Key result
Cardiology referral for raised natriuretic peptides is linked to ~13% lower all-cause mortality.
Why the study?
Loop diuretics are commonly prescribed in primary care, prompting an evaluation of HF assessment, diagnosis, and clinical outcomes following a loop diuretic prescription.
Does specialist cardiology referral reduce mortality in patients prescribed loop diuretics without a heart failure diagnosis who have elevated natriuretic peptides?
Cohort (n=71,847)
Yes
Does specialist cardiology referral reduce mortality in patients prescribed loop diuretics without a heart failure diagnosis who have elevated natriuretic peptides?
In primary care patients prescribed loop diuretics without a known heart failure diagnosis, appropriate assessment and specialist referral for those with elevated natriuretic peptides is associated with reduced all-cause mortality.
Supports specialist referral consideration; leaves open causality and requires randomized confirmation.
BACKGROUND: Loop diuretics are commonly prescribed in primary care. We explored HF assessment, diagnosis, and outcomes following a loop diuretic prescription. METHODS & RESULTS: The Clinical Practice Research Datalink Gold database linked to Hospital Episode Statistics (HES) and Office for National Statistics mortality registry in the UK was used to identify patients prescribed loop diuretics, and subsequent HF diagnoses. HF assessment was defined as natriuretic peptide (NP) testing, echocardiography, or out-patient cardiology referral. NP thresholds recommended by National Institute of Health and Care Excellence (NICE) and European Society of Cardiology (ESC) were explored. The primary endpoint was HF events (presentation to primary care with symptoms of HF, HF hospitalisation, or all-cause mortality). A total of 71,847 patients were prescribed a loop diuretic without a diagnosis of HF; 9876 (14 %) underwent HF assessment and 1483 (15 %) were diagnosed with HF within five years. Of those who were assessed, 5316 (54 %) had NP testing: 1937 (36 %) and 3200 (60 %) patients had NP concentrations above the NICE and ESC referral thresholds, respectively. Of those above the NICE threshold, 701 (36 %) were referred to cardiology. Compared to those who were not referred, there was a lower rate of all-cause mortality (47 % vs. 57 %; P < 0.001; hazard ratio = 0.87 (95 % confidence interval 0.76-0.99); P = 0.04). CONCLUSIONS: One in seven patients without HF prescribed a loop diuretic undergo HF assessment, one in six of those assessed had a HF diagnosis. Specialist referral in patients with raised NP was associated with a lower risk of death.
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Cuthbert et al. (2025) conducted a cohort in Prescribed loop diuretics without heart failure diagnosis (n=71,847). Specialist cardiology referral vs. No cardiology referral was evaluated on HF events (presentation to primary care with symptoms of HF, HF hospitalisation, or all-cause mortality) (HR 0.87, 95% CI 0.76-0.99, p=0.04). Specialist cardiology referral in patients with raised natriuretic peptides after loop diuretic prescription was associated with lower all-cause mortality compared to no referral (HR 0.87; 95% CI 0.76-0.99).
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