Department of Cardiology, Ospedale Maggiore di Lodi, Lodi, Italy.
Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
Int J Cardiol. 2024 Nov 15;415:132456. doi: 10.1016/j.ijcard.2024.132456. Epub 2024 Aug 14.
Diuretic resistance is a relevant clinical issue in acute heart failure (AHF), but a standardized, quantitative definition is still missing. The aim of this analysis was to highlight discrepancies between previously proposed definitions of diuretic response and to propose a new urinary sodium (NaU)-based definition of diuretic efficiency (DE) to identify diuretic resistant (DR) patients.
Three historical definitions of diuretic response and a new NaU-based DE definition, evaluating total NaU after the first diuretic bolus per 40 mg furosemide administered, were applied in a retrospective analysis to an AHF population treated with intravenous (i.v.) loop diuretics. Baseline characteristics, in-hospital clinical data and outcomes at discharge and mid-term follow-up were collected and compared among DR and non-DR patients for each definition.
Among 53 patients, 39 (73.6%), 51 (96.2%) and 3 (5.7%) were DR according to weight-derived, diuresis-derived, and spot NaU definition, respectively. The median value of the new NaU-based definition was 31 mmol/40 mg and patients were stratified accordingly. DR patients showed lower cumulative diuresis (5200 mL, 3300-6700 vs 9825 mL, 6200-12200, p = 0.007) and weight loss (4 kg, 1-5 vs 6 kg, 3-8.5, p = 0.023), higher BNP levels (808 pg/mL, 443-1037 vs 351 pg/mL, 209-859, p = 0.062) at the conclusion of protocol-guided i.v diuretic therapy, which was less frequently stopped due to decongestion in DR as compared to non-DR patients (57.7% vs 85.2%, p = 0.026). Six-months mortality or HF hospitalizations were more frequent in DR patients (OR 18.6, 95% CI 2.1-161.2, p = 0.008).
The NaU-based DE definition might solve discrepancies of other previously proposed definitions.
利尿剂抵抗是急性心力衰竭（AHF）中的一个重要临床问题，但目前仍缺乏标准化、定量的定义。本分析旨在强调先前提出的利尿剂反应定义之间的差异，并提出一种新的基于尿钠（NaU）的利尿剂效率（DE）定义，以识别利尿剂抵抗（DR）患者。
对接受静脉（iv）袢利尿剂治疗的 AHF 患者进行回顾性分析，应用三种历史上的利尿剂反应定义和一种新的基于 NaU 的 DE 定义，评估首次给予呋塞米 40mg 后每 40mg 利尿剂的总 NaU。收集并比较各定义下 DR 和非 DR 患者的基线特征、住院临床数据和出院及中期随访结局。
在 53 例患者中，根据体重衍生、利尿衍生和即时 NaU 定义，分别有 39 例（73.6%）、51 例（96.2%）和 3 例（5.7%）为 DR。新的基于 NaU 的定义的中位数为 31mmol/40mg，并据此进行分层。DR 患者的累积尿量（5200ml，3300-6700 vs 9825ml，6200-12200，p=0.007）和体重减轻量（4kg，1-5 vs 6kg，3-8.5，p=0.023）较低，B 型利钠肽（BNP）水平较高（808pg/ml，443-1037 vs 351pg/ml，209-859，p=0.062），在协议指导的 iv 利尿剂治疗结束时，DR 患者较少因充血而停止治疗（57.7% vs 85.2%，p=0.026）。DR 患者 6 个月死亡率或 HF 住院率更高（OR 18.6，95%CI 2.1-161.2，p=0.008）。
基于 NaU 的 DE 定义可能解决了其他先前提出的定义之间的差异。
