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Abstract: SA-PO261

Lack of Consistency in Loop Diuretic Strategies of Acute Heart Failure

Session Information

Category: Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)

  • 2000 Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)


  • Belal, Amer Ashaab, University of Florida College of Medicine, Gainesville, Florida, United States
  • Ruiz Toledo, Alejandro Javier, University of Florida College of Medicine, Gainesville, Florida, United States
  • Kazory, Amir, University of Florida College of Medicine, Gainesville, Florida, United States

Symptoms and signs of fluid overload are the primary reason for hospitalization of patients with acute heart failure (AHF). Intravenous loop diuretics (LD) remain the mainstay of therapy in this setting, with a significant subset of patients showing suboptimal response. The efficacy of combination diuretic therapy (CDT), a widely applied strategy to counter renal sodium avidity, is compared against LD-based regimens that are considered the standard of care. We sought to explore the consistency of LD use in contemporary trials of CDT in AHF.


Articles cited in the PubMed database using keywords “acute heart failure”, “diuretic”, and “congestion” were searched. Available data from clinical trials performed between January 2005 and December May 2023 were included. The studies were selected if 1) they were randomized controlled trials that explored the role of CDT in management of AHF, and 2) included loop diuretics as their control arm. Pertinent data on clinical and laboratory parameters (e.g. diuresis, weight change, and renal function) were extracted and reviewed.


A total of 13 studies with 7,826 participants were included with a mean age of 72 years. They consisted of a variety of HF populations with a mean ejection fraction of 38% and an estimated GFR of 49 ml/min. The add-on agents were SGLT-2 inhibitors, acetazolamide, hydrochlorothiazide, spironolactone, and tolvaptan. There was substantial variation across studies both in the loop regimen and the reporting of decongestion markers (e.g. diuresis and weight change). The urine output on day-1 ranged from 1183 to 2400 ml (mean 1620.8 ±413 ml), while weight loss on day-1 was more consistent (0.94 to 1.2 kg; mean 1.04±0.1 kg).


While the current guidelines of AHF recommend intensifying LD therapy prior to CDT to enhance the decongestion process, there is no consensus on an optimal diuretic strategy. This study shows that 1) the LD regimens used in contemporary trials of CDT are highly variable, 2) the inconsistency in these regimens results in a highly variable diuresis as a marker of decongestion, and 3) a reliable comparison of the efficacy of add-on agents is challenging due to lack of consistency in the control arm. These results call for the development of an optimal LD strategy for AHF to help improve the decongestion process.