title: Clinical effects and safety of different strategies for administering intravenous diuretics in acutely decompensated heart failure: a randomised clinical trial.
abstract: BACKGROUND
  The mainstay of treatment for acutely decompensated heart failure (ADHF) is intravenous diuretic therapy either as a bolus or via continuous infusion.
  
  
  OBJECTIVE
  We evaluated the clinical effects and safety of three strategies of intravenous furosemide administration used in emergency departments (EDs) for ADHF.
  
  
  METHODS
  We performed a multicentre, randomised, parallel-group study. Patients with ADHF were randomised within 2 h of ED arrival to receive furosemide by continuous infusion (10 mg/h, group 1) or boluses (20 mg/6 h, group 2; or 20 mg/8 h, group 3). The primary end point was total diuresis, and secondary end points were dyspnoea, orthopnoea, extension of rales and peripheral oedema, blood pressure, respiratory and heart rates, and pulse oximetry, which were measured at arrival and 3, 6, 12 and 24 h after treatment onset. We also measured serum creatinine, sodium and potassium levels at arrival and after 24 h.
  
  
  RESULTS
  Group 1 patients (n=36) showed greater 24 h diuresis (3705 mL) than those in groups 2 (n=37) and 3 (n=36) (3093 and 2670 mL, respectively; p<0.01), and this greater diuretic effect was observed earlier. However, no differences were observed among groups in the nine secondary clinical end points evaluated. Creatinine deterioration developed in 15.6% of patients, hyponatraemia in 9.2%, and hypokalaemia in 19.3%, with the only difference among groups observed in hypokalaemia (group 1, 36.3%; group 2, 13.5%; group 3, 8.3%; p<0.01).
  
  
  CONCLUSIONS
  In patients with ADHF attending the ED, boluses of furosemide have a smaller diuretic effect but provide similar clinical relief, similar preservation of renal function, and a lower incidence of hypokalaemia than continuous infusion.
  
  
  BACKGROUND
  This randomised trial was registered in the European Clinical Trial Database (EudraCT) with the reference number 2008-004488-20.
authors.affiliation: Emergency Department and Short-Stay Unit, Hospital General Universitario de Alicante, Alicante, Spain.
authors.forename: Pere
authors.initials: P
authors.lastname: Llorens
authors.affiliation: Emergency Department, Hospital Clinic de Barcelona; 'Emergencies: Processes and Pathologies' Research Group, IDIBAPS, Barcelona, Spain.
authors.forename: Òscar
authors.initials: Ò
authors.lastname: Miró
authors.affiliation: Emergency Department, Hospital Universitario Central de Asturias, Oviedo, Spain.
authors.forename: Pablo
authors.initials: P
authors.lastname: Herrero
authors.affiliation: Emergency Department, Hospital Clínico San Carlos de Madrid, Madrid, Spain.
authors.forename: Francisco Javier
authors.initials: FJ
authors.lastname: Martín-Sánchez
authors.affiliation: Emergency Department, Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Javier
authors.initials: J
authors.lastname: Jacob
authors.affiliation: Emergency Department, Hospital Dr Peset, Valencia, Spain.
authors.forename: Amparo
authors.initials: A
authors.lastname: Valero
authors.affiliation: Emergency Department, Hospital Marques de Valdecilla, Santander, Spain.
authors.forename: Héctor
authors.initials: H
authors.lastname: Alonso
authors.affiliation: Emergency Department, Hospital la Fe, Valencia, Spain.
authors.forename: María José
authors.initials: MJ
authors.lastname: Pérez-Durá
authors.affiliation: Emergency Department, Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: Noval
authors.affiliation: Emergency Department, Hospital Universitario Central de Asturias, Oviedo, Spain.
authors.forename: José Juan
authors.initials: JJ
authors.lastname: Gil-Román
authors.affiliation: Clinical Pharmacology Unit, Hospital General Universitario de Alicante, Alicante, Spain.
authors.forename: Pedro
authors.initials: P
authors.lastname: Zapater
authors.affiliation: Clinical Pharmacology Unit, Hospital General Universitario de Alicante, Alicante, Spain.
authors.forename: Lucía
authors.initials: L
authors.lastname: Llanos
authors.affiliation: Emergency Department, Hospital Clinic de Barcelona; 'Emergencies: Processes and Pathologies' Research Group, IDIBAPS, Barcelona, Spain.
authors.forename: Víctor
authors.initials: V
authors.lastname: Gil
authors.affiliation: Emergency Department, Hospital Clinic de Barcelona; 'Emergencies: Processes and Pathologies' Research Group, IDIBAPS, Barcelona, Spain.
authors.forename: Rafel
authors.initials: R
authors.lastname: Perelló
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D003404:Creatinine / Q000097:blood; D004232:Diuretics / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D005665:Furosemide / Q000008:administration & dosage* / Q000009:adverse effects; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D007008:Hypokalemia / Q000209:etiology; D007010:Hyponatremia / Q000209:etiology; D007262:Infusions, Intravenous; D008297:Male; D036301:Qualitative Research; D051437:Renal Insufficiency / Q000097:blood / Q000188:drug therapy*; D011795:Surveys and Questionnaires
chemical_list: D015415:Biomarkers; D004232:Diuretics; D005665:Furosemide; D003404:Creatinine
keywords: emergency departments; heart failure; treatment