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.................................................... Loop diuretics are commonly used due to their rapid onset of action and efficacy. Data defining their optimal dosing, timing, and method of administration are limited. No difference in the primary efficacy outcome of patients’ symptoms global assessment was shown with a high-dose regimen, compared with a low-dose regimen, in the DOSE trial. However, there was a greater relief of dyspnoea, change in weight and net fluid loss (with no prognostic role for increases in serum creatinine) in the higher-dose regimen.460462

High diuretic doses may cause greater neurohormonal activation and electrolyte abnormalities and are often associated with poorer outcomes, although a cause and effect relation cannot be proven by these retrospective analyses.463466 Based on these observations, it may be appropriate, when starting i.v. diuretic treatment, to use low doses, to assess the diuretic response and increase the dose when that is insufficient. Diuretic treatment should be started with an initial i.v. dose of furosemide, or equivalent dose of bumetanide or torasemide, corresponding to 12 times the daily oral dose taken by the patient before admission. If the patient was not on oral diuretics, a starting dose of 2040 mg of furosemide, or a bolus of 1020 mg i.v. torasemide, can be used.145,467 Furosemide can be given as 23 daily boluses or as a continuous infusion. Daily single bolus administrations are discouraged because of the possibility of post-dosing sodium retention.145,461 With continuous infusion, a loading dose may be used to achieve steady state earlier. Diuretic response should be evaluated shortly after start of diuretic therapy and may be assessed by performing a spot urine sodium content measurement after 2 or 6 h and/or by measuring the hourly urine output. A satisfactory diuretic response can be defined as a urine sodium content >5070 mEq/L at 2 h and/or by a urine output >100150 mL/h during the first 6 h.145,468 If there is an insufficient diuretic response, the loop diuretic i.v. dose can be doubled, with a further assessment of diuretic response.145 If the diuretic response remains inadequate, e.g. <100 mL hourly diuresis despite doubling loop diuretic dose,

Identification of acute aetiology

Cardiogenic shock and/or

respiratory failure

N

Management of patients with suspected acute heart failure

Pharmacological support

Ventilatory support

MCS

Y

acute Coronary syndrome Hypertension emergency Arrhythmia Mechanical causea Pulmonary embolism Infections Tamponade

C H A M P I T Y Immediate initiation of specific treatment

Further treatmentb

N

Urgent phase after first medical contact

Immediate phase (initial 60–120 min)

Figure 12 Initial management of acute heart failure. MCS= mechanical circulatory support. aAcute mechanical cause: myocardial rupture complicating acute coronary syndrome (free wall rupture, ventricular septal defect, acute mitral regurgitation), chest trauma or cardiac intervention, acute native or prosthetic valve incompetence secondary to endocarditis, aortic dissection or thrombosis. bSee Figures 710 for specific treatments according to different clinical presentations. Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026