Hypertonic saline (HS) appears to be safe and well tolerated as an adjuvant to loop diuretics in refractory acute decompensated heart failure (ADHF), according to a retrospective study. Although this approach has shown some promise previously, until now there have been no real-world evaluations at large US centers, Dr. Jeffrey M. Testani of Yale School of Medicine, in New Haven, Connecticut, and colleagues note in JACC: Heart Failure. The researchers identified a total of 58 episodes where HS was administered at a single hospital in 40 patients with diuretic-refractory ADHF. Serum sodium, chloride and creatinine concentrations were worsening in these patients, but improved significantly after HS administration. This was also the case for total urine output and weight loss. Diuretic efficiency, defined as change in urine output per doubling of diuretic dose, also improved and, the researchers write, "There was no discernible deterioration in respiratory status, overcorrection of hyponatremia, or progressive salt and water retention after the administration." "The most compelling observation in this series of extremely sick patients," they add, "was that signals for adverse effects of HS on oxygenation or electrolyte balance were not detected. More importantly, there was no change in the trend of oxygen use after the administration of HS." However, the researchers also point out that dosages of diuretic agents and treatment duration were "at the discretion of the treating physician, making conclusions regarding dose-dependent effects and diuretic responsiveness difficult to determine." Also, given that this was a retrospective study without randomization, "causality should not be assumed, and these observations should be considered hypothesis-generating only." "These findings suggest additional rigorous study of HS as a therapeutic agent for ADHF is warranted," the team writes. In an accompanying editorial, Dr. Maria Rosa Costanzo of Advocate Heart Institute, in Naperville, Illinois, agrees that the study "should renew interest in further exploration." However, she goes on to say that "the available data are insufficient to generate a well-designed, prospective randomized trial. The number of 'unknowns' is staggering." In fact, Dr. Costanzo told Reuters Health by email, "We are a long way from knowing whether HS is an effective approach for diuretic-resistant heart failure patients. A great deal of research in the appropriate populations is needed to adequately answer the question." Dr. Testani did not respond to requests for comments. —David Douglas Source
