Loop Diuretic Use Improves 30-Day Outcomes Following Heart Failure Hospitalization

Ali Ahmed, MD, MPH

New data from an analysis of the OPTIMIZE-HF registry is underlining the importance of initiating therapy with loop diuretics in patients hospitalized for heart failure decompensation not previously taking diuretics.

Results of the analysis, which was led by investigators from the Veterans Affairs Medical Center in Washington, DC, indicate initiating therapy with loop diuretics was associated with a 27% lower risk of 30-day all-cause mortality and a significantly lower risk of 30-day readmission, suggesting the effects of the therapy may go beyond symptom alleviation.

“Information provided by the current study has practical implications for clinicians involved in HF care,” wrote study investigators. “Despite the general impression that most clinicians would use loop diuretics to relieve symptoms in nearly all patients with HF, findings from our study suggest that many patients hospitalized for HF decompensation were not receiving diuretics before hospitalization.”

To further understand the associations between loop diuretic use and clinical outcomes among patients with heart failure, investigators designed a propensity-matched analysis to compare outcomes of patients from the Medicare-linked OPTIMIZE-HF registry. From the registry, which contains info on more than 25,000 older patients hospitalized for heart failure, a cohort of 9866 patients who were not receiving pre-admission diuretics were identified for the current study.

Of these 9866 patients, 1083 were excluded because they were receiving dialysis and 847 were excluded because they were discharged on thiazide diuretics. From the remaining 7936 patients, which included 5568 patients who were prescribed loop diuretics at discharge, investigators created 2 matched cohorts of 2191 patients based on 74 baseline characteristics.

After propensity matching, there was an absolute standardized difference of less than 5% for all 74 baseline characteristics. Investigators also pointed out 56 values had an absolute standardized difference of less than 2% and 41 values had an absolute standardized difference of less than 1%.

Among the 4382 propensity-matched patients, the mean age was 78±10 years, 54% were women, and 11% were African American. Outcomes of interest for the analysis included heart failure readmission, all-cause readmission, and all-cause mortality at 30 and 60 days. Investigators noted they also examined 2 combined endpoints of either readmission or mortality. All data on outcome events and time to events were obtained through Medicare data.

Upon analysis, results indicated 30-day all-cause mortality rates were 4.9% and 6.6% in the loop diuretics and no loop diuretics groups, respectively. Based on these results, investigators determined the hazard ratio with loop diuretic use versus nonuse was 0.73 (95% CI, 0.57-0.94; P=.016).

The analysis also indicated patients receiving loop diuretics had a significantly lower risk of 30-day heart failure readmission (HR, 0.79; 95% CI, 0.63-0.99; P=.037) but not 30-day all-cause readmission (HR, 0.89; 95% CI, 0.79-1.01; P=.081). Investigators pointed out none of these associations were statistically significant during analysis of 60-day follow-up data.

“The new message from our study is that prescription of loop diuretics at discharge may be associated with a lower risk of short-term rehospitalizations and mortality in these patients,” wrote investigators. “These findings are expected to clarify the role of loop diuretics in HF and strengthen the evidence for the guideline recommendation on loop diuretics.”

Investigators noted multiple limitations to consider when interpreting data from within the study. These limitations included basing the analysis on fee-for-service Medicare beneficiaries, which could limit generalizability, and not having access to data related to loop diuretic doses or start/restart/discontinuation after hospital discharge.

This study, “Loop Diuretic Prescription and 30-Day Outcomes in Older Patients With Heart Failure,” was published in the Journal of the American College of Cardiology.