What is the role of hypertonic saline in treating patients with heart failure?

Role of Hypertonic Saline in Heart Failure Management

Hypertonic saline is not recommended as a standard treatment for heart failure due to insufficient high-quality evidence supporting its use, though it may have a beneficial role as an adjunctive therapy in specific cases of refractory heart failure with hyponatremia. 1

Hemodynamic Effects in Heart Failure

• Hypertonic saline has demonstrated beneficial effects on hemodynamics in cardiac surgery patients, with increases in cardiac output and blood pressure, and reduced systemic vascular resistance 1
• However, these studies primarily involved relatively healthy patients undergoing cardiac procedures rather than those with established heart failure or ventricular dysfunction 2
• It remains unclear whether cardiac output improvements from hypertonic saline result from preload effects or direct inotropic action 2

Potential Applications in Specific Heart Failure Scenarios

Refractory Heart Failure with Hyponatremia

• Combination of hypertonic saline and low-dose furosemide may enhance diuretic effect in patients with refractory heart failure complicated by hyponatremia 3
• This approach appears to offset counterproductive neurohormonal upregulation, transiently improve hemodynamics, and promote renal sodium excretion with accompanied net water loss 4
• Small studies suggest this combination therapy may:
  • Increase urination and reduce hospitalization time 5
  • Improve diuretic efficiency in diuretic-resistant patients 6
  • Potentially preserve renal function during aggressive diuresis 4

Limitations of Current Evidence

• The American College of Cardiology and American Heart Association guidelines do not specifically recommend hypertonic saline for heart failure management, highlighting a gap in formal recommendations 7, 8
• Evidence is limited by:
  • Heterogeneity among studies regarding concentration of hypertonic saline used (ranging from 1.7% to 30%) 1
  • Most studies being small with methodological limitations 8
  • Lack of standardized protocols for administration 1

Safety Considerations

• No evidence of osmotic demyelination syndrome has been reported in studies of hypertonic saline use for heart failure when properly monitored 1
• Safety in patients with impaired ventricular function remains to be fully established 2

Ongoing Research

• The SALT-HF trial is currently investigating the efficacy and safety of hypertonic saline therapy in ambulatory heart failure patients 9
• This multicenter, double-blinded, randomized study will help determine whether hypertonic saline plus furosemide increases diuresis and improves decongestion compared to furosemide alone 9

Clinical Approach

• For standard heart failure management, conventional approaches remain first-line:
  • Meticulous identification and control of fluid retention 7
  • Sodium restriction (to 2g daily or less) and fluid restriction (to 2 liters daily) 7
  • Standard diuretic therapy and neurohormonal blockade 4
• Consider hypertonic saline as an adjunctive therapy only in cases of:
  • Diuretic resistance with persistent congestion 6
  • Heart failure complicated by hyponatremia 3
  • When conventional approaches have failed 4