title: Effect of admission oral diuretic dose on response to continuous versus bolus intravenous diuretics in acute heart failure: an analysis from diuretic optimization strategies in acute heart failure.
abstract: BACKGROUND
  Results from the DOSE-AHF study suggest that an initial continuous infusion of loop diuretics is not superior to bolus dosing with regard to clinical endpoints in acute heart failure. We hypothesized that outpatient furosemide dose was associated with congestion and poorer renal function and explored the hypothesis that a continuous infusion may be more effective in patients on higher outpatient diuretic doses.
  
  
  METHODS
  The DOSE-AHF study randomized 308 patients within 24 hours of admission to high versus low initial intravenous diuretic dose given as either a continuous infusion or bolus. We compared baseline characteristics and assessed associations between mode of administration (bolus vs continuous) and outcomes in patients receiving high-dose (≥120 mg furosemide equivalent, n = 177) versus low-dose (<120 mg furosemide equivalent, n = 131) outpatient diuretics.
  
  
  RESULTS
  Patients on higher doses of furosemide were less frequently on renin-angiotensin system inhibitors (P = .01) and had worse renal function and more advanced symptoms. There was a significant interaction between outpatient dose and mode of therapy (P = .01) with respect to net fluid loss at 72 hours after adjusting for creatinine and intensification strategy. Admission diuretic dose was associated with an increased risk of death or rehospitalization at 60 days (adjusted hazard ratio 1.08 per 20-mg increment in dose, 95% CI 1.01-1.16, P = .03).
  
  
  CONCLUSIONS
  In acute heart failure, patients on higher diuretic doses have greater disease severity and may benefit from an initial bolus strategy.
authors.affiliation: Cardiovascular Division, Massachusetts General Hospital, Boston, USA.
authors.forename: Ravi V
authors.initials: RV
authors.lastname: Shah
authors.forename: Steven
authors.initials: S
authors.lastname: McNulty
authors.forename: Christopher M
authors.initials: CM
authors.lastname: O'Connor
authors.forename: G Michael
authors.initials: GM
authors.lastname: Felker
authors.forename: Eugene
authors.initials: E
authors.lastname: Braunwald
authors.forename: Michael M
authors.initials: MM
authors.lastname: Givertz
mesh_terms: D000208:Acute Disease; D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D003404:Creatinine / Q000097:blood; D055316:Cystatin C / Q000097:blood; D004232:Diuretics / Q000008:administration & dosage* / Q000009:adverse effects; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D005665:Furosemide / Q000008:administration & dosage* / Q000009:adverse effects; D006333:Heart Failure / Q000097:blood / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010045:Outpatients; D010147:Pain Measurement / Q000187:drug effects; D010359:Patient Readmission; D010446:Peptide Fragments / Q000097:blood; D016016:Proportional Hazards Models; D016896:Treatment Outcome
chemical_list: D055316:Cystatin C; D004232:Diuretics; D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain; D005665:Furosemide; D003404:Creatinine