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Association between loop diuretic dose changes and outcomes in chronic heart failure: observations from the ESC-EORP
Chris J Kapelios1, Cécile Laroche2, Maria G Crespo-Leiro3
1Department of Cardiology, Laiko General Hospital, Athens, Greece.
Insights
In heart failure (HF) patients, loop diuretic (LD) doses were rarely decreased despite guidelines. Decreasing LD was associated with better outcomes, and successful reduction was linked to higher blood pressure and fewer comorbidities.
Area of Science:
- Cardiology
- Pharmacology
- Heart Failure Management
Background:
- Guidelines recommend reducing loop diuretic (LD) doses once euvolaemia is achieved in heart failure (HF) patients.
- Current clinical practice regarding LD dose adjustments in outpatients with HF requires investigation.
Purpose of the Study:
- To examine LD dose changes in daily cardiology practice for HF outpatients.
- To assess adherence to guideline recommendations for LD down-titration.
- To identify predictors of successful LD dose reduction and its association with patient outcomes.
Main Methods:
- Analysis of 8130 HF patients from the ESC-EORP Heart Failure Long-Term Registry.
- Definition of successful LD decrease: no subsequent death, HF hospitalization, NYHA class deterioration, or dose increase.
- Multivariable analysis to identify predictors of successful LD down-titration and outcomes.
Main Results:
- LD dose was increased in 16%, decreased in 8.3%, and unchanged in 76% of patients.
- LD dose increase was linked to higher HF death rates (HR 1.53).
- LD dose decrease showed a trend towards lower HF (HR 0.59) and cardiovascular mortality (HR 0.62).
- Successful LD dose reduction was associated with higher systolic blood pressure and absence of sleep apnea, peripheral congestion, and moderate/severe mitral regurgitation.
Conclusions:
- Loop diuretic doses were infrequently decreased in HF outpatients, with only 8.3% experiencing a reduction.
- Loop diuretic dose increases were associated with adverse outcomes, whereas decreases showed a trend towards improved outcomes.
- Factors such as higher systolic blood pressure and the absence of specific comorbidities predicted successful loop diuretic dose reduction.
Aims:
Guidelines recommend down-titration of loop diuretics (LD) once euvolaemia is achieved. In outpatients with heart failure (HF), we investigated LD dose changes in daily cardiology practice, agreement with guideline recommendations, predictors of successful LD down-titration and association between dose changes and outcomes.
Methods And Results:
We included 8130 HF patients from the ESC-EORP Heart Failure Long-Term Registry. Among patients who had dose decreased, successful decrease was defined as the decrease not followed by death, HF hospitalization, New York Heart Association class deterioration, or subsequent increase in LD dose. Mean age was 66 ± 13 years, 71% men, 62% HF with reduced ejection fraction, 19% HF with mid-range ejection fraction, 19% HF with preserved ejection fraction. Median [interquartile range (IQR)] LD dose was 40 (25-80) mg. LD dose was increased in 16%, decreased in 8.3% and unchanged in 76%. Median (IQR) follow-up was 372 (363-419) days. Diuretic dose increase (vs. no change) was associated with HF death [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.12-2.08; P = 0.008] and nominally with cardiovascular death (HR 1.25, 95% CI 0.96-1.63; P = 0.103). Decrease of diuretic dose (vs. no change) was associated with nominally lower HF (HR 0.59, 95% CI 0.33-1.07; P = 0.083) and cardiovascular mortality (HR 0.62, 95% CI 0.38-1.00; P = 0.052). Among patients who had LD dose decreased, systolic blood pressure [odds ratio (OR) 1.11 per 10 mmHg increase, 95% CI 1.01-1.22; P = 0.032], and absence of (i) sleep apnoea (OR 0.24, 95% CI 0.09-0.69; P = 0.008), (ii) peripheral congestion (OR 0.48, 95% CI 0.29-0.80; P = 0.005), and (iii) moderate/severe mitral regurgitation (OR 0.57, 95% CI 0.37-0.87; P = 0.008) were independently associated with successful decrease.
Conclusion:
Diuretic dose was unchanged in 76% and decreased in 8.3% of outpatients with chronic HF. LD dose increase was associated with worse outcomes, while the LD dose decrease group showed a trend for better outcomes compared with the no-change group. Higher systolic blood pressure, and absence of (i) sleep apnoea, (ii) peripheral congestion, and (iii) moderate/severe mitral regurgitation were independently associated with successful dose decrease.
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