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Decongestion Strategies in Hospitalized HF Patients
Quick Takes
- In a retrospective cohort study, in 20% of HF hospitalizations, discharge weight was higher than admission weight and in 61% of HF hospitalizations, discharge weight did not change or changed minimally from admission weight.
- Use of augmented diuretic strategies was low at 17%.
- Female sex and worsening renal function were predictors of smaller change in weight.
Study Questions:
What are the contemporary patterns of decongestion strategies and clinical predictors of weight loss in acute heart failure (HF) hospitalizations in the United States?
Methods:
This study is a retrospective analysis of a national database aggregating deidentified patient-level electronic health records across 31 diverse health care systems. All adults hospitalized with HF between 2015–2022 were included. Predictors of inpatient weight change, use of diuretic strategies, length of stay, and time to diuresis were assessed. Inpatient weight change was defined as difference between admission and discharge weights.
Results:
Analyses included 262,673 HF hospitalizations with >2 doses of intravenous (IV) loop diuretics. Average age was 74 years with 50% women and 74% White patients. Median length of stay was 5.8 days with inpatient mortality of 6%. IV furosemide was used in 94% of hospitalizations and IV bumetanide in 16%. Continuous loop diuretic infusions were used in 7% of hospitalizations, metolazone in 10%, and acetazolamide in 4%. Median inpatient weight loss was 5.3 lbs (2.4 kg). Acetazolamide, continuous diuretic infusion, and adjunctive thiazides were associated with more weight loss than without these interventions. For 61% of hospitalizations, discharge weight did not change or changed minimally compared to outpatient baseline dry weight. Female sex and worsening renal function were associated with smaller inpatient weight loss. Length of stay was longer with use of adjunctive diuretics, continuous IV loop diuretics, and worse renal function. Time to first diuretic dose was shorter in hospitalizations with use of adjunctive diuretics and continuous infusion.
Conclusions:
In a retrospective cohort study, in up to 61% of HF hospitalizations, discharge weight did not change or changed minimally compared to admission weight. Female sex and worsening renal function were associated with a smaller inpatient weight loss and augmented diuretic strategies were used in a small minority of patients.
Perspective:
Decongestion is the central goal in treatment of hospitalizations for decompensated HF. This study, using data from a national cohort, suggests that for the vast majority of HF hospitalizations, decongestion is inadequate. More aggressive diuretic strategies such as use of thiazides or acetazolamide with loop diuretics or continuous infusion of loop diuretics were used in only 17% of hospitalizations. Furthermore, over time, there was little change in diuretic strategies. These are important observations and suggest inadequate decongestion during hospitalization, especially in the context of increased focus on reducing length of stay and preventing rehospitalizations. These findings, however, need to be considered bearing in mind limitations with an observational study such as this one that relied on weight change without data on symptom change or change in physical exam during hospitalization as a measure of decongestion.
Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure
Keywords: Heart Failure, Diuretics
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