Metolazone As Early Add On Therapy For Acute Decompensated Heart Failure (MELT-HF)--A Single Center Pilot Study.

Heart failure is a major source of morbidity, mortality and growing public health cost. In
US, the number of congestive heart failure patients is more than 4 million with more than
550,000 new annually reported cases. The annual cost of heart failure management exceeds 35
billion dollars per year.The heart failure readmissions and average length of hospital stay
cost approximately $11,000 per patient.

Loop diuretics are used alone in the majority of cases to promote diuresis. An association of
increased creatinine and increased risk of renal dysfunction, the cardiorenal syndrome, in
the face of high dose loop diuretics has raised questions regarding the safety and toxicity
of high dose loop diuretics. While the dose of diuretics is ubiquitous, little data exists to
guide their use and many clinicians are uncertain as to when and how to initiate and limit
therapy.

Prospective randomized data on large number of decompensated heart failure patients receiving
metolazone in addition to standard therapy is scarce and needs further definitive evaluation
in terms of clinical outcomes and safety. In many cases, a "stepped approach" with oral loop
diuretics advancing to intravenous and finally combination high dose diuretics is employed.

Primary endpoint: Total urinary output and negative fluid balance in millilitres (ml) at 48
hours following first dose of intravenous diuretic.

Secondary endpoints:

1. Change in weight from admission to day 2.

2. Degree of improvement in dyspnea at 6,12, 24,36, and 48 hours assessed with Modified
Borg Scale (1-10)

3. All cause mortality at 30 days.

This is a single center study of at least 200 patients who are admitted to Aultman Hospital
with clinical decompensated congestive heart failure ( NYHA III-IV). It is a double blinded
randomized placebo- controlled pilot study of the addition of 5 mg of metolazone per day for
2 days compared to placebo in patients admitted with acute decompensated heart failure. We
will compare a strategy of early institution of metolazone with standard of care in patients
admitted with decompensated heart failure and volume overload. All patients will receive
standard heart failure therapy, including but not restricted to diuretics, digoxin,
angiotensin converting enzyme inhibitors or angiotensin II receptor blockers, beta blockers,
aldosterone antagonists, hydralazine, and/or nitrates, at the discretion of the treating
physician.

After informed consent is obtained, patients will be randomized 1:1 to the treatment arm or
placebo arm. Two additional doses of metolazone within 6 and 24 hours of administration of
standard intravenous diuretics will be given to the treatment arm. Patients and physicians
will be blinded to the administered drug (metolazone vs placebo).Drug will be distributed by
pharmacy when a patient is consented and enrolled in the trial. Specific
guidance/recommendations regarding diuretic therapy will be provided (documented in detail
below) but will be at the discretion of the treating physician. We will collect data on
demographics, co-morbidities, clinical presentations and outcomes with metolazone
administration with patient follow up at one week (+3) and 30 (±7) days post discharge.

Inclusion Criteria:

- Age 18 years or older

- Current hospitalization for chronic congestive heart failure with admission up to 48
hours prior to inclusion.

- Chronic heart failure will be defined as requiring treatment for a minimum of 30 days
prior to current admission, NYHA Class III or IV at the time of hospitalization, and
left ventricular ejection fraction less than 40% within one year or evidence of heart
failure with preserved ejection fraction and evidence of diastolic dysfunction on
echocardiogram.

- Admitted with clinical decompensated heart failure based on history, physical exam,
and parameters indicating extracellular volume expansion such as including JVP ≥ 8 cm
of water and 1+ or greater peripheral edema

- Is able to be dosed with study medication within six (6) hours of first dose of IV
diuretics

Exclusion Criteria:

- Baseline severe hypotension (Mean arterial pressure < 55 mm Hg)

- Creatinine clearance less than 20 ml/min or creatinine greater than 2.5 mg/dl.

- Serum sodium less than 128 meq/L.

- Serum Potassium < 3.0 meq/L.

- Known adverse reaction to metolazone

- Inability to take oral medications

- Severe Aortic Stenosis (AVA < 0.8cm2)

- History of Hypertrophic obstructive cardiomyopathy

- Metastatic Carcinoma per history

- Severe COPD, FEV < 1L

- Severe dyspnea requiring prolonged CPAP,BIPAP or intubation