Does furosemide continuous infusion or sequential nephron blockade improve weight loss and worsening renal function compared to furosemide boluses alone in patients with acute heart failure?
In acute heart failure, continuous furosemide infusion and sequential nephron blockade improve short-term weight loss compared to furosemide boluses alone, though sequential blockade increases the risk of worsening renal function.
AIMS: Several diuretic strategies, including furosemide i.v. boluses (FB) or continuous infusion (FC), are used in acute heart failure (AHF). METHODS AND RESULTS: We systematically searched phase 3 randomized clinical trials (RCTs) evaluating diuretic regimens in admitted AHF patients within 48 h and irrespective of clinical stabilization. We calculated the odds ratio (OR) of FC or FB plus another diuretic (sequential nephron blockade, SNB) compared to FB alone on 24 h weight loss (WL) and worsening renal function (WRF), with a random-effects model with inverse variance weighting. Urine output, hypokalaemia, hyponatremia, and all-cause mortality/rehospitalization were secondary endpoints. In 25 selected RCTs (7149 patients, mean age 68.9 ± 8.7 years, mean left ventricular ejection fraction 38.2 ± 10.7%), FC OR 1.55 (95% confidence interval 1.39-1.63), FB plus tolvaptan OR 1.57 (1.39-1.77), FB plus SGLT2i OR 1.23 (1.06-1.42), and FB plus thiazide OR 1.63 (1.37-1.94) were associated with greater WL than FB. FB plus SGLT2i OR 1.52 (1.19-1.94) and FB plus acetazolamide OR 1.81 (1.31-2.49) were associated with WRF. FB plus thiazide was associated with both WRF OR 1.78 (1.43-2.21) and hypokalaemia OR 1.69 (1.32-2.16). Results were consistent in sensitivity analyses considering urine output, RCTs protocol-established furosemide doses, or daily furosemide dose. Congestion/decongestion scores and clinical outcomes were reported in around 50% of RCTs. In an underpowered exploratory analysis, mortality/rehospitalization was non-significantly lower with SGLT2i OR 0.45 (0.19-1.07). CONCLUSION: FC and SNB improve surrogates of response to FB in AHF. SNB is also connoted by WRF and may induce hypokalaemia. The endpoints of diuretic RCTs should be revised and harmonized.
Cannatà et al. (Tue,) studied this question.
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