Key result
High-dose loop diuretics at discharge fail to reduce major events versus low-dose in SGLT2i-treated AHF.
Why the study?
The optimal discharge loop diuretic strategy in acute heart failure patients receiving SGLT2 inhibitors is not well established, with limited evidence on the balance between decongestion and adverse outcomes.
Does a high-dose loop diuretic regimen at discharge improve short-term clinical outcomes compared to a low-dose regimen in acute heart failure patients treated with SGLT2 inhibitors?
RCT (n=90)
1:1
Yes
Does a high-dose loop diuretic regimen at discharge improve short-term clinical outcomes compared to a low-dose regimen in acute heart failure patients treated with SGLT2 inhibitors?
In a pilot trial of AHF patients on SGLT2 inhibitors, discharge loop diuretic dose (high vs. low) did not significantly affect the 60-day composite of cardiovascular death or worsening heart failure.
Similar primary endpoint rates with low- versus high-dose loop diuretics; leaves open optimal dosing strategy in acute HF on SGLT2 inhibitors.
Introduction The optimal discharge loop diuretic strategy in acute heart failure (AHF) patients receiving sodium–glucose co-transporter 2 (SGLT2) inhibitors is not well established. Limited evidence exists regarding the balance between decongestion and adverse outcomes with varying diuretic doses in this population. Purpose To compare short-term clinical outcomes of low- versus high-dose loop diuretic regimens at discharge in patients hospitalised for AHF and treated with SGLT2 inhibitors. Methods In this prospective, multicentric, randomized (1:1) pilot trial, 90 patients admitted for AHF and receiving SGLT2 inhibitors were allocated at discharge to either a low-dose (pre-admission dose if previously prescribed, or 40 mg in diuretic-naïve patients) or high-dose regimen (50–100% increase from pre-admission dose or 80 mg in diuretic-naïve patients). The primary endpoint was the composite of cardiovascular death or worsening heart failure requiring unplanned hospitalisation or urgent intravenous therapy at 60 days. Results At 60 days, the primary endpoint incidence was similar between groups (low-dose: 15.6% vs. high-dose: 17.8%, p=1.000). Cardiovascular deaths occurred only in the high-dose arm (6.7%, n=3), while worsening heart failure episodes were slightly more frequent in the low-dose arm (15.6% vs. 11.1%), though differences were not statistically significant. Conclusions In AHF patients discharged on SGLT2 inhibitors, the loop diuretic dose at discharge did not significantly affect the composite endpoint of cardiovascular death or heart failure worsening at 60 days. Nonetheless, the differing event patterns observed between dosing strategies highlight the need for larger, outcome-focused trials to determine optimal post-discharge diuretic management.
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Ammar et al. (2026) conducted an RCT in Acute heart failure (n=90). Low-dose loop diuretic regimen vs. High-dose loop diuretic regimen (50-100% increase or 80 mg if naïve) was evaluated on Composite of cardiovascular death or worsening heart failure requiring unplanned hospitalisation or urgent intravenous therapy at 60 days (p=1.000). Low-dose loop diuretics at discharge in AHF patients on SGLT2 inhibitors yielded similar rates of cardiovascular death or worsening heart failure as a high-dose regimen (15.6% vs 17.8%, p=1.000).
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