Efficacy and safety of hypertonic saline therapy in ambulatory patients with heart failure: The SALT‐HF trial

Aims Combination of hypertonic saline solution (HSS) with intravenous loop diuretics has been suggested to improve diuretic response in patients hospitalized for heart failure (HF). The efficacy and safety of this approach in the ambulatory setting remain unexplored. Methods and results In this multicentre, double‐blind, randomized study, we allocated ambulatory patients with worsening heart failure (WHF) to a 1‐h infusion of intravenous furosemide (ivFurosemide)‐HSS versus ivFurosemide. The primary endpoint was the volume of diuresis at 3 h. Secondary endpoints included 3‐h natriuresis and weight variation, 7‐day congestion data, kidney function and electrolytes, and 30‐day clinical events. Overall, 167 participants (median age: 81 years, 30.5% female) were randomized across 13 sites between December 2020 and March 2023. There were no differences in 3‐h diuresis between treatments (ivFurosemide‐HSS: 1099 ml vs. ivFurosemide: 1103 ml, p = 0.963), 3‐h natriuresis (∆ +2.642 mEq/L, p = 0.559), or 3‐h weight (∆ +0.012 kg, p = 0.920). Patients in the ivFurosemide‐HSS arm experienced significant weight decrease at 7 days (Δ −0.586 kg, p = 0.048). There were no between‐treatment differences in clinical congestion score, biomarkers, inferior vena cava diameter, or the presence of lung ultrasound B‐lines. At 30 days, 26.5% of the patients in the ivFurosemide‐HSS group versus 33.3% in the ivFurosemide group experienced WHF (hazard ratio 0.76, p = 0.330). The incidence of death from any cause or HF hospitalization was 6% of patients in the ivFurosemide‐HSS group and 8.3% of patients in the ivFurosemide group (hazard ratio 0.69, p = 0.521). The incidence of worsening kidney function or metabolic derangements was not significantly different in the two arms. Conclusions A single infusion of ivFurosemide‐HSS did not improve 3‐h diuresis or congestion parameters in patients with ambulatory WHF. This therapy showed an appropriate safety profile. Trial design and main results. HF, heart failure; HSS, hypertonic saline solution; IV, intravenous; NYHA, New York Heart Association; WHF, worsening heart failure; WRF, worsening renal function.