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Systemic venous congestion is the primary therapeutic target of intravenous loop diuretics in patients admitted for acute heart failure (AHF). Despite their utility, a significant proportion of AHF patients are discharged with persistent clinical symptoms of congestion (residual congestion). Therefore, in recent years, there has been a growing focus on the use of tools (biomarkers, clinical ultrasound) that allow us to optimize diuretic treatment and thereby improve the prognosis of AHF patients. The objective is to analyze whether the strategy of guiding intravenous loop diuretic dosing based on intra-abdominal pressure(IAP) measurements and clinical ultrasound is superior to the conventional strategy employed in daily clinical practice. This study is a randomized, multicenter clinical trial involving consecutive patients admitted with a diagnosis of AHF in the Internal Medicine and Cardiology departments. Patients who meet the inclusion criteria, after signing informed consent, will be randomized into two groups: 1) Diuretic treatment guided by usual clinical practice and 2) Treatment guided by intra-abdominal pressure levels and clinical ultrasound (inferior vena cava and portal Doppler). This strategy will be maintained during the first 72 hours of admission, with a thorough analysis of congestion and diuretic response being conducted.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Standart of care treatment arm. | No Intervention | Loop diuretics (furosemide) will be administered intravenously according to stantard of care (Latest European heart failure guidelines) | |
| Treatment guided by intra-abdominal pressure values | Experimental | Decongestive treatment will be adjusted according to intraabdominal pressure values (IAP) and/or point of care ultrasound: Patients with IAP < 8 mmHg (normal): The intravenous diuretic dose will be twice the patient's previous oral dose. If no diuretics were taken previously, 20 mg of furosemide will be administered every 12 hours. Patients with IAP between 8 and 12 mmHg (moderately elevated): furosemide will be administered in combination with hydrochlorothiazide Patients wiht IAP > 12: Furosemide will be initiated as a continuous infusion along with hydrochlorothiazide |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Furosemide 20 Milligrams | Drug | Decongestive therapy with e.v. furosemide +/- hydrochlorothiazide will be adjusted by intraabdominal pressure and/or point of care ultrasound |
|
| Measure | Description | Time Frame |
|---|---|---|
| Significant reduction in congestion (ADVOR scale) | To evaluate the significant reduction in congestion (ADVOR Scale) after the first 72 hours of intravenous diuretic treatment in the hospital ward, comparing the standard treatment group with the intervention group (intra-abdominal pressure and ultrasound). ADVOR Scale: Oedema: No oedema (0 points), Trace oedema (1 point), Clear pitting oedema (2 points), Visual deformation above ankle (3 points), Visual deformation above knee (4 points). Pleural effusion: No pleural effusion (0 points), Minor (2 points), Major (3 points) Ascites: No ascites (0 points), Minor ascites (2 points), Significant ascites (3 points) TOTAL SCORE: Oedema score + Pleural effusion + Ascitis. Minimum 0 points; Maximum 10 points | After the first 72 hours of endovenous loop diuretic treatment |
| Measure | Description | Time Frame |
|---|---|---|
| Significant pulmonary congestion reduction through lung ultrasound assessment (b-lines) | To evaluate the complete resolution of pulmonary congestion as assessed by ultrasound (B-lines) after the first 72 hours of intravenous diuretic treatment in the hospital ward, comparing the standard of care treatment group with the interventional group (intra-abdominal pressure and ultrasound). The degree of pulmonary tissue congestion will be quantified using clinical ultrasound. Eight quadrants (four left and four right) will be examined. A quadrant will be considered positive for pulmonary tissue congestion if three or more B-lines are detected. Minimum: 0 quadrants; Maximum 8 quadrants |
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Inclusion Criteria:
Exclusion Criteria:
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Hospital Clínico Universitario Lozano Blesa | Recruiting | Zaragoza | 50008 | Spain |
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| Label | URL |
|---|---|
| Website of the Spanish Medicines Agency where the clinical trial is registered in clinical trial information system (CTIS) | View source |
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After conducting an initial comprehensive evaluation and confirming the inclusion and exclusion criteria, along with obtaining the necessary informed consent (screening), the patient will be randomized within the first 24 hours of admission into one of the two treatment groups with the aim of determining whether a diuretic treatment strategy based on intra-abdominal pressure and clinical ultrasound is superior to the conventional diuretic treatment strategy for resolving systemic congestion after the first 72 hours of admission.
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|
| From time to randomization until the first 72 hours of endovenous loop diuretics treatment at the Internal Medicine ward |
| Significant intravascular congestion reduction through venous excess ultrasound score (VEXUS score) | To evaluate the significant reduction in intravascular congestion (inferior vena cava diameter and venous excess ultrasound protocol) after the first 72 hours of intravenous diuretic treatment in the hospital ward, comparing the standard of care treatment group with the interventional group (intra-abdominal pressure and ultrasound). VEXUS score
Minimum 0 points; Maximum 3 points | After the first 72 hours of endovenous loop diuretic treatment |
| Total diuresis response | To evaluate the diuretic response (total urine volume/total dose of furosemide administered) after the first 72 hours of intravenous diuretic treatment in the hospital ward, comparing the standard treatment group with the intervention group (intra-abdominal pressure and ultrasound). | After the first 72 hours of endovenous loop diuretic treatment |
| Total dose of diuretic treatment | To compare the days and doses of intravenous loop diuretics and hydrochlorothiazide used during the first 72 hours of hospitalization between the standard treatment group and the intervention group. | After the first 72 hours of endovenous loop diuretic treatment |
| Number of patients treated for worsening heart failure | Differences in heart failure worsening (defined as the need for intravenous loop diuretic treatment after hospital discharge, whether in a day hospital, emergency department, or due to new hospital admissions at 30 and 90 days) between the two groups. | From date of discharge until 30-days post-hospitalization visit. From date of discharge until 90-days post-hospitalization visit. (cut-off period 1-year) |
| Total number of patients with cardiovascular death | Differences in cardiovascular death incidence | From date of discharge until the date of cardiovascular death (cut-off period 1 year) |
| guided directed medical therapy (GDMT) | Prevalence of GDMT prescribed at discharge according to left ventricular ejection fraction and actual heart failure guidelines | From date of admission up to discharge, from date of discharge up to 30 days after and from date of discharge up to 90 days (cut-off period 1-year) |
| length of stay | Differences in length of stay between both arms | From date of randomization until date of discharge (cut-off period 4 weeks) |
| Hospital Clínico Universitario Lozano Blesa | Not yet recruiting | Zaragoza | 50009 | Spain |
|
| ID | Term |
|---|---|
| D006333 | Heart Failure |
| D059325 | Intra-Abdominal Hypertension |
| D059347 | Cardio-Renal Syndrome |
| ID | Term |
|---|---|
| D006331 | Heart Diseases |
| D002318 | Cardiovascular Diseases |
| D003161 | Compartment Syndromes |
| D009135 | Muscular Diseases |
| D009140 | Musculoskeletal Diseases |
| D014652 | Vascular Diseases |
| D051437 | Renal Insufficiency |
| D007674 | Kidney Diseases |
| D014570 | Urologic Diseases |
| D052776 | Female Urogenital Diseases |
| D005261 | Female Urogenital Diseases and Pregnancy Complications |
| D000091642 | Urogenital Diseases |
| D052801 | Male Urogenital Diseases |
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