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No-reflow Phenomenon — EECC MCQ

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HardCoronary Artery DiseaseNo-reflow PhenomenonEECC

A patient with acute decompensated HFrEF remains markedly congested after an adequately escalated intravenous loop-diuretic regimen. Urine sodium remains low, eGFR is 38 mL/min/1.73 m², serum sodium is 127 mmol/L and bicarbonate is 38 mmol/L from chloride-depletion alkalosis. Blood pressure is maintained. Which adjunct best fits this biochemical phenotype?

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Correct answer: D — Add intravenous acetazolamide to loop diuresis with close biochemical monitoring

Acetazolamide blocks proximal sodium–bicarbonate reabsorption and, when added to loop diuresis, improves decongestion; chloride-depletion alkalosis makes that mechanism particularly useful. Metolazone is an effective alternative form of sequential blockade but can aggravate the existing hyponatraemia. Loop escalation alone has already failed, ultrafiltration is reserved for selected pharmacologically refractory cases, and renal-dose dopamine does not improve decongestion outcomes.

Reference: ADVOR trial: acetazolamide in acute decompensated heart failure with volume overload. https://pubmed.ncbi.nlm.nih.gov/36027559/