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Loop Diuretic Dose Associated With Mortality in Patients With Advanced Heart Failure and Left Ventricular Systolic Dysfunction: Presented at ESC-HF

By Chris Berrie

HAMBURG, GERMANY -- June 12, 2007 -- The use of loop diuretics on discharge from hospital has a dose-dependent association with impaired survival in patients with advanced heart failure and left ventricular systolic dysfunction, independent of other clinical variables, according to a study presented here at the Heart Failure Association of the European Society of Cardiology Heart Failure (ESC-HF) congress.

Previous research suggested that use of loop diuretics could have deleterious effects on the neurohormonal status of patients with heart failure.

Principal investigator Belén Redondo, MD, resident cardiologist, heart failure unit, cardiology department, University Hospital Virgen de la Arrixaca, Murcia, Spain, said, "It is important to find out for each patient what dose [of diuretic] they are on and the effects this can have on the prognosis in the long-term follow-up."

Dr. Redondo and colleagues conducted a study to investigate the effect of the dose of loop diuretic therapy on long-term outcomes of patients with left ventricular dysfunction. She presented the findings in a poster session on June 10th.

The researchers enrolled 212 consecutive patients (mean age, 69 years; male, 71%) with left ventricular ejection fraction (LVEF) <40% (mean, 31.9%) who were discharged from the cardiology department of their tertiary hospital.

At discharge from hospital, 57.0% of the cohort had a New York Heart Association (NYHA) class 3/4 rating; 53.0% had an ischaemic aetiology, 15.6% had valvular aetiology, 31.0% had an idiopathic or other aetiology; 29.9% had atrial fibrillation.

Patients' non-loop diuretic treatments included angiotensin-converting enzyme (ACE) inhibitors (78%), beta blockers (59%), digoxin (36%), spironolactone (29%), and each of angiotensin receptor blockers (ARBs) and ionotropics (6%).

Of the 73% of patients on loop diuretics, this divided as 60% on furosemide (mean dose, 53 mg/day) and 13% on torasemide (mean dose, 7.4 mg/day).

Loop diuretic doses were seen to significantly correlate with LVEF (P =.001), serum creatinine (P <.001) and NYHA class (P <.01). For NYHA, this was seen as mean loop diuretic doses of 18 mg/day for class 1 patients, 25 mg/day for class 2, 43 mg/day for class 3, and 52 mg/day for class 4.

While the loop diuretic doses were not dependent on ACE inhibitor use (36 vs 32 mg/day; P =.3), they were significantly higher in patients treated with digoxin (53 vs 26 mg/day; P <.01) and spironolactone (55 vs 28 mg/day; P <.01). In contrast, they were significantly lower for patients on beta blockers (31 vs 42 mg/day; P =.01).

During the 15-month follow-up period, 23% of these patients died, while 32% were readmitted due to heart failure; 47% showed the combined event.

For the correlation between use of loop diuretics and death or readmission due to heart failure, a significantly increased risk ratio (RR) was seen according to loop diuretic dose (per 10 mg/day), of 1.1 (P =.04). Similarly, there was a higher risk for readmission due to heart failure in patients on loop-diuretics (RR, 1.1; P <.001) and for combined death and readmission (RR, 1.1; P <.01).

Dr. Redondo also noted that all of these correlative effects were independent of age, gender, NYHA class, LVEF. and serum creatinine.

She stressed that this study demonstrates the need to monitor loop diuretic dosing of these patients at discharge, to find out which patients will need a more intense and longer follow-up.

She also noted that, "Our population includes very old people, who have a lot of comorbidity, and I think this is closer to what is seen in medical practice, rather than to what is in many databases, which represent less common patient conditions."

[Presentation title: Relation of Loop Diuretic Dose to Mortality in Advanced Heart Failure and Left Ventricular Systolic Dysfunction. Abstract P78]

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