Reported decision-making regarding diuretic use and urinary sodium monitoring in acute heart failure

AIMS: To assess clinicians' decision-making in relation to guideline-recommended diuretic therapy, monitoring, and escalation strategies in acute heart failure. METHODS AND RESULTS: We conducted a multinational, case-based cross-sectional survey among clinicians involved in heart failure management in Switzerland, Germany, and Austria. Participants responded to standardised hypothetical clinical vignettes addressing loop diuretic dosing, monitoring, and management of insufficient diuretic response in patients with acute heart failure. Multivariable binomial logistic regression was used to identify factors associated with guideline-concordant initial diuretic dosing and use of urinary sodium measurement.A total of 787 clinicians participated. Guideline-concordant initial loop diuretic dosing was reported by 53.4% of respondents for diuretic-naive patients and by 87.7% for patients receiving chronic diuretic therapy. Treatment monitoring using urinary sodium measurement was reported by 16.9%. In multivariable regression analysis, urinary sodium measurement was more frequent in Switzerland (OR 3.36; 95% CI 2.09-5.42) and Austria (OR 2.64; 95% CI 1.12-6.22) compared to Germany. General practitioners/internal medicine physicians (OR 3.52, 95% CI 1.83-6.79), resident physicians (OR 2.60, 95% CI 1.50-4.51), and prehospital emergency physicians (OR 2.08, 95% CI 1.08-4.03) showed higher odds of urinary sodium measurement compared to emergency medicine physicians. In rural settings odds were lower compared to urban settings (OR 0.50, 95% CI 0.29-0.88). In case of insufficient diuretic response, 64.6% favored escalation via sequential nephron blockade. CONCLUSION: Reported decision-making showed substantial variability regarding diuretic treatment monitoring and escalation strategies. Urinary sodium measurement was infrequently selected and may represent a potential target for future educational efforts.