Hyponatremia in Heart Failure
– Patient Case Video
Jun Chiong, MD
Hyponatremia in Heart Failure
– Patient Case Video
John O’Connell, MD
Hyponatremia in Heart Failure
– Patient Case Video
Chris Champion, MD
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Hyponatremia in Heart Failure
Patients with hyponatremia and heart failure (HF) are at risk in the hospital
Pathogenic properties of patients with heart failure
-
Vasopressin secretion stimulated by5:
— Decrease in blood volume/pressure of approximately 8% to 10%5 -
Vasopressin increases passive water reabsorption in the kidney, causing water retention, which may result in4:
— Increased edema4
— Hypervolemic hyponatremia4
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SAMSCA: Increases Serum Sodium Levels
In the SALT trials on Day 4 SAMSCA increased serum sodium concentration by 3.5 mEq/L vs 0.5 mEq/L for placebo. On Day 30, SAMSCA increased serum sodium concentration by 6.6 mEq/L vs 2.4 mEq/L for placebo6
SAMSCA should be initiated and re-initiated in patients only in a hospital where serum sodium can be monitored closely.
Too rapid correction of serum sodium (e.g., >12 mEq/L/24 hours) can cause serious neurologic sequelae, including osmotic demyelination syndrome (ODS).
In the SALT trials, SAMSCA was effective in increasing average daily serum [Na+] AUC at Day 4 and Day 30 both in patients with euvolemic hyponatremia (SIADH) and in patients with hypervolemic hyponatremia (HF and cirrhosis). In two identical, 30‑day, randomized, double-blind, placebo-controlled, multicenter studies, 424 patients with euvolemic (SIADH) or hypervolemic (HF and cirrhosis) hyponatremia were treated for 30 days with tolvaptan or placebo, then followed for an additional 7 days after withdrawal. The primary endpoint for these studies was the average daily AUC for change in serum sodium from baseline to Day 4 (tolvaptan, 4.0 mEq/L vs placebo, 0.4 mEq/L) and baseline to Day 30 (tolvaptan, 6.2 mEq/L vs placebo, 1.8 mEq/L). In heart failure patients, the mean change from baseline to Day 4 was 3.5 mEq/L in the SAMSCA group (n=65) and 0.5 mEq/L in the placebo group (n=61) (estimated treatment effect: 2.98, 95% Cl: 2.12-3.85, P<0.0001). The mean change from baseline to Day 30 was 6.6 mEq/L and 2.4 mEq/L, respectively (estimated treatment effect: 4.05, 95% Cl: 2.75-5.35, P<0.0001). Patients received either tolvaptan or placebo, at a starting dose of 15 mg. The dosage of tolvaptan or placebo was increased to 30 mg or 60 mg, if necessary.
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SAMSCA: Significant effect on fluid balance
With SAMSCA, urine output is greater than fluid intake. Thus there is a net negative fluid balance6
*Data on file. Protocols 156-02-235 and 156-03-238; pooled.
Only subjects whose time spans in both urine collection and fluid intake were no less than 22 hours and no more than 26 hours are included. P values were derived from ANOVA model. †Fluid balance is equal to total fluid intake (oral or IV) minus urine output.
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Clinical case by Jun Chiong, MD, Cardiologist
Insight on hyponatremia in heart failure
Patient presentation at hospitalization
73-year old male
- Hypervolemic hyponatremia in heart failure
- Congestion and edema
- No hypotension
- Fatigue, weakness, syncope
- Serum sodium 118 mEq/L
Results*
- Serum sodium improved
- Patient was discharged
*Individual results may vary.
Monitor serum potassium levels in patients with a serum potassium >5 mEq/L and in patients receiving drugs known to increase serum potassium levels.
Hyponatremia in Heart Failure
– Patient Case Video
Jun Chiong, MD
“[With SAMSCA,] I am able to improve serum sodium with free water clearance.... you can remove the water without adversely affecting the electrolytes.”
Dr. Chiong
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References:
- Gheorghiade M, Rossi JS, Cotts W, et al. Characterization and prognostic value of persistent hyponatremia in patients with severe heart failure in the ESCAPE Trial. Arch Intern Med. 2007;167(18):1998-2005.
- Douglas I. Hyponatremia: why it matters, how it presents, how we can manage it. Cleve Clin J Med. 2006;73(suppl 3):S4-S12.
- Goldsmith SR. Current treatments and novel pharmacologic treatments for hyponatremia in congestive heart failure. Am J Cardiol. 2005;95(suppl):14B-23B.
- Verbalis JG, Goldsmith SR, Greenberg A, Schrier RW, Sterns RH. Hyponatremia treatment guidelines 2007: expert panel recommendations. Am J Med. 2007;120(11, suppl 1):S1-S21.
- Ishikawa SE, Schrier RW. Pathophysiological roles of arginine vasopressin and aquaporin-2 in impaired water excretion. Clin Endocrinol (Oxf). 2003;58(1):1-17.
- Data on file: Protocols 156-02-235 and 156-03-238; pooled.
