Quick, Reliable Marker to PUSH Decongestive Therapy in AHF

Ileana Piña and Wilfried Mullens discuss the PUSH-AHF trial on a spot urine sodium protocolized approach to decongestion presented at the European Society of Cardiology.
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Ileana L. Piña, MD, MPH: Hello! I'm Ileana Piña, professor of medicine at Thomas Jefferson University, and a heart failure transplant cardiologist. I am here at the European Society of Cardiology.
There's been a large amount of talk at this meeting about diuretics - those wonderful drugs that none of us really know how to give, how to use, how to recommend - and when anybody wants the standard of care, it depends upon what hospital you're in and what city you're in. We need to decongest patients. There's no doubt about it.
Now, with the sodium-glucose cotransporter 2 (SGLT2) data, there are still discussions about whether that's a diuretic and what to do with the loop diuretics when you put the patient on the SGLT2? It doesn't matter whether it's empagliflozin or dapagliflozin; it's basically the same.
This is a very interesting trial that we're going to talk about, and I have my good friend here, Wilfried Mullens from Belgium, who will be a discussant in this trial. The trial was called PUSH-AHF. Tell me about this PUSH concept of natriuresis.
PUSH-AHF
Wilfried Mullens, MD, PhD: The trial was designed based on a consensus document that we wrote within the European Heart Failure Association a couple of years ago, trying to help physicians guide diuretic therapy better. We suggested at that moment in time, with a group of self-proclaimed experts, that we should guide diuretic therapy not so much based on diuresis only but also on natriuresis - so on the quality of the urine. We suggested that if you don't reach a spot urine sodium content threshold of 70 mEq/L, you should escalate and increase the dosages of loop-diuretic therapy.
Piña: If 70 isn't enough, what would be acceptable?
Mullens: Acceptable would be everything 70 mEq/L. Everything below would mean escalation of therapy.
Last year, we presented the ADVOR trial, where we actually combined loop-diuretic therapy with acetazolamide, showing a tremendous benefit on decongestion rates. Jozine M. ter Maaten, from Groningen, now took it one step further, and she was trying to validate this natriuresis-based approach.
There has been one trial so far, which is called the ENACT-HF trial, recently presented at the Heart Failure Association (of the ESC) meeting in Prague, that's already showed that, if you use that approach, you can increase natriuresis. The PUSH-AHF trial was looking at patients with acute heart failure with congestion and comparing a standard-of-care diuretic regimen vs that natriuresis-guided approach.
Piña: What did you call the standard of care in this trial?
Mullens: The standard of care was very smart because they didn't want to have people saying you underdosed.
Piña: Right.
Mullens: They looked at patients, and they looked at the glomerular filtration rate (GFR) and if they were diuretic naive. If the GFR was low and they were already on a diuretic, they had a really high starting dose to avoid criticism that the standard of care would have dosages that were too low.
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