Factors Associated With Loop Diuretic De-escalation in Patients With Acute Decompensated Heart Failure: The Influence of Guideline Directed Medical Therapy Initiation

Abstract

Background: In patients with heart failure (HF), loop diuretics (LD) are recommended to relieve congestion and may be de-escalated if symptoms improve. However, long-term use of the same LD dose is sometimes required owing to potential congestion exacerbation. Therefore, we investigated the factors associated with LD de-escalation in patients with acute decompensated HF (ADHF) and the relationship between this de-escalation and initiating guideline directed medical therapy (GDMT) during hospitalization. Methods: In this retrospective cohort study, patients with ADHF who were prescribed LD and GDMT at discharge were included. The primary endpoint was LD de-escalation at 6 months post-discharge. Factors associated with this de-escalation were extracted using multivariate analysis. The Cochran–Armitage trend test was used to analyze the relationship between the number of GDMT initiated during hospitalization and LD de-escalation. Results: Of 193 eligible patients, 40.4% underwent LD de-escalation. Significant de-escalation-associated factors were age <75 years (odds ratio, 2.114; 95% confidence interval, 1.125-3.972), body mass index (BMI) ≥ 22.0 kg/m2 (2.022; 1.073-3.811), and no atrial fibrillation (1.948; 1.047-3.625). The LD de-escalation rate tended to increase with the number of angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonists, and sodium-glucose transporter 2 inhibitors initiated during hospitalization (P = .013). Conclusion: Younger age, high BMI, and no atrial fibrillation were LD de-escalation-associated factors in patients with ADHF. LD de-escalation post-discharge may occur more frequently if the number of GDMT with diuretic effects was increased during hospitalization.