Does high-dose loop diuretic affect ACEi/ARB uptitration in HF patients?

  • Ter Maaten JM & al.
  • Clin Res Cardiol
  • 30 Jan 2020

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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Takeaway

  • In patients with heart failure and reduced ejection fraction (HFrEF), higher doses of loop diuretics were associated with a poorer uptitration of angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs) and with a higher risk for death and/or HF hospitalisation, irrespective of the lower likelihood of uptitration and the higher baseline risk.

Why this matters

  • The harmful effects of inappropriate use of loop diuretics may hamper the optimal uptitration of doses of ACEis/ARBs, and mineralocorticoid receptor antagonists (MRAs) recommended by guideline.

Study design

  • Data on loop diuretic dose at baseline were recorded in 2338 patients with HFrEF recruited in ‘A systems BIOlogy Study to Tailored Treatment in Chronic Heart Failure’ (BIOSTAT-CHF) trial.
  • Funding: None disclosed

Key results

  • Median daily loop diuretic dose at baseline was 40 (40-100) mg of furosemide or equivalent.
  • Higher doses of loop diuretics were associated with a higher New York Heart Association class, N-terminal pro blood natriuretic peptide levels, more severe signs and symptoms of congestion, more frequent MRAs use and lower doses of ACEis reached at 3 and 9 months (P<.01 for all>
  • After adjustment for propensity score, changes in percentage of target loop diuretics dose (from baseline to 3 months) significantly associated with a poorer uptitration of ACEis (Beta per log doubling of loop diuretic dose, −1.66; 95% CI, −3.07 to 0.25; P=.021)
  • Changes in percentage of target dose of loop diuretics from baseline to 9 months was associated with a poorer uptitration of ACEis (Beta per log doubling of loop diuretic dose, −2.09; 95% CI, −3.74 to 0.44; P=.013) but not with uptitration of MRAs (Beta per log doubling of loop diuretic dose, 0.79; 95% CI, −4.27 to 5.86; P=.758).
  • Higher doses of loop diuretics were independently associated with an increased risk of all-cause mortality or HF hospitalisation (HR per doubling of loop diuretic dose, 1.06; 95% CI, 1.01-1.12; P=.021).

Limitations

  • Retrospective design.