Urinary sodium-guided intravenous diuretic therapy in acute heart failure: transitioning from art to science?

Intravenous (IV) loop diuretics play a central role in patients with acute heart failure (AHF) and volume overload.1 Residual signs of congestion are present in up to 20% of patients with AHF at discharge, correlate with worse prognoses, and may be due partially to diuretic resistance and failure to uptitrate IV diuretics adequately.1 Few randomized clinical trials of diuretic therapy in AHF have been conducted, and robust evidence is still lacking.2-5 Guidelines suggest natriuresis as a guide for diuretic therapy, recognizing the intrinsic limitations of currently used surrogate measures, weight changes and urinary output. Recently, a nurse-driven, urinary sodium-guided, automated protocol (Yale Diuretic Protocol) (YDP) was demonstrated to be safe and effective in guiding uptitration of loop diuretic therapy in AHF.6 The purpose of this study was to assess the safety and feasibility of implementing the YDP in an Italian tertiary center and to compare it with standard diuretic therapy management.