Loop Diuretic Prescription and 30-Day Outcomes in Older Patients With Heart Failure

Faselis, Charles; Arundel, Cherinne; Patel, Samir S.; Lam, Phillip H.; Gottlieb, Stephen S.; Zile, Michael R.; Deedwania, Prakash; Filippatos, Gerasimos; Sheriff, Helen; Zeng, Qing; Morgan, Charity; Wopperer, Samuel; Nguyen, Tran; Allman, Richard M.; Fonarow, Gregg C.; Ahmed, Ali

doi:10.1016/j.jacc.2020.06.022

Cited by 53 publications

(48 citation statements)

References 30 publications

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“…The association of loop diuretic prescription and outcomes, as reported from OPTIMIZE‐HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, further shows a lower risk of 30 day all‐cause mortality associated with loop diuretic use compared with non‐use [HR 0.73 (95% CI 0.57–0.94), P = 0.016]. Patients in the loop diuretic group also had a significantly lower risk of 30 day HF readmission [HR 0.79 (95% CI 0.63–0.99), P = 0.037] 27 . The implications of these differences are uncertain but may be due, at least in part, to limited power to detect differences of effect by diuretic class.…”

Section: Discussionmentioning

confidence: 94%

“…Moreover, loop diuretic prescription can be considered as a positive factor, given the large effect size of this drug class in prospective trials. 26 27 The implications of these differences are uncertain but may be due, at least in part, to limited power to detect differences of effect by diuretic class. In addition, the key reason for inconsistency with other diuretics in this post hoc analysis might be due to the very small number of participants on MRAs at baseline.…”

Section: Discussionmentioning

confidence: 99%

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Cardiovascular and renal outcomes with canagliflozin according to baseline diuretic use: a post hoc analysis from the CANVAS Program

Arnott

Neuen

et al. 2021

ESC Heart Failure

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Aims The CANVAS Program identified the effect of canagliflozin on major adverse cardiovascular events (MACE) differed according to whether participants were using diuretics at study commencement. We sought to further evaluate this finding related to baseline differences, treatment effects, safety, and risk factor changes. Methods and results The CANVAS Program enrolled 10 142 participants with type 2 diabetes mellitus and high cardiovascular risk. Participants were randomized to canagliflozin or placebo and followed for a mean of 188 weeks. The primary outcome was major cardiovascular events, a composite of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. Secondary outcomes included multiple cardiovascular, renal, and safety events. In this post hoc subgroup analysis, participants were categorized according to baseline use of any diuretic. The effect on outcomes was compared using Cox proportional hazards models, while risk factor changes were compared using mixed-effect models. At baseline, 4490 (44.3%) participants were using a diuretic. Compared with those not using a diuretic, participants using a diuretic were more likely to be older (mean age ± standard deviation, 64.3 ± 8.0 vs. 62.5 ± 8.3), be female (38.9% vs. 33.4%), and have heart failure (19.6% vs. 10.3%) (all P difference < 0.0001). The effect of canagliflozin on major cardiovascular events was greater for those using diuretic at baseline than for those who were not [adjusted hazard ratio 0.65 (95% confidence interval 0.54-0.78) vs. adjusted hazard ratio 1.13 (95% confidence interval 0.93-1.36), P heterogeneity < 0.0001]. Changes in most risk factors, including blood pressure, body weight, and urine albumin-to-creatinine ratio, were similar between groups (all P difference > 0.11), although the effect of canagliflozin on haemoglobin A1c reduction was slightly weaker in participants using compared with not using diuretics at baseline (À0.52% vs. À0.64%, P heterogeneity = 0.0007). Overall serious adverse events and key safety outcomes, including adverse renal events, were also similar (all P heterogeneity > 0.07). Conclusions Participants on baseline diuretics derived a greater benefit for major cardiovascular events from canagliflozin, which was not fully explained by differences in participant characteristics nor risk factor changes.

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Section: Discussionmentioning

confidence: 94%

Section: Discussionmentioning

confidence: 99%

Cardiovascular and renal outcomes with canagliflozin according to baseline diuretic use: a post hoc analysis from the CANVAS Program

Arnott

Neuen

et al. 2021

ESC Heart Failure

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“…Despite an increase in LOS, medication optimization was not different in the current cohort of patients monitored for an extra day on oral diuretics. Furthermore, more patients in the oral diuretic group were discharged home off oral diuretics, which may be associated with long-term adverse events [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

Trial of Oral Diuretics Prior to Discharge Is Not Associated With Improved Outcomes in Decompensated Heart Failure

et al. 2021

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Background: Current heart failure guidelines recommend transition of intravenous (IV) diuretics to oral > 24 h prior to hospital discharge. The aim of this study was to determine whether transition to oral diuretics prior to discharge in patients hospitalized with decompensated systolic heart failure (SHF) was associated with improved 30-day events.Methods: This was a retrospective cohort study, in which adults admitted to the Loma Linda Medical Center for 3 -14 days with a primary discharge diagnosis of acute on chronic SHF were included. Mortality data were obtained from the National Death Index, while readmission only to our facility was included. The t-test and Chisquare test were used for analyses.Results: A total of 314 patients were studied. Patients who were managed with guideline-recommended trial of oral diuretics, and patients who continued to receive IV diuretics on the last full hospital day were overall similar in baseline characteristics. Patients who received oral diuretics on the day prior to discharge had longer length of stay, less weight loss, were discharged on lower diuretic doses (all P < 0.05), and had similar outcomes of 30-day readmission and 30-day hospitalization-free survival. Conclusions:The transition to oral diuretics prior to discharge in patients with decompensated SHF was not associated with improved 30-day outcomes. These results require validation in prospective trials but suggest that guideline recommendations regarding transitioning to oral diuretics prior to discharge may deserve re-evaluation.

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“…The readmission event per month is presented in Table 5. The pooled odds of readmission from nine studies (Figure 2) [11][12][13][14][15][16][17][18][19] in 5362 patients was 0.64 (95% CI 0.44, 0.92, P = 0.02) with moderate heterogeneity (I 2 = 46.5). Three studies 13,14,16 reported the HR, one study reported the incidence rate ratio 21 for readmission, and all studies were adjusted for intervention (Supporting Information, Table S8).…”

Section: Readmissionmentioning

confidence: 99%

Use of novel non‐invasive techniques and biomarkers to guide outpatient management of fluid overload and reduce hospital readmission: systematic review and meta‐analysis

et al. 2021

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Aims Fluid congestion is a leading cause of hospital admission, readmission, and mortality in heart failure (HF). We performed a systematic review and meta-analysis to determine the effectiveness of an advanced fluid management programme (AFMP). The AFMP was defined as an intervention providing tailored diuretic therapy guided by intravascular volume assessment, in hospitalized patients or after discharge. The AFMP group was compared with patients who received standard care treatment. The aim of this systematic review and meta-analysis was to determine the effectiveness of an AFMP in improving patient outcomes. Methods and results A systematic review of randomized controlled trials, case-control studies, and crossover studies using the terms 'heart failure', 'fluid management', and 'readmission' was conducted in PubMed, CINAHL, and Scopus up until November 2020. Studies reporting the association of an AFMP on readmission and/or mortality were included in our metaanalyses. Risk of bias was assessed in non-randomized studies using the Newcastle-Ottawa Scale. From 232 retrieved studies, 12 were included in the data synthesis. The 6040 patients in the included studies had a mean age of 72 ± 4 years and mean left ventricular ejection fraction of 39 ± 8%, there were slightly more men (n = 3022) than women, and the follow-up period was a mean of 4.8 ± 3.1 months. Readmission data were available in 5362 patients; of these, 1629 were readmitted. Mortality data were available in 5787 patients; of these, 584 died. HF patients who had an AFMP in hospital and/or after discharge had lower odds of all-cause readmission (odds ratio-OR 0.64 [95% confidence interval-CI 0.44, 0.92], P = 0.02) with moderate heterogeneity (I 2 = 46.5) and lower odds of all-cause mortality (OR 0.82 [95% CI 0.69, 0.98], P = 0.03) with low heterogeneity (I 2 = 0). The use of an AFMP was equally effective in reducing readmission and mortality regardless of age and follow-up duration. Effective pre-discharge diuresis was associated with significantly lower readmission odds (OR 0.43 [95% CI 0.26, 0.71], P = 0.001) compared with a fluid management plan as part of post-discharge follow-up. Conclusions An effective AFMP is associated with improving readmission and mortality in HF. Our results encourage attainment of optimal volume status at discharge and prescription of optimal diuretic dose. Ongoing support to maintain euvolaemia and effective collaboration between healthcare teams, along with effective patient education and engagement, may help to reduce adverse outcomes in HF patients.

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Loop Diuretic Prescription and 30-Day Outcomes in Older Patients With Heart Failure

Cited by 53 publications

References 30 publications

Cardiovascular and renal outcomes with canagliflozin according to baseline diuretic use: a post hoc analysis from the CANVAS Program

Cardiovascular and renal outcomes with canagliflozin according to baseline diuretic use: a post hoc analysis from the CANVAS Program

Trial of Oral Diuretics Prior to Discharge Is Not Associated With Improved Outcomes in Decompensated Heart Failure

Use of novel non‐invasive techniques and biomarkers to guide outpatient management of fluid overload and reduce hospital readmission: systematic review and meta‐analysis

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