Association between changes in loop diuretic dose and outcomes in acute heart failure

Abstract

Aims Little is known about the association between the starting of or dose changes in loop diuretics during acute heart failure (AHF) hospitalization and post‐discharge outcomes. We investigated the clinical impact of starting loop diuretics and changing the loop diuretics dose during hospitalization on post‐discharge outcomes. Methods and results From the Kyoto Congestive Heart Failure registry, 3665 consecutive patients hospitalized for HF and discharged alive were included in this study. We analysed 1906 patients without loop diuretics on admission and were discharged alive and 1759 patients who received loop diuretics on admission and were discharged alive. The primary outcome measure was all‐cause death. Of the 1906 patients without loop diuretics on admission, 1366 (71.7%) patients started loop diuretics during the index AHF hospitalization. Starting loop diuretics was not associated with lower post‐discharge mortality [adjusted hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.68–1.25]. Of the 1759 patients who received loop diuretics on admission, loop diuretic dose was decreased in 23.8%, unchanged in 44.6%, and increased in 31.6% of the patients. Changes in the dose at discharge compared with no change in dose were not associated with lower risk of post‐discharge mortality (decrease relative to no change: adjusted HR 0.98, 95% CI 0.76–1.28; increase relative to no change: adjusted HR 1.00, 95% CI 0.78–1.27). Compared with no loop diuretics at discharge, a loop diuretics dose of ≥80 mg at discharge was associated with higher post‐discharge mortality risk. Conclusions In patients with AHF, we found no association between the starting of loop diuretics and post‐discharge outcomes and between dose changes and post‐discharge outcomes.

Loop diuretic down‐titration at discharge in patients hospitalized for acute heart failure

“…DeVore and colleagues 13 analysed the impact on the prognosis of loop diuretic dose adjustments after hospitalization, showing no changes in the composite outcome of 30 day mortality or hospitalization. A recent Japanese study conducted by Seko et al 14 confirmed no difference in terms of mortality when comparing patients in whom a decreased dose of loop diuretics was prescribed at discharge with patients in whom the same dose was maintained. Some factors seem to influence the decision of the physicians on the choice of the diuretic strategy at discharge.…”

Loop diuretics in heart failure: The objective markers to guide the therapy are needed

“…The diuretic response is also highly related to the neurohormonal drive, which can also identify patients with more disrupted pathophysiology and worse outcomes 9–11 . Several studies have demonstrated the association between the dose of diuretics and the outcomes, but this has never been demonstrated in a casual‐effect manner as most of the data come from retrospective analyses or registries 12,13 . Unfortunately, at the moment, we lack objective measures that allow us to adjust the loop diuretic doses in HF patients.…”

“… 9 , 10 , 11 Several studies have demonstrated the association between the dose of diuretics and the outcomes, but this has never been demonstrated in a casual‐effect manner as most of the data come from retrospective analyses or registries. 12 , 13 Unfortunately, at the moment, we lack objective measures that allow us to adjust the loop diuretic doses in HF patients. Thus, all dose modifications (up‐ and down‐titrations) are made based on the physician's subjective decisions, which can also lead to some bias.…”