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Observational Study
. 2019 Feb;6(1):80-88.
doi: 10.1002/ehf2.12368. Epub 2018 Oct 8.

Early urine electrolyte patterns in patients with acute heart failure

Sean P Collins  1 , Cathy A Jenkins  2 , Adrienne Baughman  1 , Karen F Miller  1 , Alan B Storrow  1 , Jin H Han  1 , Nancy J Brown  3   4 , Dandan Liu  2 , James M Luther  4   5   6 , Candace D McNaughton  1 , Wesley H Self  1 , Dungeng Peng  5 , Jeffrey M Testani  7 , JoAnn Lindenfeld  8
Affiliations
Observational Study

Early urine electrolyte patterns in patients with acute heart failure

Sean P Collins et al. ESC Heart Fail. 2019 Feb.

Abstract

Aims: We conducted a prospective study of emergency department (ED) patients with acute heart failure (AHF) to determine if worsening HF (WHF) could be predicted based on urinary electrolytes during the first 1-2 h of ED care. Loop diuretics are standard therapy for AHF patients. A subset of patients hospitalized for AHF will develop a blunted natriuretic response to loop diuretics, termed diuretic resistance, which often leads to WHF. Early detection of diuretic resistance could facilitate escalation of therapy and prevention of WHF.

Methods and results: Patients were eligible if they had an ED AHF diagnosis, had not yet received intravenous diuretics, had a systolic blood pressure > 90 mmHg, and were not on dialysis. Urine electrolytes and urine output were collected at 1, 2, 4, and 6 h after diuretic administration. Worsening HF was defined as clinically persistent or WHF requiring escalation of diuretics or administration of intravenous vasoactives after the ED stay. Of the 61 patients who qualified in this pilot study, there were 10 (16.3%) patients who fulfilled our definition of WHF. At 1 h after diuretic administration, patients who developed WHF were more likely to have low urinary sodium (9.5 vs. 43.0 mmol; P < 0.001) and decreased urine sodium concentration (48 vs. 80 mmol/L; P = 0.004) than patients without WHF. All patients with WHF had a total urine sodium of <35.4 mmol at 1 h (100% sensitivity and 60% specificity).

Conclusions: One hour after diuretic administration, a urine sodium excretion of <35.4 mmol was highly suggestive of the development of WHF. These relationships require further testing to determine if early intervention with alternative agents can prevent WHF.

Keywords: Acute heart failure; Diuretic resistance; Emergency department; Urine electrolytes; Worsening heart failure.

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Figures

Figure 1
Figure 1
Patient identification and enrolment. AHF, acute heart failure; BP, blood pressure; ED, emergency department.
Figure 2
Figure 2
Urinary measures of natriuresis and diuresis in patients without and with worsening heart failure (WHF): (A) urine sodium output, (B) urine output, (C) urine sodium concentration, and (D) urine sodium/potassium ratio.
Figure 3
Figure 3
Receiver operating characteristic curves for (A) urine sodium concentration, (B) urine sodium output, (C) urine output, and (D) predicted urine sodium concentration at 6 h, during the first hour after diuretic administration to discriminate between patients with and without worsening heart failure. AUC, area under the curve.
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