Furosemide in the long-term management of heart failure: the good, the bad, and the uncertain

Ultrafiltration in Heart Failure: A Review

Ultrafiltration is an effective method to get rid of fluid retention and congestion in patients with acute decompensated heart failure (HF) without affecting the circulating volume. Although its efficacy in comparison to diuretics is debatable, the evaluation of our analysis is based on various studies that comprise published clinical trials on ultrafiltration and studies comparing the efficacy of diuretics and ultrafiltration. Apart from this, we also look at literature that provides shortcomings of the said procedure and its scope for future advancements. Heart failure ultimately leads to volume overload, which is a highly concerning complication. Diuretics have been used as a first-line treatment for fluid overload but are becoming inefficacious due to the development of resistance and renal dysfunction. Ultrafiltration, on the other hand, is an attractive alternative to counter volume overload and congestion, which are unresponsive to medical therapy. There is also evidence that it significantly decreases the probability of future episodes of decompensation. There are, however, disagreements about whether ultrafiltration is an effective method to improve mortality in these patients. There is a lack of conclusive studies demonstrating the superiority of one fluid removal method over another. Hence, it is imperative to continue searching for the most effective method to treat congestion. Priority should be given to more mechanistic studies regarding ultrafiltration.

Association of furosemide or hydrochlorothiazide use with risk of atrial fibrillation post pacemaker implantation among elderly patients

Background

Atrial fibrillation (AF) induced by artificial pacing is directly related to atrial remodeling. Previous basic research has shown that furosemide aggravates pathologic myocardial remodeling while hydrochlorothiazide alleviates it. However, whether furosemide or hydrochlorothiazide plays a role in developing AF after pacemaker implantation remains unknown. The study aims to investigate the association between oral furosemide or hydrochlorothiazide and the risk of developing AF after pacemaker implantation.

Methods

After a review of electronic medical records, elderly patients with pacemaker implantation and without a known baseline history of AF were included and information on their use of daily oral furosemide or hydrochlorothiazide was extracted. New incident AF cases were confirmed via the records of outpatient visits. A Cox proportional-hazards model was used to evaluate the association between daily oral furosemide or hydrochlorothiazide and risk of developing AF after pacemaker implantation, after adjustment for potential confounders.

Results

Among a total of 551 patients aged more than 65 years, 157 AF cases were identified after pacemaker implantation during a maximum follow up of 3.0±1.6 years. Of these, 242 had used furosemide and 97 had used hydrochlorothiazide therapy. Patients taking daily oral furosemide had a relatively higher risk of AF after pacemaker implantation [hazard ratio (HR): 1.507, 95% confidence interval (CI): 1.036–2.192; P=0.032] after being adjusted for related disease and prescribed medications, while oral taking of hydrochlorothiazide was shown to be a non-effective factor (HR: 0.666, 95% CI: 0.413–1.074), which had no statistical significance.

Conclusions

Daily oral furosemide might increase the risk of developing AF after pacemaker implantation in elderly patients, while hydrochlorothiazide has no detrimental effect.

Early continuous ultrafiltration in Chinese patients with congestive heart failure (EUC-CHF): study protocol for an open-label registry-based prospective clinical trial

BACKGROUND

Conventional pharmacologic therapies aim to reduce fluid overload in advanced heart failure (HF) represented by intravenous (IV) loop diuretics (LDs) have sometimes not so efficacious and been reported to have side effects such as unpredictable removal of water and sodium and electrolyte disturbance. It is not certain whether early ultrafiltration (UF) is effective than LDs in relieving edema. Given the weakness of evidence for early UF in patients with fluid overload, recommendations of UF in guidelines is considered as second-line therapy only for patients with refractory congestion, who failed to respond to LD-based strategies.

METHODS

The early continuous ultrafiltration in Chinese patients with congestive heart failure (EUC-CHF) trial is an open-label, registry-based, prospective study, recruiting patients with severe acute decompensated HF who are hospitalized for HF worsening due to overt fluid overload 24 h from hospital admission. Forty patients will be enrolled to two treatment groups (n = 20 for each group). The primary outcomes are the changes of weight loss and dyspnea severity score after treatment, as well as the occurrence of clinically overt major bleeding.

DISCUSSION

EUC-CHF trial was primarily designed to evaluate the efficacy and safety of early UF in patients with acute decompensated HF to reduce volume overload and improve clinical outcome. The trial aims to determine if early UF in acute HF is superior to IV LDs in clinical parameter improvement without adverse events and prevents rehospitalization up to 30 days. Also the trial is expected to establish a scoring system based on Chinese population to guide early UF treatment in appropriate patients. EUC-CHF is one of the first controlled trials tailored to determine the benefit of UF with 24 h from hospital admission.

TRIAL REGISTRATION

www.chictr.org.cn, ChiCTR1800019556. Registered on 18 November 2018.

Vitamin D deficiency is an independent predictor of mortality in patients with chronic heart failure

Purpose

Low 25-hydroxyvitamin D (25[OH]D) concentrations have been associated with adverse outcomes in selected populations with established chronic heart failure (CHF). However, it remains unclear whether 25[OH]D deficiency is associated with mortality and hospitalisation in unselected patients receiving contemporary medical and device therapy for CHF.

Methods

We prospectively examined the prevalence and correlates of 25[OH]D deficiency in 1802 ambulatory patients with CHF due to left ventricular systolic dysfunction (left ventricular ejection fraction ≤ 45%) attending heart failure clinics in the north of England.

Results

73% of patients were deficient in 25[OH]D (< 50 nmol/L). 25[OH]D deficiency was associated with male sex, diabetes, lower serum sodium, higher heart rate, and greater diuretic requirement. During a mean follow-up period of 4 years, each 2.72-fold increment in 25[OH]D concentration (for example from 32 to 87 nmol/L) is associated with 14% lower all-cause mortality (95% confidence interval (CI) 1, 26%; p = 0.04), after accounting for potential confounding factors.

Conclusions

Low 25-hydroxyvitamin D deficiency is associated with increased mortality in patients with chronic heart failure due to left ventricular systolic dysfunction. Whether vitamin D supplementation will improve outcomes is, as yet, unproven.

Electronic supplementary material

The online version of this article (10.1007/s00394-018-1806-y) contains supplementary material, which is available to authorized users.

Effect of the angiotensin receptor-neprilysin inhibitor sacubitril/valsartan on the pharmacokinetics and pharmacodynamics of a single dose of furosemide

Aims

Sacubitril/valsartan is indicated for the treatment of heart failure and reduced ejection fraction (HFrEF). Furosemide, a loop diuretic commonly used for the treatment of HFrEF, may be coadministered with sacubitril/valsartan in clinical practice. The effect of sacubitril/valsartan on the pharmacokinetics and pharmacodynamics of furosemide was evaluated in this open label, two‐period, single‐sequence study in healthy subjects.

Methods

All subjects (n = 28) received 40 mg oral single‐dose furosemide during period 1, followed by a washout of 2 days. In period 2, sacubitril/valsartan 200 mg (97/103 mg) was administered twice daily for 5 days and a single dose of 40 mg furosemide was coadministered on day 6. Serial plasma and urine samples were collected to determine the pharmacokinetics of furosemide and sacubitril/valsartan and the pharmacodynamics of furosemide. The point estimates and the associated 90% confidence intervals for pharmacokinetic parameters were evaluated.

Results

Coadministration of furosemide with sacubitril/valsartan decreased the maximum observed plasma concentration (C_max) [estimated geometric mean ratio (90% confidence interval): 0.50 (0.44, 0.56)], area under the plasma concentration–time curve (AUC) from time 0 to infinity [0.72 (0.67, 0.77)] and 24‐h urinary excretion of furosemide [0.74 (0.69, 0.79)]. When coadministered with sacubitril/valsartan, 0–4‐h, 4–8‐h and 0–24‐h diuresis in response to furosemide was reduced by ~7%, 21% and 0.2%, respectively, while natriuresis was reduced by ~ 28.5%, 7% and 15%, respectively. Post hoc analysis of the pivotal phase III Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure trial (PARADIGM‐HF) indicated that the median furosemide dose was similar at baseline and at the end of the study in the sacubitril/valsartan group.

Conclusions

Sacubitril/valsartan reduced plasma C_max and AUC and 24‐h urinary excretion of furosemide, while not significantly affecting its pharmacodynamic effects in healthy subjects.

Dietary Self-management in Heart Failure: High Tech or High Touch?

OPINION STATEMENT

Dietary management of heart failure (HF) has largely been focused on sodium and fluid restrictions. Although safety and efficacy of these interventions in HF remain unclear, a daily sodium intake between 2000 and 3000 mg/day appears to be safe in these patients. Ongoing clinical research will inform on the safety and efficacy of a more restrictive sodium intake to less than 1500 mg/day. Data shows that routine fluid restriction in HF regardless of symptoms may be unnecessary; however, in patients with signs of congestion, fluid restriction to 2.0 L/day may be advisable. Recently, more attention has been paid to other nutritional aspects of HF beyond sodium and fluid intake, although there is still little evidence available to guide nutritional management of HF. Assuring that patients meet daily requirements for key micronutrients, such as calcium, magnesium, potassium, folate, vitamin E, vitamin D, zinc, and thiamine, is essential in order to prevent deficiencies. More appropriate macronutrient composition of the diet is still to be determined; however, a diet containing 50-55% carbohydrates, 25-30% fat, and 15-20% protein seems acceptable for patients with HF with or without non-end-stage renal disease. Additionally, increased protein intake may be considered in malnourished/cachectic patients. Consulting a registered dietitian is especially helpful for patients with recent HF exacerbations or for patients with multiple comorbidities who may need to follow several dietary restrictions and may benefit of individualized dietary counseling in order to ensure appropriate intake of energy, protein, and micronutrients. Today, there are still several knowledge gaps in guiding the dietary management of HF. In this article, we review current recommendations for the dietary management of HF and the evidence supporting this practice.

WITHDRAWN: Diuretics for heart failure

This protocol was withdrawn in April 2016 as the author team was unable to progress to the final review stage. An editorial decision was taken not to pursue this title.

The editorial group responsible for this previously published document have withdrawn it from publication.

Efficacy and safety of ultrafiltration in decompensated heart failure patients with renal insufficiency

Ultrafiltration (UF) is an alternative strategy to diuretic therapy for the treatment of patients with decompensated heart failure. The impact of UF in decompensated heart failure with renal insufficiency remains unclear. A literature search was conducted for randomized controlled trials (RCTs) that investigated the use of UF in decompensated heart failure patients with renal insufficiency.Seven RCTs with 569 participants were eligible for analysis. There was significantly more 48 hour weight loss (WMD 1.59, 95% CI 0.32 to 2.86; P = 0.01; I2 = 68%) and 48 hour fluid removal (WMD 1.23, 95% CI 0.63 to 1.82; P < 0.0001; I2 = 43%) in the UF group compared to the control group. Serum creatinine (WMD 0.05; 95% CI -0.23 to 0.33; P = 0.61; I2 = 77%) and serum creatinine changes (WMD 0.05; 95% CI -0.15 to 0.26; P = 0.61; I2 = 77%) were similar between the UF and control groups. All-cause mortality (OR 0.95; 95% CI 0.58 to 1.55; P = 0.83; I2 = 0.0%) and all-cause rehospitalization (OR 0.97; 95% CI 0.49 to 1.92; P = 0.94; I2 = 52%) were also similar between the UF and control groups. Adverse events such as infection, anemia, hemorrhage, worsening heart failure, and other cardiac disorders did not differ significantly between the UF and control groups.UF is an effective and safe therapeutic strategy and produces greater weight loss and fluid removal without affecting renal function, mortality, or rehospitalization in patients with decompensated heart failure complicated by renal insufficiency.

The independent association between altered renal arterial resistance and loop diuretic dose in chronic heart failure outpatients

Background

In chronic heart failure (CHF) patients there is a wide variability in the minimal effective diuretic dose. The aim of this study is to evaluate whether renal resistance index (RRI) is associated to baseline diuretic dose and the changes at one year.

Methods and results

250 outpatients in a stable condition and in conventional therapy were enrolled. Baseline RRI was calculated by renal arterial Doppler. The total daily dose of loop diuretics was assessed at baseline and after one year. High diuretic dose (HDD) was defined as a daily furosemide equivalent dose > 100 mg. RRI was independently associated with baseline HDD at univariate (OR 1.39; 95% CI: 1.233–1.58; p < 0.001) and multivariate analysis (OR 1.27; 95% CI: 1.09–1.49; p: 0.002) after correction for other univariate predictors (age, NYHA class, left ventricular ejection fraction, tricuspid annulus peak of systolic excursion, NT-proBNP, glomerular filtration rate by EPI formula and central venous pressure). Moreover, baseline RRI was independently associated to one year stable increase in loop diuretic dose at univariate and multivariate regression analyses.

Conclusions

RRI is independently associated with high dose loop diuretics and their increase during a mid-term follow-up thus suggesting its usefulness in detecting an altered diuretic response in CHF outpatients.

Cation dyshomeostasis and cardiomyocyte necrosis: the Fleckenstein hypothesis revisited

An ongoing loss of cardiomyocytes to apoptotic and necrotic cell death pathways contributes to the progressive nature of heart failure. The pathophysiological origins of necrotic cell loss relate to the neurohormonal activation that accompanies acute and chronic stressor states and which includes effector hormones of the adrenergic nervous system. Fifty years ago, Albrecht Fleckenstein and coworkers hypothesized the hyperadrenergic state, which accompanies such stressors, causes cardiomyocyte necrosis based on catecholamine-initiated excessive intracellular Ca(2+) accumulation (EICA), and mitochondrial Ca(2+) overloading in particular, in which the ensuing dysfunction and structural degeneration of these organelles leads to necrosis. In recent years, two downstream factors have been identified which, together with EICA, constitute a signal-transducer-effector pathway: (i) mitochondria-based induction of oxidative stress, in which the rate of reactive oxygen metabolite generation exceeds their rate of detoxification by endogenous antioxidant defences; and (ii) the opening of the mitochondrial inner membrane permeability transition pore (mPTP) followed by organellar swelling and degeneration. The pathogenesis of stress-related cardiomyopathy syndromes is likely related to this pathway. Other factors which can account for cytotoxicity in stressor states include: hypokalaemia; ionized hypocalcaemia and hypomagnesaemia with resultant elevations in parathyroid hormone serving as a potent mediator of EICA; and hypozincaemia with hyposelenaemia, which compromise antioxidant defences. Herein, we revisit the Fleckenstein hypothesis of EICA in leading to cardiomyocyte necrosis and the central role played by mitochondria.

End-of-life care in heart failure

The clinical syndrome of heart failure is increasing in prevalence, as is the number of elderly persons with heart failure. Increasing frailty and progression of heart failure in large numbers of patients means clinicians are increasingly challenged to provide end-of-life care for heart failure patients. End-of-life care has been little studied, but management can be understood from early clinical trials of advanced heart failure. Evidence-based heart failure medications, including angiotensin-converting enzyme inhibitors and beta blockers, improve symptoms in patients with advanced heart failure and depressed ejection fraction and should usually be continued in end-stage disease. Patients also should have ongoing meticulous management of fluid status to maximize quality of life. End-of-life care should be planned with the patient and family and should incorporate comprehensive symptom management, bereavement support, and spiritual support. Ongoing communication with patients and families about prognosis can ease the planning of care when the end of life nears.

A propensity-matched study of the effects of chronic diuretic therapy on mortality and hospitalization in older adults with heart failure

BACKGROUND

Non-potassium-sparing diuretics may increase mortality and hospitalizations in heart failure patients. Most heart failure patients are older adults, yet the effect of diuretics on cause-specific mortality and hospitalizations in older adults with heart failure is unknown. The objective of this propensity-matched study was to determine the effect of diuretics on mortality and hospitalizations in heart failure patients >or=65 years.

METHODS

Of the 7788 Digitalis Investigation Group participants, 4036 were >or=65 years and 3271 (81%) were receiving diuretics. Propensity scores for diuretic use for each of the 4036 patients were calculated using a non-parsimonious multivariable logistic regression model incorporating all measured baseline covariates, and were used to match 651 (85%) patients not receiving diuretics with 651 patients receiving diuretics. Effects of diuretics on mortality and hospitalization at 37 months of median follow-up were assessed using matched Cox regression models.

RESULTS

All-cause mortality occurred in 173 patients not receiving diuretics and 208 patients receiving diuretics respectively during 2056 and 1943 person-years of follow-up (hazard ratio {HR}=1.36; 95% confidence interval {CI}=1.08-1.71; p=0.009). All-cause hospitalizations occurred in 413 patients not receiving and 438 patients receiving diuretics respectively during 1255 and 1144 person-years of follow-up (HR=1.18; 95% CI=0.99-1.39; p=0.063). Diuretic use was associated with significant increased risk of cardiovascular mortality (HR=1.50; 95% CI=1.15-1.96; p=0.003).and heart failure hospitalization (HR=1.48; 95% CI=1.13-1.94; p=0.005).

CONCLUSIONS

Chronic diuretic use was associated with significant increased mortality and hospitalization in ambulatory older adults with heart failure receiving angiotensin converting enzyme inhibitor and diuretics.

Novel strategies: challenge loop diuretics and sodium management in heart failure--Part I

This is the first of a 2-part series. This article reviews the relationships among diuretics, neurohormonal activation, renal function, fluid and Na management, the cardiorenal syndrome, and heart failure. Part II will describe novel therapies based on these relationships, focusing particularly on vasopressin antagonists and treatment using hypertonic saline solution with high-dose loop diuretics. Heart failure (HF) is a complex hemodynamic disorder characterized by chronic and progressive pump failure and fluid accumulation. Diuretics are a vital component of symptomatic management, and enhancing diuretic response in the setting of diuretic resistance is therefore pivotal. In HF patients treated with diuretics, compensatory pathophysiologic mechanisms to maintain vascular resistance, such as nonosmotic stimulation of vasopressin secretion and activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, promote renal Na and water reabsorption. Thus, there remains a need to develop novel therapies for HF patients who are refractory to conventional medical treatment. The conflicting results of diuretic treatments in HF and the importance of Na management in the context of the cardiorenal syndrome and neurohormonal activation have suggested novel and counterintuitive strategies, focusing primarily on the use of vasopressin antagonists and hypertonic saline solution with high doses of loop diuretics and neurohormonal interference. The authors review the current evidence for these therapies and suggest hypothetical bases for their efficacy.

Heart failure, chronic diuretic use, and increase in mortality and hospitalization: an observational study using propensity score methods

AIMS

Non-potassium-sparing diuretics are commonly used in heart failure (HF). They activate the neurohormonal system, and are potentially harmful. Yet, the long-term effects of chronic diuretic use in HF are largely unknown. We retrospectively analysed the Digitalis Investigation Group (DIG) data to determine the effects of diuretics on HF outcomes.

METHODS AND RESULTS

Propensity scores for diuretic use were calculated for each of the 7788 DIG participants using a non-parsimonious multivariable logistic regression model, and were used to match 1391 (81%) no-diuretic patients with 1391 diuretic patients. Effects of diuretics on mortality and hospitalization at 40 months of median follow-up were assessed using matched Cox regression models. All-cause mortality was 21% for no-diuretic patients and 29% for diuretic patients [hazard ratio (HR) 1.31; 95% confidence interval (CI) 1.11-1.55; P = 0.002]. HF hospitalizations occurred in 18% of no-diuretic patients and 23% of diuretic patients (HR 1.37; 95% CI 1.13-1.65; P = 0.001).

CONCLUSION

Chronic diuretic use was associated with increased long-term mortality and hospitalizations in a wide spectrum of ambulatory chronic systolic and diastolic HF patients. The findings of the current study challenge the wisdom of routine chronic use of diuretics in HF patients who are asymptomatic or minimally symptomatic without fluid retention, and are on complete neurohormonal blockade. These findings, based on a non-randomized design, need to be further studied in randomized trials.

Ultrafiltration in decompensated heart failure

Fluid congestion is the hallmark of decompensated heart failure. As heart failure progresses, reduced response to diuretics is common. In these patients, ultrafiltration has been found to alleviate excess volume and improve diuretic sensitivity. Compared with diuretics, ultrafiltration provides a more predictable and safer way to achieve euvolemia with minimal electrolyte abnormalities and neurohormonal activation. The emerging familiarity and ease of use of ultrafiltration suggests that in the future this will be an important therapy for the treatment of acute and chronic volume overload associated with decompensated heart failure.

The benefits of early vasoactive therapy in the treatment of acute decompensated heart failure

PURPOSE

To review current issues in the management of acute decompensated heart failure (ADHF), focusing on the early initiation of intravenous (i.v.) vasoactive therapy and including the effects of vasoactive drugs on patient outcomes and the benefits and limitations of each medication class.

DATA SOURCES

Review of the worldwide scientific literature on ADHF.

CONCLUSIONS

The management of ADHF may be improved by early initiation of i.v. vasoactive therapy, reduced use of inotropic agents, and judicious use of diuretics. Data to date suggest that early treatment with the natriuretic peptide nesiritide reduces duration of hospitalization, in-hospital mortality, and requirements for i.v. inotropes and diuretics.

IMPLICATIONS FOR PRACTICE

Advance practice nurses play an integral role in the management of patients with ADHF from initial triage in the emergency department through final discharge from the hospital. Because they are typically responsible for administering medications and monitoring patient status, nurses need to be familiar with the benefits and limitations of each class of vasoactive agent. They need to recognize that prompt initiation of i.v. vasodilator therapy is important for improving patient outcomes. Further, advance practice nurses should participate in team management that promotes the use of evidence-based ADHF care by developing, using, and assertively communicating the need for processes of care that facilitate best practices.