Fig. 2: The urinary sodium and diuresis-based treatment protocol in PUSH-AHF.

Schematic of the treatment protocol, showing that loop diuretics were administered twice daily (in black), at 12 h intervals. At the timepoints at which natriuresis and diuresis was assessed, in the case of an insufficient response as determined by predetermined cutoffs (box 1), treatment was intensified according to the treatment algorithm (box 2). First step was the administration of an additional dose of loop diuretics (double the previous dose to a maximum of 5 mg of bumetanide). If an additional, increased dose of loop diuretic was administered, the maintenance dose (the twice-daily administered loop diuretic dose) was further increased to a level that was double the previous dose, to a maximum of 5 mg bumetanide. If response continued to be insufficient despite two consecutive maximum doses of loop diuretic, combination diuretic therapy was started. First choice for combination diuretic therapy was the addition of hydrochlorothiazide; however, if a patient for instance already used combination diuretic therapy with hydrochlorothiazide before admission or response remained insufficient after addition of hydrochlorothiazide, acetazolamide or an SGLT2i was added. T refers to the time in hours after start of loop diuretic treatment. ED, emergency department; LD, loop diuretic. Created with BioRender.com.