Impact of routine urine sodium evaluation on diuretic practices in patients with acute heart failure

Natriuresis-guided diuresis has been investigated in prospective trials for acute heart failure (HF), but its impact on diuretic prescribing in clinical practice is uncertain.

From September 2021, routine urine sodium measurement was implemented for all patients admitted with acute HF to our intensive cardiac care unit. We compared diuretic prescribing in 160 prospective post-implementation patients (up to April 2023) with 206 historical controls (from January 2020). Multivariable logistic regression evaluated the odds of aggressive diuretic use, defined as the upper tertile of total furosemide dose administered within the first 72 h (≥340 mg). Propensity score matching on prespecified covariates created a balanced cohort for sensitivity analysis.

The median age was 71 (interquartile range 60-80), with 252 (69%) men. Post-implementation, patients received higher median total furosemide dose at 72 h (340 [180-525] mg vs. 220 [120-320] mg; P < .001), and were more likely to receive aggressive diuresis (adjusted OR 4.8, 95% CI 2.86-8.25; P < .001). Propensity score matching of 264 patients yielded consistent results (adjusted OR 5.2, 95% CI 3.004-9.46; P < .001). At 72 h, the post-implementation group had higher cumulative urine output (6250 mL vs. 4873 mL; P < .001) and more frequent resolution of jugular venous distension (25% vs. 5%; P < .001) and peripheral oedema (14% vs. 5%; P = .009), with no difference in pleural effusion (7% vs. 5%; P = .550).

Routine urine sodium measurement in acute HF patients in intensive care settings was associated with more aggressive diuretic use, increased diuresis, and more rapid improvement in congestion markers.