Heart failure & cardiomyopathies
Diuretic strategies in acute heart failure: a systematic review and network meta-analysis of randomized clinical trials
Authors' conclusion
FC and SNB improve surrogates of response to FB in AHF. SNB is also connoted by WRF and may induce hypokalaemia. The endpoints of diuretic RCTs should be revised and harmonized.
Study context
- Population
- Admitted acute heart failure (AHF) patients within 48 h, irrespective of clinical stabilizationpatients in 25 selected randomized clinical trials (RCTs), mean age 68.9 ± 8.7 years, mean left ventricular ejection fraction 38.2 ± 10.7%
- Participants
- 7,149 patients
- Comparison
- FC or FB plus another diuretic compared to FB alone
- Outcome
- Weight loss (WL)
- Follow-up
- 24 h
Methodological detailsphase 3 randomized clinical trials, random-effects model with inverse variance weighting
- Phase 3 randomized clinical trials
- Random-effects model with inverse variance weighting
Pooled result
As reported in the abstract
Each group vs FBOdds ratio (95% CI)
FC
1.55(1.39–1.63)
FB plus tolvaptan
1.57(1.39–1.77)
FB plus SGLT2i
1.23(1.06–1.42)
FB plus thiazide
1.63(1.37–1.94)
Further pooled results
| Outcome | OR (CI) | |
|---|---|---|
| Mortality/rehospitalizationFB plus SGLT2ivs FBNon-significantly lower with SGLT2i · underpowered exploratory analysis | 0.45 (0.19–1.07) | |
| 0.20.5125Odds ratio (log scale) |
Sensitivity analyses (urine output, protocol-established furosemide doses, daily furosemide dose)
- Results were consistent in sensitivity analyses
Reporting of congestion/decongestion scores and clinical outcomes
- Reported in around 50% of RCTs
- around 50%
Safety
| Outcome | OR (CI) | |
|---|---|---|
| Worsening renal function (WRF)FB plus SGLT2ivs FB | 1.52 (1.19–1.94) | |
| Worsening renal function (WRF)FB plus acetazolamidevs FB | 1.81 (1.31–2.49) | |
| Worsening renal function (WRF)FB plus thiazidevs FB | 1.78 (1.43–2.21) | |
| HypokalaemiaFB plus thiazidevs FB | 1.69 (1.32–2.16) | |
| 0.512Odds ratio (log scale) |
Original publication
Diuretic strategies in acute heart failure: a systematic review and network meta-analysis of randomized clinical trials. Eur Heart J Cardiovasc Pharmacother. Published 10 September 2025. doi:10.
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