Subsequent dose can be adjusted based on urinary sodium or urine output. Urinary sodium uNa > 70 mEq/L at 2 hours or urine output > 100 ml/hr during first 6hours is considered satisfactory. The dose diuretics must be doubled in case insufficient response.
Once optimal decongestion is achieved, IV diuretics may be switched to oral if needed to maintain the oral status.
Evidence
ENACT-HF Study (Circ Heart Fail. 2024) is a international, multicentric, open label, pragmatic study done to compare current standard care with standardised diuretic protocol. The natriuresis after 1 day was significantly higher in the protocol arm compared with the standard of care arm (282 versus 174 mmol; adjusted mean ratio, 1.64; P<0.001). The protocol arm had a shorter length of stay (5.8 versus 7.0 days; adjusted mean ratio, 0.87; P=0.036). In-hospital mortality was low and did not significantly differ between the 2 arms (1.4% versus 2.0%; P=0.852). The study concluded that a standardized natriuresis-guided diuretic protocol to guide decongestion in acute heart failure was feasible, safe, and resulted in higher natriuresis and diuresis, as well as a shorter length of stay.
PUSH-AHF (Nature Medicine.2023) is a pragmatic, single centre, randomized, open label study to asses the efficacy of Urinary sodium based diuretic treatment algorithm v/s usual care. The intervention group the treatment was intensified based on serum sodium levels. The study found that natriuresis was 409 mmol in the intervention group v/s 345 mmol in usual care group (p =0.0061). The study concluded that natriuresis guided therapy as a first step towards personalised treatment of AHF.
DOSE AHF is a prospective, double blinded, randomised trail to compare intermittent verus continuous infusion and at either low dose or a high dose. In the comparison of bolus with continuous infusion, there was no significant difference in patients’ global assessment of symptoms (mean AUC, 4236±1440 and 4373±1404, respectively; P=0.47) or in the mean change in the creatinine level (0.05±0.3 mg per deciliter [4.4±26.5 μmol per liter] and 0.07±0.3 mg per deciliter [6.2±26.5 μmol per liter], respectively; P=0.45). In the comparison of the high-dose strategy with the low-dose strategy, there was a nonsignificant trend toward greater improvement in patients’ global assessment of symptoms in the high-dose group (mean AUC, 4430±1401 vs. 4171±1436; P=0.06). Study concluded y patients with acute decompensated heart failure, there were no significant differences in patients’ global assessment of symptoms or in the change in renal function when diuretic therapy was administered by bolus as compared with continuous infusion or at a high dose as compared with a low dose.
Reference
- ter Maaten, J.M., Beldhuis, I.E., van der Meer, P. et al. Natriuresis-guided diuretic therapy in acute heart failure: a pragmatic randomized trial. Nat Med 29, 2625–2632 (2023). https://doi.org/10.1038/s41591-023-02532-z
- Circ Heart Fail. 2024;17:e011105. DOI:10.1161/CIRCHEARTFAILURE.123.011105
- Lars Køber, Marianna Adamo, Anne-Christine Ruwald, Daniela Tomasoni, Lisa J Anderson, Charlotte Andersson, Jasper J Brugts, Ovidiu Chioncel, Erwan Donal, Peter Ferdinandy, Pardeep S Jhund, Francisco Leyva, Roberto Lorusso, Michael Madigan, Wilfried Mullens, Stefania Paolillo, Nicola Ryan, Maggie Simpson, Holger Thiele, Jens Jakob Thune, Emeline M Van Craenenbroeck, Linda W Van Laake, Mariette Verbakel, ESC Guidelines Advisory Group , 2026 ESC Guidelines for the management of heart failure: Developed by the task force for the management of heart failure of the European Society of Cardiology (ESC)With the special contribution of the Heart Failure Association (HFA) of the ESC Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS), European Heart Journal, 2026;, ehag100, https://doi.org/10.1093/eurheartj/ehag100
