Diuretic strategies in patients with acute decompensated heart failure

G Michael Felker, Kerry L Lee, David A Bull, Margaret M Redfield, Lynne W Stevenson, Steven R Goldsmith, Martin M LeWinter, Anita Deswal, Jean L Rouleau, Elizabeth O Ofili, Kevin J Anstrom, Adrian F Hernandez, Steven E McNulty, Eric J Velazquez, Abdallah G Kfoury, Horng H Chen, Michael M Givertz, Marc J Semigran, Bradley A Bart, Alice M Mascette, Eugene Braunwald, Christopher M O'Connor
New England Journal of Medicine 2011 March 3, 364 (9): 797-805

BACKGROUND: Loop diuretics are an essential component of therapy for patients with acute decompensated heart failure, but there are few prospective data to guide their use.

METHODS: In a prospective, double-blind, randomized trial, we assigned 308 patients with acute decompensated heart failure to receive furosemide administered intravenously by means of either a bolus every 12 hours or continuous infusion and at either a low dose (equivalent to the patient's previous oral dose) or a high dose (2.5 times the previous oral dose). The protocol allowed specified dose adjustments after 48 hours. The coprimary end points were patients' global assessment of symptoms, quantified as the area under the curve (AUC) of the score on a visual-analogue scale over the course of 72 hours, and the change in the serum creatinine level from baseline to 72 hours.

RESULTS: In the comparison of bolus with continuous infusion, there was no significant difference in patients' global assessment of symptoms (mean AUC, 4236±1440 and 4373±1404, respectively; P=0.47) or in the mean change in the creatinine level (0.05±0.3 mg per deciliter [4.4±26.5 μmol per liter] and 0.07±0.3 mg per deciliter [6.2±26.5 μmol per liter], respectively; P=0.45). In the comparison of the high-dose strategy with the low-dose strategy, there was a nonsignificant trend toward greater improvement in patients' global assessment of symptoms in the high-dose group (mean AUC, 4430±1401 vs. 4171±1436; P=0.06). There was no significant difference between these groups in the mean change in the creatinine level (0.08±0.3 mg per deciliter [7.1±26.5 μmol per liter] with the high-dose strategy and 0.04±0.3 mg per deciliter [3.5±26.5 μmol per liter] with the low-dose strategy, P=0.21). The high-dose strategy was associated with greater diuresis and more favorable outcomes in some secondary measures but also with transient worsening of renal function.

CONCLUSIONS: Among patients with acute decompensated heart failure, there were no significant differences in patients' global assessment of symptoms or in the change in renal function when diuretic therapy was administered by bolus as compared with continuous infusion or at a high dose as compared with a low dose. (Funded by the National Heart, Lung, and Blood Institute; number, NCT00577135.).

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Abdul Khan

Basically validates what we already practice


James French

Deciding if the patient has a preload, rate, inotropy or afterload emergency is key and often overlooked. There is no one size fits all for CCF.


Ioannis Tsagurnis

No difference often means none of the options are any good! Use a nitrate infusion instead; you can titrate the pump rate to response and it wears off quickly if there is an adverse reaction. Diuretics cause a drop in cardiac output after all, which I would object to of I was the patient


Salil Gupta

Infusion of lasix works better and addition of metolazone makes it even better. Shortens length is stay by diuresing faster


Ian Goldberg

Still see continuous infusion used more often the bolus


Enoc Flores G

En casi todos los estudios al respecto , se llega a las mismas conclusiones. En la practica, usamos la infusión.


Paulo Salim

Old therapy is better


Mohamed Elmustafa Elsayed

Exactly, reassuring though.


habib shams

Very interesting


Andre Holder

40% treatment failure with diuretics? I spend much of my time in an academic center with a similarly sick patient population. I don't see this kind of failure. Would be nice to see what percentage of pts had adjuncts used and the kinds used (NIPPV, inotropes, etc.) and the percentage of those who ended up in the ICU.


Ali Saqlain Haider

Should use high doses of diuretics in continous infusions if hemodynamics allows .


Ariel Meyer

Use of thiazide type diuretic in addition to loop gives a bigger bang for the buck


Krishna Rai

Continuous vs bolus later one always better


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