Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Via Pietro Valdoni 7, 34100, Trieste, Italy.
Department of Cardiovascular Science, Faculty of Life Science and Medicine, King's College London, London, UK.
Clin Res Cardiol. 2023 Mar;112(3):419-430. doi: 10.1007/s00392-022-02126-8. Epub 2022 Nov 17.
For patients with heart failure, prescription of loop diuretics (LD) and of higher doses are associated with an adverse prognosis. We investigated LD dose trajectories and their associations with outcomes in patients with dilated cardiomyopathy (DCM).
Associations between outcomes and both furosemide-equivalent dose (FED) at enrolment and change in FED in the subsequent 24 months were evaluated. According to FED trajectory, patients were classified as (i) dose↑ (FED increase by ≥ 50% or newly initiated); (ii) dose↓ (FED decrease by ≥ 50%); (iii) stable dose (change in FED by < 50%); and (iv) never-users. The primary outcome was all-cause-death/heart transplantation/ventricular-assist-device/heart failure hospitalization. The secondary outcome was all-cause-death/heart transplantation/ventricular-assist-device.
Of 1,131 patients enrolled, 738 (65%) were prescribed LD at baseline. Baseline FED was independently associated with outcome (HR per 20 mg increase: 1.12 [95% CI 1.04-1.22], p = 0.003). Of the 908 with information on FED within 24 months from enrolment, 31% were never-users; 29% were dose↓; 26% were stable dose and 14% were dose↑. In adjusted models, compared to never-users, stable dose had a higher risk of the primary outcome (HR 2.42 [95% CI 1.19-4.93], p = 0.015), while dose↑ had the worst prognosis (HR 2.76 [95% CI 1.27-6.03], p = 0.011). Results were similar for the secondary outcome. Compared to patients who remained on LD, discontinuation of LD (143, 24%) was associated with an improved outcome (HR 0.43 [95% CI 0.28-0.65], p < 0.001).
In patients with DCM, LD use and increasing FED are powerful markers of adverse outcomes. Patients who never receive LD have an excellent prognosis. Among 1131 DCM patients 65% received loop diuretics at enrolment (upper left side). The bar chart on the upper right side shows the categorization in never-users/ dose↓/stable dose/ dose↑ over 24 months of follow-up. At the bottom is reported on the left side of each panel (observation period) the trajectory of LD dose in the four groups (left panel) and in patients who have their LD suspended vs those who continue LD (right panel) in the first two years. On the right side of each panel is shown the incidence of primary outcomes during the subsequent follow-up in the subgroups (outcome assessment).
对于心力衰竭患者，开具袢利尿剂（LD）和较高剂量与不良预后相关。我们研究了扩张型心肌病（DCM）患者的 LD 剂量轨迹及其与结局的关系。
评估结局与纳入时的呋塞米等效剂量（FED）和随后 24 个月内 FED 的变化之间的相关性。根据 FED 轨迹，患者分为（i）剂量↑（FED 增加≥50%或新开始）；（ii）剂量↓（FED 减少≥50%）；（iii）稳定剂量（FED 变化<50%）；和（iv）从未使用者。主要结局为全因死亡/心脏移植/心室辅助装置/心力衰竭住院。次要结局为全因死亡/心脏移植/心室辅助装置。
在纳入的 1131 名患者中，738 名（65%）在基线时开具 LD。基线 FED 与结局独立相关（每增加 20mg 的 HR：1.12[95%CI 1.04-1.22]，p=0.003）。在纳入后 24 个月内有 908 名有 FED 信息的患者中，31%为从未使用者；29%为剂量↓；26%为稳定剂量，14%为剂量↑。在调整后的模型中，与从未使用者相比，稳定剂量的主要结局风险更高（HR 2.42[95%CI 1.19-4.93]，p=0.015），而剂量↑的预后最差（HR 2.76[95%CI 1.27-6.03]，p=0.011）。次要结局结果相似。与继续使用 LD 的患者相比，LD 停药（143 例，24%）与结局改善相关（HR 0.43[95%CI 0.28-0.65]，p<0.001）。
在 DCM 患者中，LD 应用和 FED 增加是不良结局的有力标志物。从未接受 LD 的患者预后良好。在 1131 名 DCM 患者中，65%在入组时接受了袢利尿剂（左上角）。右上角的柱状图显示了在 24 个月的随访中从未使用者/剂量↓/稳定剂量/剂量↑的分类。底部是在每个面板的左侧（观察期）报告了四个组中的 LD 剂量轨迹（左侧面板）以及在第一年中停用 LD 的患者与继续使用 LD 的患者（右侧面板）的 LD 剂量（右侧面板）。每个面板的右侧显示了随后随访中亚组的主要结局发生率（结果评估）。
