Comparative Strategies to Overcome Diuretic Resistance in Heart Failure: A Network Meta-Analysis.

Area of Science:

• Cardiology
• Pharmacology
• Nephrology

Background:

• Diuretic resistance is a significant challenge in managing fluid overload in heart failure (HF).
• Current add-on strategies for diuretic resistance lack comparative efficacy and safety data.
• Understanding optimal treatment pathways is crucial for improving patient outcomes.

Purpose of the Study:

• To conduct a network meta-analysis comparing pharmacologic strategies for diuretic resistance in HF.
• To evaluate the efficacy and safety of various treatments using randomized controlled trials (RCTs).
• To provide evidence-based guidance for clinical decision-making in resistant HF.

Main Methods:

• Systematic search of PubMed and Embase databases (January 2000-June 2024) for relevant RCTs.
• Inclusion of adult HF patients with diuretic resistance.
• Random-effects network meta-analysis to pool data on urine output, weight change, hospitalizations, mortality, and acute kidney injury (AKI).

Main Results:

• Tolvaptan and low-dose loop diuretics plus tolvaptan significantly increased 72-hour urine output.
• Hydrochlorothiazide and tolvaptan demonstrated the greatest standardized reductions in 72-hour weight.
• Sodium-glucose cotransporter 2 inhibitors (dapagliflozin, empagliflozin) reduced HF hospitalizations.
• High-dose loop diuretics and hydrochlorothiazide were associated with increased risk of AKI.

Conclusions:

• Sodium-glucose cotransporter 2 inhibitors may reduce HF rehospitalizations with a favorable renal safety profile.
• Nephron-segment add-on therapies improve short-term decongestion but necessitate monitoring for AKI and electrolyte imbalances.
• Treatment choices should consider absolute effects and confidence intervals, recognizing the exploratory nature of comparative rankings.