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Association between loop diuretic dose changes and outcomes in chronic heart failure: observations from the ESC‐EORP Heart Failure Long‐Term Registry
Author(s) -
Kapelios Chris J.,
Laroche Cécile,
CrespoLeiro Maria G.,
Anker Stefan D.,
Coats Andrew J.S.,
DíazMolina Beatria,
Filippatos Gerasimos,
Lainscak Mitja,
Maggioni Aldo P.,
McDonagh Theresa,
Mebazaa Alexandre,
Metra Marco,
Moura Brenda,
Mullens Wilfried,
Piepoli Massimo F.,
Rosano Giuseppe M.C.,
Ruschitzka Frank,
Seferovic Petar M.,
Lund Lars H.
Publication year - 2020
Publication title -
european journal of heart failure
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 5.149
H-Index - 133
eISSN - 1879-0844
pISSN - 1388-9842
DOI - 10.1002/ejhf.1796
Subject(s) - medicine , heart failure , hazard ratio , interquartile range , loop diuretic , ejection fraction , diuretic , cardiology , confidence interval , odds ratio , heart failure with preserved ejection fraction
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.