Use of hypertonic saline to treat uncompensated heart failure Fernando G Z et al. CLINICS 2011;66(4):717-718 Figure 1 high-dose diuretic therapy, with promising results.1 Most of the data available on the use of HTS are from chronic ambulatory patients, with only one report from an acute- care setting. Additionally, these data were generally from patients with cardiogenic shock resulting from right ventricular infarction.2 Another report also evaluated the use of hypertonic saline as an adjunct therapy in uncom- pensated heart failure patients and indicated that hyper- tonic saline had positive effects on renal function.3 In experimental models, hypertonic saline improved myocar- dial contractility,4 but its immediate impact on the hemo- dynamic profile during acute UHF has not been studied or reported to date. In the present case study, hypertonic saline was the only available non-invasive option for the treatment of the patient. Its use improved the patient’s blood pressure so that vasodilators could effectively be used. No side effects were observed after the infusion. To our knowledge, this is the first report of the use of HTS as the primary therapy in the management of UHF. HTS infusion also restored the patient’s normal breathing pattern. Periodic pattern breathing and CSR are both associated with UHF and low cardiac output states.5 In 718 ambulatory patients, CSR is associated with increased mortality, impeded exercise capacity and arrhythmias.5 The pathophysiology of CSR is complex and appears to involve circulation delay, increased chemoreceptor sensi- tivity and hyperventilation or hypocapnia.5 We hypothesize that HTS administration exerted a beneficial effect on the patient’s myocardial contractility and improved his cardiac output, which reduced his periodic breathing pattern and improved his blood pres- sure. Interestingly, this improvement occurred in under three minutes (figure 1). Unfortunately, due to the quick action of HTS, we were unable to measure cardiac output before and after infusion. However, the possibility that the hypertonic solution exerted a direct effect on breathing control mechanisms (especially on chemoreceptors) cannot be excluded. In conclusion, hypertonic saline was able to restore hemodynamic parameters and breathing patterns almost immediately after administration to a patient suffering from uncompensated heart failure. Therefore, hypertonic saline may be an attractive therapeutic option for the initial management of UHF. These data suggest that randomized controlled trials to evaluate the role of HTS early in the treatment of UHF are clearly warranted. REFERENCES 1. Licata G, Di Pasquale P, Parrinello G, Cardinale A, Scandurra A, Follone G, et al. Effects of high-dose furosemide and small-volume hypertonic saline solution infusion incomparison with a high dose of furosemide as bolus in refractory congestive heart failure: long-term effects. Am Heart J. 2003;145:459-66, doi: 10.1067/mhj.2003.166. 2. Ramires JA, Serrano Ju´ nior CV, Ce´sar LA, Velasco IT, Rocha e Silva Junior M, Pileggi F. Acute hemodynamic effects of hypertonic (7.5%) saline infusion in patients with cardiogenic shock due to right ventricular infarction. Circ Shock. 1992;37:220-5. 3. Issa VS, Bacal F, Mangini S, Carneiro RM, Azevedo CH, Chizzola PR, et al. Hypertonic saline solution for renal failure prevention in patients with decompensated heart failure. Arq Bras Cardiol. 2007;89:251-5, doi: 10.1590/S0066-782X2007001600007. 4. Kien ND, Reitan JA, White DA, Wu CH, Eisele JH. Cardiac contractility and blood flow distribution following resuscitation with 7.5% hypertonic saline in anesthetized dogs. Circ Shock. 1991;35:109-16. 5. Francis DP, Willson K, Davies LC, Coats AJ, Piepoli M. Quantitative General Theory for Periodic Breathing in Chronic Heart Failure and its Clinical Implications. Circulation. 2000;102:2214-21.