Potential Role of Natriuretic Response to Furosemide Stress Test During Acute Heart Failure

Pérez, Pedro Caravaca; Nuche, Jorge; Fernández, Laura Nuevo; Lora, David; Blázquez-Bermejo, Zorba; López‐Azor, Juan Carlos; Bagudá, Javier de Juan; Carmena, María Dolores García-Cosío; Escribano, Pilar; Salguero‐Bodes, Rafael; Arribas, Fernando; Delgado, Juan

doi:10.1161/circheartfailure.120.008166

Cited by 23 publications

(14 citation statements)

References 24 publications

(61 reference statements)

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“…These points reflect a selected cohort of cardiovascular patients for whom fluid depletion may be necessary, such as in patients with pulmonary weaning failure [ 32 ]. Indications for diuretic were left to the physician, but the response to diuretic was evaluated by the evolution of a clinical–biological congestive score [ 22 ]. Even though this score was adapted from previous studies, it was in accordance with the literature that demonstrated congestive score being clinically relevant and associated with outcomes [ 4 , 9 ].…”

Section: Discussionmentioning

confidence: 99%

“…Based on the literature [ 4 , 22 ], we constructed a congestion score based on clinical indicator and biomarkers of congestion: pulmonary rales/crackles (graded between 0 (no), 1 (< 50% of lung) and 2 (> 50% of lung)), peripheral edema (graded between 0 (no), 1 (ankle), 2 (leg) and 3 (body)), B-lines and/or lung ‘comets’ (graded between 0 (no), 1 (more than 2 area) and 2 (diffuse)), and/or pleural effusion (graded between 0 (no), 1 (unilateral) and 2 (bilateral)) on lung ultrasound, and NT-proBNP (N-terminal pro B-type natriuretic peptide) value over 1500 pg mL −1 [ 4 , 22 ]. The positive fluid balance was not a criterion in the clinical congestion score calculation.…”

Section: Methodsmentioning

confidence: 99%

“…The positive fluid balance was not a criterion in the clinical congestion score calculation. The congestion score ranged from 0 to 10, and a patient with a score ≥ 3 was considered as having significant clinical congestion [ 4 , 22 ]. Then, appropriate diuretic-induced fluid depletion was considered with a score lower than 3 at the end of the study for patients who had significant clinical congestion at baseline [ 22 ].…”

Section: Methodsmentioning

confidence: 99%

“…The congestion score ranged from 0 to 10, and a patient with a score ≥ 3 was considered as having significant clinical congestion [ 4 , 22 ]. Then, appropriate diuretic-induced fluid depletion was considered with a score lower than 3 at the end of the study for patients who had significant clinical congestion at baseline [ 22 ]. Patients with baseline congestion score lower than 3 or who did not lower the congestion score with diuretic were considered as the control group.…”

Section: Methodsmentioning

confidence: 99%

“…The primary endpoint was the appropriate diuretic-induced fluid depletion on the last day of ICU [ 22 ].…”

Section: Methodsmentioning

confidence: 99%

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Doppler study of portal vein and renal venous velocity predict the appropriate fluid response to diuretic in ICU: a prospective observational echocardiographic evaluation

et al. 2022

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Background Fluid overload and venous congestion are associated with morbi-mortality in the ICU (intensive care unit). Administration of diuretics to correct the fluid balance is common, although there is no strong relationship between the consequent fluid loss and clinical improvement. The aim of the study was to evaluate the ability of the portal pulsatility index, the renal venous impedance index, and the VEXUS score (venous ultrasound congestion score) to predict appropriate diuretic-induced fluid depletion. Methods The study had a prospective, observational, single-center observational design and was conducted in a university-affiliated medico-surgical ICU. Adult patients for whom the clinician decided to introduce loop diuretic treatment were included. Hemodynamic and ultrasound measurements (including the portal pulsatility index, renal venous impedance index and VEXUS score) were performed at inclusion and 2 hours after the initiation of the diuretics. The patients’ characteristics were noted at inclusion, 24 h later, and at ICU discharge. The appropriate diuretic-induced fluid depletion was defined by a congestive score lower than 3 after diuretic fluid depletion. The congestive score included clinical and biological parameters of congestion. Results Eighty-one patients were included, and 43 (53%) patients presented with clinically significant congestion score at inclusion. Thirty-four patients (42%) had an appropriate response to diuretic-induced fluid depletion. None of the left- and right-sided echocardiographic parameters differed between the two groups. The baseline portal pulsatility index was the best predictor of appropriate response to diuretic-induced fluid depletion (AUC = 0.80, CI95%:0.70–0.92, p = 0.001), followed by the renal venous impedance index (AUC = 0.72, CI95% 0.61–0.84, p = 0.001). The baseline VEXUS score (AUC of 0.66 CI95% 0.53–0.79, p = 0.012) was poorly predictive of appropriate response to diuretic-induced fluid depletion. Conclusion The portal pulsatility index and the renal venous impedance index were predictive of the appropriate response to diuretic-induced fluid depletion in ICU patients. The portal pulsatility index should be evaluated in future randomized studies.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

“…The primary endpoint was the appropriate diuretic-induced fluid depletion on the last day of ICU [ 22 ].…”

Section: Methodsmentioning

confidence: 99%

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Doppler study of portal vein and renal venous velocity predict the appropriate fluid response to diuretic in ICU: a prospective observational echocardiographic evaluation

et al. 2022

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Dose of furosemide before admission predicts diuretic efficiency and long‐term prognosis in acute heart failure

et al. 2021

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Aims The outpatient diuretic dose is a marker of diuretic resistance and prognosis in chronic heart failure (HF). Still, the impact of the preadmission dose on diuretic efficiency (DE) and prognosis in acute HF is not fully known. Methods and results We conducted an observational and prospective study. All patients admitted for acute HF treated with intravenous diuretic and at least one criterion of congestion on admission were evaluated. Decongestion [physical examination, hemoconcentration, N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) change, and lung ultrasound], DE (weight loss and urine output per unit of 40 mg furosemide), and urinary sodium were monitored on the fifth day of admission. DE was dichotomized into high–low based on the median value. A multivariate Cox regression analysis was conducted to find predictors of HF readmission or mortality. A total of 105 patients were included between July 2017 and July 2019. Mean age was 74.5 ± 12.0 years, 64.8% were male, 33.3% had de novo HF, and mean left ventricular ejection fraction was 46 ± 17%. Median follow‐up was 26 [15–35] months. Low DE based on weight loss was associated with a higher previous dose of furosemide (odds ratio [OR] 1.01 [1.00–1.02]), thiazide treatment before admission (OR 9.37 [2.19–40.14]), and lower diastolic blood pressure (OR 0.95 [0.91–0.98]) in the multivariate regression model. Only previous dose of furosemide (OR 1.01 [1.00–1.02]) and haemoglobin at admission (OR 0.76 [0.58–0.99]) were associated with low DE based on urine output in the multivariate analysis. The correlation between the previous dose of furosemide and DE based on weight loss was poor (r = −0.12; P = 0.209) and with DE based on urine output was weak to moderate (r = −0.33; P < 0.001). Low DE based on weight loss and urine output was associated with lesser decongestion measured by NT‐proBNP (P = 0.011; P = 0.007), hemoconcentration (P = 0.006; P = 0.044), and lung ultrasound (P = 0.034; P = 0.029), but not by physical examination (P = 0.506; P = 0.560). Survival and event‐free survival in acute decompensated HF (ADHF) were lower than in de novo HF; a preadmission dose of furosemide > 80 mg in ADHF identified patients with particularly poor prognosis (log‐rank < 0.001). In ADHF, the preadmission dose of furosemide (hazard ratio [HR] 1.34 [1.08–1.67] per 40 mg) and NT‐proBNP at admission (HR 1.03 [1.01–1.06] per 1000 pg/mL) were independently associated with mortality or HF readmission in the multivariate Cox regression analysis. Conclusions The outpatient dose of furosemide before acute HF admission predicts DE and must be taken into account when deciding on the initial diuretic dose. In ADHF, the outpatient dose of furosemide can predict long‐term prognosis better than DE during hospitalization.

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Nurse‐led diuretic titration via a point‐of‐care urinary sodium sensor in patients with acute decompensated heart failure (EASY‐HF): A single‐centre, randomized, open‐label study

Meekers,

Martens,

Dauw

et al. 2024

European J of Heart Fail

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AimsEarly evaluation of the natriuretic response is recommended to guide diuretic therapy in acute decompensated heart failure (ADHF). However, its implementation in daily practice is hampered by implementation barriers and increased time constraints. The Readily Available Urinary Sodium Analysis in Patients with Acute Decompensated Heart Failure (EASY‐HF) study assessed the feasibility, efficacy and safety of a nurse‐led urinary sodium‐based diuretic titration protocol with the use of a point‐of‐care urinary sodium sensor.Methods and resultsThe EASY‐HF study was a single‐centre, randomized, open‐label study comparing diuretic management at the treating physician's discretion as standard of care (SOC) with a nurse‐led natriuresis‐guided protocol in patients with ADHF. The LAQUAtwin Sodium Meter (HORIBA) was used as point‐of‐care sensor to measure urine sodium concentration. The primary endpoint was natriuresis after 48 h. Secondary endpoints included safety profile and user‐friendliness of both the protocol and the point‐of‐care sensor. Sixty patients were randomized towards SOC (n = 30) versus protocolized care (n = 30). The mean age was 80 ± 8 years, 25% were women and median N‐terminal pro‐B‐type natriuretic peptide was 4667 (2667–7709) ng/L. Natriuresis after 48 h was significantly higher in the protocolized versus SOC group (820 ± 279 vs. 657 ± 273 mmol; p = 0.027). Pre‐defined safety endpoints were similar among both groups. The sensor‐based protocol was evaluated as easy to use by the nursing staff, and preferred over urinary collections.ConclusionA nurse‐led diuretic titration protocol via a point‐of‐care urinary sodium sensor was feasible, safe and resulted in an increased natriuresis in ADHF compared to SOC.

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Potential Role of Natriuretic Response to Furosemide Stress Test During Acute Heart Failure

Cited by 23 publications

References 24 publications

Doppler study of portal vein and renal venous velocity predict the appropriate fluid response to diuretic in ICU: a prospective observational echocardiographic evaluation

Doppler study of portal vein and renal venous velocity predict the appropriate fluid response to diuretic in ICU: a prospective observational echocardiographic evaluation

Dose of furosemide before admission predicts diuretic efficiency and long‐term prognosis in acute heart failure

Nurse‐led diuretic titration via a point‐of‐care urinary sodium sensor in patients with acute decompensated heart failure (EASY‐HF): A single‐centre, randomized, open‐label study

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