High-dose Aldosterone Antagonist for Acute Decompensated Heart Failure

Step-by-Step Methods:

Pre-screening: Patients meeting the inclusion and exclusion criteria will be approached to
participate in the study. Informed consent will be taken at this time. These patients will
receive intravenous loop diuretic per the discretion of treating physician and will be
closely followed for weight loss and symptoms relief.

Screening: The patients who don't respond as measured by symptoms relief or <0.5 kg weight
loss/day

1. Despite furosemide ≥ 160 mg IV total daily dose or equivalent dose of torsemide or
bumetanide. (1 mg bumetanide = 10 mg torsemide = 20 mg furosemide). OR

2. After 48 hours irrespective of diuretic dose.

will be considered for the study intervention. Patients who have not participated in the
pre-screening phase and do not respond adequately to furosemide >160 mg iv daily dose will
directly be enrolled into active intervention part of the study.

Intervention (High-Dose Spironolactone + Patiromer): Patients will be initiated on
spironolactone 100 mg orally once daily along with patiromer 8.4 gm orally (if serum K >4.3
meq/L). The dose of loop diuretic will stay same during rest of the study period. On day 2,
the dose of spironolactone will be titrated to 200 mg orally once a day depending on the
diuretic response and lab results. Serum potassium will be monitored twice a day. The dose of
patiromer will be increased to 16.8 gm in patients with potassium levels exceeding 5.5 meq/L;
or it will be held for serum K <4.3 mEq/L. Treatment will continue till patients achieve
euvolemia or get discharged. Euvolemia is defined as resolution of symptoms and signs of
volume overload.

Patients will be followed till achievement of euvolemia or discharge. Daily assessment will
be done for symptoms, and signs of volume overload including shortness of breath, orthopnea,
paroxysmal nocturnal dyspnea, abdominal bloating, lower extremity edema, JVD, and body weight
changes. Serum chemistry will be assessed twice a day and urine electrolytes once a day.
Neurohormonal analysis will be done at the pre-screening, initiation of active intervention
and at the end of the study duration.

Primary Safety Endpoints:

1. Incidence of hyperkalemia as defined by serum K >5.5 meq/day.

2. Renal function: assessed by daily serum creatinine

Primary Efficacy Endpoints:

1. Weight loss: using same calibrated scale every day in hospital gown.

2. Symptom relief: assessed using a 5-point Likert scale describing magnitude of shortness
of breath while the patient is in the supine position.

Inclusion Criteria:

1. More than18 years old

2. Hospitalized with history of chronic heart failure and at least one symptom (dyspnea,
orthopnea or edema) and one sign (rales, peripheral edema, ascites, or radiographic
pulmonary edema or pleural effusion)

3. Use of loop diuretics

4. Women of child bearing age with negative urine pregnancy test

Exclusion Criteria:

1. Acute coronary syndrome

2. Patients with a baseline eGFR < 30 ml/min by MDRD equation

3. Baseline potassium concentration ≥ 5.5 mEq/L

4. Requirement for intravenous vasodilators or inotropic agents

5. Systemic infection

6. Patients with concomitant end-stage liver disease

7. Hemodynamically significant uncorrected valvular disease

8. Patients with pulmonary embolism

9. Patients with high output heart failure

10. Pregnant patients