A Systematic Review of Baseline Characteristics of Patients With Successful Decongestion on Combination Diuretic Therapy in Acute Decompensated Heart Failure (ADHF).

Acute decompensated heart failure (ADHF) often necessitates combination diuretic therapy when patients develop resistance to loop diuretics alone. Understanding baseline characteristics predictive of successful decongestion is essential for tailoring treatment strategies. This systematic review aimed to identify baseline characteristics associated with successful decongestion in ADHF patients undergoing combination diuretic therapy and to evaluate the effectiveness and risks of these therapies. A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with a literature search spanning 2019 to 2024 across PubMed and other databases. Studies included randomized controlled trials (RCTs) and clinical trials focusing on combination diuretic therapy, including thiazide diuretics and acetazolamide. Inclusion criteria emphasized studies reporting baseline characteristics and decongestion outcomes. From 43 initially identified articles, four studies met inclusion criteria. Combination diuretic therapy improved diuretic response and congestion resolution, with specific therapies such as metolazone, hydrochlorothiazide, and tolvaptan showing varying levels of effectiveness. Patients with lower baseline congestion scores, preserved renal function (estimated glomerular filtration rate (eGFR) ≥41 ± 20 mL/min/1.73m²), and higher ejection fractions (≥35%) were more likely to experience favorable outcomes. Risks such as renal impairment occurred more frequently in patients with pre-existing chronic kidney disease (CKD), highlighting the importance of careful monitoring. Notably, metolazone led to greater weight loss (e.g., -6 kg vs. -3 kg) and enhanced diuretic response (940 ± 149 mL/40 mg furosemide/day vs. 541 ± 314 mL). Combination diuretic therapy is effective for improving fluid management in resistant ADHF, but baseline patient characteristics significantly influence outcomes. This review provides novel insights into the role of individualized treatment strategies in optimizing therapy. Future research should focus on validating biomarkers, risk stratification tools, and promising but understudied combinations to improve safety and efficacy.