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Chronic Diuretic Use in Heart Failure Patients Called Into Question: Presented at ACC

By Jill Stein

NEW ORLEANS, LA -- March 9, 2004 -- New results challenge the longstanding practice of using chronic diuretics to treat heart failure patients with insufficient renal function.

The data, reported here on March 8^th at the 53^rd Annual Scientific Session of the American College of Cardiology, showed an increased mortality associated with chronic diuretic use in both heart failure patients who had renal insufficiency and in those with earlier stages of renal disease.

The findings are from the Acute Decompensated Heart Failure National Registry (ADHERE), which is an ongoing national database of patients hospitalized with acute decompensated heart failure.

"The ADHERE study is the first evaluation of this scope to suggest that long-term diuretic use may be unsuitable in heart failure patients with renal insufficiency," said Dr. Maria Rosa Costanzo, with Midwest Heart Specialists in Naperville, Illinois.

Instead, she said that there are several new treatments available for patients with decompensated heart failure, such as intravenous vasoactive agents, that should possibly be examined for their effects on outcomes in heart failure patients with renal insufficiency.

Dr. Costanzo's team evaluated resource utilization and outcomes from ADHERE registry data on 46,599 patients hospitalized with decompensated heart failure. Patients were stratified into two groups based on their creatinine level. Overall, 35,423 patients had creatinine levels <2.0 mg/dL, while 10,317 had creatinine levels of at least 2.0 mg/dL.

In the study, 24,775 heart failure patients with minimal to no renal insufficiency were treated chronically with diuretics (usually furosemide), while 10,648 patients with minimal to no renal insufficiency were not treated chronically with diuretics. The percentage of patients with more pronounced renal insufficiency who were treated chronically with diuretics was similar. Overall, 7,380 (72%) patients with more pronounced renal insufficiency were treated with diuretics, and 2,937 (28%) patients with more pronounced renal insufficiency did not receive diuretics.

The investigation showed that heart failure patients who had the lowest mortality and the shortest length of stay in the hospital were those who had minimal to no renal insufficiency and who did not undergo chronic diuretic treatment. Heart failure patients who had the highest mortality and longest length of stay in hospital were those with more pronounced renal insufficiency who did receive chronic diuretic treatment.

Dr. Costanzo pointed out that the results should be interpreted with caution, given certain study limitations. "For example, there may be residual confounding variables that were not adjusted for, suggesting that the observed associations may not be due to a cause-and-effect relationship," she said.

She also said that the clinical reason for chronic diuretic prescriptions in her patient population was not known. Thus, patients on chronic diuretics may have been sicker for a longer period or have "some other issue" unknown in this analysis.

Both high creatinine levels and chronic diuretic therapy were strong independent predictors of mortality. In patients with low creatinine levels, mortality was higher in those receiving chronic diuretics (3.3% vs. 2.7%; P < .001). In patients with high creatinine levels, mortality was also higher in those receiving chronic diuretics (7.8% vs. 5.5%; P < .001).

When the investigators controlled for baseline creatinine levels, chronic diuretic therapy was still associated with significantly increased mortality in heart failure patients.

Overall, the results show that chronic diuretic therapy is an independent predictor of poor clinical outcomes in heart failure patients with renal insufficiency, Dr. Costanzo said. Alternative therapies, she added, may yield better outcomes.

Until now, there has been little information on renal insufficency in heart failure patients due to the exclusion of patients with renal insufficiency from clinical trials of heart failure.

The study was sponsored by Scios, Inc., in Fremont, California.


[Study title: Impact of Renal Insufficiency and Chronic Diuretic Therapy on Outcome and Resource Utilization in Patients With Acute Decompensated Heart Failure. Abstract 1069-114]

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