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ENACT-HF: Standardised diuretic protocol improves natriuresis in acute heart failure

Presented By
Dr Jeroen Dauw, AZ Sint-Lucas in Ghent, Belgium
HFA 2023

Following a natriuresis guided protocol in diuretic use led to a 64% increased natriuresis after 24 hours. In addition, duration of hospitalisation was 1 day shorter in the intervention group in the prospective ENACT-HF trial.

Current guidelines recommend a standardised diuretic protocol for diuretic use that has not been evaluated prospectively. To test whether a standardised diuretic protocol is superior to standard-of-care, Dr Jeroen Dauw (AZ Sint-Lucas in Ghent, Belgium) performed the prospective, multicentre, open-label, non-randomised, pragmatic ENACT-HF trial [1]. The study included 29 centres in 18 countries worldwide. In each centre, standard-of-care was compared with a standardised diuretic protocol in 2 sequential phases of recruitment: standard-of-care was used in phase 1, and the standardised protocol was followed in phase 2.

All 401 study participants had been admitted with acute heart failure and had at least 1 sign of volume overload. The primary endpoint was natriuresis after 1 day. Secondary endpoints included natriuresis and diuresis after 2 days, weight loss after 2 days, change in a congestion score, and duration of hospitalisation.

Following the standardised protocol led to an increase in natriuresis of 64% after 1 day (natriuresis after 1 day was 174 mmol in the standard-of-care group compared with 282 mmol in the protocol group; 95% CI 1.37–1.95; P<0.001). A predefined subgroup analysis revealed that patients had a benefit independent of age, sex, kidney function, and left ventricular ejection fraction. “Those with a lower glomerular filtration rate had even a higher benefit,” Dr Dauw said.

The superiority of the protocol was also seen in both natriuresis and diuresis on day 2. They were significantly higher in the group following the diuretic protocol (P<0.001 for both comparisons). No difference was seen in weight loss and congestion score after 2 days, but weight loss is possibly less reliable in a pragmatic design. “We had a high congestion score already at the beginning of the trial, it might therefore take more time for these patients to see a difference,” Dr Dauw said. Patients following the protocol had a 1-day shorter duration of hospitalisation. There was no difference in the safety endpoints between standard-of-care and the diuretic protocol.

    1. Dauw J. Efficacy of a standardised diuretic protocol in acute heart failure. Session Late breaking clinical trials: acute heart failure and patients monitoring, Heart Failure 2023, 20–23 May, Prague, Czechia.


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