Tolvaptan should be used very carefully in very elderly patients

We were very interested to read the article entitled ’The clinical utility of early use of tolvaptan in very elderly patients with acute decompensated heart failure’ by Niikura et al. (1) recently published in the Anatol J Cardiol 2017; 18: 206-12 and the editorial comment entitled 'Tolvaptan in the very elderly with acute decompensated heart failure- a therapeutic option worth of consideration' by Ndrepepa (2) in the same issue, which evaluated the safety and efficacy of tolvaptan, a selective vasopressin V2 receptor antagonist, in very elderly patients. Tolvaptan’s efficacy has been evaluated in various trials for the treatment of congestive heart failure (HF) (3). In these trials, while improving many signs and symptoms of HF, it did not reduce long-term mortality or HF-related morbidity. Because of its pure water excretion, without influencing renal function and electrolyte balance, it has been used for many years, especially in the treatment of hypervolemic HF patients. A singlecenter trial conducted by Sağ et al. (4) assessed the efficacy and safety of tolvaptan in hyponatremic and hypervolemic HF patients in Turkey, and found tolvaptan to be very effective. In all of these trials, hypervolemia is the main cause of congestion, especially in chronic HF. But in acute decompensated HF patients, vasoconstriction caused by sympathetic hyperactivity triggered by an underlying etiological factor, such as COPD exacerbation or infection, is also an important pathophysiologic mechanism, as well as volume overload.