Diuretic Resistance Risk and the Efficacy of Natriuresis-Guided Diuretic Therapy in Acute Heart Failure: Post Hoc Analysis From the PUSH-AHF Trial (JACC Heart Failure July 2026)-Article: Diuretic Resistance Risk and the Efficacy of Natriuresis-Guided Diuretic Therapy in Acute Heart Failure: Post Hoc Analysis From the PUSH-AHF Trial

Article: Diuretic Resistance Risk and the Efficacy of Natriuresis-Guided Diuretic Therapy in Acute Heart Failure: Post Hoc Analysis From the PUSH-AHF Trial

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This post hoc analysis of the PUSH-AHF trial examined whether the BAN-ADHF score, a validated predictor of diuretic resistance (DR) in acute decompensated heart failure (ADHF), modifies the benefit of natriuresis-guided diuretic therapy.<br /><br />Among 306 patients, 21% had a high BAN-ADHF score, indicating high DR risk. These patients had worse baseline renal and congestion-related profiles, lower natriuresis at 24, 48, and 72 hours, and substantially poorer outcomes, including longer hospital stays and higher rates of heart failure rehospitalization and 180-day mortality.<br /><br />Natriuresis-guided therapy improved 24-hour natriuresis regardless of DR risk. The BAN-ADHF score did not change the treatment effect on the main clinical endpoint of all-cause mortality or heart failure rehospitalization at 180 days, which remained neutral. However, the score did modify later natriuretic responses: patients at high DR risk showed greater improvement in 48-hour and a trend toward better 72-hour natriuresis with natriuresis-guided therapy compared with standard care. There was also a significant interaction for length of stay, with a trend toward shorter hospitalization in the high-risk group.<br /><br />The therapy did not significantly affect diuresis, NT-proBNP change, rehospitalization, or mortality differently across DR risk groups, and it did not increase kidney safety events.<br /><br />Overall, the BAN-ADHF score identified patients with impaired diuretic response and worse prognosis. Natriuresis-guided therapy was effective and safe across risk groups, with particularly strong later natriuretic effects in patients at high risk of DR. The findings support using BAN-ADHF for early risk stratification and suggest that targeted natriuresis-guided protocols deserve prospective testing in high-DR-risk patients.

Meta Tag

Concept BAN-ADHF Score

Concept Diuretic Resistance

Concept Natriuresis-Guided Therapy

Concept Acute Decompensated Heart Failure

Concept Natriuresis

Keywords

PUSH-AHF trial

BAN-ADHF score

diuretic resistance

acute decompensated heart failure

natriuresis-guided therapy

heart failure rehospitalization

180-day mortality

renal congestion

natriuretic response

risk stratification

BAN-ADHF Score

Diuretic Resistance

Natriuresis-Guided Therapy

Acute Decompensated Heart Failure

Natriuresis