypernatremia. Objective In this study, we investigated the usefulness and safety of PATH in elderly patients with CHF over a 10-year period. Methods This study included 792 patients (1,288 admissions) aged 70 years or older who were admitted to our hospital for CHF between April 2014 and July 2025 and discharged home alive. They were divided into two groups: those before and those after the introduction of the pathway (N group (until July 2015): 101 patients, 164 admissions); and those after the introduction of the pathway (P group (from August 2015): 691 patients, 1,124 admissions). Patient background and clinical data at the time of admission were compared for both groups based on data from the first admission during the period. Various medical conditions in the acute phase after admission, clinical course, and incidence of adverse events related to tolvaptan were compared between all admissions in both groups, and differences were examined. Results Regarding patient characteristics at the time of admission, the mean age was higher and the proportion of patients with HFpEF was higher in P group(Figure 1). Treatment procedures for acute CHF were significantly simplified overall in P group . Furthermore, in P group, significantly fewer patients experienced a decline in activity level at discharge compared to admission, and the mean length of hospital stay was also significantly shorter. The proportions of patients who unplannedly discontinued tolvaptan use due to renal impairment or hypernatremia were 1.1% and 2.0%, respectively (Figure 2). Conclusion Our original clinical pathway for acute care of congestive heart failure, which prescribes the use of tolvaptan immediately after admission with the aim of early mobilization through early diuresis, had been in place for 10 years, and its usefulness in clinical progression had been confirmed even in elderly patients. The safety of the active use of tolvaptan in these patients was also acceptable, but as rare events can occur, careful attention should be paid to acute clinical data.