Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F-CRIN INI-CRCT, Reicatra, Vandoeuvre-lès-Nancy, 54500, France.
Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP). Sorbonne University Medical School, Paris, France.
ESC Heart Fail. 2023 Oct;10(5):2843-2852. doi: 10.1002/ehf2.14467. Epub 2023 Jul 5.
The prognostic value of 'high dose' loop diuretics in advanced heart failure outpatients is unclear. We aimed to assess the prognosis associated with loop diuretic dose in ambulatory patients awaiting heart transplantation (HT).
All ambulatory patients (n = 700, median age 55 years and 70% men) registered on the French national HT waiting list between 1 January 2013 and 31 December 2019 were included. Patients were divided into 'low dose', 'intermediate dose', and 'high dose' loop diuretics corresponding to furosemide equivalent doses of ≤40, 40-250, and >250 mg, respectively. The primary outcome was a combined criterion of waitlist death and urgent HT. N-terminal pro-B-type natriuretic peptide, creatinine levels, pulmonary capillary wedge pressure, and pulmonary pressures gradually increased with higher diuretic dose. At 12 months, the risk of waitlist death/urgent HT was 7.4%, 19.2%, and 25.6% (P = 0.001) for 'low dose', 'intermediate dose', and 'high dose' patients, respectively. When adjusting for confounders, including natriuretic peptides, hepatic, and renal function, the 'high dose' group was associated with increased waitlist mortality or urgent HT [adjusted hazard ratio (HR) 2.23, 1.33 to 3.73; P = 0.002] and a six-fold higher risk of waitlist death (adjusted HR 6.18, 2.16 to 17.72; P < 0.001) when compared with the 'low dose' group. 'Intermediate doses' were not significantly associated with these two outcomes in adjusted models (P > 0.05).
A 'high dose' of loop diuretics is strongly associated with residual congestion and is a predictor of outcome in patients awaiting HT despite adjustment for classical cardiorenal risk factors. This routine variable may be helpful for risk stratification of pre-HT patients.
在晚期心力衰竭门诊患者中，“大剂量”袢利尿剂的预后价值尚不清楚。我们旨在评估在等待心脏移植（HT）的门诊患者中，袢利尿剂剂量与预后的相关性。
本研究纳入了 2013 年 1 月 1 日至 2019 年 12 月 31 日期间在法国国家 HT 等待名单上登记的所有门诊患者（n=700，中位年龄 55 岁，70%为男性）。患者被分为“低剂量”、“中剂量”和“高剂量”袢利尿剂，分别对应于呋塞米等效剂量≤40、40-250 和>250mg。主要结局是等待名单上的死亡和紧急 HT 的联合标准。N 末端前 B 型利钠肽、肌酐水平、肺毛细血管楔压和肺压随着利尿剂剂量的增加而逐渐升高。在 12 个月时，低剂量、中剂量和高剂量患者的等待名单上死亡/紧急 HT 的风险分别为 7.4%、19.2%和 25.6%（P=0.001）。在调整混杂因素，包括利钠肽、肝和肾功能后，高剂量组与等待名单上的死亡率或紧急 HT 增加相关[调整后的危险比（HR）2.23，1.33 至 3.73；P=0.002]，并且等待名单上的死亡风险增加六倍（调整后的 HR 6.18，2.16 至 17.72；P<0.001）与低剂量组相比。在调整后的模型中，中剂量与这两个结局没有显著相关性（P>0.05）。
尽管调整了经典的心脏肾脏危险因素，但“大剂量”袢利尿剂与残留充血密切相关，是等待 HT 患者预后的预测指标。这种常规变量可能有助于 HT 前患者的风险分层。
