Hypertonic saline and high-dose furosemide in very elderly patients hospitalized for acute heart failure: A real-world cohort study

BACKGROUND: The combination of hypertonic saline solution (HSS) and high-dose furosemide may enhance diuretic response in acute heart failure (AHF), but evidence in real-world populations, particularly very elderly patients admitted to internal medicine wards, remains limited. METHODS: Retrospective, single-center, uncontrolled observational study of patients hospitalized with AHF and treated between 2021 and 2024 with HSS and high-dose intravenous furosemide (SMACHF protocol), plus discretionary sequential diuretics. We analyzed clinical characteristics, laboratory changes, diuretic response by mean daily urine output, safety and clinical events. RESULTS: We included 191 treatment episodes in 140 patients (median age 84 years, preserved ejection fraction 75%, advanced chronic kidney disease 41%). Diuretic response was good in 41% of episodes, intermediate in 45% and poor in 13%. Renal function remained stable, serum sodium increased and NT-proBNP decreased in the paired measurements. Most treatments ended because of clinical improvement (71.2%); 30-day mortality was 35.7%. Compared with a good response, a poor diuretic response was associated with early clinical failure at 30 days (penalized OR 7.90, 95% CI 1.09-102) and with higher 30-day mortality: restricted mean survival was 4.4 versus 27.3 days. CONCLUSIONS: In this real-world cohort of very elderly patients with AHF, HSS with high-dose intravenous furosemide, plus discretionary sequential diuretics, was feasible and had an acceptable short-term safety profile. Poor diuretic response identified a subgroup with very high early mortality, whereas mid-term outcomes related more to baseline characteristics. These hypothesis-generating findings describe a population common in internal medicine wards and seldom represented in published studies.