Adequacy of Loop Diuretic Dosing in Treatment of Acute Heart Failure: Insights from the BAN-ADHF Diuretic Resistance Risk Score

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.