INTENSIV-News
Effects of high-dose furosemide and small-volume hypertonic
saline solution infusion in comparison with a high dose of furosemide as
bolus in refractory congestive heart failure: long-term effects.
Licata G, Di Pasquale P, Parrinello G, et al. Am Heart J 2003; 145:459-66
Department of Internal Medicine, University of Palermo, Palermo, Italy.
BACKGROUND:
Diuretics have been accepted as first-line treatment in refractory
congestive heart failure (CHF), but a lack of response to them is a
frequent event. A randomized, single-blind study was performed to
evaluate the effects of the combination of high-dose furosemide and
small-volume hypertonic saline solution (HSS) infusion in the treatment
of refractory New York Heart Association (NYHA) class IV CHF and a
normosodic diet during follow-up. Materials and Methods One hundred
seven patients (39 women and 68 men, age range 65 - 90 years) with
refractory CHF (NYHA class IV) of different etiologies, who were
unresponsive to high oral doses of furosemide, angiotensin-converting
enzyme inhibitors, digitalis, and nitrates, were enrolled. Inclusion
criteria included an ejection fraction (EF) < 35%, serum creatinine
level < 2 mg/dL, blood urea nitrogen level < or =60 mg/dL, reduced
urinary volume, and low natriuresis. The patients were randomized in
2 groups (single-blind). Patients in group 1 (20 women and 33 men)
received an intravenous (IV) infusion of furosemide (500 - 1000 mg) plus
HSS (150 mL of 1,4% - 4,6% NACl) twice a day in 30 minutes. Patients in
group 2 (19 women and 35 men) received an IV bolus of furosemide (500 -
1000 mg) twice a day, without HSS, during a period lasting 6 to 12
days. Both groups received IV KCl (20 - 40 mEq) to prevent hypokalemia. At
study entry, all patients underwent a physical examination and
measurement of body weight (BW), blood pressure (BP), and heart rate
(HR), an evaluation of signs of CHF, and measurement of control levels
of serum Na, K, Cl, bicarbonate, albumin, uric acid, creatinine, urea,
and glycemia daily during hospitalization, and measurements of the daily
output of urine for Na, K, and Cl. A chest radiograph,
electrocardiogram, and echocardiogram were obtained at study entry,
during hospitalization, and at the time of discharge from the hospital.
During the treatment and after discharge, the daily dietary Na intake
was 120 mmol in group 1 versus 80 mmol in group 2, with a fluid intake
of 1000 mL daily in both groups. An assessment of BW and 24-hour urinary
volume, serum, and urinary laboratory parameters were performed daily
until patients reached a compensated state, when IV furosemide was
replaced with oral administration (250 -500 mg/d). After discharge from
the hospital, patients were observed as outpatients weekly for the first 3 months and, subsequently, once a month.
RESULTS:
The groups were similar in age, sex, EF, risk factors, treatment, and
etiology of CHF. All patients showed a clinical improvement. Ten
patients in both groups had hyponatremia at entry. A significant
increase in daily diuresis and natriuresis was observed in both groups,
but it was more significant in the group receiving HSS (P <.05). The
serum Na level increased in group 1 and decreased in group 2 (P
<.05). The serum K level was decreased in both groups (P <.05). BW
was reduced in both groups (P <.05). Group 2 had an increase in
serum creatinine level. Serum uric acid levels increased in both groups.
BP values decreased and HR was corrected to normal values in both
groups. In the follow-up period (31 +/- 14 months), 25 patients from
group 1 were readmitted to the hospital for heart failure. In group 2,
43 patients were readmitted to the hospital at a higher class than at
discharge. Twenty-four patients in group 1 died during follow-up, versus
47 patients in group 2 (P <.001).
CONCLUSIONS: This treatment is
effective and well tolerated, improves the quality of life through the
relief of signs and symptoms of congestion, and may delay more
aggressive treatments. The effects were also beneficial in a long period
for mortality reduction (55% vs 13% survival rate) and for clinical
improvement.
In jedem Lehrbuch, jeder Therapierichtlinie steht, dass bei Patienten
mit kardialer Insuffizienz eine Beschränkung der Natrium-Zufuhr
vorgenommen werden muss. Dies ist also "Allgemeinwissen", ein seit
vielen Jahrzehnten bestehendes Dogma. Pathophysiologische Basis dieser
Empfehlung ist die bestens belegte Tatsache, dass durch die
neurohumoralen Veränderungen des Herzversagens, durch die Änderung der
renalen Hämodynamik (massive Vasokonstriktion schon in Frühstadien) eine
Natrium- und Wasserretention verursacht wird, durch die eine Erhöhung
des Natrium-Pools und eine Expansion des extrazellulären Volumens
bewirkt werden. Da die Wasserretention nicht zuletzt auch wegen einer
erhöhten ADH-Ausschüttung überproportional zur Natriumretention
ausgeprägt ist, kommt es mit fortschreitendem Herzversagen zur
Ausbildung von Ödemen und einer progredienten Hyponatriämie. Daher die
logische Folgerung, dass in der Therapie die Wasser- und Natriumzufuhr
beschränkt werden muss.
Nun wird von Lacata und Mitarbeitern (wie schon in mindestens drei
Vorpublikationen) gezeigt, dass die Zufuhr von hypertonem Natrium
(immerhin im Schnitt 300 ml 3% NaCl pro Tag) gemeinsam mit (eher hohen
Dosen von) Furosemid (500 bis 1000 mg) bei Patienten mit Herzversagen
(NYHA IV) und Diuretikaresistenz, zu einer eindrucksvollen klinischen
Besserung, Steigerung der Harnausscheidung und Nierenfunktion, aber auch
von "harten" Endpunkten, wie Hospitalisierungsdauer und der
Überlebensrate führt. Auch bei ambulanten Patienten haben sie keine
wesentliche Natrium-Beschränkung (120 mmol/ Tag) vorgenommen.
Wir wollen Fachärzte und Pfleger topaktuell und wissenschaftlich fundiert über Studien, fachspezifische Entwicklungen und deren praktische Umsetzung informieren, um sie in ihrer Arbeit und Fortbildung zu unterstützen.
Wählen Sie dazu bitte Ihr Land aus.