Aggressive loop diuretic therapy does not affect GDMT prescription rates after acute HF

In a PUSH-AHF substudy among hospitalized acute HF patients, the proportions of patients receiving GDMT at discharge and the achieved GDMT doses did not differ between the natriuresis-guided therapy and standard-care arms.

This summary is based on the publication of Voors AA, Damman K, Beldhuis IE, et al. - Discharge Medication After Natriuresis-Guided Dosing of Diuretic Therapy in Patients Hospitalized for Acute Heart Failure: A PUSH-AHF Substudy. JACC Heart Fail. 2025 Jan;13(1):179-181. doi: 10.1016/j.jchf.2024.09.018

Introduction and methods

Background

Recently, the PUSH-AHF (Pragmatic Urinary Sodium–Based Treatment Algorithm in Acute Heart Failure) trial recently showed that natriuresis-guided diuretic therapy improved natriuresis and diuresis in patients hospitalized for acute HF (AHF) compared with standard care [1]. However, this personalized approach came with a greater eGFR decline during the first 3 days, which was attenuated at discharge [2]. There is concern that a temporary decline in renal function leads to delayed initiation and uptitration of GDMT.

Aim of the study

In a substudy of the PUSH-AHF trial, the authors compared the proportions of patients receiving GDMT at discharge and the GDMT doses achieved in hospitalized AHF patients treated with natriuresis-guided therapy versus standard care.

Methods

The PUSH-AHF trial was a prospective, single-center, pragmatic, open-label RCT in which 310 patients with AHF who required treatment with intravenous loop diuretics were randomized to natriuresis-guided therapy or standard care. In the natriuresis-guided therapy arm, diuretic treatment was intensified according to a prespecified stepwise approach in patients with low spot urinary sodium levels (<70 mmol/L) or insufficient diuresis (<150 mL/h) and maintained in those with sufficient decongestive response.

Main results

• The proportions of patients treated with an ACEi/ARB/ARNI, MRA, or SGLT2 inhibitor at discharge did not differ between the natriuresis-guided therapy and standard-care groups (all P>0.05).
• The median percentages of the recommended GDMT doses at discharge were not different for patients randomized to natriuresis-guided therapy and those assigned to the standard care (all P>0.05).
• Furthermore, the frequencies of adverse events, including worsening HF and worsening renal function, and serious adverse events were similar in the 2 treatment groups.

Conclusion

In this substudy of the PUSH-AHF trial among hospitalized AHF patients, the proportions of patients receiving GDMT at discharge and the achieved GDMT doses did not differ between the natriuresis-guided therapy and standard-care arms. The authors therefore believe that “intensified diuretic strategy in patients resulting in a temporary decline of kidney function is not in conflict with the proven strategy of early and fast uptitration of GDMT.”

Find this article online at JACC Heart Fail.

References

1. Ter Maaten JM, Beldhuis IE, van der Meer P, et al. Natriuresis-guided diuretic therapy in acute heart failure: a pragmatic randomized trial. Nat Med. 2023;29:2625–2632.
2. Damman K, Beldhuis IE, van der Meer P, et al. Renal function and natriuresis guided diuretic therapy—a prespecified analysis from the PUSH-AHF trial. Eur J Heart Fail. 2024;26(6):1347–1357.