Efficacy and safety of ambulatory, weekly, high-intensity intravenous diuretic strategy for congestion-refractory heart failure patients: insights from the DEA-HF prospective randomized clinical trial - The 72nd Annual Conference of the Israel Heart Society in association with the Israel Society of Cardiothoracic Surgery

Ronnie Abbo ¹ Amit Gruber ^1,2 Ina Volis ¹ Doron Aronson ^1,2 Nicolas Girerd ³ Elena Sitnitsky ¹ Anton Kruger ¹ Ludmila Helmer ¹ Polina Khasis ¹ Evgeny Bravo ¹ Boaz Elad ¹ Oren Caspi ^1,2,4

¹Cardiology Department, Rambam Health Care Campus, Israel
²Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel
³Centre d'Investigations Cliniques-Plurithmatique, Universite de Lorraine, France
⁴Clinical Research Institute (CRIR), Rambam Health Care Campus, Israel

Introduction:

Ambulatory oral diuretic treatment has limited efficacy in managing chronic heart failure (HF) patients. Novel strategies are needed to manage patients with refractory congestion despite optimal HF therapy and high-dose oral diuretic treatment. We prospectively quantified the efficacy and safety of an ambulatory, weekly, high-dose parenteral diuresis strategy.

Methods and results:

Data from the prospective, randomized, cross-over controlled study for comparisons of diuresis efficacy in HF patients (DEA-HF) was analyzed. 42 patients with congestion despite guideline-directed medical therapy were enrolled to receive three high-intensity diuretic regimens, once a week, in a randomized order: intravenous (IV) furosemide 250mg; IV furosemide 250mg+oral metolazone 5mg; and IV furosemide 250mg+IV acetazolamide 500mg. The primary outcome compared the total sodium excretion following each diuretic regimen. Here, all regimens were pooled to assess the effect of the weekly intensive diuresis approach on congestion parameters. Following 3 consecutive weekly treatments, the mean body weight decreased from 85.5kg (95% CI: 79.7-91.2) to 83.1kg (95% CI: 77.4-88.9. P=0.0005), accompanied by a significant decrease in NT-ProBNP levels, congestion score, and lung ultrasound B-line count. Serum creatinine mildly but significantly increased from 1.81mg/dl (95% CI: 1.62-2.01) to 2.01mg/dl (95% CI: 1.81-2.21. P<0.001). No HF-related hospitalizations or renal replacement therapies were performed, nor did acute kidney injury hospitalizations occur in a 4-week follow-up period.

Conclusions:

In patients with congestion-refractory HF, a strategy utilizing high-intensity weekly IV diuresis therapy in addition to daily oral diuretics achieved effective decongestion without major safety concerns. This escalated strategy may improve clinical outcomes and prevent hospitalizations of chronic HF patients who require diuresis intensification.