The efficacy of a standardized natriuresis guided diuretic protocol in patients with with acute heart failure (ENACT-HF study)

The latest guidelines from the European Society of Cardiology (ESC), recommend the use of urinary sodium to guide diuretic therapy in case of acute heart failure, because despite the widespeared recommendations of diuretic by both the ESC, AHA, ACC, there is a paucity of data supporting diuretic strategies, encompassing factors such a type, dosage, and route of administration.

In January 2024, was published the ENACT-HF study, which included 401 patients from 29 centers in 18 countries, stands for efficacy of standardized diuretic protocol in acute heart failure. Patients were divided into two groups: a group of patients who were on standard diuretic therapy and a group of patients who were treated with diuretics according to a protocol with dose calculation depending on the concentration of sodium in the urine.

The protocol used in the second group of patients involved intravenous bolus administration of loop diuretics twice daily. The initial bolus was administered in a volume equal to twice the oral diuretic dose (maximum dose of 200 mg furosemide). Urinary sodium concentration was then assessed 2 hours later (target urinary sodium > 100 mL/h). The second bolus of diuretic was administered 6–12 hours after the first bolus. If urinary sodium concentration and urine output met predetermined goals, a second bolus was administered at the same dose as the first. Natriuresis was higher in the protocol-treated group compared with the standard-of-care group (282 vs. 174 mmol; mean ratio 1.64; p < 0.001). In addition, the difference was significantly greater in patients with a lower estimated glomerular filtration rate and in patients receiving higher doses of oral maintenance loop diuretics (mean ratio 1.88 ; p < 0.001). There was also a shorter length of hospital stay in the per-protocol group (5.8 vs 7.0 days; mean ratio 0.87; p=0.036). In-hospital mortality was low and did not differ between groups (1.4% vs. 2.0%; p=0.852).

The use of standardized natriuresis-guided loop diuretic protocol was found to be feasible and safe. It was further linked to heightened natriuresis and diuresis, along with a reduced length of hospital stay.

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