Clinical implication of initial intravenous diuretic dose for acute decompensated heart failure

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Acute decompensated heart failure (n=1093). Intervention: Initial intravenous diuretic dose above guideline recommendation vs. Guideline-recommended initial intravenous diuretic dose. Primary outcome: All-cause 60-day mortality (HR 3.11, 95% CI 1.29-7.49, p=0.011).

Kenji Yoshioka; Daichi Maeda; Takahiro Okumura; Keisuke Kida; Shogo Oishi; Eiichi Akiyama; Satoshi Suzuki; Masayoshi Yamamoto; Akira Mizukami; Shunsuke Kuroda; Nobuyuki Kagiyama; Tetsuo Yamaguchi; Tetsuo Sasano; Akihiko Matsumura; Takeshi Kitai; Yuya Matsue

doi:10.1038/s41598-022-06032-x

February 8, 2022Scientific ReportsOpen Access

Clinical implication of initial intravenous diuretic dose for acute decompensated heart failure

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Key result

An initial intravenous diuretic dose above guideline recommendations was associated with a higher 60-day mortality rate compared to the standard dose in patients with acute decompensated heart failure.

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Why the study?

Intravenous diuretics are a cornerstone of acute heart failure treatment, but the optimal initial dose remains unclear.

Does initial intravenous diuretic dose above or below guideline recommendations affect 60-day mortality and hospital stay in patients with acute decompensated heart failure?

Key Points

To evaluate the clinical outcomes associated with initial intravenous diuretic doses relative to guideline-recommended doses in patients hospitalized with acute decompensated heart failure.
Post-hoc analysis of the REALITY-AHF prospective multicenter observational registry evaluating 1,093 patients with acute heart failure.
Patients were categorized based on whether their initial intravenous diuretic dose was below (n=429), standard (n=558), or above (n=106) guideline recommendations individualized to home oral diuretic intake.
Endpoints evaluated included diuretic response within six hours, length of hospital stay, and 60-day mortality.
Patients in the below-guideline group had significantly greater diuretic response within six hours and significantly longer hospital stays compared to the standard group after adjusting for covariates.
Kaplan-Meier analysis and multivariable adjustment demonstrated a significantly higher incidence of 60-day mortality in the above-guideline group compared to the standard group.

Study Design

Type

Observational (n=1,093)

Multicenter

Yes

Structured PICO

Does initial intravenous diuretic dose above or below guideline recommendations affect 60-day mortality and hospital stay in patients with acute decompensated heart failure?

P

Population

1,093 patients aged 20 years or older hospitalized with acute decompensated heart failure who received an initial intravenous furosemide bolus within six hours of admission, followed for 60 days.

E

Exposure

Initial intravenous furosemide dose categorized as Below (n=429) or Above (n=106) the guideline-recommended dose. The guideline-recommended dose was defined as 40 mg IV furosemide for diuretic-naive patients, or IV furosemide at the same dose as the oral loop diuretics for those already taking them.

C

Comparator

Standard group (n=558) receiving the exact guideline-recommended initial intravenous furosemide dose.

O

Outcome

All-cause 60-day mortalityhard clinical

Main Result

Hazard Ratio: 3.11 (95% CI 1.29–7.49)

p-value: p=0.011

Limitations

Retrospective analysis of registry data, which may be subject to unmeasured confounders.
A significant number of patients were excluded due to late administration of the first IV furosemide.
Baseline characteristics differed between groups, meaning worse outcomes in the higher dose group might reflect disease severity rather than the impact of the dose itself.
The overall dose of diuretics in the study was relatively lower than in previous studies, limiting generalizability to populations receiving higher doses.
Retrospective analysis of registry data (not predefined)
Significant number of patients excluded for late administration of first IV furosemide
Baseline characteristics differed between groups, meaning worse outcomes in the higher dose group might reflect disease severity
Potential for unmeasured confounders
Relatively lower dose of diuretics compared to previous studies like the DOSE trial

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Implication

Adhering to guideline-recommended initial intravenous diuretic doses in acute heart failure is associated with optimal outcomes, as lower doses prolong hospital stay and higher doses are associated with increased 60-day mortality.

Abstract

Although intravenous diuretics is a cornerstone of acute heart failure treatment (AHF), its optimal initial dose is unclear. This is a post-hoc analysis of the REALITY-AHF, a prospective multicentre observational registry of AHF. The initial intravenous diuretic dose used in each patient was categorised into below, standard, or above the recommended dose groups according to guideline-recommended initial intravenous diuretic dose. The recommended dose was individualised based on the oral diuretic dose taken at admission. We compared the study endpoints, including 60-day mortality, diuretics response within six hours, and length of hospital stay (HS). Of 1093 patients, 429, 558, and 106 were assigned to the Below, Standard, and Above groups, respectively. The diuretics response and HS were significantly greater in the Below group than in the Standard group after adjusting for covariates. Kaplan-Meier analysis indicated a significantly higher incidence of 60-day mortality in the Above group than the Standard group. This difference was retained after adjusting for other prognostic factors. Treatment with a lower than guideline-recommended intravenous diuretic dose was associated with longer HS, whereas above the guideline-recommended dose was associated with a higher 60-day mortality rate. Our results reconfirm that the guideline-recommended initial intravenous diuretic dose is feasible for AHF.

Discussion

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Cite This Study

Yoshioka et al. (2022) conducted an observational in Acute decompensated heart failure (n=1,093). Initial intravenous diuretic dose above guideline recommendation vs. Guideline-recommended initial intravenous diuretic dose was evaluated on All-cause 60-day mortality (HR 3.11, 95% CI 1.29-7.49, p=0.011). An initial intravenous diuretic dose above guideline recommendations was associated with a higher 60-day mortality rate compared to the standard dose in patients with acute decompensated heart failure.

synapsesocial.com/papers/6a8c29a90ca85c7e33df2d89 https://doi.org/10.1038/s41598-022-06032-x

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Clinical implication of initial intravenous diuretic dose for acute decompensated heart failure

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Clinical implication of initial intravenous diuretic dose for acute decompensated heart failure

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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