Outpatient Use of Intravenous Furosemide in Patients with Heart Failure

Abstract

Introduction: There is limited evidence supporting the use of intravenous (IV) diuretics in the outpatient setting for patients with acute decompensated heart failure (ADHF). In January 2023, our heart failure clinic implemented a protocol to administer IV furosemide for patients presenting with signs of fluid overload during clinic visits. Outpatient IV furosemide may serve as an alternative to hospitalization for ADHF management, potentially reducing the burden on inpatient resources; however, its real-world impact remains unclear. The objective of this study was to evaluate the impact of outpatient IV furosemide protocol implementation at the clinic level, rather than to assess individual patient-level treatment effectiveness. This study aimed to evaluate whether protocol implementation was associated with changes in ADHF-related hospitalizations and mortality.
Methodology: This was a single-center, retrospective, pre- and post-implementation study of outpatient IV furosemide included adult heart failure patients followed by the heart failure clinic between 01/01/2022–07/31/2022 (pre-implementation) and 01/01/2024–07/31/2024 (post-implementation). Patients were included if they were receiving loop diuretics (≥ 40 mg oral furosemide or equivalent) and presented with symptoms of fluid overload. Exclusion criteria included a history of heart transplantation, left ventricular assist device insertion, or outpatient inotrope use. The outcomes of the study were the number of hospitalizations and mortality within 30 and 90 days of the clinic visit.
Results: A total of 402 patients were included with 200 patients in the pre-implementation cohort and 202 in the post-implementation group, of whom 14 (7%) received outpatient IV furosemide. At 30 days, ADHF-related hospitalizations occurred in 6% of patients in the pre-implementation cohort and 7.9% in the post-implementation group (p = 0.449), while at 90 days, the proportions were 10% in both groups (p = 0.892). Thirty-day mortality was 1% in both groups (p = 0.994).
Discussion: A higher number of both ADHF-related and all-cause hospitalizations were observed in the post-implementation group. Several factors may explain the limited benefit observed, including a small proportion of post-implementation patients receiving outpatient IV furosemide (7%), baseline differences between groups, and potential residual impacts of the COVID-19 pandemic.
Conclusion: The implementation of an outpatient IV furosemide protocol did not result in a significant reduction in heart failure-related hospitalizations or mortality in this study. These findings reflect real-world implementation challenges rather than definitive evidence against outpatient IV diuretics. Further research is needed to evaluate the optimal patient population and timing for outpatient IV diuresis.