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Higher Emergency Department Diuretic Dosing for Acute Heart Failure Associated With Lower Risk of Hospitalization
Dana R Sax1, Dustin G Mark1, Jie Huang2
1Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California, USA; Kaiser Permanente Division of Research, Pleasanton, California, USA.
JACC. Heart Failure
|July 31, 2026
Summary
Higher doses of intravenous diuretics in the emergency department for acute heart failure were linked to fewer hospital admissions. This approach did not increase the risk of persistent acute kidney injury (AKI) upon discharge.
Area of Science:
- Cardiology
- Nephrology
- Emergency Medicine
Background:
- Clinical guidelines suggest higher intravenous diuretic doses for acute heart failure.
- Limited emergency department (ED) outcome data exists for these dosing strategies.
Purpose of the Study:
- To evaluate the association between initial ED diuretic dose and hospital admission or acute kidney injury (AKI) within 48 hours.
- Secondarily, to assess the impact on persistent AKI at hospital discharge.
Main Methods:
- Retrospective cohort study of 14,983 adult patients with acute heart failure across 21 EDs.
- Patients received intravenous diuretics categorized by dose (low, medium, high) relative to oral home dose.
- Inverse propensity treatment weights were used to balance groups and analyze outcomes.
Main Results:
- Higher diuretic doses (medium and high) were associated with significantly lower hospital admission rates compared to low doses.
- While short-term AKI at 48 hours was higher in the high-dose group, no significant difference in persistent AKI at discharge was observed.
- No increased risk of persistent AKI at discharge was found with higher initial diuretic doses.
Conclusions:
- Higher-dose intravenous diuretic administration in the ED for acute heart failure correlates with reduced hospital admissions.
- This strategy did not demonstrate an increased risk of persistent acute kidney injury (AKI) at hospital discharge.
- Further research is recommended to investigate adherence to guideline-recommended diuretic dosing in clinical practice.
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