Please select the eligibility criteria that correspond to the clinical trial below.
Title: Primary Mode of Therapy in Acute Decompensated Heart Failure:Comparison Between Usual Care Plus Tolvaptan and Ultrafiltration.
Brief Summary: For patients hospitalized with acute decompensated heart failure,volume removal remains the primary therapeutic objective. The current standard of care remains loop diuretics.The high likelihood of readmissions and poor outcomes highlights the need to examine and improve in-hospital protocols for these patients. Ultrafiltration allows for greater volume removal, less neurohormonal stimulation and greater sodium removal.However it is associated with increased costs, line complications, and relative immobility during treatment. Tolvaptan in addition to diuretic therapy has been shown to improve the amount of volume removed compared to diuretic alone.

The study proposes to compare the strategy of adding tolvaptan to usual care with ultrafiltration as primary mode of therapy in acute decompensated HF(ADHF) patients.

Hypothesis: addition of tolvaptan to usual care for hospitalized HF patients will result in:

* greater volume and weight reduction compared with usual care
* similar efficacy outcomes compared with ultrafiltration, with less complications of therapy


Options:
A: Inclusion Criteria:

* Patients over 18 years;
* Patients with diagnosis of ADHF(dyspnea, orthopnea, peripheral edema or major fatigue and at least two clinical signs including rales, hepatomegaly, pulmonary congestion on chest radiography, jugular vein dilatation, or a third heart sound);
* Blood BNP \> 100 pg/mL;

ADHF: Acute Decompensated Heart Failure; BNP: B-type Natriuretic Peptide; IV: IntraVenous; LVEF: Left Ventricular Ejection Fraction.

Exclusion Criteria:

* Patients who receive more than 40 mg of IV furosemide;
* End-Stage renal disease or renal replacement therapy;
* Recent myocardial infarction (within thirty days of screening);
* Systolic blood pressure \< 80 mmHg;
* Creatinine levels \> 4 mg/dL;
* Patients affected by sepsis, liver diseases, inflammatory diseases or neoplastic diseases.
B: Inclusion criteria:

* Hospitalized for episode of worsening heart failure as primary cause of admission or significant heart failure symptoms that develop during the hospitalization when the initial reason for admission was not heart failure.
* Systolic dysfunction (LVEF \< 40%) or heart failure symptoms in the setting of preserved systolic function (diastolic dysfunction).

Exclusion criteria:

* This study has no exclusion criteria.
C: Inclusion Criteria:

* Patients hospitalized with primary diagnosis of acute decompensated congestive heart failure (adCHF)
* Evidence of fluid overload as indicated by:

  1. pitting edema (2+) of lower extremities;
  2. jugular venous distension;
  3. pulmonary edema or pleural effusion;
  4. ascites;
  5. paroxysmal nocturnal dyspnea or 2-pillow orthopnea

Exclusion Criteria:

* Acute coronary syndrome
* Creatinine greater than 3.0
* Systolic blood pressure less than or equal to 90 mmHg
* Hematocrit greater than 45%
* Prior administration of IV vasoactive drugs in the emergency room (ER)
* Clinical instability requiring pressors during hospitalization
* Recent use of iodinated contrast material
* Severe concomitant disease expected to prolong hospitalization
* Sepsis
* On or requires renal dialysis
* Had a cardiac transplant
* Heparin allergy
D: Inclusion Criteria:

* 2 of 3 physical exam findings of volume overload (rales, JVP over 5 cm and edema)
* BNP over 300
* no contraindication to ultrafiltration (line insertion, heparin use)

Exclusion Criteria:

* serum creatinine \> 3mg/dL or Na \> 145
* inotrope or vasopressor dependency
* active infection, including urinary tract
* resynchronization therapy or coronary intervention in past 30 days
* life expectancy less than 6 months
* hypertrophic obstructive cardiomyopathy with peak resting gradient \> 20 mmHg
* IV contrast or NSAID use in the past 1 week (uNGAL related requirement)

Answer: D