Clinical Question: Does initial dosing of diuretics for heart failure admissions change length of stay (LOS) or have any bearing on outcomes?
Background: Little is known about the initial dosing of loop diuretics among patients hospitalized for heart failure and its association with outcomes. Guidelines recommend an initial IV dose at least equal to the home oral dose, and clinical practice commonly follows this by empirically converting and increasing home diuretics on admission. Yet outcomes data behind this practice have been limited.
Study Design: A retrospective cohort study
Setting: 12 Allina Health hospitals in central Minnesota and western Wisconsin and 12 Atrium Health hospitals in North Carolina between January 1, 2017, and December 31, 2020
Synopsis: A substantial proportion of hospitalized congestive heart failure (CHF) patients (more than a third) started with a dose that was less than or equal to their home dose. Among the 14,332 patients in the cohort, 13% received a lower-than-home initial dose, 22% an equivalent dose, and 65% a higher-than-home dose. Lower initial doses were linked to longer hospital stays, possibly due to slower symptom control or the need for repeated dosing. The median LOS was 4.9 days in the lower-dose group versus 4.0 days in the equivalent- and higher-dose groups. Higher initial doses were associated with a modestly increased acute kidney injury risk (12.5% versus 10.9% with equivalent dosing; adjusted incidence rate ratio, 1.17; 95% CI, 1.04 to 1.31), but a reduced rate of 30-day readmission (15.3% versus 17.9%; adjusted incidence rate ratio, 0.85; 95% CI, 0.78 to 0.93). There was no significant mortality difference between the two groups. A secondary chart review of 1,010 patients supported this pathway: those who started on a lower-than-home dose had less net fluid loss in the first days of hospitalization and were roughly four times more likely to need a diuretic dose increase on day two of admission.
Bottom Line: In a multicenter cohort of patients hospitalized for CHF exacerbation, a higher-than-home initial diuretic dose was associated with shorter LOS and higher risk of acute kidney injury, with no change in mortality. These findings suggest that initial diuretic dosing plays an important role in determining clinical outcomes for acute HF.
Citation: Qadri N, et al. Cohort study of initial diuretic dosing and outcomes among patients hospitalized for congestive heart failure. J Am Heart Assoc. 2026;15(6):e038783. https://doi.org/10.1161/JAHA.124.038783.
Dr. Smith
Dr. Smith is an academic hospitalist at Erlanger Hospital and an affiliated assistant professor of medicine at University of Tennessee Health Science Center College of Medicine, both in Chattanooga, Tenn.