Physicians' Academy for Cardiovascular Education

Natriuresis as marker for personalized diuretic therapy in patients with acute HF

News - Aug. 29, 2023

PUSH-AHF: Natriuresis guided therapy in acute heart failure

Presented at the ESC Congress 2023 by: Jozine ter Maaten, MD, PhD - Groningen, the Netherlands

Introduction and methods

The standard treatment of acute HF (AHF) with loop diuretics is not sufficient for a large number of patients. Based on loop diuretics’ ability to promote urinary sodium excretion (natriuresis), the researchers hypothesized natriuresis is a potential marker to guide diuretic therapy and improve treatment of these patients.

The PUSH-AHF (Pragmatic Urinary Sodium-based treatment algoritHm in Acute Heart Failure) trial was a single-center, pragmatic, open-label RCT in which 310 AHF patients who required intravenous (IV) loop diuretic therapy were randomized to natriuresis-guided diuretic therapy or standard of care. In the natriuresis-guided therapy group, spot urine sodium levels were assessed at set time points until 36 hours after initiation of IV loop diuretic therapy. In this treatment group, decongestive therapy was adjusted in patients with an insufficient response based on a prespecified treatment algorithm (spot urinary sodium <70 mmol/L).

The 2 coprimary endpoints were: (1) 24-hour natriuresis; and (2) a composite outcome of time to all-cause mortality or adjudicated HF rehospitalization at 180 days. Statistical significance was set at P<0.025.

Main results


This pragmatic trial showed that natriuresis-guided diuretic therapy was safe and improved natriuresis and diuresis in AHF patients compared with standard of care, without affecting 180-day clinical outcomes. The researchers conclude “natriuresis-guided diuretic therapy is a first personalized approach in treating patients with AHF.”

- Our reporting is based on the information provided at the ESC Congress –

The results of this study were simultaneously published in Nature Medicine.

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