Tolvaptan in the very elderly with acute decompensated heart failure- a therapeutic option worthy of consideration

Acute decompensated heart failure (ADHF) is a common and potentially fatal event in the natural history of heart failure that is associated with a greater risk of mortality and rehospitalization compared with stable heart failure (1). Elderly patients represent an important fraction of patients with ADHF, and these patients are at higher risk for in-hospital mortality and require a longer hospital stay to stabilize the condition compared with younger patients (2). Acute congestion related to rapid fluid accumulation and increased venous pressure is a constant finding and a major target of acute therapy in patients with ADHF (3). Loop diuretics remain the mainstay decongestive therapy in patients with ADHF (4). However, the benefits of these agents are limited by diuretic resistance, neurohormonal activation, electrolyte disturbance, or worsening of renal function (WRF) (4). Randomized studies have shown that the oral vasopressin-2 receptor antagonist tolvaptan reduces congestion and relieves symptoms in patients with ADHF (5, 6). Tolvaptan promotes electrolyte-free water excretion (aquaresis) and is indicated in hypervolemic (or euvolemic) states associated with hyponatremia (7). The drug does not appear to adversely affect renal function or cause neurohormonal activation (8). The evidence on the use of tolvaptan in elderly patients with ADHF is limited (9, 10).