Loop Diuretics and 30-Day Outcomes in Heart Failure

Quick Takes

  • In a retrospective, propensity-matched cohort study, patients hospitalized with HF not on diuretics at admission, had a lower 30-day all-cause mortality and 30-day HF re-hospitalization when discharged on a loop diuretic.
  • This association was homogenous when analyzed for subgroups of patients with HF with reduced EF and preserved EF.
  • Discharge prescription for loop diuretic was not associated with a lower all-cause mortality or HF re-hospitalization at 60 days.

Study Questions:

What is the association between loop diuretics and clinical outcomes in patients with heart failure (HF)?

Methods:

This was a retrospective analysis of the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) registry, which enrolled 48,612 HF hospitalizations in 259 hospitals between 2003 and 2004. The study group included 7,936 patients hospitalized with HF who were not on diuretics prior to hospitalization. The cohort was divided into patients discharged on loop diuretics versus not. To account for characteristics influencing discharge on a loop diuretic, the two groups were propensity matched. Outcomes of interest included HF and all-cause readmission and all-cause mortality at 30 and 60 days from discharge.

Results:

The propensity-matched cohort consisted of 4,382 patients with a mean age of 78 ± 10 years, 54% were women, and 11% were African American. Patients discharged on loop diuretics had a lower 30-day mortality compared to those not (4.9% vs. 6.6%; hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.57-0.94). This association did not persist at 60 days. This association persisted for both HF with reduced ejection fraction (EF) and for HF with preserved EF. Similarly, 30-day HF re-hospitalization rates were lower in patients discharged on loop diuretics versus not (6.2% vs. 7.7%; HR, 0.79; 95% CI, 0.63-0.99). However, 30-day non-HF re-hospitalization did not differ between the two groups. Association between lower 60-day HF re-hospitalization and loop diuretic prescription did not persist. The combined endpoint of 30-day HF re-hospitalization or all-cause mortality was lower in the group discharged on loop diuretics versus not (11% vs. 14%; HR, 0.76; 95% CI, 0.64-0.91). This association was stronger among patients who presented with pulmonary rales and lower extremity edema versus those without.

Conclusions:

In this large, retrospective cohort study, propensity-matched analysis of patients hospitalized with HF, those discharged on loop diuretics had lower 30-day all-cause mortality and 30-day HF re-hospitalization, compared to those not on diuretics. These associations persisted for patients with reduced and preserved EF, but did not persist at 60 days post-discharge.

Perspective:

Loop diuretics offer significant morbidity benefit in HF patients by improving symptoms of volume overload. However, they have not been associated with a reduction in mortality, unlike neurohormonal blockade. In this study, despite propensity matching for several characteristics in an attempt to mitigate bias, discharge prescription for loop diuretics was associated with lower 30-day all-cause mortality and HF re-hospitalization. This association did not persist at 60 days, which may be a reflection of increased use of loop diuretics post-discharge with time. Ostensibly, loop diuretics at discharge are used for patients perceived to have a higher burden of symptoms reflecting more advanced disease. This suggests that these results provide a conservative estimate of the benefit of loop diuretics. However, one common reason for discontinuation of loop diuretics is worsening renal function during hospitalization. While the authors did propensity match for admission creatinine, discharge creatinine was not adjusted for. Furthermore, with robust clinical trial data supporting sustained mortality benefit with sodium-glucose cotransporter-2 inhibitors in HF patients, these agents may start playing a larger role in HF management as diuretics.

Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Acute Heart Failure, Chronic Heart Failure

Keywords: Creatinine, Diuretics, Edema, Cardiac, Geriatrics, Heart Failure, Outcome Assessment (Health Care), Patient Discharge, Patient Readmission, Sodium Potassium Chloride Symporter Inhibitors, Stroke Volume


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