Physicians' Academy for Cardiovascular Education

Low sodium excretion after diuretics associated with all-cause mortality in acute HF

Clinical importance of urinary sodium excretion in acute heart failure

Literature - Damman K, Ter Maaten JM, Coster JE et al., - Eur J Heart Fail. 2020. doi: 10.1002/ejhf.1753.

Introduction and methods

Treatment of acute heart failure (AHF) is focused on alleviation of congestion, volume overload, and shortening of hospital stay [1,2]. Most of the decongestion is achieved early after admission and decreased in the following days. 25% Of patients have residual signs of congestion at discharge [3]. A rigorous and quick diuretic response is associated with improved outcomes. However, it has been proven difficult to assess the treatment effect of diuretics by evaluating congestion status after start of therapy [4-7].

An Heart Failure Association ESC consensus paper has proposed to study spot urinary sodium and/or diuresis very early after initiation of diuretics, and to intensify or expand (loop) diuretic treatment if natriuresis or diuresis are insufficient [8]. This single-center prospective study aimed to investigate the clinical importance of urinary sodium excretion in AHF patients.

The diagnosis of AHF was based on the ESC heart failure guidelines [1] and enrolled patients (n=175, mean age was 71±14 years, 44% were female) presented with signs and symptoms of congestion, requiring intravenous diuretic therapy. Patients received intravenous vasodilators when systolic blood pressure was >110 mmHg at admission and all patients received bumetanide as the preferred loop diuretic (dose was determined by the treating physician). Urinary volume and urinary sodium were measured from urine collected in the following time frames: 0-6h, 6-24h, 24-48h, 48-72h, and 72-96h after diuretic initiation. The variable of interest was urinary sodium excretion in the first 6 hours after diuretic initiation (urinary sodium concentration x urinary volume over 6h).

The primary clinical endpoint was all-cause mortality after admission. Secondary endpoints included HF rehospitalization after discharge and a combined endpoint of first occurrence of all-cause mortality and/or HF rehospitalization. The median follow-up was 257 (152-427) days.

Main results


This prospective study in patients with AHF showed that low urinary sodium excretion during the first 6h after diuretic initiation was associated with lower urine volume in the first 24h, and with all-cause mortality.


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Find this article online at Eur J Heart Fail.

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