Diuretic strategies in acute heart failure: a systematic review and network meta-analysis of randomized clinical trials.

IF 6.1 1区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

European Heart Journal - Cardiovascular Pharmacotherapy Pub Date : 2025-09-10 DOI:10.1093/ehjcvp/pvaf067

A Cannatà, G Anastasia, V De Marzo, O Caspi, D Bromage, I Porto, G Savarese, T McDonagh, Z L Cox, P Ameri

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引用次数: 0

Abstract

Aims: Several diuretic strategies, including furosemide iv boluses (FB) or continuous infusion (FC), are used in acute heart failure (AHF).

Methods and results: We systematically searched phase 3 randomized clinical trials (RCTs) evaluating diuretic regimens in admitted AHF patients within 48 hours and irrespective of clinical stabilization. We calculated the odds ratio (OR) of FC or FB plus another diuretic (sequential nephron blockade, SNB) compared to FB alone on 24-hour weight loss (WL) and worsening renal function (WRF), with a random-effects model with inverse variance weighting. Urine output, hypokalaemia, hyponatremia, and all-cause mortality/rehospitalization were secondary endpoints.In 25 selected RCTs (7,149 patients, mean age 68.9±8.7 years, mean LVEF 38.2±10.7%), FC (OR 1.55 [95% confidence interval 1.39-1.63], FB plus tolvaptan (OR 1.57 [1.39-1.77]), FB plus SGLT2i (OR 1.23 [1.06-1.42]), and FB plus thiazide (OR 1.63 [1.37-1.94]) were associated with greater WL than FB. FB plus SGLT2i (OR 1.52 [1.19-1.94]) and FB plus acetazolamide (OR 1.81 [1.31-2.49]) were associated with WRF. FB plus thiazide was associated with both WRF (OR 1.78 [1.43-2.21]) and hypokalaemia (OR 1.69 [1.32-2.16]). Results were consistent in sensitivity analyses considering urine output, RCTs protocol-established furosemide doses, or daily furosemide dose. Congestion/decongestion scores and clinical outcomes were reported in around 50% of RCTs. In an underpowered exploratory analysis, mortality/rehospitalization was non-significantly lower with SGLT2i (OR 0.45 [0.19-1.07]).

Conclusions: FC and SNB improve surrogates of response to FB in AHF. SNB is also connoted by WRF and may induce hypokalaemia. The endpoints of diuretic RCTs should be revised and harmonized.

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急性心力衰竭的利尿策略：随机临床试验的系统回顾和网络荟萃分析。

目的：几种利尿策略，包括速尿静脉注射（FB）或持续输注（FC），用于急性心力衰竭（AHF）。方法和结果：我们系统地检索了3期随机临床试验（rct），这些试验评估了住院AHF患者48小时内的利尿剂方案，而不考虑临床稳定情况。我们计算了与单独使用FB相比，FC或FB联合另一种利尿剂（序贯肾元阻断剂，SNB）在24小时体重减轻（WL）和肾功能恶化（WRF）方面的比值比（OR），采用随机效应模型，方差加权为负。尿量、低钾血症、低钠血症和全因死亡率/再住院是次要终点。在所选择的25项随机对照试验（7149例患者，平均年龄68.9±8.7岁，平均LVEF 38.2±10.7%）中，FC (OR 1.55[95%可信区间1.39-1.63]，FB联合托伐普坦（OR 1.57 [1.39-1.77]）， FB联合SGLT2i （OR 1.23[1.06-1.42]）和FB联合噻嗪（OR 1.63[1.37-1.94]）与WL的相关性大于FB。FB + SGLT2i （OR为1.52[1.19-1.94]）和FB +乙酰唑胺（OR为1.81[1.31-2.49]）与WRF相关。FB加噻嗪与WRF （OR为1.78[1.43-2.21]）和低钾血症（OR为1.69[1.32-2.16]）相关。考虑尿量、随机对照试验方案建立的呋塞米剂量或每日呋塞米剂量的敏感性分析结果是一致的。大约50%的随机对照试验报告了拥堵/去拥堵评分和临床结果。在一项不足的探索性分析中，SGLT2i患者的死亡率/再住院率无显著性降低（OR 0.45[0.19-1.07]）。结论：FC和SNB可改善AHF患者对FB的应答。SNB也包含在WRF中，可能导致低钾血症。利尿剂随机对照试验的终点应该修订和统一。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

European Heart Journal - Cardiovascular Pharmacotherapy Medicine-Cardiology and Cardiovascular Medicine

CiteScore

10.10

自引率

14.10%

发文量

期刊介绍： The European Heart Journal - Cardiovascular Pharmacotherapy (EHJ-CVP) is an international, peer-reviewed journal published in English, specifically dedicated to clinical cardiovascular pharmacology. EHJ-CVP publishes original articles focusing on clinical research involving both new and established drugs and methods, along with meta-analyses and topical reviews. The journal's primary aim is to enhance the pharmacological treatment of patients with cardiovascular disease by interpreting and integrating new scientific developments in this field. While the emphasis is on clinical topics, EHJ-CVP also considers basic research articles from fields such as physiology and molecular biology that contribute to the understanding of cardiovascular drug therapy. These may include articles related to new drug development and evaluation, the physiological and pharmacological basis of drug action, metabolism, drug interactions, and side effects.