Department of Cardiology, Laiko General Hospital, Athens, Greece.
EURObservational Research Programme, European Society of Cardiology, Sophia-Antipolis, France.
Eur J Heart Fail. 2020 Aug;22(8):1424-1437. doi: 10.1002/ejhf.1796. Epub 2020 Apr 1.
Guidelines recommend down-titration of loop diuretics (LD) once euvolaemia is achieved. In outpatients with heart failure (HF), we investigated LD dose changes in daily cardiology practice, agreement with guideline recommendations, predictors of successful LD down-titration and association between dose changes and outcomes.
We included 8130 HF patients from the ESC-EORP Heart Failure Long-Term Registry. Among patients who had dose decreased, successful decrease was defined as the decrease not followed by death, HF hospitalization, New York Heart Association class deterioration, or subsequent increase in LD dose. Mean age was 66 ± 13 years, 71% men, 62% HF with reduced ejection fraction, 19% HF with mid-range ejection fraction, 19% HF with preserved ejection fraction. Median [interquartile range (IQR)] LD dose was 40 (25-80) mg. LD dose was increased in 16%, decreased in 8.3% and unchanged in 76%. Median (IQR) follow-up was 372 (363-419) days. Diuretic dose increase (vs. no change) was associated with HF death [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.12-2.08; P = 0.008] and nominally with cardiovascular death (HR 1.25, 95% CI 0.96-1.63; P = 0.103). Decrease of diuretic dose (vs. no change) was associated with nominally lower HF (HR 0.59, 95% CI 0.33-1.07; P = 0.083) and cardiovascular mortality (HR 0.62, 95% CI 0.38-1.00; P = 0.052). Among patients who had LD dose decreased, systolic blood pressure [odds ratio (OR) 1.11 per 10 mmHg increase, 95% CI 1.01-1.22; P = 0.032], and absence of (i) sleep apnoea (OR 0.24, 95% CI 0.09-0.69; P = 0.008), (ii) peripheral congestion (OR 0.48, 95% CI 0.29-0.80; P = 0.005), and (iii) moderate/severe mitral regurgitation (OR 0.57, 95% CI 0.37-0.87; P = 0.008) were independently associated with successful decrease.
Diuretic dose was unchanged in 76% and decreased in 8.3% of outpatients with chronic HF. LD dose increase was associated with worse outcomes, while the LD dose decrease group showed a trend for better outcomes compared with the no-change group. Higher systolic blood pressure, and absence of (i) sleep apnoea, (ii) peripheral congestion, and (iii) moderate/severe mitral regurgitation were independently associated with successful dose decrease.
指南建议一旦达到血容量正常化，就将利尿剂（LD）的剂量减少。在心力衰竭（HF）门诊患者中，我们研究了每日心脏病学实践中 LD 剂量的变化、与指南推荐的一致性、成功 LD 减量的预测因素以及剂量变化与结局之间的关系。
我们纳入了 ESC-EORP 心力衰竭长期注册研究中的 8130 例 HF 患者。在剂量降低的患者中，成功降低定义为未因死亡、HF 住院、纽约心脏协会（NYHA）心功能恶化或随后 LD 剂量增加而导致剂量降低。平均年龄为 66±13 岁，71%为男性，62%为射血分数降低性心力衰竭，19%为射血分数中间值心力衰竭，19%为射血分数保留性心力衰竭。中位数[四分位间距（IQR）]LD 剂量为 40（25-80）mg。LD 剂量增加 16%，减少 8.3%，不变 76%。中位（IQR）随访时间为 372（363-419）天。利尿剂剂量增加（与无变化相比）与 HF 死亡相关[风险比（HR）1.53，95%置信区间（CI）1.12-2.08；P=0.008]，与心血管死亡有一定相关性（HR 1.25，95%CI 0.96-1.63；P=0.103）。利尿剂剂量降低（与无变化相比）与 HF（HR 0.59，95%CI 0.33-1.07；P=0.083）和心血管死亡率（HR 0.62，95%CI 0.38-1.00；P=0.052）降低有一定相关性。在 LD 剂量降低的患者中，收缩压[每增加 10mmHg 的比值比（OR）1.11，95%CI 1.01-1.22；P=0.032]和不存在（i）睡眠呼吸暂停（OR 0.24，95%CI 0.09-0.69；P=0.008）、（ii）外周充血（OR 0.48，95%CI 0.29-0.80；P=0.005）和（iii）中度/重度二尖瓣反流（OR 0.57，95%CI 0.37-0.87；P=0.008）与成功减量独立相关。
慢性 HF 门诊患者中，76%的患者利尿剂剂量保持不变，8.3%的患者剂量减少。利尿剂剂量增加与预后较差相关，而与无变化组相比，LD 剂量减少组的预后有改善趋势。较高的收缩压和不存在（i）睡眠呼吸暂停、（ii）外周充血和（iii）中度/重度二尖瓣反流与成功的剂量减少独立相关。
