Hypertonic saline combined with furosemide enhances decongestion and preserves electrolytes in decompensated heart failure: a three-arm prospective comparative study

Hypertonic saline solution (HSS) combined with furosemide has been proposed as a strategy to enhance decongestion in acute decompensated heart failure (ADHF). We aimed to compare two HSS regimens with conventional furosemide therapy with respect to neurohormonal and echocardiographic markers of decongestion at 72 h. In this prospective, open-label, randomized, three-arm comparative study, 78 patients with ADHF (NYHA class III) were randomized to the following: group 1 (n = 28): HSS 50 mL BID + furosemide 3 × 2 amp IV bolus; group 2 (n = 25): HSS 100 mL OD + furosemide bolus-to-infusion; and group 3 (n = 25): conventional furosemide bolus-to-infusion. Primary endpoints were NT-proBNP reduction and IVC diameter change at 72 h. HSS groups achieved significantly greater reductions in NT-proBNP (− 2317 vs. − 416 pg/mL; p = 0.010) and IVC diameter (− 0.32 vs. − 0.20 cm; p = 0.036) compared with conventional therapy. Urine output and body weight reduction were numerically higher in the HSS groups but did not reach statistical significance (p = 0.089 and p = 0.114, respectively). HSS was associated with superior preservation of plasma sodium and potassium (both p = 0.001). No neurological or cardiopulmonary adverse events were observed. The addition of HSS to furosemide in patients with ADHF was associated with greater improvement in neurohormonal and echocardiographic indices of decongestion while maintaining electrolyte homeostasis compared with conventional furosemide therapy. These findings support further evaluation of this therapeutic approach in larger prospective randomized studies.