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Cleveland Clinic Journal of MedicineHow Do We Maximize Diuresis in Acute Decompensated Heart Failure?

Maximizing Diuresis in Acute Decompensated Heart Failure: Clinical Strategies and Outcomes

In the management of acute decompensated heart failure (ADHF), optimizing diuretic therapy is crucial for improving patient outcomes and reducing hospital readmissions. This article synthesizes current strategies and evidence-based practices for enhancing diuresis, primarily focusing on the use of loop diuretics, addressing diuretic resistance, and exploring combination therapies. It highlights the importance of personalized dosing and monitoring to achieve effective fluid management in ADHF patients, shedding light on the broader implications for minimizing heart failure exacerbations and related healthcare burdens.

Key Points:

  • ADHF results in more than one million hospitalizations annually in the US, with poor diuretic management being a significant factor for readmissions and increased mortality.
  • Initial diuretic therapy in ADHF should involve maximizing intravenous loop diuretics, adjusting the dosage based on urine output and spot urine sodium levels.
  • The DOSE trial indicates that aggressive intravenous loop diuretic dosing (2.5 times the oral dose) improves symptoms more effectively than equivalent doses, with a need to adjust doses based on short-term urine output.
  • Diuretic resistance, characterized by inadequate response to escalating diuretic doses, can be predicted early by failure to meet short-term urine sodium goals, necessitating alternative diuretic strategies.
  • Combination therapy, including thiazide diuretics, can be effective after optimizing loop diuretic dosing, as they target different nephron sites, potentially improving diuresis and avoiding renal dysfunction.
  • Advanced diuretic strategies like continuous furosemide infusion or adjunctive use of carbonic anhydrase inhibitors (e.g., acetazolamide) and potassium-sparing diuretics may enhance diuresis in refractory cases.
  • Nontraditional approaches such as hypertonic saline infusion and selective vasopressin receptor antagonists (e.g., tolvaptan) offer alternative methods for managing fluid overload, particularly in patients with hyponatremia or renal dysfunction.
  • Hemodynamic monitoring and invasive evaluations like pulmonary artery pressure monitoring are recommended for patients with refractory symptoms to guide further therapeutic adjustments.

In HF patients, the prevalence of diuretic resistance (DR) is estimated as 20%-30%.

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