Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis
Background In acute decompensated heart failure, guidelines recommend increasing loop diuretic dose or adding a thiazide diuretic when diuresis is inadequate. We set out to determine the adverse events associated with a diuretic strategy relying on metolazone or high‐dose loop diuretics. Methods and...
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| Format: | Article |
| Language: | English |
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Wiley
2018-09-01
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| Series: | Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease |
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| Online Access: | https://www.ahajournals.org/doi/10.1161/JAHA.118.009149 |
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| author | Meredith A. Brisco‐Bacik Jozine M. ter Maaten Steven R. Houser Natasha A. Vedage Veena Rao Tariq Ahmad F. Perry Wilson Jeffrey M. Testani |
| author_facet | Meredith A. Brisco‐Bacik Jozine M. ter Maaten Steven R. Houser Natasha A. Vedage Veena Rao Tariq Ahmad F. Perry Wilson Jeffrey M. Testani |
| author_sort | Meredith A. Brisco‐Bacik |
| collection | DOAJ |
| description | Background In acute decompensated heart failure, guidelines recommend increasing loop diuretic dose or adding a thiazide diuretic when diuresis is inadequate. We set out to determine the adverse events associated with a diuretic strategy relying on metolazone or high‐dose loop diuretics. Methods and Results Patients admitted to 3 hospitals using a common electronic medical record with a heart failure discharge diagnosis who received intravenous loop diuretics were studied in a propensity‐adjusted analysis of all‐cause mortality. Secondary outcomes included hyponatremia (sodium <135 mEq/L), hypokalemia (potassium <3.5 mEq/L) and worsening renal function (a ≥20% decrease in estimated glomerular filtration rate). Of 13 898 admissions, 1048 (7.5%) used adjuvant metolazone. Metolazone was strongly associated with hyponatremia, hypokalemia, and worsening renal function (P<0.0001 for all) with minimal effect attenuation following covariate and propensity adjustment. Metolazone remained associated with increased mortality after multivariate and propensity adjustment (hazard ratio=1.20, 95% confidence interval 1.04–1.39, P=0.01). High‐dose loop diuretics were associated with hypokalemia and hyponatremia (P<0.002) but only worsening renal function retained significance (P<0.001) after propensity adjustment. High‐dose loop diuretics were not associated with reduced survival after multivariate and propensity adjustment (hazard ratio=0.97 per 100 mg of IV furosemide, 95% confidence interval 0.90–1.06, P=0.52). Conclusions During acute decompensated heart failure, metolazone was independently associated with hypokalemia, hyponatremia, worsening renal function and increased mortality after controlling for the propensity to receive metolazone and baseline characteristics. However, under the same experimental conditions, high‐dose loop diuretics were not associated with hypokalemia, hyponatremia, or reduced survival. The current findings suggest that until randomized control trial data prove otherwise, uptitration of loop diuretics may be a preferred strategy over routine early addition of thiazide type diuretics when diuresis is inadequate. |
| first_indexed | 2024-12-23T04:53:30Z |
| format | Article |
| id | doaj.art-0259db3cf71949718e8160a0bd653ccd |
| institution | Directory Open Access Journal |
| issn | 2047-9980 |
| language | English |
| last_indexed | 2024-12-23T04:53:30Z |
| publishDate | 2018-09-01 |
| publisher | Wiley |
| record_format | Article |
| series | Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease |
| spelling | doaj.art-0259db3cf71949718e8160a0bd653ccd2022-12-21T17:59:23ZengWileyJournal of the American Heart Association: Cardiovascular and Cerebrovascular Disease2047-99802018-09-0171810.1161/JAHA.118.009149Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity AnalysisMeredith A. Brisco‐Bacik0Jozine M. ter Maaten1Steven R. Houser2Natasha A. Vedage3Veena Rao4Tariq Ahmad5F. Perry Wilson6Jeffrey M. Testani7Divisions of Cardiology and Cardiovascular Research Lewis Katz School of Medicine at Temple University Philadelphia PADepartment of Cardiology University Medical Center Groningen Groningen The NetherlandsDivisions of Cardiology and Cardiovascular Research Lewis Katz School of Medicine at Temple University Philadelphia PADivisions of Cardiology and Cardiovascular Research Lewis Katz School of Medicine at Temple University Philadelphia PADepartment of Internal Medicine Yale University School of Medicine New Haven CTSection of Cardiovascular Medicine Yale University School of Medicine New Haven CTDepartment of Internal Medicine Yale University School of Medicine New Haven CTSection of Cardiovascular Medicine Yale University School of Medicine New Haven CTBackground In acute decompensated heart failure, guidelines recommend increasing loop diuretic dose or adding a thiazide diuretic when diuresis is inadequate. We set out to determine the adverse events associated with a diuretic strategy relying on metolazone or high‐dose loop diuretics. Methods and Results Patients admitted to 3 hospitals using a common electronic medical record with a heart failure discharge diagnosis who received intravenous loop diuretics were studied in a propensity‐adjusted analysis of all‐cause mortality. Secondary outcomes included hyponatremia (sodium <135 mEq/L), hypokalemia (potassium <3.5 mEq/L) and worsening renal function (a ≥20% decrease in estimated glomerular filtration rate). Of 13 898 admissions, 1048 (7.5%) used adjuvant metolazone. Metolazone was strongly associated with hyponatremia, hypokalemia, and worsening renal function (P<0.0001 for all) with minimal effect attenuation following covariate and propensity adjustment. Metolazone remained associated with increased mortality after multivariate and propensity adjustment (hazard ratio=1.20, 95% confidence interval 1.04–1.39, P=0.01). High‐dose loop diuretics were associated with hypokalemia and hyponatremia (P<0.002) but only worsening renal function retained significance (P<0.001) after propensity adjustment. High‐dose loop diuretics were not associated with reduced survival after multivariate and propensity adjustment (hazard ratio=0.97 per 100 mg of IV furosemide, 95% confidence interval 0.90–1.06, P=0.52). Conclusions During acute decompensated heart failure, metolazone was independently associated with hypokalemia, hyponatremia, worsening renal function and increased mortality after controlling for the propensity to receive metolazone and baseline characteristics. However, under the same experimental conditions, high‐dose loop diuretics were not associated with hypokalemia, hyponatremia, or reduced survival. The current findings suggest that until randomized control trial data prove otherwise, uptitration of loop diuretics may be a preferred strategy over routine early addition of thiazide type diuretics when diuresis is inadequate.https://www.ahajournals.org/doi/10.1161/JAHA.118.009149acute heart failurecardio‐renal syndromediureticsmetolazoneworsening renal function |
| spellingShingle | Meredith A. Brisco‐Bacik Jozine M. ter Maaten Steven R. Houser Natasha A. Vedage Veena Rao Tariq Ahmad F. Perry Wilson Jeffrey M. Testani Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease acute heart failure cardio‐renal syndrome diuretics metolazone worsening renal function |
| title | Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis |
| title_full | Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis |
| title_fullStr | Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis |
| title_full_unstemmed | Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis |
| title_short | Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis |
| title_sort | outcomes associated with a strategy of adjuvant metolazone or high dose loop diuretics in acute decompensated heart failure a propensity analysis |
| topic | acute heart failure cardio‐renal syndrome diuretics metolazone worsening renal function |
| url | https://www.ahajournals.org/doi/10.1161/JAHA.118.009149 |
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