In acute heart failure, an inadequate response to loop diuretic is usually recognised late, after a day of little weight change. A spot urine sodium about two hours after the dose, and hourly urine output over the first six hours, give an early read. A low urine sodium or poor output points to doubling the loop dose and, if that fails, adding a second diuretic class. This approach is set out in the ESC heart failure guidance and avoids a lost first day.
- Send a spot urine sodium about two hours after the first intravenous loop dose.
- Measure urine output over the first six hours.
- If urine sodium is low or output poor, double the loop dose before adding another agent.
- Recheck creatinine and potassium daily while escalating.
Why it matters
Early escalation shortens congestion, and congestion at discharge predicts readmission.
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