Higher Emergency Department Diuretic Dosing for Acute Heart Failure Associated With Lower Risk of Hospitalization

Clinical guidelines recommend treating acute heart failure with intravenous diuretic agents at 1 to 2.5 times the equivalent daily oral loop diuretic dose, although emergency department (ED) outcome data are limited.

This study aimed to assess the association between initial ED diuretic dose and hospital admission or acute kidney injury (AKI) at 48 hours and, secondarily, persistent AKI at hospital discharge.

A retrospective cohort study of adult patients with acute heart failure receiving intravenous diuretic agents from January 1, 2023, to December 31, 2024, across 21 EDs was conducted. Patients were categorized as receiving low (<1× daily outpatient diuretic dose), medium (1-2× daily dose), or high (≥2× daily dose) diuretic dosing, relative to the bioequivalent oral home dose. The authors used inverse propensity treatment weights to balance treatment groups and report risk differences.

This study included 14,983 ED encounters. The median age was 79 years; 7,664 (51.2%) patients were women; and 5,436 (36.3%), 5,329 (35.6%), and 4,218 (28.2%) received a low, medium, and high dose, respectively. Compared with the low-dose group, hospital admission was lower in both the medium- and high-dose groups (risk difference: -2.6%; 95% CI: -4.4% to -0.9% and -1.2%; 95% CI: -3.1% to -0.7%, respectively). Although shorter-term AKI was higher at 48 hours in the high-dose group (2.9%; 95% CI: 1.4%-4.5%), there were no significant differences in persistent AKI at hospital discharge in the higher-dose groups.

Use of higher-dose diuretic agents was associated with lower hospital admissions without evidence of persistent AKI. Future studies should explore adherence to guideline-recommended diuretic dosing.