Initial Diuretic Strategy During Hospitalization for Heart Failure and Associated Outcomes: Insights From the TREAT-AHF Registry

BACKGROUND: Real-world data regarding diuretic strategies and associated outcomes in patients hospitalized for heart failure (HF) in community health systems are limited. OBJECTIVES: Evaluate associations between initial diuretic therapy, markers of decongestion, and clinical outcomes in patients hospitalized due to HF. METHODS: Patients hospitalized due to HF from 2015 to 2022 across 30 health systems in the U.S. were identified in the Truveta national database. High-dose loop diuretics were defined as >2.5× home dose or >160 mg intravenous furosemide equivalent over 24 hours. Four study groups were defined on the basis of the most intensive diuretic strategy used within 48 hours of admission: (1) high-dose loop diuretics with adjuvant therapy (thiazide or acetazolamide); (2) high-dose loop diuretics alone; (3) low-dose loop diuretics with adjuvant therapy; and (4) low-dose loop diuretics alone. Multivariable logistic and linear regression models adjusted for clinical and demographic covariates were developed to evaluate the associations between initial diuretic strategies and both in-hospital outcomes (acute kidney injury, hemoconcentration, and weight change) and the composite of readmission or death. RESULTS: Patients were treated with low-dose loop diuretics (N = 81,734; 74.9%), high-dose loop diuretics (N = 17,187; 15.7%), low-dose loop diuretics plus adjuvant therapy (N = 7027; 6.4%), or high-dose loop diuretics plus adjuvant therapy (N = 3210; 2.9%). Patients treated with more intensive strategies had greater illness severity, including more frequent prior HF hospitalizations and worse kidney function. Adjusted weight loss during hospitalization was greater for patients treated with more intensive strategies (high-dose loop diuretics with adjuvant therapy: 4.6 lbs. [4.0-5.2]; high-dose loop diuretics alone: 2.1 lbs. [1.9-2.4]; low-dose loop diuretics with adjuvant therapy: 1.4 lbs. [1.0-1.8]), as were adjusted odds of acute kidney injury. The adjusted odds of 90-day readmission/death were not lower with more intensive initial diuretic strategies. However, the odds of 90-day readmission/death were lower for every 5 lbs. of achieved weight loss (adjusted odds ratio: 0.97, 95% confidence interval 0.96-0.97). CONCLUSIONS: More intensive diuretic strategies were used in sicker patients, and they improved in-hospital decongestion, but they were not associated with improved 90-day outcomes. However, greater weight loss was associated with modestly lower risk of death or readmission. These data highlight the need for prospective studies to evaluate whether enhancing decongestion can improve outcomes in patients hospitalized due to HF.