Diuretics, including
furosemide,
metolazone, and
spironolactone, have historically been the mainstay of
therapy for acute decompensated
heart failure patients. The addition of an aquaretic-like
vasopressin antagonist may enhance diuresis further. However, clinical experience with this quadruple combination is lacking in the acute setting. We present two hospitalized patients with acute decompensated
heart failure due to massive fluid overload treated with a combination strategy of triple
diuretics in conjunction with the aquaretic
tolvaptan. The first patient lost 72.1 lbs. (32.7 kg) with an average urine output of 3.5 to 7.5 L/day over eight days on combined
therapy with
furosemide,
metolazone,
spironolactone, and
tolvaptan. The second patient similarly achieved a
weight loss of 28.2 lbs. (12.8 kg) over 4 days on the same treatment. Both patients maintained stable serum
sodium,
potassium, and
creatinine over this period and remained out of the hospital for more than 30 days. Thus, patients hospitalized with acute decompensated
heart failure due to volume overload can achieve euvolemia rapidly and without
electrolytes disturbances using this regimen, while being under the close supervision of a team of cardiologists and nephrologists. Additionally, this
therapy can potentially decrease the need for ultrafiltration and the length of
hospital stay.