Background:Diuretics are a mainstay therapy for the symptomatic treatment of heart failure. However, in contemporary US outpatient practice, the degree to which diuretic dosing changes over time and the associations with clinical outcomes and health care resource utilization are unknown.Methods:Among 3426 US outpatients with chronic heart failure with reduced ejection fraction in the Change the Management of Patients with Heart Failure registry with complete medication data and who were prescribed a loop diuretic, diuretic dose increase was defined as: (1) change to a total daily dose higher than their previous total daily dose, (2) addition of metolazone to the regimen, (3) change from furosemide to either bumetanide or torsemide, and the change persists for at least 7 days. Adjusted hazard ratios or rate ratios along with 95% CIs were reported for clinical outcomes among patients with an increase in oral diuretic dose versus no increase in diuretic dose.Results:Overall, 796 (23%) had a diuretic dose increase (18 episodes per 100 patient-years). The proportion of patients with dyspnea at rest (38% versus 26%), dyspnea at exertion (79% versus 67%), orthopnea (32% versus 21%), edema (60% versus 43%), and weight gain (40% versus 23%) were significantly (all P <0.001) higher in the diuretic increase group. Baseline angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (hazard ratio, 0.75 [95% CI, 0.65–0.87]) use were associated with lower likelihood of diuretic increase over time. Patients with a diuretic dose increase had a significantly higher number of heart failure hospitalizations (rate ratio, 2.53 [95% CI, 2.10–3.05]), emergency department visits (rate ratio, 1.84 [95% CI, 1.56–2.17]), and home health visits (rate ratio, 1.88 [95% CI, 1.39–2.54]), but not all-cause mortality (hazard ratio, 1.10 [95% CI, 0.89–1.36]). Similarly, greater furosemide dose equivalent increases were associated with greater resource utilization but not with mortality, compared with smaller increases.Conclusions:In this contemporary US registry, 1 in 4 patients with heart failure with reduced ejection fraction had outpatient escalation of diuretic therapy over longitudinal follow-up, and these patients were more likely to have sign/symptoms of congestion. Outpatient diuretic dose escalation of any magnitude was associated with heart failure hospitalizations and resource utilization, but not all-cause mortality.

中文翻译：

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射血分数降低的心力衰竭的利尿剂变化、医疗资源利用和临床结果：来自心力衰竭患者管理的变化登记处

背景：利尿剂是心力衰竭对症治疗的主要疗法。然而，在当代美国门诊实践中，利尿剂剂量随时间变化的程度以及与临床结果和医疗资源利用的关联尚不清楚。在具有完整药物数据且被开具袢利尿剂处方的心力衰竭患者中，利尿剂剂量增加的定义为：(1) 每日总剂量高于他们之前的每日总剂量，(2) 将美托拉宗添加到(3) 从呋塞米改为布美他尼或托拉塞米，并且这种变化至少持续 7 天。在口服利尿剂剂量增加与利尿剂剂量未增加的患者中，报告了调整后的风险比或比率以及 95% CI 的临床结果。 100 患者年）。休息时呼吸困难（38% 对 26%）、劳力时呼吸困难（79% 对 67%）、端坐呼吸（32% 对 21%）、水肿（60% 对 43%）和体重增加（40 % 与 23%）显着（所有磷<0.001）在利尿剂增加组中更高。基线血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（风险比，0.75 [95% CI，0.65–0.87]）的使用与利尿剂随时间增加的可能性降低相关。利尿剂剂量增加的患者心力衰竭住院次数（比率，2.53 [95% CI，2.10-3.05]），急诊就诊（比率，1.84 [95% CI，1.56-2.17]），和家庭健康访问（比率，1.88 [95% CI，1.39-2.54]），但不是全因死亡率（风险比，1.10 [95% CI，0.89-1.36]）。类似地，与较小的增加相比，较大的呋塞米剂量当量增加与更大的资源利用相关，但与死亡率无关。结论：在这个当代美国登记处，在纵向随访期间，每 4 名射血分数降低的心力衰竭患者中就有 1 名在门诊升级了利尿剂治疗，这些患者更有可能出现充血的体征/症状。任何幅度的门诊利尿剂剂量增加都与心力衰竭住院和资源利用有关，但与全因死亡率无关。