BACKGROUND: Acute decompensated heart failure (ADHF) is a clinical syndrome associated with high morbidity and mortality. Current guidelines emphasize the importance of oxygenation and diuresis; however, there is no clear recommendation regarding whether loop diuretics should be administered as bolus or continuous infusion. This study aimed to compare the early effectiveness of bolus versus continuous infusion diuretic therapy in the emergency department (ED).
METHODS: This was a single-center, prospective, randomized, double-blind, parallel-group clinical trial. Patients aged =18 years with ADHF and no known chronic kidney disease were included. They were randomized in a 1:1 ratio to receive intravenous furosemide as either a bolus or continuous infusion. Allocation concealment was achieved using opaque envelopes. Double-blinding was maintained by applying placebo-mimicking interventions in both groups. The primary outcome was cumulative urine output at 2 and 4 h. Secondary outcomes were changes in the internal jugular vein collapsibility index (JVCI) at 2 and 4 h. The tertiary outcome was spot urinary sodium levels measured at 2 and 4 h.
RESULTS: A total of 136 patients were screened, 56 were randomized, and 50 were included in the final analysis. The median cumulative urine output at 0-4 h was 2150 mL (IQR 800-4200) in the bolus group and 2400 mL (IQR 900-6250) in the infusion group, with no significant difference between groups (p = 0.60). No significant differences were observed in JVCI changes at 2 and 4 h (p = 0.138 and p = 0.892, respectively). However, JVCI increased significantly over time across the entire cohort (p < 0.001). Median spot urinary sodium levels were 117 (IQR 74-132) in the bolus group and 107 (IQR 70-141) in the infusion group, without a significant difference (p = 0.273).
CONCLUSION: In ED patients with ADHF, bolus and continuous infusion diuretic therapies showed no significant difference in early diuresis or urinary sodium excretion. The observed dynamic changes in JVCI suggest that congestion may be monitored in the early phase. These findings indicate that patient hemodynamics and objective congestion assessment may be more clinically relevant than the method of diuretic administration. The study was registered at ClinicalTrials.gov (NCT07464249).
| Discipline Area | Score |
|---|---|
| Emergency Medicine |  |
| Hospital Doctor/Hospitalists | Coming Soon... |
| Internal Medicine | Coming Soon... |
| Cardiology | Coming Soon... |
High-quality RCT that answers an important clinical question.
This is a small double-blinded RCT. The study addressed a relevant topic for Emergency Medicine and Critical Care. They did not find any differences in urine output, urine sodium at 2 hours and 4 hours post-intervention. The study period might be too short.
I frequently treat patients with acute heart failure, so the topic of the present trial is of particular interest to me. I usually administer boluses of furosemide, reserving continuous infusion for diuretic resistance or when high doses of loop diuretics are needed. These situations are not addressed in the present trial, which focuses on the initial management of acute heart failure, but additional information regarding the best way of administering loop diuretics is welcome. It would be particularly valuable for future studies to focus on patients with specific conditions linked to a poor prognosis, such as diuretic resistance, in which continuous infusion is thought to offer greater benefits.
The sample size is small and the primary outcome seems restrictive from a clinical point of view. Results are in concordance with most of the previous research: no difference between bolus or infusion for diuretics in ADHF.
