Association between loop diuretic dose changes and outcomes in chronic heart failure: observations from the ESC-EORP Heart Failure Long-Term Registry

[Abstract] Aims. Guidelines recommend down-titration of loop diuretics (LD) once euvolaemia is achieved. In outpatients with heart failure (HF), we investigated LD dose changes in daily cardiology practice, agreement with guideline recommendations, predictors of successful LD down-titration and association between dose changes and outcomes. Methods and results. We included 8130 HF patients from the ESC-EORP Heart Failure Long-Term Registry. Among patients who had dose decreased, successful decrease was defined as the decrease not followed by death, HF hospitalization, New York Heart Association class deterioration, or subsequent increase in LD dose. Mean age was 66±13 years, 71% men, 62% HF with reduced ejection fraction, 19% HF with mid-range ejection fraction, 19% HF with preserved ejection fraction. Median [interquartile range (IQR)] LD dose was 40 (25–80) mg. LD dose was increased in 16%, decreased in 8.3% and unchanged in 76%. Median (IQR) follow-up was 372 (363–419) days. Diuretic dose increase (vs. no change) was associated with HF death [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.12–2.08; P = 0.008] and nominally with cardiovascular death (HR 1.25, 95% CI 0.96–1.63; P = 0.103). Decrease of diuretic dose (vs. no change) was associated with nominally lower HF (HR 0.59, 95% CI 0.33–1.07; P = 0.083) and cardiovascular mortality (HR 0.62 95% CI 0.38–1.00; P = 0.052). Among patients who had LD dose decreased, systolic blood pressure [odds ratio (OR) 1.11 per 10 mmHg increase, 95% CI 1.01–1.22; P = 0.032], and absence of (i) sleep apnoea (OR 0.24, 95% CI 0.09–0.69; P = 0.008), (ii) peripheral congestion (OR 0.48, 95% CI 0.29–0.80; P = 0.005), and (iii) moderate/severe mitral regurgitation (OR 0.57, 95% CI 0.37–0.87; P = 0.008) were independently associated with successful decrease. Conclusion. Diuretic dose was unchanged in 76% and decreased in 8.3% of outpatients with chronic HF. LD dose increase was associated with worse outcomes, while the LD dose decrease group showed a trend for better outcomes compared with the no-change group. Higher systolic blood pressure, and absence of (i) sleep apnoea, (ii) peripheral congestion, and (iii) moderate/severe mitral regurgitation were independently associated with successful dose decrease

Sex- and age-related differences in the management and outcomes of chronic heart failure: an analysis of patients from the ESC HFA EORP Heart Failure Long-Term Registry

Aims: This study aimed to assess age- and sex-related differences in management and 1-year risk for all-cause mortality and hospitalization in chronic heart failure (HF) patients. Methods and results: Of 16 354 patients included in the European Society of Cardiology Heart Failure Long-Term Registry, 9428 chronic HF patients were analysed [median age: 66 years; 28.5% women; mean left ventricular ejection fraction (LVEF) 37%]. Rates of use of guideline-directed medical therapy (GDMT) were high (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists: 85.7%, 88.7% and 58.8%, respectively). Crude GDMT utilization rates were lower in women than in men (all differences: P\ua0 64 0.001), and GDMT use became lower with ageing in both sexes, at baseline and at 1-year follow-up. Sex was not an independent predictor of GDMT prescription; however, age >75 years was a significant predictor of GDMT underutilization. Rates of all-cause mortality were lower in women than in men (7.1% vs. 8.7%; P\ua0=\ua00.015), as were rates of all-cause hospitalization (21.9% vs. 27.3%; P\ua075 years. Conclusions: There was a decline in GDMT use with advanced age in both sexes. Sex was not an independent predictor of GDMT or adverse outcomes. However, age >75 years independently predicted lower GDMT use and higher all-cause mortality in patients with LVEF 6445%

EURObservational Research Programme: Regional differences and 1-year follow-up results of the Heart Failure Pilot Survey (ESC-HF Pilot)

AimsThe ESC-HF Pilot survey was aimed to describe clinical epidemiology and 1-year outcomes of outpatients and inpatients with heart failure (HF). The pilot phase was also specifically aimed at validating structure, performance, and quality of the data set for continuing the survey into a permanent Registry.MethodsThe ESC-HF Pilot study is a prospective, multicentre, observational survey conducted in 136 Cardiology Centres in 12 European countries selected to represent the different health systems across Europe. All outpatients with HF and patients admitted for acute HF on 1 day per week for eight consecutive months were included. From October 2009 to May 2010, 5118 patients were included: 1892 (37%) admitted for acute HF and 3226 (63%) patients with chronic HF. The all-cause mortality rate at 1 year was 17.4% in acute HF and 7.2% in chronic stable HF. One-year hospitalization rates were 43.9% and 31.9%, respectively, in hospitalized acute and chronic HF patients. Major regional differences in 1-year mortality were observed that could be explained by differences in characteristics and treatment of the patients.ConclusionThe ESC-HF Pilot survey confirmed that acute HF is still associated with a very poor medium-term prognosis, while the widespread adoption of evidence-based treatments in patients with chronic HF seems to have improved their outcome profile. Differences across countries may be due to different local medical practice as well to differences in healthcare systems. This pilot study also offered the opportunity to refine the organizational structure for a long-term extended European network. © 2013 The Author

EURObservational Research Programme: Regional differences and 1-year follow-up results of the Heart Failure Pilot Survey (ESC-HF Pilot)

AimsThe ESC-HF Pilot survey was aimed to describe clinical epidemiology and 1-year outcomes of outpatients and inpatients with heart failure (HF). The pilot phase was also specifically aimed at validating structure, performance, and quality of the data set for continuing the survey into a permanent Registry.MethodsThe ESC-HF Pilot study is a prospective, multicentre, observational survey conducted in 136 Cardiology Centres in 12 European countries selected to represent the different health systems across Europe. All outpatients with HF and patients admitted for acute HF on 1 day per week for eight consecutive months were included. From October 2009 to May 2010, 5118 patients were included: 1892 (37%) admitted for acute HF and 3226 (63%) patients with chronic HF. The all-cause mortality rate at 1 year was 17.4% in acute HF and 7.2% in chronic stable HF. One-year hospitalization rates were 43.9% and 31.9%, respectively, in hospitalized acute and chronic HF patients. Major regional differences in 1-year mortality were observed that could be explained by differences in characteristics and treatment of the patients.ConclusionThe ESC-HF Pilot survey confirmed that acute HF is still associated with a very poor medium-term prognosis, while the widespread adoption of evidence-based treatments in patients with chronic HF seems to have improved their outcome profile. Differences across countries may be due to different local medical practice as well to differences in healthcare systems. This pilot study also offered the opportunity to refine the organizational structure for a long-term extended European network

Acute heart failure congestion and perfusion status – impact of the clinical classification on in-hospital and long-term outcomes; insights from the ESC-EORP-HFA Heart Failure Long-Term Registry

none614siAims: Classification of acute heart failure (AHF) patients into four clinical profiles defined by evidence of congestion and perfusion is advocated by the 2016 European Society of Cardiology (ESC)guidelines. Based on the ESC-EORP-HFA Heart Failure Long-Term Registry, we compared differences in baseline characteristics, in-hospital management and outcomes among congestion/perfusion profiles using this classification. Methods and results: We included 7865 AHF patients classified at admission as: ‘dry-warm’ (9.9%), ‘wet-warm’ (69.9%), ‘wet-cold’ (19.8%) and ‘dry-cold’ (0.4%). These groups differed significantly in terms of baseline characteristics, in-hospital management and outcomes. In-hospital mortality was 2.0% in ‘dry-warm’, 3.8% in ‘wet-warm’, 9.1% in ‘dry-cold’ and 12.1% in ‘wet-cold’ patients. Based on clinical classification at admission, the adjusted hazard ratios (95% confidence interval) for 1-year mortality were: ‘wet-warm’ vs. ‘dry-warm’ 1.78 (1.43–2.21) and ‘wet-cold’ vs. ‘wet-warm’ 1.33 (1.19–1.48). For profiles resulting from discharge classification, the adjusted hazard ratios (95% confidence interval) for 1-year mortality were: ‘wet-warm’ vs. ‘dry-warm’ 1.46 (1.31–1.63) and ‘wet-cold’ vs. ‘wet-warm’ 2.20 (1.89–2.56). Among patients discharged alive, 30.9% had residual congestion, and these patients had higher 1-year mortality compared to patients discharged without congestion (28.0 vs. 18.5%). Tricuspid regurgitation, diabetes, anaemia and high New York Heart Association class were independently associated with higher risk of congestion at discharge, while beta-blockers at admission, de novo heart failure, or any cardiovascular procedure during hospitalization were associated with lower risk of residual congestion. Conclusion: Classification based on congestion/perfusion status provides clinically relevant information at hospital admission and discharge. A better understanding of the clinical course of the two entities could play an important role towards the implementation of targeted strategies that may improve outcomes.noneChioncel O.; Mebazaa A.; Maggioni A.P.; Harjola V.-P.; Rosano G.; Laroche C.; Piepoli M.F.; Crespo-Leiro M.G.; Lainscak M.; Ponikowski P.; Filippatos G.; Ruschitzka F.; Seferovic P.; Coats A.J.S.; Lund L.H.; Auer J.; Ablasser K.; Fruhwald F.; Dolze T.; Brandner K.; Gstrein S.; Poelzl G.; Moertl D.; Reiter S.; Podczeck-Schweighofer A.; Muslibegovic A.; Vasilj M.; Fazlibegovic E.; Cesko M.; Zelenika D.; Palic B.; Pravdic D.; Cuk D.; Vitlianova K.; Katova T.; Velikov T.; Kurteva T.; Gatzov P.; Kamenova D.; Antova M.; Sirakova V.; Krejci J.; Mikolaskova M.; Spinar J.; Krupicka J.; Malek F.; Hegarova M.; Lazarova M.; Monhart Z.; Hassanein M.; Sobhy M.; El Messiry F.; El Shazly A.H.; Elrakshy Y.; Youssef A.; Moneim A.A.; Noamany M.; Reda A.; Dayem T.K.A.; Farag N.; Halawa S.I.; Hamid M.A.; Said K.; Saleh A.; Ebeid H.; Hanna R.; Aziz R.; Louis O.; Enen M.A.; Ibrahim B.S.; Nasr G.; Elbahry A.; Sobhy H.; Ashmawy M.; Gouda M.; Aboleineen W.; Bernard Y.; Luporsi P.; Meneveau N.; Pillot M.; Morel M.; Seronde M.-F.; Schiele F.; Briand F.; Delahaye F.; Damy T.; Eicher J.-C.; de Groote P.; Fertin M.; Lamblin N.; Isnard R.; Lefol C.; Thevenin S.; Hagege A.; Jondeau G.; Logeart D.; Le Marcis V.; Ly J.-F.; Coisne D.; Lequeux B.; Le Moal V.; Mascle S.; Lotton P.; Behar N.; Donal E.; Thebault C.; Ridard C.; Reynaud A.; Basquin A.; Bauer F.; Codjia R.; Galinier M.; Tourikis P.; Stavroula M.; Tousoulis D.; Stefanadis C.; Chrysohoou C.; Kotrogiannis I.; Matzaraki V.; Dimitroula T.; Karavidas A.; Tsitsinakis G.; Kapelios C.; Nanas J.; Kampouri H.; Nana E.; Kaldara E.; Eugenidou A.; Vardas P.; Saloustros I.; Patrianakos A.; Tsaknakis T.; Evangelou S.; Nikoloulis N.; Tziourganou H.; Tsaroucha A.; Papadopoulou A.; Douras A.; Polgar L.; Merkely B.; Kosztin A.; Nyolczas N.; Nagy A.C.; Halmosi R.; Elber J.; Alony I.; Shotan A.; Fuhrmann A.V.; 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Gaita F.; Merlo M.; Cinquetti M.; Sinagra G.; Ramani F.; Fabris E.; Stolfo D.; Artico J.; Miani D.; Fresco C.; Daneluzzi C.; Proclemer A.; Cicoira M.; Zanolla L.; Marchese G.; Torelli F.; Vassanelli C.; Voronina N.; Erglis A.; Tamakauskas V.; Smalinskas V.; Karaliute R.; Petraskiene I.; Kazakauskaite E.; Rumbinaite E.; Kavoliuniene A.; Vysniauskas V.; Brazyte-Ramanauskiene R.; Petraskiene D.; Stankala S.; Switala P.; Juszczyk Z.; Sinkiewicz W.; Gilewski W.; Pietrzak J.; Orzel T.; Kasztelowicz P.; Kardaszewicz P.; Lazorko-Piega M.; Gabryel J.; Mosakowska K.; Bellwon J.; Rynkiewicz A.; Raczak G.; Lewicka E.; Dabrowska-Kugacka A.; Bartkowiak R.; Sosnowska-Pasiarska B.; Wozakowska-Kaplon B.; Krzeminski A.; Zabojszcz M.; Mirek-Bryniarska E.; Grzegorzko A.; Bury K.; Nessler J.; Zalewski J.; Furman A.; Broncel M.; Poliwczak A.; Bala A.; Zycinski P.; Rudzinska M.; Jankowski L.; Kasprzak J.D.; Michalak L.; Soska K.W.; Drozdz J.; Huziuk I.; Retwinski A.; Flis P.; Weglarz J.; Bodys A.; Grajek S.; Kaluzna-Oleksy M.; Straburzynska-Migaj E.; Dankowski R.; Szymanowska K.; Grabia J.; Szyszka A.; Nowicka A.; Samcik M.; Wolniewicz L.; Baczynska K.; Komorowska K.; Poprawa I.; Komorowska E.; Sajnaga D.; Zolbach A.; Dudzik-Plocica A.; Abdulkarim A.-F.; Lauko-Rachocka A.; Kaminski L.; Kostka A.; Cichy A.; Ruszkowski P.; Splawski M.; Fitas G.; Szymczyk A.; Serwicka A.; Fiega A.; Zysko D.; Krysiak W.; Szabowski S.; Skorek E.; Pruszczyk P.; Bienias P.; Ciurzynski M.; Welnicki M.; Mamcarz A.; Folga A.; Zielinski T.; Rywik T.; Leszek P.; Sobieszczanska-Malek M.; Piotrowska M.; Kozar-Kaminska K.; Komuda K.; Wisniewska J.; Tarnowska A.; Balsam P.; Marchel M.; Opolski G.; Kaplon-Cieslicka A.; Gil R.J.; Mozenska O.; Byczkowska K.; Gil K.; Pawlak A.; Michalek A.; Krzesinski P.; Piotrowicz K.; Uzieblo-Zyczkowska B.; Stanczyk A.; Skrobowski A.; Ponikowski P.; Jankowska E.; Rozentryt P.; Polonski L.; Gadula-Gacek E.; Nowalany-Kozielska E.; Kuczaj A.; Kalarus Z.; Szulik M.; Przybylska K.; Klys J.; Prokop-Lewicka G.; Kleinrok A.; Aguiar C.T.; Ventosa A.; Pereira S.; Faria R.; Chin J.; De Jesus I.; Santos R.; Silva P.; Moreno N.; Queiros C.; Lourenco C.; Pereira A.; Castro A.; Andrade A.; Guimaraes T.O.; Martins S.; Placido R.; Lima G.; Brito D.; Francisco A.R.; Cardiga R.; Proenca M.; Araujo I.; Marques F.; Fonseca C.; Moura B.; Leite S.; Campelo M.; Silva-Cardoso J.; Rodrigues J.; Rangel I.; Martins E.; Correia A.S.; Peres M.; Marta L.; da Silva G.F.; Severino D.; Durao D.; Leao S.; Magalhaes P.; Moreira I.; Cordeiro A.F.; Ferreira C.; Araujo C.; Ferreira A.; Baptista A.; Radoi M.; Bicescu G.; Vinereanu D.; Sinescu C.-J.; Macarie C.; Popescu R.; Daha I.; Dan G.-A.; Stanescu C.; Dan A.; Craiu E.; Nechita E.; Aursulesei V.; Christodorescu R.; Otasevic P.; Seferovic P.M.; Simeunovic D.; Ristic A.D.; Celic V.; Pavlovic-Kleut M.; Lazic J.S.; Stojcevski B.; Pencic B.; Stevanovic A.; Andric A.; Iric-Cupic V.; Jovic M.; Davidovic G.; Milanov S.; Mitic V.; Atanaskovic V.; Antic S.; Pavlovic M.; Stanojevic D.; Stoickov V.; Ilic S.; Ilic M.D.; Petrovic D.; Stojsic S.; Kecojevic S.; Dodic S.; Adic N.C.; Cankovic M.; Stojiljkovic J.; Mihajlovic B.; Radin A.; Radovanovic S.; Krotin M.; Klabnik A.; Goncalvesova E.; Pernicky M.; Murin J.; Kovar F.; Kmec J.; Semjanova H.; Strasek M.; Iskra M.S.; Ravnikar T.; Suligoj N.C.; Komel J.; Fras Z.; Jug B.; Glavic T.; Losic R.; Bombek M.; Krajnc I.; Krunic B.; Horvat S.; Kovac D.; Rajtman D.; Cencic V.; Letonja M.; Winkler R.; Valentincic M.; Melihen-Bartolic C.; Bartolic A.; Vrckovnik M.P.; Kladnik M.; Pusnik C.S.; Marolt A.; Klen J.; Drnovsek B.; Leskovar B.; Anguita M.J.F.; Page J.C.G.; Martinez F.M.S.; Andres J.; Bayes-Genis A.; Mirabet S.; Mendez A.; Garcia-Cosio L.; Roig E.; Leon V.; Gonzalez-Costello J.; Muntane G.; Garay A.; Alcade-Martinez V.; Fernandez S.L.; Rivera-Lopez R.; Puga-Martinez M.; Fernandez-Alvarez M.; Serrano-Martinez J.L.; Crespo-Leiro M.; Grille-Cancela Z.; Marzoa-Rivas R.; Blanco-Canosa P.; Paniagua-Martin M.J.; Barge-Caballero E.; Cerdena I.L.; Baldomero I.F.H.; Padron A.L.; Rosillo S.O.; Gonzalez-Gallarza R.D.; Montanes O.S.; Manjavacas A.M.I.; Conde A.C.; Araujo A.; Soria T.; Garcia-Pavia P.; Gomez-Bueno M.; Cobo-Marcos M.; Alonso-Pulpon L.; Cubero J.S.; Sayago I.; Gonzalez-Segovia A.; Briceno A.; Subias P.E.; Hernandez M.V.; Cano M.J.R.; Sanchez M.A.G.; Jimenez J.F.D.; Garrido-Lestache E.B.; Pinilla J.M.G.; de la Villa B.G.; Sahuquillo A.; Marques R.B.; Calvo F.T.; Perez-Martinez M.T.; Gracia-Rodenas M.R.; Garrido-Bravo I.P.; Pastor-Perez F.; Pascual-Figal D.A.; Molina B.D.; Orus J.; Gonzalo F.E.; Bertomeu V.; Valero R.; Martinez-Abellan R.; Quiles J.; Rodrigez-Ortega J.A.; Mateo I.; ElAmrani A.; Fernandez-Vivancos C.; Valero D.B.; Almenar-Bonet L.; Sanchez-Lazaro I.J.; Marques-Sule E.; Facila-Rubio L.; Perez-Silvestre J.; Garcia-Gonzalez P.; Ridocci-Soriano F.; Garcia-Escriva D.; Pellicer-Cabo A.; de la Fuente Galan L.; Diaz J.L.; Platero A.R.; Arias J.C.; Blasco-Peiro T.; Julve M.S.; Sanchez-Insa E.; Aured-Guallar C.; Portoles-Ocampo A.; Melin M.; Hagglund E.; Stenberg A.; Lindahl I.-M.; Asserlund B.; Olsson L.; Dahlstrom U.; Afzelius M.; Karlstrom P.; Tengvall L.; Wiklund P.-A.; Olsson B.; Kalayci S.; Temizhan A.; Cavusoglu Y.; Gencer E.; Yilmaz M.B.; Gunes H.Chioncel, O.; Mebazaa, A.; Maggioni, A. P.; Harjola, V. -P.; Rosano, G.; Laroche, C.; Piepoli, M. F.; Crespo-Leiro, M. G.; Lainscak, M.; Ponikowski, P.; Filippatos, G.; Ruschitzka, F.; Seferovic, P.; Coats, A. J. S.; Lund, L. H.; Auer, J.; Ablasser, K.; Fruhwald, F.; Dolze, T.; Brandner, K.; Gstrein, S.; Poelzl, G.; Moertl, D.; Reiter, S.; Podczeck-Schweighofer, A.; Muslibegovic, A.; Vasilj, M.; Fazlibegovic, E.; Cesko, M.; Zelenika, D.; Palic, B.; Pravdic, D.; Cuk, D.; Vitlianova, K.; Katova, T.; Velikov, T.; Kurteva, T.; Gatzov, P.; Kamenova, D.; Antova, M.; Sirakova, V.; Krejci, J.; Mikolaskova, M.; Spinar, J.; Krupicka, J.; Malek, F.; Hegarova, M.; Lazarova, M.; Monhart, Z.; Hassanein, M.; Sobhy, M.; El Messiry, F.; El Shazly, A. H.; Elrakshy, Y.; Youssef, A.; Moneim, A. A.; Noamany, M.; Reda, A.; Dayem, T. K. A.; Farag, N.; Halawa, S. I.; Hamid, M. A.; Said, K.; Saleh, A.; Ebeid, H.; Hanna, R.; Aziz, R.; Louis, O.; Enen, M. A.; Ibrahim, B. S.; Nasr, G.; Elbahry, A.; Sobhy, H.; Ashmawy, M.; Gouda, M.; Aboleineen, W.; Bernard, Y.; Luporsi, P.; Meneveau, N.; Pillot, M.; Morel, M.; Seronde, M. -F.; Schiele, F.; Briand, F.; Delahaye, F.; Damy, T.; Eicher, J. -C.; de Groote, P.; Fertin, M.; Lamblin, N.; Isnard, R.; Lefol, C.; Thevenin, S.; Hagege, A.; Jondeau, G.; Logeart, D.; Le Marcis, V.; Ly, J. -F.; Coisne, D.; Lequeux, B.; Le Moal, V.; Mascle, S.; Lotton, P.; Behar, N.; Donal, E.; Thebault, C.; Ridard, C.; Reynaud, A.; Basquin, A.; Bauer, F.; Codjia, R.; Galinier, M.; Tourikis, P.; Stavroula, M.; Tousoulis, D.; Stefanadis, C.; Chrysohoou, C.; Kotrogiannis, I.; Matzaraki, V.; Dimitroula, T.; Karavidas, A.; Tsitsinakis, G.; Kapelios, C.; Nanas, J.; Kampouri, H.; Nana, E.; Kaldara, E.; Eugenidou, A.; Vardas, P.; Saloustros, I.; Patrianakos, A.; Tsaknakis, T.; Evangelou, S.; Nikoloulis, N.; Tziourganou, H.; Tsaroucha, A.; Papadopoulou, A.; Douras, A.; Polgar, L.; Merkely, B.; Kosztin, A.; Nyolczas, N.; Nagy, A. C.; Halmosi, R.; Elber, J.; Alony, I.; Shotan, A.; Fuhrmann, A. V.; Amir, O.; Romano, S.; Marcon, S.; Penco, M.; Di Mauro, M.; Lemme, E.; Carubelli, V.; Rovetta, R.; Metra, M.; Bulgari, M.; Quinzani, F.; Lombardi, C.; Bosi, S.; Schiavina, G.; Squeri, A.; Barbieri, A.; Di Tano, G.; Pirelli, S.; Ferrari, R.; Fucili, A.; Passero, T.; Musio, S.; Di Biase, M.; Correale, M.; Salvemini, G.; Brognoli, S.; Zanelli, E.; Giordano, A.; Agostoni, P.; Italiano, G.; Salvioni, E.; Copelli, S.; Modena, M. G.; Reggianini, L.; Valenti, C.; Olaru, A.; Bandino, S.; Deidda, M.; Mercuro, G.; Dessalvi, C. C.; Marino, P. N.; Di Ruocco, M. V.; Sartori, C.; Piccinino, C.; Parrinello, G.; Licata, G.; Torres, D.; Giambanco, S.; Busalacchi, S.; Arrotti, S.; Novo, S.; Inciardi, R. M.; Pieri, P.; Chirco, P. R.; Galifi, M. A.; Teresi, G.; Buccheri, D.; Minacapelli, A.; Veniani, M.; Frisinghelli, A.; Priori, S. G.; Cattaneo, S.; Opasich, C.; Gualco, A.; Pagliaro, M.; Mancone, M.; Fedele, F.; Cinque, A.; Vellini, M.; Scarfo, I.; Romeo, F.; Ferraiuolo, F.; Sergi, D.; Anselmi, M.; Melandri, F.; Leci, E.; Iori, E.; Bovolo, V.; Pidello, S.; Frea, S.; Bergerone, S.; Botta, M.; Canavosio, F. G.; Gaita, F.; Merlo, M.; Cinquetti, M.; Sinagra, G.; Ramani, F.; Fabris, E.; Stolfo, D.; Artico, J.; Miani, D.; Fresco, C.; Daneluzzi, C.; Proclemer, A.; Cicoira, M.; Zanolla, L.; Marchese, G.; Torelli, F.; Vassanelli, C.; Voronina, N.; Erglis, A.; Tamakauskas, V.; Smalinskas, V.; Karaliute, R.; Petraskiene, I.; Kazakauskaite, E.; Rumbinaite, E.; Kavoliuniene, A.; Vysniauskas, V.; Brazyte-Ramanauskiene, R.; Petraskiene, D.; Stankala, S.; Switala, P.; Juszczyk, Z.; Sinkiewicz, W.; Gilewski, W.; Pietrzak, J.; Orzel, T.; Kasztelowicz, P.; Kardaszewicz, P.; Lazorko-Piega, M.; Gabryel, J.; Mosakowska, K.; Bellwon, J.; Rynkiewicz, A.; Raczak, G.; Lewicka, E.; Dabrowska-Kugacka, A.; Bartkowiak, R.; Sosnowska-Pasiarska, B.; Wozakowska-Kaplon, B.; Krzeminski, A.; Zabojszcz, M.; Mirek-Bryniarska, E.; Grzegorzko, A.; Bury, K.; Nessler, J.; Zalewski, J.; Furman, A.; Broncel, M.; Poliwczak, A.; Bala, A.; Zycinski, P.; Rudzinska, M.; Jankowski, L.; Kasprzak, J. D.; Michalak, L.; Soska, K. W.; Drozdz, J.; Huziuk, I.; Retwinski, A.; Flis, P.; Weglarz, J.; Bodys, A.; Grajek, S.; Kaluzna-Oleksy, M.; Straburzynska-Migaj, E.; Dankowski, R.; Szymanowska, K.; Grabia, J.; Szyszka, A.; Nowicka, A.; Samcik, M.; Wolniewicz, L.; Baczynska, K.; Komorowska, K.; Poprawa, I.; Komorowska, E.; Sajnaga, D.; Zolbach, A.; Dudzik-Plocica, A.; Abdulkarim, A. -F.; Lauko-Rachocka, A.; Kaminski, L.; Kostka, A.; Cichy, A.; Ruszkowski, P.; Splawski, M.; Fitas, G.; Szymczyk, A.; Serwicka, A.; Fiega, A.; Zysko, D.; Krysiak, W.; Szabowski, S.; Skorek, E.; Pruszczyk, P.; Bienias, P.; Ciurzynski, M.; Welnicki, M.; Mamcarz, A.; Folga, A.; Zielinski, T.; Rywik, T.; Leszek, P.; Sobieszczanska-Malek, M.; Piotrowska, M.; Kozar-Kaminska, K.; Komuda, K.; Wisniewska, J.; Tarnowska, A.; Balsam, P.; Marchel, M.; Opolski, G.; Kaplon-Cieslicka, A.; Gil, R. 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C.; Araujo, A.; Soria, T.; Garcia-Pavia, P.; Gomez-Bueno, M.; Cobo-Marcos, M.; Alonso-Pulpon, L.; Cubero, J. S.; Sayago, I.; Gonzalez-Segovia, A.; Briceno, A.; Subias, P. E.; Hernandez, M. V.; Cano, M. J. R.; Sanchez, M. A. G.; Jimenez, J. F. D.; Garrido-Lestache, E. B.; Pinilla, J. M. G.; de la Villa, B. G.; Sahuquillo, A.; Marques, R. B.; Calvo, F. T.; Perez-Martinez, M. T.; Gracia-Rodenas, M. R.; Garrido-Bravo, I. P.; Pastor-Perez, F.; Pascual-Figal, D. A.; Molina, B. D.; Orus, J.; Gonzalo, F. E.; Bertomeu, V.; Valero, R.; Martinez-Abellan, R.; Quiles, J.; Rodrigez-Ortega, J. A.; Mateo, I.; Elamrani, A.; Fernandez-Vivancos, C.; Valero, D. B.; Almenar-Bonet, L.; Sanchez-Lazaro, I. J.; Marques-Sule, E.; Facila-Rubio, L.; Perez-Silvestre, J.; Garcia-Gonzalez, P.; Ridocci-Soriano, F.; Garcia-Escriva, D.; Pellicer-Cabo, A.; de la Fuente Galan, L.; Diaz, J. L.; Platero, A. R.; Arias, J. C.; Blasco-Peiro, T.; Julve, M. S.; Sanchez-Insa, E.; Aured-Guallar, C.; Portoles-Ocampo, A.; Melin, M.; Hagglund, E.; Stenberg, A.; Lindahl, I. -M.; Asserlund, B.; Olsson, L.; Dahlstrom, U.; Afzelius, M.; Karlstrom, P.; Tengvall, L.; Wiklund, P. -A.; Olsson, B.; Kalayci, S.; Temizhan, A.; Cavusoglu, Y.; Gencer, E.; Yilmaz, M. B.; Gunes, H

Association between loop diuretic dose changes and outcomes in chronic heart failure: observations from the ESC-EORP Heart Failure Long-Term Registry

Aims: Guidelines recommend down-titration of loop diuretics (LD) once euvolaemia is achieved. In outpatients with heart failure (HF), we investigated LD dose changes in daily cardiology practice, agreement with guideline recommendations, predictors of successful LD down-titration and association between dose changes and outcomes. Methods and results: We included 8130 HF patients from the ESC-EORP Heart Failure Long-Term Registry. Among patients who had dose decreased, successful decrease was defined as the decrease not followed by death, HF hospitalization, New York Heart Association class deterioration, or subsequent increase in LD dose. Mean age was 66 ± 13 years, 71% men, 62% HF with reduced ejection fraction, 19% HF with mid-range ejection fraction, 19% HF with preserved ejection fraction. Median [interquartile range (IQR)] LD dose was 40 (25–80) mg. LD dose was increased in 16%, decreased in 8.3% and unchanged in 76%. Median (IQR) follow-up was 372 (363–419) days. Diuretic dose increase (vs. no change) was associated with HF death [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.12–2.08; P = 0.008] and nominally with cardiovascular death (HR 1.25, 95% CI 0.96–1.63; P = 0.103). Decrease of diuretic dose (vs. no change) was associated with nominally lower HF (HR 0.59, 95% CI 0.33–1.07; P = 0.083) and cardiovascular mortality (HR 0.62,. 95% CI 0.38–1.00; P = 0.052). Among patients who had LD dose decreased, systolic blood pressure [odds ratio (OR) 1.11 per 10 mmHg increase, 95% CI 1.01–1.22; P = 0.032], and absence of (i) sleep apnoea (OR 0.24, 95% CI 0.09–0.69; P = 0.008), (ii) peripheral congestion (OR 0.48, 95% CI 0.29–0.80; P = 0.005), and (iii) moderate/severe mitral regurgitation (OR 0.57, 95% CI 0.37–0.87; P = 0.008) were independently associated with successful decrease. Conclusion: Diuretic dose was unchanged in 76% and decreased in 8.3% of outpatients with chronic HF. LD dose increase was associated with worse outcomes, while the LD dose decrease group showed a trend for better outcomes compared with the no-change group. Higher systolic blood pressure, and absence of (i) sleep apnoea, (ii) peripheral congestion, and (iii) moderate/severe mitral regurgitation were independently associated with successful dose decrease. © 2020 European Society of Cardiolog

Sacubitril/valsartan eligibility and outcomes in the ESC-EORP-HFA Heart Failure Long-Term Registry: bridging between European Medicines Agency/Food and Drug Administration label, the PARADIGM-HF trial, ESC guidelines, and real world

Aims: To assess the proportion of patients with heart failure and reduced ejection fraction (HFrEF) who are eligible for sacubitril/valsartan (LCZ696) based on the European Medicines Agency/Food and Drug Administration (EMA/FDA) label, the PARADIGM-HF trial and the 2016 ESC guidelines, and the association between eligibility and outcomes. Methods and results: Outpatients with HFrEF in the ESC-EORP-HFA Long-Term Heart Failure (HF-LT) Registry between March 2011 and November 2013 were considered. Criteria for LCZ696 based on EMA/FDA label, PARADIGM-HF and ESC guidelines were applied. Of 5443 patients, 2197 and 2373 had complete information for trial and guideline eligibility assessment, and 84%, 12% and 12% met EMA/FDA label, PARADIGM-HF and guideline criteria, respectively. Absent PARADIGM-HF criteria were low natriuretic peptides (21%), hyperkalemia (4%), hypotension (7%) and sub-optimal pharmacotherapy (74%); absent Guidelines criteria were LVEF>35% (23%), insufficient NP levels (30%). and sub-optimal pharmacotherapy (82%); absent label criteria were absence of symptoms (New York Heart Association class I). When a daily requirement of ACEi/ARB ≥ 10 mg enalapril (instead of ≥ 20 mg) was used, eligibility rose from 12% to 28% based on both PARADIGM-HF and guidelines. One-year heart failure hospitalization was higher (12% and 17% vs. 12%) and all-cause mortality lower (5.3% and 6.5% vs. 7.7%) in registry eligible patients compared to the enalapril arm of PARADIGM-HF. Conclusions: Among outpatients with HFrEF in the ESC-EORP-HFA HF-LT Registry, 84% met label criteria, while only 12% and 28% met PARADIGM-HF and guideline criteria for LCZ696 if requiring ≥ 20 mg and ≥ 10 mg enalapril, respectively. Registry patients eligible for LCZ696 had greater heart failure hospitalization but lower mortality rates than the PARADIGM-HF enalapril group