Pratama Vireza, Budiono Jordan, Thobari Jarir At, Widyantoro Bambang, Anggraeni Vita Yanti, Dinarti Lucia Kris
Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
Department of Cardiology, Gatot Soebroto Central Army Hospital (RSPAD), Jakarta, Indonesia.
Front Cardiovasc Med. 2024 May 30;11:1367442. doi: 10.3389/fcvm.2024.1367442. eCollection 2024.
Several conflicting reviews have concluded that the use of loop diuretics is associated with poorer clinical and safety outcomes. Therefore, this study aimed to investigate the efficacy and safety of tolvaptan as an adjunct to conventional diuretic therapy in patients with acute heart failure (AHF).
A comprehensive search was conducted on PubMed, Embase, ProQuest, EBSCO, and Cochrane Library until 24 May 2023 to identify randomized controlled trials that compared the effects of tolvaptan with conventional therapy and placebo in patients with AHF. The quality assessment of the included trials was conducted using the Cochrane risk of bias. A network meta-analysis (NMA) was conducted to examine the dosage effect of tolvaptan.
A total of 17 studies with 18 reports, involving 10,039 patients, were selected. The tolvaptan add-on therapy significantly alleviated dyspnea [24 h: RR 1.16 (1.04, 1.29), 48 h: RR 1.18 (1.04, 1.33)], reduced body weight within 48 h [Asian group, MD -0.93 (-1.48, -0.38); non-Asian group, MD -2.76 (-2.88, -2.65)], reduced edema [RR 1.08 (1.02, 1.15)], increased serum sodium [non-Asian group, MD 3.40 (3.02, 3.78)], and resulted in a change in serum creatinine [MD -0.10 (-0.18, -0.01)]. No significant differences were observed in mortality and rehospitalization. The NMA suggested that an intermediate dosage (15 mg/day) might offer the best efficacy in reducing dyspnea within 24 h, reducing edema, increasing serum sodium, and lowering the incidence of worsening renal function (WRF).
In conclusion, the meta-analysis showed that tolvaptan contributed to the short-term alleviation of congestive symptoms, elevated sodium levels, and a lower incidence of WRF. However, no significant benefits were observed in long-term symptoms, rehospitalization rates, and mortality. An intermediate dosage of tolvaptan might be considered the optimal choice for various clinical outcomes.
https://www.crd.york.ac.uk/, PROSPERO (CRD42023420288).
几项相互矛盾的综述得出结论，襻利尿剂的使用与较差的临床和安全性结果相关。因此，本研究旨在探讨托伐普坦作为急性心力衰竭（AHF）患者传统利尿治疗辅助药物的疗效和安全性。
在PubMed、Embase、ProQuest、EBSCO和Cochrane图书馆进行全面检索，直至2023年5月24日，以确定比较托伐普坦与传统治疗及安慰剂对AHF患者疗效的随机对照试验。采用Cochrane偏倚风险对纳入试验进行质量评估。进行网络荟萃分析（NMA）以研究托伐普坦的剂量效应。
共纳入17项研究的18篇报告，涉及10039例患者。托伐普坦联合治疗显著缓解呼吸困难[24小时：RR 1.16（1.04，1.29），48小时：RR 1.18（1.04，1.33）]，48小时内减轻体重[亚洲组，MD -0.93（-1.48，-0.38）；非亚洲组，MD -2.76（-2.88，-2.65）]，减轻水肿[RR 1.08（1.02，1.15）]，提高血清钠水平[非亚洲组，MD 3.40（3.02，3.78）]，并导致血清肌酐变化[MD -0.10（-0.18，-0.01）]。在死亡率和再住院率方面未观察到显著差异。NMA表明，中等剂量（15毫克/天）在减轻24小时内呼吸困难、减轻水肿、提高血清钠水平和降低肾功能恶化（WRF）发生率方面可能具有最佳疗效。
总之，荟萃分析表明，托伐普坦有助于短期缓解充血症状、提高钠水平并降低WRF发生率。然而，在长期症状、再住院率和死亡率方面未观察到显著益处。托伐普坦的中等剂量可能被认为是各种临床结局的最佳选择。
