Natriuresis-guided diuretic therapy to facilitate decongestion in acute HF

The PUSH-AHF trial demonstrated that natriuresis-guided diuretic therapy outperformed placebo in terms of natriuresis and diuresis in patients with acute heart failure (HF). Moreover, it was a safe strategy; thus, claim the authors, these results are directly implementable into clinical practice.

“Quick and adequate decongestion in patients with acute HF remains difficult in today’s practice,” said Dr Jozine ter Maaten (University of Groningen, the Netherlands) [1]. “The one-size-fits-all approach that is used falls short in many patients.” Urinary sodium (natriuresis) may guide diuretic therapy to personalise therapy and improve decongestion. The pragmatic, single-centre, open-label, randomised-controlled PUSH-AHF trial (NCT04606927) assessed the effectiveness and safety of natriuresis-guided diuretic therapy in acute HF. Participants in the experimental arm (n=150) received a standardised starting dose of loop diuretics based on renal function and outpatient dose. If the dose was insufficient, defined as urinary sodium <70 mmol/L and diuresis <150 mL/hour, the bolus dose was doubled. If this still proved to be insufficient, hydrochlorothiazide, acetazolamide, or an SGLT2 inhibitor was added. Participants in the control arm (n=160) received the standard-of-care. The dual primary endpoints were 24-hour natriuresis and 180-day all-cause mortality or adjudicated HF hospitalisation.

The first primary endpoint was met, in favour of the natriuresis-guided arm, with an estimated difference of 63 mmol/L urinary sodium at 24 hours (95% CI 18–109; P=0.0061). The second primary endpoint was not met (HR 0.92; 95% CI 0.62–1.38; P=0.70). The effect of natriuresis-guided therapy on natriuresis was maintained at 48 hours (P=0.024). Furthermore, diuresis was improved at both 24 hours (P=0.0053) and 48 hours (P=0.014) in the experimental arm. Dr ter Maaten emphasised that natriuresis-guided therapy did not lead to electrolyte disorders or higher rates of renal or cardiac adverse events.

In summary, natriuresis-guided diuretic therapy was safe, improved natriuresis and diuresis in patients with acute HF. There was, however, no effect of this intervention on 180-day all-cause mortality or adjudicated HF hospitalisation. “The results of this trial are directly applicable as spot urinary sodium values are inexpensive and easy to obtain, as are the medications used in the treatment algorithm,” argued Dr ter Maaten. “Finally, these findings underscore the use of repeated spot urinary sodium assessments for personalised treatment targets as proposed by the ESC HF guidelines.”

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   1. Ter Maaten JM, et al. The pragmatic urinary sodium-based treatment algorithm in acute heart failure (PUSH-AHF) trial. Hot Line Session 8, ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.

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Posted on 30 October 202330 October 2023