Diuretic Resistance and Decongestion With Upfront Acetazolamide in Acute Decompensated Heart Failure

T he BAN-ADHF (blood urea nitrogen, atrial fibrillation, natriuretic peptide in acute decompensated heart failure) score identifies patients with ADHF who have impaired diuretic efficiency. 1 Subsequent studies imply that the BAN-ADHF score may identify a proportion of diureticresistant patients that may have been inadequately dosed with loop diuretics or benefit from adjunctive therapy after discharge. 2,3Herein, we sought to evaluate a modified version of the BAN-ADHF score (without information on previous acute decompensated heart failure [ADHF] hospitalization) and its association with decongestion, natriuresis, urine output, and bicarbonate levels and impact of addon acetazolamide in hospitalized patients with ADHF receiving intravenous loop diuretics.The design and outcomes of the ADVOR (Acetazolamide in Decompensated Heart Failure with Volume Overload; NCT03505788) trial, which included 518 patients with ADHF and home oral diuretic use, have been previously described. 4,5We conducted this post-hoc subanalysis of ADVOR using a modified version of BAN-ADHF score 2 that was calculated from 7 clinical variables, including laboratory values (amino-terminal pro-B-type natriuretic peptide [NT-proBNP], serum creatinine, blood urea nitrogen), comorbidities (atrial fibrillation, hypertension), diastolic blood pressure, and home diuretic dose (furosemide equivalent).Previous heart failure hospitalization within the last 12 months was not available in ADVOR, thus it was not included.We stratified the cohort by modified BAN-ADHF score by #12 vs >12.The primary endpoint of the ADVOR trial was defined as successful decongestion (the absence of signs of volume overload) on the third morning after randomization without escalating decongestive therapies due to poor loop diuretic efficacy.Key secondary endpoints for this analysis included urinary sodium excretion, total urine output, serum bicarbonate, and daily congestion score, as previously described. 5To examine the continuous relationship between BAN-ADHF score and the probability of successful decongestion, we fitted a logistic regression model using restricted cubic splines with 3 knots for BAN-ADHF score, including an interaction term with treatment group (acetazolamide vs placebo).The effects of acetazolamide over time on clinical congestion were assessed by modeling congestion score using a cumulative link mixed-effects model with a logit link.Fixed effects