Frederik H. Verbrugge Profile picture
Nov 6, 2022 9 tweets 8 min read Read on X
Really proud moment for me today, presenting 1st time in a Featured Science session @AHAScience.

Deeper insight in #ADVOR trial with key contributions from @WilfriedMullens @PieterMartensMD @JeroenDauw @petra_nijst @EvelyneMeekers among many others. Proudly 🇧🇪!
Tweetorial below!
From #ADVOR population, we included 462 or 89% of patients with 2 correctly performed consecutive urine collections and urine sodium concentration (UNa) available.

Natriuresis:
- UNa [mmol/L] ~ diuretic efficiency
- Total natriuresis [mmol] ~ ECV & interstitial Na buffer removed
#Acetazolamide, after multivariate adjustment, was strongest predictor of #natriuresis in #ADVOR:
UNa + 16 mmol/L
Total natriuresis +115 mmol

👊 within 2 days !!!
👍 much stronger than effect on urine output itself

"#acetazolamide keeps the urine salted"
1. Already on 1st morning after randomization:
more natiuresis 🟰 better decongestion, effect increasing over time

2. Significant interaction between #natriuresis & #acetazolamide

3. Effect #acetazolamide no longer significant after correction for interaction
Conclusion is that the effect of #acetazolamide on decongestion was MEDIATED by an effect on #natriuresis. Good natriuresis translated in shorter length of hospital stay for index admission!

12.5 (UNa <50 mmol/L) to 8 days (UNa >100 mmol/L)
And good clinical outcome without death or #heartfailure readmission...
Very intriguingly, if one has a good natriuretic response to diuretics (UNa >80 mmol/L), it did not matter which diuretics one received.

However, 7 patients treated with #acetazolamide meant 1 more to achieve this target.
Key now is to identify what we need to do with those who have no good natriuretic response to #acetazolamide + #loopdiuretics:
❓Underdosed loop diuretics
❓Need a thiazide as well
❓Volume not the primary problem
For future #Heartfailure trials with #diuretics, remember: "The Key is in the Pee"
#decongestion = #desalinization

• • •

Missing some Tweet in this thread? You can try to force a refresh
 

Keep Current with Frederik H. Verbrugge

Frederik H. Verbrugge Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!

PDF

Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @FH_Verbrugge

Feb 28
Reviewing current evidence on #hyponatremia in #heartfailure together with our bright visiting fellow @GiulioMonde!

Tweetorial 👇

link.springer.com/article/10.100…
#hyponatremia in #heartfailure 🟰 mainly dilutional: ➡️Impaired water excretion & extracellular volume expansion!

However, we tend to underestimate the depletional component due to chronic potassium and magnesium losses
➡️Intracellular dehydration
➡️Intracellular sodium shift Image
Replenishing potassium & magnesium stores alone actually increases serum Na in depletional hyponatremia!
K & Mg go intracellular ➡️Na goes back extracellular

Best K level probably ~4.5 mmol/L
3.5-4.0 mmol/L: K deficit ~ 200 mmol (!), so be aggressive!

pubmed.ncbi.nlm.nih.gov/28866674/
Image
Read 14 tweets
May 18, 2023
Read our latest analysis from the #ADVOR trial @JACCJournals. Deeper dive into the relationship of #natriuresis with decongestion & clinical outcomes after diuretic therapy in acute #heartfailure! Tweetorial below...

authors.elsevier.com/a/1h4wr2d9GHwT…

@PieterMartensMD @WilfriedMullens
First, look at detailed #ADVOR protocol below:
onlinelibrary.wiley.com/doi/full/10.10…

We did 2 consecutive urine collections:
1. Randomization => First morning (<24 h)
2. First morning => Second morning (=24 h)

If in those 2 collections, cumulative urine output <3.5 L ➡️ Failed decongestion! Image
Allocation to #acetazolamide clearly increased:
✅total urine output (+12.6%)
✅total natriuresis (+26.9%)

In relative terms: effect on natriuresis > urine output, UO🚫significant after 1st diuretic dose, natriuresis remained high!

*Normalized UO to 24 h for collection 1. Image
Read 20 tweets
Mar 16, 2023
Teaming up again with the great @VerwerftJan to share our experience with #echoCPET in #HFpEF. This hot-of-the-press paper @ESC_Journals demonstrates myriad of opportunities for diagnosis & treatment, far beyond #SGLT2i only. Tweetorial below!

@SarahStroobant2 @HerbotsLieven Image
We have recently described our set-up for a dedicated #dyspnoeaclinic in detail @JACCJournals



In #HFpEF, early & correct diagnosis are important, #phenotyping is everything. There are a lot of mechanisms for dyspnoea involved Image
Current @ESC_Journals paper goes one step further: "In patients with confirmed HFpEF or probability >90% according to well-validated HFpEF scores (both are complimentary in our view), why #echoCPET within a dedicated #dyspnoea clinic? What is the impact of findings?" Image
Read 9 tweets
Oct 9, 2022
What is your take on #vasodilators in acute #HeartFailure? The upcoming November issue of #EHJACVC will bring you a PRO/CON "Vasodilator therapy in acute heart failure revisited"

As our PRO paper was published in advanced access, a sneak preview Tweetorial below...

@EHJACVCEiC
First some background...
Current @escardio guidelines state (IIb, B): "In patients with AHF and a systolic blood pressure (SBP) >110 mmHg, intravenous vasodilators may be considered as an initial therapy to improve symptoms and reduce congestion."
Only 1 flowchart has them in...
So far, I consider this a fair recommendation... In hyper/normotensive pulmonary oedema, they might be helpful in some cases, with their main benefit a reduced need for (non-)invasive ventilation!

Beautiful (older) trial by Gad Cotter on this: thelancet.com/journals/lance…
Read 14 tweets
Sep 7, 2022
Don't miss our monthly educational review #EHJACVC @ESC_Journals!

This month by the great @ArgaizR: fluids in #AKI
Co-starring: @ThinkingCC @khaycock2

Extremely proud that our journal offers a platform to 3 great clinicians & Twitter educators. I always learn from them... Image
A strong argument is made to switch mainstream thinking in #AKI away from the fallacious concept of fluid responsiveness in all to a primary assessment of fluid tolerance.

Probably the most important thing I have learned on Twitter: #VExUS Image
Why do I like #VExUS so much? Because it really changed my everyday practice... Portal vein became part of my standard #echocardiography assessment.

And that's what we want to achieve with this review, offer something directly applicable at your bedside! Image
Read 5 tweets
Aug 27, 2022
For those who can't get enough from #ADVOR, below the promised Tweetorial!

Acetazolamide in acute #HeartFailure w volume overload on background high-dose loop diuretics:
👍Increases diuresis & natriuresis
👍More euvolemia after 3 days & discharge
👍⬇️LOS
#ESCCongress #Cardiology
First, the unsung hero's of this trial, done with a little bit over 2 million €, bargain for largest diuretic #RCT ever!
@KatrienTartagl2 & her team, with only 3FTE, they ran the most successful trial in #AHF
@PieterMartensMD & @JeroenDauw who did most fieldwork
👏
How did we come up with the idea? Actually, cause we all love #physiology. Credits go to Prof. Em. Paul Steels who teached us all how kidneys work.
@GLW_UHasselt

65% of sodium is reabsorbed in the proximal tubules, can be up to 85% in #HeartFailure
Read 12 tweets

Did Thread Reader help you today?

Support us! We are indie developers!


This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Don't want to be a Premium member but still want to support us?

Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal

Or Donate anonymously using crypto!

Ethereum

0xfe58350B80634f60Fa6Dc149a72b4DFbc17D341E copy

Bitcoin

3ATGMxNzCUFzxpMCHL5sWSt4DVtS8UqXpi copy

Thank you for your support!

Follow Us!

:(