Low dose equivalent to patient s previous oral dose versus high dose 2. Evaluating the safety and efficacy of loop and thiazide diuretics used in combination for patients with acute decompensated heart failure. 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. Although this therapy is costly, if patients can be kept out of the hospital for longer, it may prove costeffective. Renal failure commonly occurs in heart failure hf, where it contributes adversely to major clinical outcomes. The epithet of acute decompensated heart failure adhf is volume overload. Diuretic strategies and renal dysfunction in heart failure. Jan 21, 20 despite the widespread use of loop diuretics to treat acute decompensated heart failure adhf, robust data supporting their role and optimal dosing strategies are scarce. The acute decompensated heart failure national registry, together with the 20 american college of cardiology foundation and american heart association heart failure guidelines, earlier retrospective and prospective studies including the diuretic optimization strategies evaluation dose, the trial of intensified vs standard medical therapy in. In addition, observational studies have demonstrated worsening creatinine and clinical outcomes with higher dose of furosemide. Loop diuretics are typically the first line diuretic strategy for the treatment of acute heart failure. Pdf loop diuretics are an essential component of therapy for patients with acute decompensated heart failure, but there are few prospective. Methods we performed a multicentre, randomised, parallelgroup study.
Tolvaptan in patients hospitalized with acute heart failure. Heart failure hf therapy has innovated during the past few decades, but diuretics have been the mainstay of. Diuretic strategies in patients with acute decompensated heart failure. Diuretic strategies in acute heart failure and renal. The use of diuretics in heart failure with congestion a. When evaluating patients with heart failure hf for diuretic resistance, both net urine output and diuretic dose provide incomplete information as isolated parameters. Efficacy of rapid decongestion strategy in patients. Data from the acute decompensated heart failure national registry adhere reveal that 88% of patients hospitalized with adhf receive intravenous iv loop diuretics during their admission.
The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of diuretic therapy. Diuretic strategies in patients with acute decompensated heart. In the ultrafiltration versus iv diuretics for patients hospitalized for acute decompensated heart failure trial unload, 200 adhf patients were randomized to ultrafiltration versus diruetics alone. Medication noncompliance, excessive salt intake, comorbidities, andor disease progression can attribute to volume overload. Heart failure is a complex syndrome that involves both acute and chronic processes. Clinical congestion is the most dominant feature in patients with acute decompensated heart failure hf. Although this phenomenon is commonly reported, no consensus definition exists and recommendations regarding an optimal. Clinical pharmacology in diuretic use american society of. There are few prospective data available for establishing a standard diuretic administration regimen for patients with acute decompensated heart failure adhf. We aimed to assess the safety and efficacy of three regimens of furosemide administration in patients with adhf with regard to diuresis, renal functions, and in hospital outcomes. Diuretic resistance creates challenges in the management of acute decompensated heart failure hf. Loop diuretics are an essential component of therapy for patients with acute decom pensated heart failure, but there are few prospective data to. Pdf diuretic strategies in patients with acute decompensated. Diuretic strategies in patients with acute decompensated.
Diuretic efficacy may be limited by adverse neurohormonal activation and by. Diuretic strategies in patients with acute decompensated heart failure dose study prospective, double blind, randomized trial 308 patients with adhf 2x2 design bolus every 12 hours versus continuous infusion low dose equivalent to patients previous oral dose versus high dose 2. In patients presenting with acute decompensated heart failure and previously on oral loop diuretics at home, there is no difference between. Fluid overload is a major pathophysiological mechanism underlying both acute decompensation episodes of hf and the progress of the syndrome. Use of diuretics in patients with heart failure, by colucci and sterns. Worsening renal function in patients with acute heart. A diuretic protocol increases volume removal and reduces. The demonstrated efficacy of loop diuretics in managing congestion is balanced by the recognized limitations of diuretic resistance, neurohormonal activation, and worsening renal function. Comparison of three diuretic treatment strategies for patients with acute decompensated heart failure article pdf available in herz 408 july 2015 with 448 reads how we measure reads.
Diuretics and ultrafiltration in acute decompensated heart. In a prospective, doubleblind, 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 patients previous oral dose or a high dose 2. Pdf comparison of three diuretic treatment strategies for. The primary end points were urine outputs, body weight loss, all causes of mortality, and death from cardiovascular causes. Early studies suggested better volume loss with dopamine related to improvements in renal function and blood flow. The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. Despite the widespread use of loop diuretics to treat acute decompensated heart failure adhf, robust data supporting their role and optimal dosing strategies are scarce. Diuretic strategies in patients with acute decompensated heart failure dose study prospective, double blind, randomized trial 308 patients with adhf 2x2 design bolus every 12 hours versus continuous infusion low dose equivalent to patient s previous oral dose versus high dose 2. Hospital management of acute decompensated heart failure. Introduction acute decompensated heart failure adhf is a common and potentially fatal cause of acute respiratory distress. Pdf comparison of three diuretic treatment strategies.
In addition, adverse effects related to diuretic treatment are common, including worsening kidney function and electrolyte disturbances. 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. Relief and recurrence of congestion during and after hospitalization for acute heart failure. Diuretic strategies in patients with acute decompensated heart failure article pdf available in new england journal of medicine 3649. Diuretics remain the mainstay of therapy for patients with adhf.
Current guidelines, based only on expert consensus, recommend supplementing loop diuretics with thiazides. Background combination diuretic regimens to overcome loop dr are commonly used but with limited evidence. Correspondence from the new england journal of medicine diuretic strategies in patients with acute heart failure. Diuretic strategies in severely ill patients with acute. Comparison of three diuretic treatment strategies for. A randomized controlled trial of diuretic strategies in. Congestion and volume overload are the hallmarks of acute decompensated heart failure adhf, and loop diuretics have historically been the cornerstone of treatment.
This is because the quantity of urine output after a loop diuretic is only interpretable in the context of the amount of diuretic given. Diuretic strategies for loop diuretic resistance in acute. Intravenous loop diuretics remain the mainstay of therapy for acute decompensated heart failure adhf. Clinical effects and safety of different strategies for. 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. The diuretic optimization strategies evaluation dose trial is the largest prospective, double blind, randomized adhf trial to evaluate initial diuretic strategies in pa tients with acute decompensated heart failure. Removal of excess sodium and fluid is a primary therapeutic objective in acute decompensated heart failure adhf and commonly monitored with fluid balance and weight loss.
Comparison of metolazone versus chlorothiazide in acute. The roseahf trial renal optimization strategies evaluation acute heart failure provides an experimental platform for the study of mechanisms of wrf during aggressive diuresis for acute heart failure because the roseahf protocol dictated highdose loop diuretic therapy in all patients. However, however, uncertainty exists due to the permutations and combinations of congestion status and decongestion strategies. Decongestive treatment of acute decompensated heart. Acute decompensated heart failure adhf is the leading cause of hospital admissions in patients older than 65 years. Felker gm 1, lee kl, bull da, redfield mm, stevenson lw, goldsmith. The use of diuretics is common in patients with heart failure hf, to relieve the congestive symptoms of hf.
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. A total of 43 patients who presented with adhf were. Loop diuretic strategies in patients with acute decompensated. 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. Patients global assessment of symptoms change in serum creatinine over 72h baseline characteristics evenly matched diuretic strategies in patients with acute decompensated heart failure dose study. However, we noticed that the results did not include the actual doses of. In summary, among patients with acute decompensated heart failure, the mode of administration bolus vs.
Most patients with acute decompensated heart failure adhf present with signs and symptoms of volume overload, and those with a significant history of diuretic exposure may demonstrate varying degrees of diuretic resistance. Diuretic strategies in acute decompensated heart failure. Taking on diuretic resistance in patients with acute heart failure frederick a. Use of diuretics in patients with heart failure uptodate. Diuretic strategies in patients with acute heart failure. The clinical syndrome is characterized by the development of dyspnea, generally associated with rapid accumulation of fluid within the lungs interstitial and alveolar spaces, which is the result of acutely elevated cardiac filling pressures cardiogenic pulmonary. Present findings correlate with the transient kidney function changes observed in the dosehf diuretic optimization strategy evaluation in acute decompensated heart failure and rosehf renal optimization strategies evaluation, which appeared not to be driven by true renal injury 12,20. Objectives we evaluated the clinical effects and safety of three strategies of intravenous furosemide administration used in emergency departments eds for adhf.
Loop diuretics in acute decompensated heart failure. Electrolyte adverse events were infrequent, with only. In this setting of clinical uncertainty, the diuretic optimization strategies evaluation dose trial was conducted in 2008 to gauge the safety and effectiveness of different dosing strategies of loop diuretics for patients with acute decompensated heart failure. Clinical pharmacology in diuretic use american society. Diuretic therapy in heart failure current approaches.
Standardized patient centered outcomes measurement set for heart failure patients. 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. Mar 10, 2009 acute decompensated heart failure adhf is a syndrome defined by worsening fatigue, dyspnea, or edema that results from deteriorating heart function and usually leads to hospital admission or unscheduled medical intervention. Diuretic optimization strategies evaluation in acute heart failure. For patients with considerable fluid re tention, there is some evidence that initial treatment. These hospitalisations are highly risky and are associated with poor outcomes, including rehospitalisation and death. Among patients with acute decompensated hf, how do continuous vs.
Background the mainstay of treatment for acutely decompensated heart failure adhf is intravenous diuretic therapy either as a bolus or via continuous infusion. Most patients with acute decompensated heart failure adhf are admitted for symptomatic treatment of congestion with intravenous diuretics and to a much lesser degree for respiratory failure, cardiogenic shock, incessant ventricular tachycardia, or the need for urgent diagnostic or therapeutic procedures 6,20,21,3140. Diuretic therapy in acute decompensated heart failure. Acute decompensated heart failure adhf characterized by volume overload accounts for 90% of the one million heart failure hf. Taking on diuretic resistance in patients with acute heart. Despite diuretic therapy, many patients remain volume overloaded and symptomatic. Oct 15, 2019 most patients with acute decompensated heart failure adhf are admitted for symptomatic treatment of congestion with intravenous diuretics and to a much lesser degree for respiratory failure, cardiogenic shock, incessant ventricular tachycardia, or the need for urgent diagnostic or therapeutic procedures 6,20,21,3140.
This analysis aimed to compare clinical outcomes of patients admitted with adhf who received a diuretic dosing protocol with those who received the usual diuretic therapy. Rapid and highly accurate prediction of poor loop diuretic. Adhf is associated with a rising number of hospital admission for volume overload. Ultrafiltration versus intravenous diuretics for patients. In the ropadop randomized evaluation of heart failure with preserved ejection fraction patients with acute heart failure and dopamine study, sharma et al. Removal of excess extracellular fluid with diuretics to treat peripheral andor pulmonary edema is one of the mainstays of volume management. Diuretic optimization strategies evaluation in acute heart. The recent failure of serelaxin, as well as other agents such as tolvaptan and natrecor, in the setting of acute decompensated heart failure is disappointing. Felker gm, oconnor cm, braunwald e, heart failure clinical research network investigators. The diuretic strategies in patients with acute decompensated heart failure trial compared high and low doses of loop diuretics for acute decompensated heart failure and showed that the higher dose 2. As per the dose study, 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. Loop diuretics remain a cornerstone in the pharmacological treatment of adhf and are administered in about 90 % of patients hospitalised for hf. Conceptual considerations for devicebased therapy in. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure partially presented as a late breaking clinical trial at the 55th scientific sessions of the american college of cardiology, march 1114, 2006, atlanta, georgia.
Oct 15, 2014 in patients presenting with acute decompensated heart failure and previously on oral loop diuretics at home, there is no difference between lowdose and highdose furosemide, or bolus and continuous infusions, on the patients global assessment of symptoms and changes in serum creatinine at 72 hours. Objectives this study compared combination diuretic strategies in acute heart failure ahf complicated by diuretic resistance dr. In patients with acute decompensated heart failure adhf, treatment aimed at adequate decongestion of the volume overloaded state is essential. Acute decompensated heart failure adhf is predominantly a disease of fluid overload. The management of adhf is drastically different from that of chronic heart failure as inpatient treatment consists primarily of haemodynamic stabilisation. They also highlight the urgency of reexamining the dose study and considering more diuretics for our patients before discharge. One of the most common reasons for hospitalization in acute decompensated heart failure adhf is excess volume accumulation which leads to untoward symptoms including dyspnea,orthopnea, and edema. Jacc heart fail 2019 dec 11 three diuretic escalation approaches were associated with similar weight loss at 48 hours. Acute decompensated heart failure is the most common cause of hospital admissions among patients older than 65 years of age and is responsible for more than 1 million hospitalizations annually in. Methods this study was a randomized, doubleblinded trial in 60 patients hospitalized with ahf and intravenous iv loop dr. Although they are widely used, there are limited data on their ability to modulate hfrelated morbidity and mortality. Current goals in the acute treatment of heart failure are focused on pulmonary and systemic decongestion with loop diuretics as the cornerstone of therapy. Despite rapid relief of symptoms in patients with acute decompensated heart failure, after intravenous use of loop diuretics, the use of these agents has been consistently associated with adverse events, including hypokalemia, azotemia.
In conclusion, among patients with acute decompensated heart failure and moderatetohigh baseline diuretic requirements, there were no significant differences in the patients global assessment of symptoms or in changes from baseline renal function with either bolus as compared with continuous infusion of intravenous furosemide or with a lowdose strategy as compared with a highdose strategy. Diuretic resistance in acute decompensated heart failure. In the diuretic strategies in patients with acute decompensated heart failure dose trial, felker et al. Pharmacological and nonpharmacological strategies for. The pharmacotherapy of adhf has not changed recently, but studies have indicated that most therapy is efficaciously, though not economically. The burden of heart failure in the united states is growing rapidly to epic proportions with serious clinical implications for patients and economic strain for healthcare systems. Nonosmotic anti diuretic hormone adh release contributes to hyponatraemia and also to increased urea reabsorption in the collecting duct.