Intravenous acetazolamide improved decongestion across all renal function ranges in ADHF, despite a higher incidence of transient worsening renal function (40.5% vs. 18.9%; P<0.001).
RCT (n=519)
Does intravenous acetazolamide improve decongestion and affect renal function in patients with acute decompensated heart failure across different baseline eGFR levels?
Acetazolamide improves decongestion in acute decompensated heart failure across all ranges of baseline renal function, and although it increases the risk of transient worsening renal function, this does not worsen clinical outcomes.
Absolute Event Rate: 40.5% vs 18.9%
p-value: p=< .001
BACKGROUND AND AIMS: In the ADVOR trial, acetazolamide improved decongestion in acute decompensated heart failure (ADHF). Whether the beneficial effects of acetazolamide are consistent across the entire range of renal function remains unclear. METHODS: This is a pre-specified analysis of the ADVOR trial that randomized 519 patients with ADHF to intravenous acetazolamide or matching placebo on top of intravenous loop diuretics. The main endpoints of decongestion, diuresis, natriuresis, and clinical outcomes are assessed according to baseline renal function. Changes in renal function are evaluated between treatment arms. RESULTS: On admission, median estimated glomerular filtration rate (eGFR) was 40 (30-52) mL/min/1.73 m². Acetazolamide consistently increased the likelihood of decongestion across the entire spectrum of eGFR (P-interaction = .977). Overall, natriuresis and diuresis were higher with acetazolamide, with a higher treatment effect for patients with low eGFR (both P-interaction < .007). Acetazolamide was associated with a higher incidence of worsening renal function (WRF; rise in creatinine ≥ 0.3 mg/dL) during the treatment period (40.5% vs. 18.9%; P < .001), but there was no difference in creatinine after 3 months (P = .565). This was not associated with a higher incidence of heart failure hospitalizations and mortality (P-interaction = .467). However, decongestion at discharge was associated with a lower incidence of adverse clinical outcomes irrespective of the onset of WRF (P-interaction = .805). CONCLUSIONS: Acetazolamide is associated with a higher rate of successful decongestion across the entire range of renal function with more pronounced effects regarding natriuresis and diuresis in patients with a lower eGFR. While WRF occurred more frequently with acetazolamide, this was not associated with adverse clinical outcomes. CLINICALTRIALS.GOV IDENTIFIER: NCT03505788.
“suggest the use of acetazolamide as a reasonable adjunct to achieving more rapid decongestion”
Meekers et al. (2023) conducted an RCT in acute decompensated heart failure (ADHF) (n=519). intravenous acetazolamide vs. matching placebo was evaluated on worsening renal function (WRF; rise in creatinine ≥ 0.3 mg/dL) during the treatment period (p=< .001). Intravenous acetazolamide improved decongestion across all renal function ranges in ADHF, despite a higher incidence of transient worsening renal function (40.5% vs. 18.9%; P<0.001).