Does In-Hospital Diuretic Intensity Impact 30-Day Outcomes in Heart Failure Patients?

Study Questions:

What is the association between short-term in-hospital diuretic use and post-discharge 30-day clinical outcomes in patients discharged with and without signs of persistent congestion in the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study With Tolvaptan) trial?


This was a post hoc analysis of the EVEREST trial. EVEREST was an international, multicenter, randomized, double-blind, placebo-controlled trial comparing the safety and efficacy of tolvaptan (a selective vasopressin-2 receptor antagonist), versus matching placebo, in addition to standard care, in 4,133 subjects hospitalized for worsening heart failure (HF). Cox proportional hazards models were used to estimate the association between average loop diuretic dose (high-dose, ≥160 mg/day or low dose, <160 mg/day), congestion status at discharge, and 30-day post-discharge all-cause mortality and HF re-hospitalization.


There were 380 events (12.5%, 67 deaths, 340 re-hospitalizations, 27 with both) in the study population over a follow-up duration of 30 days. In analyses adjusted for prespecified covariants of disease severity, diuretic dose was not associated with increased risk of the endpoint (hazard ratio, 1.11; 95% confidence interval, 0.89-1.38; p = 0.35). Discharge congestion status did not modify the effect of diuretic exposure on the combined endpoint.


Short-term diuretic treatment during hospitalization for worsening HF was not an independent predictor of 30-day post-discharge all-cause mortality and HF re-hospitalization.


This is a valuable study that aims to clarify the divergent data on diuretic dose in hospitalized HF patients and eventual clinical outcomes. The authors provide convincing evidence that high-dose diuretics are not an independent predictor of adverse outcomes in patients hospitalized with worsening HF. Such evidence corroborates current guidelines and the practice of adjustment of diuretic dose to achieve euvolemia.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Benzazepines, Diuretics, Heart Failure, Hospitalization, Mortality, Outcome Assessment (Health Care), Patient Discharge, Sodium Chloride Symporter Inhibitors, Vasopressins

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