Author + information
- Maria Rosa Costanzo, MD∗ (, )
- Gregg C. Fonarow, MD and
- Jose Nabut, MS
- ↵∗Advocate Heart Institute, Edward Heart Hospital 4th Floor, 801 South Washington Street, Naperville, Illinois 60566
The investigators of the AVOID-HF (Aquapheresis Versus Intravenous Diuretics and Hospitalizations for Heart Failure) trial are grateful to Drs. Marenzi and Kazory for the opportunity to clarify some important aspects of the AVOID-HF trial’s primary results paper (1).
Of the 106 patients assigned to the ultrafiltration (UF) arm, 55 subjects (52%) had central and 50 (47%) had peripheral venous access. The type of venous access was unknown in 1 patient. Forty-one central and 31 peripheral venous access patients experienced at least 1 adverse event (1). Therefore it is not possible to conclude that 1 type of venous access is safer than the other. However it should be noted that neither the initial nor the final sponsor of the trial provided consistent technical support to the study’s sites. The AVOID-HF investigators believe that stronger technical support, more rigorous site personnel training, and standardized venous access procedures would be very helpful in minimizing the adverse events associated with UF therapy.
We agree with Drs. Marenzi and Kazory that the table describing the study’s population baseline characteristics is unclear regarding the meaning of the 55% value of the patients receiving diuretic agents. All patients enrolled in the AVOID-HF trial were taking oral loop diuretic agents. Indeed therapy with daily oral loop diuretic agents constituted 1 of the inclusion criteria for the AVOID-HF trial (2). Fifty-five percent is the proportion of patients given ≥2 doses of intravenous diuretic agents before randomization to either adjustable UF or adjustable loop diuretic therapy.
As Drs. Marenzi and Kazory note, there was a discrepancy between weight loss, which was similar in the 2 treatment arms and net fluid loss, which was greater in the adjustable UF arm. Regardless of this discrepancy, the adjustable UF patients had a trend toward a longer time to first hospitalization for heart failure in 90 days and a significant reduction in 30-day heart failure and cardiovascular rehospitalizations. This reduction may be a marker of effective decongestion superior to either weight or net fluid loss. Indeed, more than 2 decades ago, Dr. Marenzi coauthored a study in which by design, patients randomized to intravenous furosemide or UF had similar fluid loss. The study found that, compared with patients given intravenous diuretic agents, those receiving UF had sustained weight loss, lower neurohormonal activation, and better functional capacity up to 90 days (3). Therefore, the results of the AVOID-HF trial are consistent with the notion that UF may provide more effective decongestion than intravenous loop diuretic agents do.
Please note: Drs. Costanzo and Fonarow have received compensation for their work for the AVOID-HF Trial Steering Committee. The institutions of all investigators have received a research grant initially from Gambro and subsequently from Baxter for the conduct of the AVOID-HF trial. Mr. Nabut is a former employee of Baxter Healthcare.
- American College of Cardiology Foundation