What is the clinical evidence from this study?

Study design: Observational. Population: Acute heart failure (n=73). Intervention: Insufficient diuretic response vs. Adequate diuretic response. Primary outcome: Prevalence of insufficient diuretic response (natriuresis <70 mEq/L or diuresis volume <600 ml) (28.8%, 95% CI 18.4-39.2).

May 2, 2022Open Access

Role of Early Assesment of Diuresis and Natriuresis in Detecting In-Hospital Diuretic Resistance in Acute Heart Failure

Q: What are the key findings of this study?

The diagnostic algorithm based on early assessment of diuresis and natriuresis detected insufficient diuretic response in 28.8% of patients with acute heart failure.

Key Result

The diagnostic algorithm based on early assessment of diuresis and natriuresis detected insufficient diuretic response in 28.8% of patients with acute heart failure.

Study Design

Type

Observational (n=73)

Multicenter

Structured PICO

Does early assessment of diuresis and natriuresis detect insufficient diuretic response in patients with acute heart failure?

Population

73 adult patients (median age 76, 41% female) hospitalized with acute heart failure and congestive signs, evaluated for early diuretic response.

Exposure

Early assessment of diuresis and natriuresis (diuretic naïve received 40 mg IV furosemide; outpatient diuretic regimen received 2 times ambulatory dose). Diuresis volume assessed at 6h, spot urinary sample at 2h.

Outcome

Insufficient diuretic response defined as natriuresis <70 mEq/L or diuresis volume <600 mlsurrogate

The ESC diagnostic algorithm based on early diuresis and natriuresis successfully identified 29% of acute heart failure patients with insufficient diuretic response who may benefit from intensified therapy.

Main Result

Effect estimate: 28.8% (95% CI 18.4-39.2)

Limitations

Single academic institution cohort, findings may not be generalizable to the wider acute HF population
Low percentage of patients included (11%) in terms of overall acute HF admissions
Patients with predominantly pulmonary congestion without other congestion signs were not included
Some patients did not follow the protocol by decision of the responsible staff
Recruitment was affected by the COVID-19 pandemic

Abstract

Background and Purpose: European Guidelines recommend early evaluation of diuresis and natriuresis after the first administration of diuretic to identify patients with insufficient diuretic response during acute heart failure. The aim of this work is to evaluate the prevalence and characteristics of patients with insufficient diuretic response according to this new algorithm. Methods: Prospective observational single centre study of consecutive patients with acute heart failure and congestive signs. Clinical evaluation, echocardiography and blood tests were performed. Diuretic naïve patients received 40 mg of intravenous furosemide. Patients on an oupatient diuretic regimen received 2 times the ambulatory dose. The diuresis volume was assessed 6 h after the first loop diuretic administration, and a spot urinary sample was taken after 2 h. Insufficient diuretic response was defined as natriuresis 70 mEq/L or diuresis volume 600 ml. Results: From January 2020 to December 2021, 73 patients were included (59% males, median age 76 years). Of these, 21 patients (28.8%, 95%CI 18.4; 39.2) had an insufficient diuretic response. Diuresis volume was 600 ml in 13 patients (18.1%), and 12 patients (16.4%) had urinary sodium 70 mEq/L. These patients had lower systolic blood pressure, worse glomerular filtration rate, and higher aldosterone levels. Ambulatory furosemide dose was also higher. These patients required more frequently thiazides and inotropes during admission. Conclusion: The diagnostic algorithm based on diuresis and natriuresis was able to detect up to 29% of patients with insufficient diuretic response, who showed some characteristics of more advanced disease.

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