Hypertonic saline and high-dose furosemide in very elderly patients hospitalized for acute heart failure: A real-world cohort study
In brief
In patients 84+, poor diuretic response cuts 30-day survival to 4 days
In a real-world cohort of 140 very elderly acute heart-failure patients (median age 84), hypertonic saline plus high-dose furosemide yielded a good urine response in 41% of episodes; those with a poor response survived a median of only 4.4 days versus 27.3 days for good responders. The regimen was feasible and renal function stable, but the stark mortality difference highlights the need for better early markers of diuretic failure.
- Journal
- European journal of internal medicine (Q1)
- Published
- 21 September 2026
- Study design
- Retrospective cohort
- Evidence level
- Level 3, Low (CEBM 3b)
- Authors
- Guillermo Ropero-Luis, María Eugenia Carmona-Moreno, Marina Melgar-Velasco, José María González-Miret, Francisco José Guerrero-Márquez
- PMID
- 42767926
- DOI
- 10.1016/j.ejim.2026.107201
Why clinicians should know about it
- Picked for Internal Medicine (paper of the day, 25 September 2026): Hypertonic saline + high-dose furosemide in very elderly acute heart
Abstract
BACKGROUND: The combination of hypertonic saline solution (HSS) and high-dose furosemide may enhance diuretic response in acute heart failure (AHF), but evidence in real-world populations, particularly very elderly patients admitted to internal medicine wards, remains limited. METHODS: Retrospective, single-center, uncontrolled observational study of patients hospitalized with AHF and treated between 2021 and 2024 with HSS and high-dose intravenous furosemide (SMACHF protocol), plus discretionary sequential diuretics. We analyzed clinical characteristics, laboratory changes, diuretic response by mean daily urine output, safety and clinical events. RESULTS: We included 191 treatment episodes in 140 patients (median age 84 years, preserved ejection fraction 75%, advanced chronic kidney disease 41%). Diuretic response was good in 41% of episodes, intermediate in 45% and poor in 13%. Renal function remained stable, serum sodium increased and NT-proBNP decreased in the paired measurements. Most treatments ended because of clinical improvement (71.2%); 30-day mortality was 35.7%. Compared with a good response, a poor diuretic response was associated with early clinical failure at 30 days (penalized OR 7.90, 95% CI 1.09-102) and with higher 30-day mortality: restricted mean survival was 4.4 versus 27.3 days. CONCLUSIONS: In this real-world cohort of very elderly patients with AHF, HSS with high-dose intravenous furosemide, plus discretionary sequential diuretics, was feasible and had an acceptable short-term safety profile. Poor diuretic response identified a subgroup with very high early mortality, whereas mid-term outcomes related more to baseline characteristics. These hypothesis-generating findings describe a population common in internal medicine wards and seldom represented in published studies.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.