From the Research
Heart failure patients with high urinary angiotensinogen should receive more aggressive decongestion therapy, as this approach has been associated with improved outcomes in recent studies. These patients typically show increased renin-angiotensin-aldosterone system (RAAS) activation, which contributes to fluid retention and worsening heart failure 1. More intensive diuretic therapy could include higher doses of loop diuretics such as furosemide (40-80mg twice daily), bumetanide (1-2mg twice daily), or torsemide (20-50mg daily), or combination therapy adding a thiazide diuretic like metolazone (2.5-10mg daily) or chlorothiazide (500-1000mg IV) 2.
Some key points to consider when implementing aggressive decongestion therapy include:
- The door to diuretic time should not exceed 60 min, with a starting IV dose of 20-40 mg furosemide equivalents in loop diuretic naïve patients or double the preexisting oral home dose 1
- Monitoring responses within the first hours is crucial, with target measures including spot urinary sodium ≥50-70 mmol/L after 2 h, urine output ≥100-150 mL/hour after 6 h, and a change in weight of 0.5-1.5 kg in 24 hours 2
- If congestion persists after maximization of loop diuretic therapy, an adjunctive diuretic such as thiazide or acetazolamide should be added, with careful consideration of the patient's renal function and electrolyte balance 1
- Emerging evidence supports the concept of early combination diuretic therapy, with the addition of acetazolamide or hydrochlorothiazide to loop diuretics, particularly in patients with severely impaired kidney function or those who require more intensive therapy 1
Careful monitoring is essential during aggressive decongestion, including daily weights, fluid balance, electrolytes (particularly potassium and sodium), renal function, and blood pressure 3. Urinary angiotensinogen serves as a marker of intrarenal RAAS activation and may identify patients with more severe neurohormonal derangements who require more intensive therapy to achieve adequate decongestion 4. However, this approach must balance effective volume removal against the risk of worsening renal function, electrolyte abnormalities, and hypotension.
The most recent and highest quality study on this topic, published in 2024, provides guidance on selecting an appropriate approach for different patients, emphasizing the importance of individualized assessment and careful monitoring 1. By prioritizing the single most recent and highest quality study, we can ensure that our recommendation is based on the best available evidence, with a focus on minimizing morbidity, mortality, and improving quality of life for heart failure patients with high urinary angiotensinogen.