Small-volume hypertonic saline solution and high-dosage furosemide in the treatment of refractory congestive heart failure. A pilot study

Objective: To evaluate a new therapeutic approach to hospitalised patients with refractory congestive heart failure (CHF) based on published data on the efficacy of furosemide (frusemide) intravenous infusion in refractory CHF and of small volumes of hypertonic saline solution in the low-flow state. Design and Setting: Prospective, uncontrolled study of hospital inpatients. Study Participants and Interventions: Thirty patients (20 males and 10 females) aged 65 to 85 years with refractory New York Heart Association (NYHA) functional class IV CHF were given a twice-daily intravenous infusion of a small volume of hypertonic saline solution (150 ml of 1.4 to 4.6 NaCl) containing high-dosage furosemide (250 to 2000 mg/day) for 6 to 12 days. A daily oral fluid intake of 1000 ml was maintained during the period; previous treatments (digoxin, nitrates or ACE inhibitors) were continued unmodified. Main Outcome Measures: Bodyweight, systolic and diastolic blood pressure, heart rate, 24-hour urinary volume, plasma and urinary electrolyte concentration and renal function parameters were evaluated daily. Chest x-ray, ECG and MB-mode echocardiogram were performed before, during and at the end of treatment. Results: The intravenous infusion was well tolerated. At the end of treatment, all the patients exhibited an improvement in clinical signs and symptoms of CHF such as dyspnoea, oedema and weakness, with changes in NYHA functional class in all patients. Bodyweight was significantly reduced in proportion to increased urinary volume. After a 12-month follow-up, 24 patients (80) were still alive and maintained the NYHA class achieved at discharge from hospital. Conclusions: These findings suggest that this new therapeutic approach to refractory CHF is effective and well tolerated. It should represent an innovative tool for the management of refractory CHF.