Diuretic Strategies in Severely Ill Patients with Acute Decompensated Heart Failure

Introduction Intravenous loop diuretics remain the mainstay of therapy for acute decompensated heart failure (ADHF); however, most physicians rely on clinical experience when choosing a diuretic strategy. Studies have compared continuous versus intermittent loop diuretic strategies, but few have looked at severely ill patients with acute kidney injury (AKI) or on inotropes. Our study aimed to determine the characteristics and outcomes of patients with ADHF receiving continuous versus intermittent loop diuretic strategies without excluding patients with renal failure or later requiring inotropes. Methods Using a retrospective cohort design, we included patients admitted to the University of Alabama at Birmingham Hospital for ADHF who received right heart catheterization from 2012 to 2017. Exclusion criteria included LVEF ≥ 40% and requiring inotropes prior to the index hospitalization. Measures of interest included 30- and 90-day readmissions, need for renal replacement therapy, length of stay, and in-hospital mortality. Continuous and categorical variables were analyzed using student's t-test and chi-square testing. A p-value ≤0.05 was considered significant. Results A total of 206 patients met inclusion criteria. Age, ethnicity, LVEF, type of cardiomyopathy, presence of severe valve disease and comorbidities were similar between patients receiving an intermittent versus continuous loop diuretic strategy. Patients who received a continuous loop diuretic strategy were more likely to be male (71.8% vs 54.5%, p = 0.01), have a higher BMI (32.9 vs 29.3, p = 0.004), have an AKI on admission (52.5% vs 35.1%, p = 0.02), and be on inotropes both pre- and post-RHC (77.6% vs 38.8%, p = Conclusion At our institution, patients receiving a continuous loop diuretic strategy were more likely to be male, have a higher BMI, have an AKI present on admission, and be placed on inotropes during their hospital stay. Patients with this strategy had a longer length of stay but no difference in 30- or 90-day readmissions. Because patients who received continuous loop diuretics were more likely to have acute renal failure and be on inotropes, it will be important to further assess this group's response to continuous versus intermittent loop diuretics as these patients were excluded from prior landmark trials.