Introduction Hyponatraemia is common in end stage heart failure (ESHF). It is associated with poorer outcomes and limits the use of increasing doses of loop diuretics to alleviate congestive symptoms. Inability to reduce symptoms from hospitalised patients with ESHF can be the difference between patients dying in hospital or being discharged into the community. Tolvaptan is a vasopressin antagonist with diuretic effect with minimal effect on sodium levels. We present our current clinical experience with tolvaptan in palliative care patients with ESHF, hyponatraemia and congestive symptoms.

Method Hyponatraemic patients with ESHF and intractable symptoms (either unresponsive to or conventionally unsuitable for further escalation of loop diuretic therapy) were considered for tolvaptan by their managing cardiologist. Seven patients were selected, 1 died on the day tolvaptan was started, notes were unavailable in 1 case.

Results We report on 5 patients – 4 had tolvaptan started in hospital. Demographics: 4 male, mean age 71.8 years, mean number of co-morbidities was 5.6. Mean duration of treatment was 9.6 days. There were no adverse events or side effects. Loop diuretic doses were continued unchanged in 4 and increased in 1. Sodium Creatinine Weight in mmol/l in μmol/l in kg Before tolvaptan mean (SD) 122(4) 108(57) 81.1 (13.6) After tolvaptan mean (SD) 128 (4) 103 (48) 77.6 (12.4) All hospitalised patients were subsequently discharged. One patient died 3 months after treatment. The total cost of tolvaptan was £4300.80. This appears marginal compared to the total cost of hospitalisation (cumulative in patient stay of 169 days).

Conclusion Tolvaptan is safe, well tolerated and reduces congestion without significantly worsening either hyponatraemia or (in our patients) renal function. It can aid discharge from hospital to facilitate patient's palliative care choices. Tolvaptan adds to strategies for symptom relief in ESHF by palliative care specialists and cardiologists alike.