Clinical question: For patients admitted with acute heart failure, is early and aggressive diuresis associated with improved dyspnea without an associated worsening in renal function?
Background: Acute heart failure is one of the leading causes of hospitalization in the U.S. and intravenous loop diuretics are considered the mainstay of therapy. Data and guidelines regarding diuretic goals and the safety of early aggressive diuresis are lacking.
Study design: Retrospective, pooled-cohort analysis
Setting: Merged data from the DOSE, ROSE, and ATHENA-HF trials
Synopsis: A pooled cohort of 807 patients admitted with acute heart failure was assorted into quartiles based on median net fluid status at 48 hours post study enrollment. There were two primary outcomes observed, including a 72-hour change in creatinine and a 72-hour change in dyspnea. Dyspnea was measured using the visual analog scale (VAS). The secondary outcome was a composite 60-day rehospitalization or mortality.
Increasing net negative fluid status was associated with improved creatinine up to 3.5 L. After 3.5 L, there was no statistical association between net fluid status and creatinine improvement or worsening. Similarly, each liter net negative was associated with an improvement in dyspnea by a VAS of 1.4 points. Dyspnea reversibility was greater in younger patients and inversely related to higher baseline creatinine.
For the secondary outcome, there was a 12% decrease in odds of 60-day rehospitalization or mortality with each liter net negative. Increased odds of 60-day rehospitalization or death were seen in higher baseline creatinine and each 80-mg increase of furosemide.
The findings demonstrate that each liter net negative up to 3.5 L was associated with improvement in creatinine and dyspnea. Additional diuresis beyond 3.5 L did not have any impact on 72-hour creatinine levels but did show continued improvement in dyspnea. Readmission and mortality risk reduction was also associated with each liter net negative.
Study limitations include lack of follow-up data beyond 72 hours and possible confounding factors such as diuretic efficiency and diuretic resistance, as well as sample generalizability.
Bottom line: For patients admitted with acute heart failure exacerbations, aggressive net fluid targets within the first 48 hours were associated with effective relief of patient self-reported dyspnea as well as reduced 60-day rehospitalization and mortality without adversely affecting renal function.
Citation: Chen AY, et al. Association of 48-h net fluid status with change in renal function and dyspnea among patients with decompensated heart failure: a pooled cohort analysis of three acute heart failure trials. J Hosp Med. 2023;18(5):382-90.
Dr. Fielder
Dr. Doraiswamy
Drs. Fielder and Doraiswamy are clinical assistant professors in the division of hospital medicine at The Ohio State University Wexner Medical Center in Columbus, Ohio.
I have been treating patients with severe chronic combined systolic and diastolic heart failure for years with combined diuretics, loop diuretics and aldosterone antagonists ( metolazone , furosemide and spironolactone ) with great response to this therapy in patients with and without CKD STAGE 1 to 4 , both groups have excellent responses to the therapy, clinically documented improvement in dyspnea , legs edema and largely improve diuresis and lost weight without worsening renal function , dyspnea is resolved as high as 90% of the cases but overall 100% have some significant improvement, nevertheless those with worse renal dysfunction stage 5 improved in their dyspnea but do not resolve edema significantly! Always f/u is one week first then every 8 weeks until fully stabilized! Doses of Metolazone 2.5 to 5 mg , Furosemide 20 mg and Spironolactone 25 mg , all in a twice daily dose.