Intensification of pharmacological decongestion but not the actual daily loop diuretic dose predicts worse chronic heart
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ORIGINAL PAPER
Intensification of pharmacological decongestion but not the actual daily loop diuretic dose predicts worse chronic heart failure outcome: insights from TIME‑CHF Justas Simonavičius1,2,3 · Micha T. Maeder4 · Casper G. M. J. Eurlings1 · Arantxa Barandiarán Aizpurua1 · Jelena Čelutkienė5 · Jūratė Barysienė5 · Stefan Toggweiler6 · Beat A. Kaufmann7 · Hans‑Peter Brunner‑La Rocca1 Received: 19 March 2020 / Accepted: 2 November 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Background Both loop diuretics (LDs) and congestion have been related to worse heart failure (HF) outcome. The relationship between the cause and effect is unknown. The aim of this study was to investigate the interaction between congestion, diuretic use and HF outcome. Methods Six hundred and twenty-two chronic HF patients from TIME-CHF were studied. Congestion was measured by means of a clinical congestion index (CCI). Loop diuretic dose was considered at baseline and month 6. Treatment intensification was defined as the increase in LD dose over 6 months or loop diuretic and thiazide or thiazide-like diuretic coadministration. The end-points were survival and HF hospitalisation-free survival. Results High-LD dose at baseline and month 6 (≥ 80 mg of furosemide per day) was not identified as an independent predictor of outcome. CCI at baseline remained independently associated with impaired survival [hazard ratio (HR) 1.34, (95% confidence interval) (95% CI) (1.20–1.50), p 0.05). A total of 489 patients, i.e. 79% of TIME-CHF participants survived the first 6 months and did not drop out. Of those, 316 (65%) required LD dose down-titration or remained on a stable LD dose and received no thiazides together with a LD (no treatment intensification group); 173 (35%) required LD dose up-titration or a co-administration of a thiazide drug (treatment intensification group). The comparison of patients receiving no intensification with patients undergoing intensification of congestion treatment is shown in Table 3. Patients in the intensification group were sicker: they had a higher comorbidity burden, their functional capacity was more impaired, their plasma NT-proBNP level at month 6 was higher, their haemoglobin was lower, their renal function was worse, and they were more likely to experience a WRF and to be congested. The median follow-up of patients with survival ≥ 6 months was 30 [19–43] months. Univariable and multivariable predictors of death, and death or HF hospitalisation are shown in Table 4. LD dose administered at month 6 was not identified as an independent predictor of outcome, whilst treatment intensification remained an independent predictor of outcome. Although congestion at month 6 did not appear as an independent predictor of mortality, it remained a strong and independent predictor of HF hospitalisation-free survival after month 6.
Clinical Research in Cardiology
Loop diuretic dose adjustment, congestion and outcome A total of 256 (55%) patients had no or only mild congestion (CCI
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