Predictors of Poor Very Early Diuretic Response and Effectiveness of Early Tolvaptan in Symptomatic Acute Heart Failure

Background Diuretic response (DR) in patients with symptomatic acute decompensated heart failure (ADHF) has an impact on prognosis. This study aimed to identify predictive factors influencing acute 6 h poor DR and to assess DR after early administration of tolvaptan (TLV). Methods This multicenter retrospective study included 1670 patients who were admitted for ADHF and received intravenous furosemide within 1 h of presentation in clinical scenario 1 or 2 defined based on initial systolic blood pressure ≥100 mmHg with severe symptoms (New York Heart Association class III or IV ( n = 830). The score for the poor DR factors in the very acute phase was calculated in patients treated with furosemide-only diuretics ( n = 439). The DR to TLV administration was also assessed in patients who received an additional dose of TLV within 6 h ( n = 391). Results The time since discharge from the hospital for a previous heart failure < 3 months (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.34–5.83; p = 0.006), loop diuretics at admission (OR 3.05, 95% CI 1.74–5.36; p < 0.0001), and estimated glomerular filtration rate (eGFR) < 45 mL/min/1.73 m 2 (OR 2.99, 95% CI 1.58–5.74; p = 0.0007) were independent determinants of poor DR. The frequency of poor DR according to the risk stratification group was low risk (no risk factor), 18.9%; middle risk (one risk factor), 33.1%; and high risk (two to three risk factors), 58.0% ( p < 0.0001). All risk groups demonstrated a significantly lower incidence of poor DR with early TLV administration: 10.7% in the early TLV group versus 18.9% in the loop diuretics group ( p = 0.09) of the low-risk group; 18.4% versus 33.1% ( p = 0.01) in the middle-risk group, and 20.2% versus 58.0% ( p < 0.0001) in the high-risk group. Conclusion Early administration of TLV in patients with predicted poor DR contributed to a significant diuretic effect and suppression of worsening renal function.