Natriuretic response and diuretic exposure according to congestion phenotype
F Croset, E Perez, M Garcia, C Perez, M Vergara, P Cevallos, J E Rodriguez, B Del Hoyo, J Campos, A Perez, P Llacer, L ManzanoAbstract
Background
Distinct congestion phenotypes have been described in patients hospitalized with acute heart failure (AHF). Early natriuresis has emerged as a key biomarker to guide decongestion and optimize titration of IV loop diuretics during the initial phase of hospitalization. While differences in natriuretic response across congestion phenotypes have not been previously characterized, it is also unclear whether these phenotypes are associated with differences in diuretic exposure during hospitalization.
Purpose
The primary objective was to assess the association between congestion phenotype and early natriuretic response, with a secondary aim of evaluating differences in diuretic exposure.
Methods
We conducted a retrospective observational study of patients hospitalized for acute heart failure who received intravenous furosemide. At admission, patients were classified into four mutually exclusive congestion phenotypes: intravascular (JVP >6 cm H₂O without tissue congestion), tissue (peripheral oedema ≥2+, pulmonary rales over ≥1/3 of lung fields, or mild oedema with limited rales), combined (both intravascular and tissue congestion), and mild (JVP <6 cm H₂O with mild oedema or limited rales). Urinary sodium and chloride were measured 2 hours after the first IV furosemide dose on day 2 of admission, following initiation of an ESC natriuresis-guided decongestion protocol during the first 24 hours.
Results
We included 808 patients (median age 88 years, IQR 84–91; 66% women; 80% with preserved LVEF). Congestion phenotypes were mild in 161 (20%), intravascular in 70 (9%), tissue in 444 (55%), and combined in 133 (16%). Urinary sodium and chloride differed across phenotypes (p=0.005 and p=0.015), highest in combined congestion. The proportion with high natriuretic response (uNa >70 mmol/L) increased progressively from mild to intravascular, tissue, and combined congestion (p=0.004) (Figure 1). Pre-admission oral furosemide did not differ (p=0.145), but total and daily IV furosemide doses varied significantly (both p<0.001) (Figure 2). Combination diuretic use was similar (p=0.499), whereas oral furosemide at discharge differed by phenotype (p<0.001).
Conclusions
Congestion phenotype at admission is associated with significant differences in early natriuretic response in patients with AHF. In addition, congestion phenotypes were associated with distinct patterns of diuretic exposure during hospitalization and at discharge. These findings suggest that diuretic therapy should be individualized, as distinct congestion phenotypes may require different treatment strategies.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.