Adequacy of Loop Diuretic Dosing in Treatment of Acute Heart Failure: Insights from the BAN-ADHF Diuretic Resistance Risk Score
Joseph Mauch, Max Puthenpura, Pieter Martens, Timothy Engelman, Justin L. Grodin, Matthew W. Segar, Ambarish Pandey, W.H. Wilson Tang
Abstract
Diuretic resistance (DR) is common among patients admitted with acute heart failure (AHF) and can be estimated by BAN-ADHF scores. Among 317 consecutive patients hospitalized for AHF, BAN-ADHF scores were compared with metrics of DR and composite endpoint of all-cause mortality, HF hospitalization, LVAD, or heart transplantation. The BAN-ADHF score was incorporated into a diuretic dosing calculator and retroactively applied to a patient's diuretic dose to categorize them as adequately dosed or under-dosed (inadequate). The primary outcome studied was attaining >3 L of urine output within the first 24 hours of admission. The median BAN-ADHF score was 9 (IQR of 7-13). A higher BAN-ADHF score was associated with greater DR based on weight loss and urine output (all p <0.001). The highest quartile (Q4) had fewer patients achieve the admission urinary output goal (15% vs 32%, p = 0.004) and lower total urine output (2,009 mL vs 2,559 mL, p = 0.029) compared with the first 3 quartiles. In time-to-event analysis, Q4 of BAN-ADHF score was associated with increased risk of the primary composite endpoint (HR 2.07, 95% CI 1.41 to 3.04). Compared to those below the calculator's recommended dose, patients receiving loop diuretics at goal doses (37.7% of cohort) had greater 24-hour UOP (3,050 vs 2,050 mL), likelihood of UOP goal (45% vs 19%), and weight loss at discharge (8.95 kg vs 5.94 kg; all p <0.001). In conclusion, BAN-ADHF score correlated with diuretic resistance and prognosis, and may capture the risk of DR compared traditional measures like CKD or NT-proBNP.