Key result
In-hospital GDMT initiation is linked to loop diuretic de-escalation, occurring in ~40% of ADHF patients.
Why the study?
Loop diuretics may be de-escalated if heart failure symptoms improve, but long-term maintenance doses are often required to prevent congestion exacerbation, leaving the factors associated with de-escalation unclear.
Does initiation of guideline-directed medical therapy improve loop diuretic de-escalation in patients with acute decompensated heart failure?
Does initiation of guideline-directed medical therapy improve loop diuretic de-escalation in patients with acute decompensated heart failure?
Initiation of GDMT with diuretic effects during hospitalization, along with younger age, higher BMI, and absence of atrial fibrillation, is associated with a higher likelihood of loop diuretic de-escalation at 6 months post-discharge in ADHF patients.
GDMT initiation during ADHF may support later loop diuretic de-escalation; hypothesis-generating and requires RCT confirmation before practice change.
BackgroundIn patients with heart failure (HF), loop diuretics (LD) are recommended to relieve congestion and may be de-escalated if symptoms improve. However, long-term use of the same LD dose is sometimes required owing to potential congestion exacerbation. Therefore, we investigated the factors associated with LD de-escalation in patients with acute decompensated HF (ADHF) and the relationship between this de-escalation and initiating guideline directed medical therapy (GDMT) during hospitalization.MethodsIn this retrospective cohort study, patients with ADHF who were prescribed LD and GDMT at discharge were included. The primary endpoint was LD de-escalation at 6 months post-discharge. Factors associated with this de-escalation were extracted using multivariate analysis. The Cochran-Armitage trend test was used to analyze the relationship between the number of GDMT initiated during hospitalization and LD de-escalation.ResultsOf 193 eligible patients, 40.4% underwent LD de-escalation. Significant de-escalation-associated factors were age <75 years (odds ratio, 2.114; 95% confidence interval, 1.125-3.972), body mass index (BMI) ≥ 22.0 kg/m² (2.022; 1.073-3.811), and no atrial fibrillation (1.948; 1.047-3.625). The LD de-escalation rate tended to increase with the number of angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonists, and sodium-glucose transporter 2 inhibitors initiated during hospitalization (P = .013).ConclusionYounger age, high BMI, and no atrial fibrillation were LD de-escalation-associated factors in patients with ADHF. LD de-escalation post-discharge may occur more frequently if the number of GDMT with diuretic effects was increased during hospitalization.
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Hanazawa et al. (2026) studied this question. Loop diuretic de-escalation occurred in 40.4% of ADHF patients and was associated with age <75 (OR 2.11), BMI ≥22 (OR 2.02), no atrial fibrillation, and more GDMT initiated (p=0.013).
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