Patients who are hospitalized with heart failure (HF) and receive both diuretics and intravenous fluids early in their care may be associated with worse outcomes, according to a study published Feb. 2 in JACC: Heart Failure.

The retrospective cohort study was led by Behnood Bikdeli, MD, a research scholar at Yale Center for Outcomes Research and Evaluation (CORE) and a second-year internal medicine resident at Yale-New Haven Hospital, and looked at 131,430 HF patients hospitalized at 346 hospitals from 2009 to 2010.

The authors found that 11 percent were in-patients treated with intravenous fluids (median volume=1,000 ml) during the first two days. Patients who were treated with intravenous fluids had higher rates of subsequent clinical care admission (5.7 percent vs. 3.8 percent; p < 0.0001), intubation (1.4 percent vs. 1.0 percent; p = 0.0012), renal replacement therapy (0.6 percent vs. 0.3 percent; p < 0.0001), and hospital death (3.3 percent vs. 1.8 percent; p < 0.0001) compared with those who received only diuretics.

The authors note that the study is the first to examine use of common intravenous fluids in hospitalized HF patients. "Because fluid overload is a major contributor to acute decompensation in patients with HF, the administration of intravenous fluids in addition to loop diuretic therapy is an unanticipated observation," the authors explain. They conclude that "this practice may occur inadvertently for many patients, warrants further investigation, and may be an opportunity for improvement."

"Our findings are surprising and provocative," adds Bikdeli. "We need to better understand who these patients are, why they received intravenous fluids, and whether use of intravenous fluids was the cause of their worse outcomes. In the interim, it would be helpful for hospital administrators to promote policies that help reduce inadvertent use of intravenous fluids for patients with HF."

In a related editorial comment, Larry Allen, MD, MHS, FACC, adds that "all in all, mixing furosemide and saline is no yin and yang. Pointing out the frequency with which U.S. hospitals give intravenous fluid and loop diuretics to patients presenting with worsening HF suggests a way forward to our goal of improving acute care."

Keywords: Cohort Studies, Diuretics, Furosemide, Goals, Heart Failure, Hospital Administrators, Hospitals, Internal Medicine, Intubation, Outcome Assessment, Health Care, Publishing, Renal Replacement Therapy, Research, Sodium Potassium Chloride Symporter Inhibitors

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