Acetazolamide in Decompensated heart failure with Volume OveRload (ADVOR)

Presented at the ESC congress 2022 by: Prof. Wilfried Mullens, MD, PhD- Genk, Belgium

Introduction and methods

ADVOR was an academic, prospective, multicenter, randomized, double-blind, placebo-controlled trial that aimed to examine whether addition of acetazolamide to standardized iv loop diuretic therapy would improve incidence of successful decongestion in patients with acute decompensated HF.

ADVOR included patients with acute decompensated HF and volume overload, who were on a loop diuretic for at least one month and had a NT-proBNP > 1000 pg/ml. A total of 519 patients were randomized to acetazolamide (n=259) or placebo (n=260) for 3 days. All patients received standardized iv loop diuretic therapy.

The primary endpoint was successful decongestion defined as congestion score ≤1 within 3 days after randomization without an indication for escalation of decongestive therapy. Secondary endpoint were duration of index hospitalization and the composite of all-cause death and HF hospitalization within 3 months.

Main results

- Successful decongestion at 3 days was achieved in 42.2% of patients in the acetazolamide group compared to 30.5% in the placebo group. This translates to a 46% higher incidence of successful decongestion with acetazolamide, compared to placebo (RR 1.46, 95% CI 1.17-1.82, P = 0.0009, NNT = 8.5).

- The treatment effect of acetazolamide vs placebo increased over consecutive days.

- Patients in the acetazolamide group had a shorter stay in the hospital compared with those in the placebo group (average of 8.8 days vs. 9.9 days, P =0.02). There was no difference in the composite secondary outcome of all-cause death and HF hospitalization between treatment arms.

Conclusion

In patients with acute decompensated HF, addition of acetazolamide to standardized iv loop diuretic led to a 46% higher incidence of successful decongestion after 3 days.

Prof. Mullens said that the increasing treatment effect over consecutive days highlights the importance of treating congestion both early and aggressively. Mullens concluded “ADVOR supports utilization of acetazolamide as it is a cheap, off-patent, easy-to-use, safe and very effective drug to improve decongestion”.

-Our reporting is based on the information provided at the ESC Congress-

The findings of this trial were simultaneously published in N Eng J Med