The ADVOR study, presented at the European Congress (ESC 2022), aimed to assess whether the use of acetazolamide associated with standard therapy with intravenous loop diuretics would lead to greater success in improving congestion in patients with heart failure (HF).
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It was a multicenter, randomized, placebo-controlled, double-blind study that included patients with decompensated HF with at least one sign of volume overload (edema, pleural effusion, or ascites) confirmed by imaging (radiography or ultrasound of the chest and abdomen) with more than one month of use of loop diuretics and NT-proBNP > 1000pg/mL or BNP > 250pg/mL. Exclusion criteria were previous medication use, use of iSGLT2 (the medication was not routinely recommended at baseline), systolic blood pressure less than 90 mmHg, and GFR less than 20 ml/min.
Regarding congestion assessment, physicians were trained to calculate a congestion score, used to define treatment time and outcome assessment.
The primary end point was success in improving congestion at 3 days and the secondary end point was length of hospital stay and mortality or hospitalization for HF at 3 months of follow-up.
The mean age of patients was 78.5 years in the placebo group and 77.9 in the acetazolamide group, ejection fraction was 43% in both groups, glomerular filtration rate 38 in the placebo group and 40 in the acetazolamide and NT-proBNP group. of 6483 in the placebo group and 5600 in the acetazolamide. Compared to other HF studies, these patients were older and had higher NT-proBNP levels, representing a more severely ill patient group.
The 500mg intravenous dose associated with the standard loop diuretic showed a significant reduction in congestion in three days (46% more chance of reducing congestion, with p = 0.0009), with an improvement in 42.2% of the acetazolamide group and in 30.5% of the placebo group. This benefit occurred in all subgroups and the NNT was 8.5.
In addition, patients who used the medication had a shorter hospital stay and, at discharge, the success rate of improvement in congestion was 78.8% in the acetazolamide group and 62.5% in the placebo group, with an RR 1 .27, p = 0.0001 and NNT = 6. That is, a result that shows great benefit in improving congestion at discharge, which is related to a lower rate of readmissions for HF. Furthermore, this benefit was incremental, with benefit from the first day of use and increasing in this benefit over time.
This was the largest study that showed the benefit of the use of diuretics in improving congestion in patients with acutely decompensated HF and using a cheap, easy-to-use, safe and very effective medication.
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