To the Editor,
We would like to thank Dr. Kahraman and Dr. Yılmaz for their interest in our recently published paper (1). We agree with your indication that a very elderly patient should use tolvaptan more carefully since acute decompensated heart failure (ADHF) is usually caused by multiple mechanisms. As mentioned by Dr. Kahraman and Dr. Yılmaz, it may be somewhat difficult to completely exclude the possibility that vasoconstriction caused by sympathetic hyperactivity is involved in the development of ADHF. However, it could be identified in patients with hypovolemia in a clinical scenario (2). In our study, 6% of the patients demonstrated clinical scenario 3. We think that in that case hypotension can be avoided by using tolvaptan at a low dose of 3.75 mg or 7.5 mg.
The timing of initiating tolvaptan is also important. We never use tolvaptan immediately after admission. We always use a low dose of furosemide before initiating tolvaptan. This way, we are able to identify the signs of unexpected hypotension. Of course, because our findings were derived from a small sample size, they should be interpreted with caution and continue to generate hypotheses. Due to characteristics such as physical and social frailty, elderly patients are more prone to drug side effects and organ dysfunctions resulting in long periods of hospitalization. Therefore, after correct diagnosis of the clinical scenario, the initiation of tolvaptan within 24 hours after furosemide use can improve quality of life after discharge without a reduction in physiological activity.
Finally, we again thank Dr. Kahraman and Dr. Yılmaz for adding variable comments to our paper.
References
- 1.Niikura H, Iijima R, Anzai H, Kogame N, Fukui R, Takenaka H, et al. The clinical utility of early use of tolvaptan in very elderly patients with acute decompensated heart failure. Anatol J Cardiol. 2017;18:206–12. doi: 10.14744/AnatolJCardiol.2017.7628. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Mebazaa A, Gheorghiade M, Piña IL, Harjola VP, Hollenberg SM, Follath F, et al. Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes. Crit Care Med. 2008;36(1 Suppl):S129–39. doi: 10.1097/01.CCM.0000296274.51933.4C. [DOI] [PubMed] [Google Scholar]