Exploring spatial and temporal symptoms of the freshwater salinization syndrome in a rural to urban watershed.

The freshwater salinization syndrome (FSS), a concomitant watershed-scale increase in salinity, alkalinity, and major-cation and trace-metal concentrations, over recent decades, has been described for major rivers draining extensive urban areas, yet few studies have evaluated temporal and spatial FSS variations, or causal factors, at the subwatershed scale in mixed-use landscapes. This study examines the potential influence of land-use practices and wastewater treatment plant (WWTP) effluent on the export of major ions and trace metals from the mixed-use East Branch Brandywine Creek watershed in southeastern Pennsylvania, during the 2019 water year. Separate analysis of baseflow and stormflow subsets revealed similar correlations among land-use characteristics and streamwater chemistry. Positive associations between percent impervious surface cover, which ranged from 1.26 % to 21.9 % for the 13 sites sampled, and concentrations of Ca2+, Mg2+, Na+, and Cl- are consistent with road-salt driven reverse cation exchange and weathering of the built environment. The relative volume of upstream WWTP was correlated with Cu and Zn, which may be derived in part from corroded water-conveyance infrastructure; chloride to sulfate mass ratios (CSMR) ranged from ~6.3 to ~7.7× the 0.5 threshold indicating serious corrosivity potential. Observed exceedances of U.S. Environmental Protection Agency Na+ and Cl- drinking water and aquatic life criteria occurred in winter months. Finally, correlations between percent cultivated cropland and As and Pb concentrations may be explained by the persistence of agricultural pesticides that had been used historically. Study results contribute to the understanding of FSS solute origin, fate, and transport in mixed-use watersheds, particularly those in road salt-affected regions. Study results also emphasize the complexity of trace-metal source attribution and explore the potential for FSS solutes to affect human health, aquatic life, and infrastructure.

Metal accumulation in salt marsh soils along the East Coast of the United States.

Coastal salt marshes are depositional environments that can accumulate pollutants introduced to the environment from human activities. Metals are a contaminant of concern in coastal environments due to their longevity and toxicity. We assessed metal concentrations and accumulation rates in nine salt marsh sites along the U.S. East Coast from Maine to Georgia. Following a metal mobility assay in organic-rich and mineral dominated salt marsh soils under aerobic/anaerobic and freshwater/saltwater conditions, we focused on profiles of chromium, nickel, copper, zinc, cadmium, lead, and uranium in two soil cores from each of the nine marshes that had previously been dated using lead-210 radioisotope techniques. We examined how land cover and the spatial distribution of land cover, marsh vertical accretion, and other watershed characteristics correlated with metal concentrations and depth/time-integrated accumulation of metals. We found statistically significant differences in metal concentrations and/or inventories between sites, with accumulation of metals positively correlated with both developed land cover in the watershed and rates of vertical accretion in the tidal marsh. The accumulation of chromium, cadmium, and lead were significantly correlated with developed land cover while the accumulation of chromium, nickel, copper, zinc, and lead were correlated with factors that determine sediment delivery from the landscape (e.g., riverine suspended sediment, soil erodibility in the watershed, and agricultural land cover skewed towards the coast) and measured wetland accretion rates. We observed declines in the concentration of many metals since 1925 at sites along the U.S. East Coast, indicating pollution mitigation strategies have succeeded in reducing metal pollution and delivery to the coastal zone. However, increasing rates of salt marsh vertical accretion over recent decades largely offset reductions in metal concentrations, resulting in rates of metal accumulation in coastal salt marsh soils that have not changed or, in some instances, increased over time.

A First-in-Human Study of AMG 986, a Novel Apelin Receptor Agonist, in Healthy Subjects and Heart Failure Patients.

PURPOSE: AMG 986 is a novel apelin receptor (APJ) agonist that improves cardiac contractility in animal models without adversely impacting hemodynamics. This phase 1b study evaluated the safety/tolerability, pharmacokinetics, and pharmacodynamics of AMG 986 in healthy subjects and patients with heart failure (HF). METHODS: Healthy adults (Parts A/B) and HF patients (Part C) aged 18-85 years were randomized 3:1 to single-dose oral/IV AMG 986 or placebo (Part A); multiple-dose oral/IV AMG 986 or placebo (Part B); or escalating-dose oral AMG 986 or placebo (Part C). PRIMARY ENDPOINT: treatment-emergent adverse events, laboratory values/vital signs/ECGs; others included AMG 986 pharmacokinetics, left ventricular (LV) function. RESULTS: Overall, 182 subjects were randomized (AMG 986/healthy: n = 116, placebo, n = 38; AMG 986/HF: n = 20, placebo, n = 8). AMG 986 had acceptable safety profile; no clinically significant dose-related impact on safety parameters up to 650 mg/day was observed. AMG 986 exposures increased nonlinearly with increasing doses; minimal accumulation was observed. In HF with reduced ejection fraction patients, there were numerical increases in percent changes from baseline in LV ejection fraction and stroke volume by volumetric assessment with AMG 986 vs placebo (stroke volume increase not recapitulated by Doppler). CONCLUSIONS: In healthy subjects and HF patients, short-term AMG 986 treatment was well tolerated. Consistent with this observation, clinically meaningful pharmacodynamic effects in HF patients were not observed. Changes in ejection fraction and stroke volume in HF patients suggest additional studies may be needed to better define the clinical utility and optimal dosing for this molecule. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT03276728. DATE OF REGISTRATION: September 8, 2017.

Long-term impacts of impervious surface cover change and roadway deicing agent application on chloride concentrations in exurban and suburban watersheds.

Roadway deicing agents, including rock salt and brine containing NaCl, have had a profound impact on the water quality and aquatic health of rivers and streams in urbanized areas with temperate climates. Yet, few studies evaluate impacts to watersheds characterized by relatively low impervious surface cover (ISC; < 15 %). Here, we use long-term (1997-2019), monthly streamwater quality data combined with daily streamflow for six exurban and suburban watersheds in southeastern Pennsylvania to examine the relations among chloride (Cl-) concentrations and ISC. Both flow-normalized Cl- concentrations and ISC increased over time in each of the six watersheds, consistent with changes in watershed management (e.g., ISC, road salt application, etc.). The watersheds that experienced the greatest changes in percent ISC (e.g., agriculture replaced by residential and commercial development) experienced the greatest changes in flow-normalized Cl- concentrations. We also utilized a comprehensive mass-balance model (2011-2018) that indicated Cl- inputs exceeded the outputs for the study watersheds. Road salt applied to state roads, non-state roads, and other impervious surfaces accounted for the majority of Cl- inputs to the six watersheds. Furthermore, increasing Cl- concentrations during baseflow conditions confirm impacts to shallow groundwater. Although flow-normalized Cl- concentrations are below the U.S. Environmental Protection Agency's chronic threshold value for impacts to aquatic organisms, year-round exceedances may result before the end of this century based on current trends. Though reduced Cl- loading to streams may be achieved by limiting the expansion of impervious surfaces in exurban and suburban watersheds, changes in baseflow concentrations are likely to be gradual because of the accumulated Cl- in groundwater.

Bioaccumulation of trace metals in two oyster species from southwest Puerto Rico.

As coastal ecosystems are impacted by land use change and anthropogenic activities, oysters can be an important tool for monitoring local water quality. We collected oysters (Crassostrea rhizophorae and Isognomon alatus) from coastal sites near Guánica and La Parguera in southwest Puerto Rico and analyzed their tissue for concentrations of Ag, As, Cd, Co, Cr, Cu, Ni, Pb, V, and Zn. All trace metals were found in both species, with high bioaccumulation factors for Ag, Cd, and Zn in both species and Cr in C. rhizophorae. Some trace metals are likely associated with anthropogenic sources, including paints and vehicles (Cu and Zn), oil (Ni and V), and wood preservatives (As). Cr in oysters near Guánica is most likely associated with sediment from erosion in the watershed. Both species could be used to monitor changes in trace metal concentrations and the influence of future watershed management strategies in the region.

Impacts of Road Deicing Application on Sodium and Chloride Concentrations in Philadelphia Region Drinking Water.

Historical application of roadway deicing agents (e.g., road salt and brines) has led to an increase in sodium and chloride concentrations in surface water over time. Numerous studies have explored the impacts of road salt on freshwater aquatic organisms such as amphibians and benthic macroinvertebrates; however, the public health risk associated with consuming drinking water with elevated sodium has been largely unexplored in the literature. Yet, sodium ingestion, primarily through diet, has been linked to adverse human health conditions, such as hypertension. This study documents weekly sodium and chloride concentrations in municipal tap water from three municipalities within the Philadelphia metropolitan area during winter 2018-2019 (November through March). A late winter peak in sodium and chloride concentrations was observed for all three municipalities immediately following successive snow events coupled with daily high temperatures above 0°C. Among municipalities, mean and peak sodium and chloride concentrations were associated with relatively higher development in upstream areas. Observed sodium concentrations ranged from 1 to 6.4x the USEPA recommended guideline of 20 mg/L for individuals restricted to a total sodium intake of 500 mg/day. Additionally, the contribution of sodium ingestion from water consumption to the recommended daily sodium intake limits for adults ranged from 3.5% to 18.8% for non-restricted and 4.2%-33.3% for "low salt" (i.e., <1,500 mg/day) diets, respectively. The study results coupled with a records review for 40 U.S. municipalities in snow affected regions indicate the need for real-time communication between water utilities and the general public regarding sodium exposure risk during winter months.

Vasopressin antagonism in heart failure: a review of the hemodynamic studies and major clinical trials.

For decades, plasma arginine vasopressin (AVP) levels have been known to be elevated in patients with congestive heart failure (HF). Excessive AVP signaling at either or both the V1a and V2 receptors could contribute to the pathophysiology of HF by several mechanisms. V1a activation could cause vasoconstriction and/or direct myocardial hypertrophy as intracellular signaling pathways are closely related to those for angiotensin II. V2 activation could cause fluid retention and hyponatremia. A hemodynamic study with the pure V2 antagonist tolvaptan (TV) showed minimal hemodynamic effects. Compared with furosemide in another study, the renal and neurohormonal effects of TV were favorable. Several clinical trials with TV as adjunctive therapy in acute HF have shown beneficial effects on fluid balance and dyspnea, with no worsening of renal function or neurohormonal stimulation. Two smaller studies, one in acute and one in chronic HF, have shown comparable clinical and more favorable renal and neurohormonal effects of TV compared with loop diuretics. However, long-term treatment with TV did not alter outcomes in acute HF. No data are available other than single-dose studies of an intravenous pure V1a antagonist, which showed a vasodilating effect if plasma AVP levels were elevated. One hemodynamic study and one short-duration clinical trial with the balanced intravenous V1a/V2 antagonist conivaptan (CV) showed hemodynamic and clinical effects largely similar to those with TV in similar studies. A new orally effective balanced V1/V2 antagonist (pecavaptan) is currently undergoing phase II study as both adjunctive and alternative therapy during and after hospitalization for acute HF. The purpose of this review is to summarize what we have learned from the clinical experience with TV and CV, and to suggest implications of these findings for future work with newer agents.

Dual Vasopressin Receptor Antagonism to Improve Congestion in Patients With Acute Heart Failure: Design of the AVANTI Trial.

BACKGROUND: Loop diuretics are the main treatment for patients with acute heart failure, but are associated with neurohormonal stimulation and worsening renal function and do not improve long-term outcomes. Antagonists to arginine vasopressin may provide an alternative strategy to avoid these effects. The AVANTI study will investigate the efficacy and safety of pecavaptan, a novel, balanced dual-acting V1a/V2 vasopressin antagonist, both as adjunctive therapy to loop diuretics after admission for acute heart failure, and later as monotherapy. METHODS AND RESULTS: AVANTI is a double-blind, randomized phase II study in 571 patients hospitalized with acute heart failure and signs of persistent congestion before discharge. In part A, patients will receive either pecavaptan 30 mg/d or placebo with standard of care for 30 days. In part B, eligible patients will continue treatment or receive pecavaptan or diuretics as monotherapy for another 30 days. The primary end points for part A are changes in body weight and serum creatinine; for part B, changes in body weight and blood urea nitrogen/creatinine ratio. CONCLUSIONS: This study will provide the first evidence that a balanced V1a/V2 antagonist may safely enhance decongestion, both as an adjunct to loop diuretics and as an alternative strategy. TRIAL REGISTRATION NUMBER: NCT03901729.

Physical controls and ENSO event influence on weathering in the Panama Canal Watershed.

Recent empirical studies have documented the importance of tropical mountainous rivers on global silicate weathering and suspended sediment transport. Such field studies are typically based on limited temporal data, leaving uncertainty in the strength of observed relationships with controlling parameters over the long term. A deficiency of long-term data also prevents determination of the impact that multi-year or decadal climate patterns, such as the El Niño Southern Oscillation (ENSO), might have on weathering fluxes. Here we analyze an 18-year hydrochemical dataset for eight sub-basins of the Panama Canal Watershed of high-temporal frequency collected between 1998 and 2015 to address these knowledge gaps. We identified a strongly positive covariance of both cation (Ca2+, Mg2+, K+, Na+) and suspended sediment yields with precipitation and extent of forest cover, whereas we observed negative relationships with temperature and mosaic landcover. We also confirmed a statistical relationship between seasonality, ENSO, and river discharge, with significantly higher values occurring during La Niña events. These findings emphasize the importance that long-term datasets have on identifying short-term influences on chemical and physical weathering rates, especially, in ENSO-influenced regions.

Congestion in heart failure: a contemporary look at physiology, diagnosis and treatment.

Congestion is the main reason for hospitalization in patients with acute decompensated heart failure and is an important target for therapy. However, achieving complete decongestion can be challenging. Furthermore, residual congestion before discharge from hospital is associated with a high risk of early rehospitalization and death. An improved understanding of the pathophysiology of congestion is of great importance in finding better and more personalized therapies. In this Review, we describe the two different forms of congestion - intravascular congestion and tissue congestion - and hypothesize that differentiating between and specifically treating these two different forms of congestion could improve the outcomes of patients with acute decompensated heart failure. Although the majority of these patients have a combination of both intravascular and tissue congestion, one phenotype can dominate. Each of these two forms of congestion has a different pathophysiology and requires a different diagnostic approach. We provide an overview of novel and established biomarkers, imaging modalities and mechanical techniques for identifying each type of congestion. Treatment with loop diuretics, the current cornerstone of decongestive treatment, reduces circulating blood volume and thereby reduces intravascular congestion. However, the osmolality of the circulating blood decreases with the use of loop diuretics, which might result in less immediate translocation of fluid from the tissues (lungs, abdomen and periphery) to the circulation when the plasma refill rate is exceeded. By contrast, aquaretic drugs (such as vasopressin antagonists) predominantly cause water excretion, which increases the osmolality of the circulating blood, potentially improving translocation of fluid from the tissues to the circulation and thereby relieving tissue congestion.

Targeting pulmonary capillary permeability to reduce lung congestion in heart failure: a randomized, controlled pilot trial.

AIMS: Lung congestion in patients with heart failure (HF) has traditionally been treated using interventions that reduce pulmonary capillary hydrostatic pressure. The transient receptor potential vanilloid 4 (TRPV4) channel regulates fluid transit across the pulmonary capillary-interface, and represents a novel target to reduce lung water, independent of pulmonary capillary hypertension. This pilot study examined the safety and potential efficacy of TRPV4 blockade as a novel treatment for HF. METHODS AND RESULTS: In this randomized, double-blind, placebo-controlled crossover pilot trial, 11 subjects with chronic, compensated HF were treated with a novel TRPV4 antagonist (GSK2798745) or placebo. The primary endpoint was lung diffusing capacity for carbon monoxide (DLCO ) after 7 days of treatment with GSK2798745 as compared to placebo. Secondary endpoints included additional diffusion parameters, spirometry and safety assessments. Compared to placebo, treatment with GSK2798745 resulted in a trend to improvement in DLCO (placebo: -0.336 mL/mmHg/min; GSK2798745: +0.458 mL/mmHg/min; treatment difference: +0.793 mL/mmHg/min; 95% confidence interval: -0.925 to 2.512) that was not statistically significant. GSK2798745 was well-tolerated with no serious adverse events. CONCLUSION: In this pilot trial, GSK2798745 was found to be safe and well-tolerated, with a trend toward improved gas transfer. Further investigation is warranted in larger studies to determine whether treatment with TRPV4 antagonists or alternative treatments targeting capillary permeability might be effective to improve lung congestion, pulmonary gas transfer and clinical status in patients with acute or chronic HF.

Triclosan export from low-volume sources in an urban to rural watershed.

Triclosan (TCS), an emerging contaminant linked to antimicrobial resistance, has been the focus of many surface water studies to date. However, these initial studies have predominantly used sampling locations downstream of large volume (i.e., >0.5 million gallons per day) wastewater treatment plants (WWTPs). This approach overlooks potential inputs from their low volume counterparts as well as non-point sources, such as sewage network leaks, biosolid application to agricultural fields and leach fields associated with septic systems. Here we examine the range of concentrations, overall loading, and potential controls on TCS delivery to the East Branch of the Brandywine Creek (EBBC), a rural to suburban watershed located in southeastern Pennsylvania. TCS measurements were collected from 13 locations in the EBBC during baseflow conditions and immediately following a storm event. A regulatory database review identified WWTP density an order of magnitude greater than the national average, thereby confirming their pervasiveness in rural to urban systems. Detectable concentrations of TCS in the EBBC ranged from 0.2 to 0.6 ng/L during baseflow conditions and 0.5 to over 1000 ng/L following a storm event. The lack of a statistical relationship between TCS concentrations and yields with the number of upstream WWTPs and/or volume of treated effluent during both sampling periods confirm the importance of individual WWTP practices and the volume of the receiving water body, while a positive statistically-significant relationship between TCS concentrations and upstream developed open space following the storm event was likely influenced by runoff of spray-applied treated wastewater and/or sewage network leaks. Furthermore, the presence of detectable concentrations of TCS in sub-watersheds with no WWTP systems implies field applied biosolids or treated wastewater, as well as septic tank related leach fields are all viable sources of TCS. These findings suggest we must greatly expand our consideration of sources for emerging contaminants in waterways.

Meta-Analysis Comparing Torsemide Versus Furosemide in Patients With Heart Failure.

Although torsemide's oral bioavailability and half-life theoretically render it a more efficient diuretic than furosemide, the clinical outcomes of torsemide compared with furosemide remain unclear. We performed a systematic review and meta-analysis, including all published studies that compared torsemide and furosemide use in heart failure patients from January 1996 through August 2019. Nineteen studies (9 randomized control trials [RCTs] and 10 observational studies) with a total of 19,280 patients were included. During a mean follow-up duration of 15 months, torsemide was associated with a numerically lower risk of hospitalization due to heart failure (10.6% vs 18.4%; odds ratio [OR] 0.72, 95% confidence interval [CI] [0.51, 1.03], p = 0.07, I2 = 18%; number needed to treat [NNT] = 23) compared with furosemide. Torsemide was associated with statistically significant more improvement in functional status from New York Heart Association (NYHA) class III/IV to I/II (72.5% vs 58%; OR 2.32, 95% CI (1.32, 4.1), p = 0.004, I2 = 27%; NNT = 5) and lower risk of cardiac mortality (1.5% vs 4.4%; OR 0.37, 95% CI (0.20, 0.66), p <0.001, I2 = 0%, NNT = 40) compared with furosemide. However, there was no difference in all-cause mortality or medication side effects between the 2 groups. In conclusion, compared with furosemide, torsemide use was associated with significant more improvement in functional status and lower cardiac mortality; and numerically fewer hospitalizations in patients with heart failure.

Arginine vasopressin antagonism in heart failure: Current status and possible new directions.

Modulating neurohormonal imbalance is the cornerstone of successful therapy in patients with chronic heart failure with reduced ejection fraction (HFrEF). Plasma arginine vasopressin (AVP) levels are elevated in HFrEF and may contribute to disease progression by excess signaling at either the V1a or V2 receptors. The effects of V1a receptor antagonism are almost completely unexplored, but V1a signaling is closely related to that for angiotensin II and blocking that receptor deserves further study. Interfering with V2 signaling causes free water diuresis and improves congestion without worsening renal function when added to loop diuretics but alone did not improve outcomes when carried into the post-acute phase in one large study. Outcomes in chronic HFrEF are quite good while outcomes in acute HF remain poor. Therefore, further study of V2 or combined V1/V2 blockade of the effects of AVP would most likely yield positive results in patients with acute HF, perhaps especially as alternative, not adjunctive therapy to loop diuretics.

Direct comparison of ultrafiltration to pharmacological decongestion in heart failure: a per-protocol analysis of CARRESS-HF.

AIMS: Mechanical ultrafiltration (UF) involves the removal of an iso-osmotic filtrate from the blood. Its benefit in acute decompensated heart failure, however, remains inconclusive. We sought to better understand the direct effects of UF in comparison to an aggressive, urine output-guided pharmacological protocol for decongestion on fluid loss, renal function, and neurohormonal activation. METHODS AND RESULTS: A per-protocol analysis of the Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS-HF) trial (n = 188) was performed. Participants were included if randomized to UF and had UF output collected, or if randomized to the pharmacological arm and had urine but not UF output collected. Using these definitions, there were 163 participants at 24 h, 156 at 48 h, 129 at 72 h, and 106 at 96 h. UF was associated with higher cumulative fluid loss (P = 0.003), net fluid loss (P = 0.001), and relative reduction in weight (P = 0.02). UF was also associated with higher serum creatinine and blood urea nitrogen by 72 h (P-interaction <0.05 for both), lower serum sodium by 48 h (P-interaction <0.01) and increased plasma renin activity by 96 h (P = 0.04). The pharmacological arm was associated with higher serum bicarbonate after 24 h (P-interaction <0.002). There were no differences in 60-day outcomes between the UF and pharmacological arms. CONCLUSIONS: Ultrafiltration vs. pharmacological therapy was associated with more fluid removal but also rise in serum creatinine and neurohormonal activation. Additionally, loop diuretic use vs. UF was associated with an increase in serum bicarbonate despite less decongestion, data which question the commonly held conception of a 'contraction alkalosis'.

Dual Vasopressin V1a/V2 Antagonism: The Next Step in Neurohormonal Modulation in Patients With Heart Failure?

Stimulation of the V1a receptor for arginine vasopressin produces myocardial and vascular effects similar to those of angiotensin II while stimulation of the V2 receptor causes fluid retention. There are no data with sustained blockade of the V1a receptor while single-dose experiments suggest benefit. Acute and chronic administration of selective V2 receptor antagonists reliably relieves dyspnea and produces diuresis without adverse effects on renal function or neurohormonal stimulation, either as adjunctive or alternative therapy to loop diuretics, but has not been shown to improve outcomes as adjunctive therapy. Combined antagonism has been tried only in single-dose studies in stable patients or over the short-term in acute heart failure, with encouraging results. Based on the both the pathophysiologic rationale for additional neurohormonal blockade and these results, chronically blocking both receptors, particularly in more congested patients, may offer significant benefit either as adjunctive or alternative therapy to standard diuretics.

Neurohormonal Imbalance: A Neglected Problem-And Potential Therapeutic Target-In Acute Heart Failure.

Decompensated or acute heart failure (AHF) is characterized by increased ventricular and atrial pressures which may lead to and be caused by circulatory congestion. Unless due to a primary decrease in cardiac function, congestion arises from volume expansion or vasoconstriction. In turn, volume expansion and vasoconstriction are due to neurohormonal imbalance since both result from activation of the sympathetic nervous system, the renin-angiotensin-aldosterone axis and excess secretion of arginine vasopressin. Outcomes in AHF remain dismal. Loop diuretics are the mainstay of therapy for AHF and may themselves aggravate neurohormonal imbalance. No adjunctive pharmacotherapy has yielded improvement in outcomes in AHF despite many attempts with various vasodilators and inotropes. We, therefore, propose that insufficient attention has been paid to neurohormonal imbalance in AHF. As in chronic HF, rectifying the effects of neurohormonal imbalance may lead to better outcomes. The use of alternative decongestive strategies or adjunctive pharmacotherapy directed at neurohormonal activation could yield benefit.

Prognostic importance of sodium level trajectory in acute heart failure.

Low sodium levels are strongly associated with poor prognosis in acute heart failure (AHF); however, the prognostic impact of the sodium level trajectory overtime has not been determined. A secondary analysis of the AQUAMARINE study in which patients with AHF and renal impairment were randomized to receive either tolvaptan or conventional treatment was performed. Sodium levels were evaluated at the baseline and at 6, 12, 24, and 48 h. We defined 'sodium dipping' as sodium level falling below the baseline level at any time point. The primary endpoint was the combined event of all-cause death and heart failure rehospitalization during follow-up. The analysis included 184 patients with a median follow-up of 21.1 months. Sodium levels more steeply increased during the 48 h in patients without events as compared to sodium levels in patients with events (P = 0.018 in linear-mixed effect model). The sodium dipping group (n = 100; 54.3%) demonstrated significantly less urine output, less body weight reduction, and poorer diuretic response within 48 h compared to the non-dipping group. The sodium dipping group was also significantly associated with a low combined-event-free survival after adjustment for other prognostic factors (HR 1.97; 95% CI 1.06-3.38; P = 0.033). The trajectory of sodium levels during the acute phase is associated with the prognosis of patients with AHF independently of the baseline sodium level.