Clinical implication of initial intravenous diuretic dose for acute decompensated heart failure

Kenji Yoshioka,Tetsuo Sasano,Takeshi Kitai,Nobuyuki Kagiyama,Akihiko Matsumura,Masayoshi Yamamoto,Shunsuke Kuroda,Daichi Maeda,Eiichi Akiyama,Satoshi Suzuki,Akira Mizukami,Tetsuo Yamaguchi,Yuya Matsue,Keisuke Kida,Shogo Oishi,Takahiro Okumura

doi:10.1038/s41598-022-06032-x

Abstract

Although intravenous diuretics is a cornerstone of acute heart failure treatment (AHF), its optimal initial dose is unclear. This is a post-hoc analysis of the REALITY-AHF, a prospective multicentre observational registry of AHF. The initial intravenous diuretic dose used in each patient was categorised into below, standard, or above the recommended dose groups according to guideline-recommended initial intravenous diuretic dose. The recommended dose was individualised based on the oral diuretic dose taken at admission. We compared the study endpoints, including 60-day mortality, diuretics response within six hours, and length of hospital stay (HS). Of 1093 patients, 429, 558, and 106 were assigned to the Below, Standard, and Above groups, respectively. The diuretics response and HS were significantly greater in the Below group than in the Standard group after adjusting for covariates. Kaplan–Meier analysis indicated a significantly higher incidence of 60-day mortality in the Above group than the Standard group. This difference was retained after adjusting for other prognostic factors. Treatment with a lower than guideline-recommended intravenous diuretic dose was associated with longer HS, whereas above the guideline-recommended dose was associated with a higher 60-day mortality rate. Our results reconfirm that the guideline-recommended initial intravenous diuretic dose is feasible for AHF.

Highlights

Intravenous diuretics is a cornerstone of acute heart failure treatment (AHF), its optimal initial dose is unclear
Of the 1,682 patients enrolled in the REALITY-AHF, 1109 remained after excluding those not treated with furosemide within six hours of admission or treated with continuous furosemide infusion
Significant between group differences were observed in blood pressure, presence of orthopnoea and pulmonary oedema, history of heart failure, being treated with loop diuretics, betablockers, and/or aldosterone blocker before admission, and levels of haemoglobin, creatinine, and blood urea nitrogen

Summary

Introduction

Intravenous diuretics is a cornerstone of acute heart failure treatment (AHF), its optimal initial dose is unclear. Kaplan–Meier analysis indicated a significantly higher incidence of 60-day mortality in the Above group than the Standard group. This difference was retained after adjusting for other prognostic factors. Current guidelines recommend 20 to 40 mg of IV furosemide for patients with AHF not receiving oral diuretics, or an equivalent or higher dose than the oral diuretics for those already taking it.

Methods

Results

Conclusion