What is the clinical evidence from this study?

Study design: Cohort. Population: Severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) (n=4431). Intervention: Increased loop diuretic treatment vs. Reduced or unchanged loop diuretic treatment. Primary outcome: All-cause mortality (5-year cumulative risk) (HR 1.36, 95% CI 1.22-1.52).

March 16, 2023Open Access

Diuretic treatment before and after transcatheter aortic valve implantation: A Danish nationwide study

Key Result

Increased loop diuretic treatment at 1-year post-TAVI was associated with a higher 5-year risk of all-cause mortality compared with reduced or unchanged treatment (HR 1.36).

Study Design

Type

Cohort (n=4,431)

Multicenter

Yes

Structured PICO

Does increased loop diuretic treatment at 1-year post-TAVI predict higher all-cause mortality in patients surviving one year after TAVI?

Population

4,431 Danish citizens (median age 81.5, 46% female) who underwent first-time TAVI and survived at least one year post-discharge, followed to assess the association between changes in loop diuretic treatment and all-cause mortality.

Exposure

Increased loop diuretic treatment at 1-year post-TAVI compared to pre-TAVI

Comparator

Reduced or unchanged loop diuretic treatment at 1-year post-TAVI compared to pre-TAVI

Outcome

Change in loop diuretic treatment pre-TAVI and at 1-year post-TAVI and all-cause mortality among patients alive one year after discharge for TAVI procedurehard clinical

Increased loop diuretic treatment 1-year post-TAVI, serving as a proxy for lack of symptom relief, is associated with a significantly higher risk of long-term mortality compared to reduced or unchanged diuretic treatment.

Main Result

Hazard Ratio: 1.36 (95% CI 1.22–1.52)

Absolute Event Rate: 61% vs 47.4%

Limitations

Non-randomized, observational study design
Lack of data on NYHA classification, symptom burden, echocardiographic findings, and objective measurements of heart failure
No information on paravalvular regurgitation, mean gradient across the aortic valve, or indication for starting loop diuretics
Calculation of treatment duration and dose is an approximation based on prescription registries

Abstract

OBJECTIVES: We examined loop diuretic treatment before and 1-year after transcatheter aortic valve implantation (TAVI), as a proxy for changes in symptom severity and secondly assessed how changes in loop diuretics related to mortality risk. BACKGROUND: Randomized clinical trials suggest that approximately one third of patients undergoing TAVI do not achieve symptom relief, but "all-comer" data are lacking. METHODS: Using Danish nationwide registries, we identified all citizens, who underwent TAVI from 2008 to 2019 and were alive at 1-year post-discharge. Loop diuretic treatment pre-TAVI and at 1-year post-TAVI were assessed and grouped as receiving 1) no-loop diuretics; 2) low: 1-40 mg of furosemide (or equivalent bumetanide) daily; 3) intermediate: 41-120 mg of furosemide daily; or 4) high: >120 mg furosemide daily. RESULTS: Among the 4431 patients undergoing TAVI, 2173 (49%) patients were not treated with loop diuretics at the time of TAVI, 918 (21%) had low-loop diuretics, 881 (20%) had intermediate-loop diuretics, and 459 (10%) had high-loop diuretics. At 1-year post-TAVI, 893 (20%) patients had increased, 1010 (23%) had reduced, and 2528 (57%) had unchanged loop diuretic treatment. The cumulative 5-year risk of death in patients surviving one year, was 61% (95% CI: 56.4% to 65.3%) in patients with increased and 47% (95% CI: 44.9% to 49.9%) in patients with reduced/unchanged loop diuretic treatment, respectively. In multivariable Cox proportional hazard analysis, increased loop diuretic treatment was associated with a higher risk of death compared with reduced/unchanged loop diuretic treatment (Hazard ratio: 1.4; 95% CI: 1.22 to 1.52). CONCLUSIONS: Among patients undergoing TAVI, surviving one year, one fifth of patients had increased loop diuretic treatment, and a little over one fifth had reduced loop diuretic treatment 1-year post-procedure. In patients with increased diuretic treatment, the risk of death was higher compared to those with reduced/unchanged loop diuretic treatment.

Bookmark

View Full Paper