Hypertonic saline and high-dose furosemide in very elderly patients hospitalized for acute heart failure: A real-world cohort study.

Background

The combination of hypertonic saline solution (HSS) and high-dose furosemide may enhance diuretic response in acute heart failure (AHF), but evidence in real-world populations, particularly very elderly patients admitted to internal medicine wards, remains limited.

Methods

Retrospective, single-center, uncontrolled observational study of patients hospitalized with AHF and treated between 2021 and 2024 with HSS and high-dose intravenous furosemide (SMACHF protocol), plus discretionary sequential diuretics. We analyzed clinical characteristics, laboratory changes, diuretic response by mean daily urine output, safety and clinical events.

Results

We included 191 treatment episodes in 140 patients (median age 84 years, preserved ejection fraction 75%, advanced chronic kidney disease 41%). Diuretic response was good in 41% of episodes, intermediate in 45% and poor in 13%. Renal function remained stable, serum sodium increased and NT-proBNP decreased in the paired measurements. Most treatments ended because of clinical improvement (71.2%); 30-day mortality was 35.7%. Compared with a good response, a poor diuretic response was associated with early clinical failure at 30 days (penalized OR 7.90, 95% CI 1.09-102) and with higher 30-day mortality: restricted mean survival was 4.4 versus 27.3 days.

Conclusions

In this real-world cohort of very elderly patients with AHF, HSS with high-dose intravenous furosemide, plus discretionary sequential diuretics, was feasible and had an acceptable short-term safety profile. Poor diuretic response identified a subgroup with very high early mortality, whereas mid-term outcomes related more to baseline characteristics. These hypothesis-generating findings describe a population common in internal medicine wards and seldom represented in published studies.