A realistic natriuresis-guided diuretic strategy in sufferers with acute coronary heart failure considerably will increase 24-hour natriuresis with out impacting all-cause mortality or coronary heart failure rehospitalization, in accordance with late breaking analysis introduced in a Scorching Line session in the present day at ESC Congress 2023.

The PUSH-AHF trial offers the primary randomized proof supporting the natriuresis-guided remedy strategy suggested within the ESC coronary heart failure tips.”

Dr. Jozine ter Maaten, Principal Investigator, College Medical Centre Groningen

Hospitalization for acute coronary heart failure is predominantly on account of indicators and signs of congestion, similar to breathlessness, edema and fatigue. The first aim is to do away with the surplus fluid, and the principle remedy for that is loop diuretic remedy. Nonetheless, a lot of sufferers have an inadequate response to diuretics, which is related to residual congestion and an elevated danger of mortality and coronary heart failure rehospitalization. In present follow, it’s tough to adequately and reliably monitor response to diuretics. Surrogate measures similar to weight reduction and internet fluid output are sometimes used, however these are sometimes unreliable and require ready a minimum of 24 hours after the beginning of diuretics for the primary evaluation. ESC tips advocate early and repeated evaluation of spot urinary sodium in sufferers with acute coronary heart failure to information diuretic remedy, however to this point there are restricted, non-randomized knowledge displaying the usefulness of this strategy.

The PUSH-AHF trial investigated the effectiveness of natriuresis-guided diuretic remedy on natriuresis and scientific outcomes in sufferers with acute coronary heart failure and offers the primary randomized knowledge on this proposed customized remedy strategy. Grownup sufferers presenting with acute coronary heart failure requiring remedy with intravenous loop diuretics have been enrolled. The inclusion and exclusion standards have been deliberately broad to enroll a recent, consultant, all-comer acute coronary heart failure inhabitants.

Sufferers have been randomized in a 1:1 ratio to natriuresis-guided diuretic remedy or normal of care utilizing digital well being information. Within the natriuresis-guided group, spot urinary sodium was decided at 2, 6, 12, 18, 24 and 36 hours after beginning intravenous loop diuretics. Diuretic remedy was consequently intensified utilizing a prespecified stepwise strategy if response was inadequate (spot urinary sodium under 70 mmol and/or diuresis under 150 ml/hour). Physicians have been blinded to urinary sodium ranges in the usual of care arm to stop cross-over between remedy arms.

The examine had two major endpoints and p<0.025 for every was thought of statistically vital: 1) 24-hour natriuresis, and a couple of) a mixed endpoint of time to all-cause mortality or coronary heart failure rehospitalization at 180 days.

A complete of 310 sufferers have been enrolled from the College Medical Centre Groningen, the Netherlands. The median age of the sufferers was 74 years and 45% have been girls. Natriuresis throughout the first 24 hours was considerably larger within the natriuresis-guided versus standard-of-care group (409±178 vs. 345±202 mmol, respectively; p=0.0061). The mixed endpoint of time to all-cause mortality or first coronary heart failure rehospitalization at 180 days occurred in 46 sufferers (31%) within the natriuresis-guided group and in 50 sufferers (31%) within the standard-of-care group with no vital distinction between teams (hazard ratio: 0.92; 95% confidence interval 0.62-1.38; p=0.6980).

Relating to secondary endpoints, natriuresis guided remedy resulted in elevated 48-hour natriuresis (653±249 vs. 575±290 mmol; p=0.0241), 24-hour diuresis (3,900 [interquartile range (IQR) 3,200-4,945] vs. 3,330 [IQR 2,510-4,500] mL; p=0.0053), in addition to 48-hour diuresis (6,655 [IQR 5,401-7,824] vs. 5915 [IQR 4,600-7,400] mL; p=0.0140). The size of hospital keep was not considerably totally different within the natriuresis-guided group (6 [IQR 5-9] days) versus the usual of care group (7 [IQR 5-10 days]; p=0.1436).

Natriuresis-guided remedy had an identical security profile to straightforward of care and there was no distinction in prespecified renal security endpoints or worsening renal operate.

Dr. ter Maaten stated: “The outcomes verify the speculation that early, repeated evaluation of urinary sodium and subsequent changes to diuretic remedy result in higher response. Though 180-day scientific consequence was not affected on this comparatively small pattern dimension, the technique was protected and didn’t end in vital renal or electrolyte perturbations in contrast with normal of care. Clinicians ought to think about natriuresis guided diuretic remedy as a primary step to a customized remedy strategy in sufferers with acute coronary heart failure to enhance decongestion.”