Continuous Infusion and Sequential Nephron Blockade Versus Bolus Furosemide in Acute Heart Failure: A Systematic Review
Abstract
Acute heart failure (AHF) is a leading cause of hospitalization worldwide, with congestion as its central pathophysiologic feature. Loop diuretics, particularly furosemide, remain the cornerstone of decongestive therapy, yet the optimal administration strategy, continuous infusion versus bolus dosing, remains debated. Furthermore, sequential nephron blockade through the addition of distal tubule-acting diuretics or sodium-glucose cotransporter-2 (SGLT2) inhibitors has emerged as a strategy to overcome diuretic resistance. This systematic review had two primary objectives: first, to compare continuous infusion versus bolus dosing of furosemide; second, to evaluate the efficacy and safety of adjunctive sequential nephron blockade (SGLT2 inhibitors, thiazides, and acetazolamide) added to loop diuretics within the context of the ongoing debate over optimal decongestion in AHF. A systematic literature search was conducted in PubMed, Scopus, Web of Science, the Cochrane Library, and ClinicalTrials.gov for studies published between 2021 and 2025. Eligible studies included randomized controlled trials (RCTs) and prospective observational studies evaluating either continuous furosemide infusion versus bolus furosemide or adjunctive sequential nephron blockade (added to loop diuretics) versus placebo, usual care, or, in one case, an active diuretic comparator. The Cochrane Risk of Bias 2 (RoB 2) tool was used for RCTs, and the Risk of Bias in Non-randomized Studies of Interventions…
How strong is the evidence?
Evidence Hub reads this as a systematic review, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 2,972 participants or records.
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