Faselis Charles, Lam Phillip H, Patel Samir, Arundel Cherinne, Filippatos Gerasimos, Deedwania Prakash, Zile Michael R, Wopperer Samuel, Nguyen Tran, Allman Richard M, Fonarow Gregg C, Ahmed Ali
Veterans Affairs Medical Center, Washington, DC; George Washington University, Washington, DC; Uniformed Services University, Washington, DC.
Veterans Affairs Medical Center, Washington, DC; Georgetown University, Washington, DC; MedStar Washington Hospital Center, Washington, DC.
Am J Med. 2021 Jun;134(6):797-804. doi: 10.1016/j.amjmed.2020.11.019. Epub 2021 Jan 28.
The effect of loop diuretics on clinical outcomes in heart failure has not been evaluated in randomized controlled trials. In hospitalized patients with heart failure, a discharge loop diuretic prescription has been shown to be associated with improved 30-day outcomes, which appears to be more pronounced in subgroups with congestion. In the current study, we examined these associations and association modifications during longer follow-up.
We assembled a propensity score-matched cohort of 2191 pairs of hospitalized heart failure patients discharged with, vs without, a prescription for loop diuretics, balanced on 74 baseline characteristics (mean age 78 years; 54% women; 11% African American).
Hazard ratio (HR) and 95% confidence interval (CI) for 6-year combined endpoint of heart failure readmission or all-cause mortality was 1.02 (0.96-1.09). HRs and 95% CIs for this combined endpoint in patients with no, mild-to-moderate, and severe pulmonary rales were 1.19 (1.07-1.33), 0.95 (0.86-1.04), and 0.77 (0.63-0.94), respectively (P for interaction, < .001). Respective HRs (95% CIs) for no, mild-to-moderate, and severe lower extremity edema were 1.16 (1.06-1.28), 0.94 (0.85-1.04), and 0.71 (0.56-0.89; interaction P < .001).
The association between a discharge loop diuretic prescription and long-term clinical outcomes in hospitalized patients with heart failure is modified by admission congestion with worse, neutral, and better outcomes in patients with no, mild-to-moderate, and severe congestion, respectively. If these findings can be replicated, congestion may be used to risk-stratify patients with heart failure for potential optimization of loop diuretic prescription and outcomes.
在随机对照试验中，尚未评估襻利尿剂对心力衰竭临床结局的影响。在住院的心力衰竭患者中，出院时开具襻利尿剂处方已被证明与30天结局改善相关，这在有充血症状的亚组中似乎更为明显。在本研究中，我们在更长的随访期内研究了这些关联及关联修正情况。
我们组建了一个倾向评分匹配队列，包括2191对出院时开具或未开具襻利尿剂处方的住院心力衰竭患者，在74项基线特征（平均年龄78岁；54%为女性；11%为非裔美国人）上达到平衡。
心力衰竭再入院或全因死亡率的6年联合终点的风险比（HR）及95%置信区间（CI）为1.02（0.96 - 1.09）。无、轻至中度和重度肺部啰音患者该联合终点的HR及95%CI分别为1.19（1.07 - 1.33）、0.95（0.86 - 1.04）和0.77（0.63 - 0.94）（交互作用P < 0.001）。无、轻至中度和重度下肢水肿患者的相应HR（95%CI）分别为1.16（1.06 - 1.28）、0.94（0.85 - 1.04）和0.71（0.56 - 0.89；交互作用P < 0.001）。
出院时开具襻利尿剂处方与住院心力衰竭患者长期临床结局之间的关联因入院时的充血情况而有所修正，在无充血、轻至中度充血和重度充血的患者中，结局分别更差、无差异和更好。如果这些发现能够得到重复验证，充血情况可用于对心力衰竭患者进行风险分层，以优化襻利尿剂处方及改善结局。
