Outcomes Associated With a Strategy of Adjuvant Metolazone or High-Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis

Background-In acute decompensated heart failure, guidelines recommend increasing loop diuretic dose or adding a thiazide diuretic when diuresis is inadequate. We set out to determine the adverse events associated with a diuretic strategy relying on metolazone or high-dose loop diuretics. Methods and Results-Patients admitted to 3 hospitals using a common electronic medical record with a heart failure discharge diagnosis who received intravenous loop diuretics were studied in a propensity-adjusted analysis of all-cause mortality. Secondary outcomes included hyponatremia (sodium = 20% decrease in estimated glomerular filtration rate). Of 13 898 admissions, 1048 (7.5%) used adjuvant metolazone. Metolazone was strongly associated with hyponatremia, hypokalemia, and worsening renal function (P Conclusions-During acute decompensated heart failure, metolazone was independently associated with hypokalemia, hyponatremia, worsening renal function and increased mortality after controlling for the propensity to receive metolazone and baseline characteristics. However, under the same experimental conditions, high-dose loop diuretics were not associated with hypokalemia, hyponatremia, or reduced survival. The current findings suggest that until randomized control trial data prove otherwise, uptitration of loop diuretics may be a preferred strategy over routine early addition of thiazide type diuretics when diuresis is inadequate

Common clinical dilemmas in left ventricular assist device therapy: A glimpse into current trends

Background Left ventricular assist device (LVAD) therapy has been thrust into the forefront of surgical treatment for advanced heart failure (HF). Despite advancements in survival and quality of life with these devices, the multi-disciplinary care for these patients remains far from standardized across institutions. Methods A survey of current practices in LVAD was carried out at the St. Jude Medical User’s meeting representing a variety of caregivers including cardiac surgeons, HF cardiologists, non-HF cardiologists, advanced practice providers and ventricular assist device coordinators, with representation from several continents. Utilizing an audience response system, eleven questions were asked related to the demographics of the audience, left ventricular assist device patient selection and patient management. Results A total of 120 audience members representing both transplant and LVAD centers, destination therapy only LVAD centers and non-implanting, shared care centers across a multitude of disciplines responded to the survey. Questions comprised of patient selection (body mass index, pre-existing renal failure, care giver presence and abstinence from substance abuse) and patient management (anticoagulation regimens, first line therapy for hemolysis, implantable cardioverter-defibrillator usage and route of preferred dialysis) issues. Conclusions LVAD technology will continue to change and improve with the next generation of pumps on the horizon. Progress cannot be made without pausing to understand the current state of technology, practice patterns and patient determinants of success. This survey underscores the lack of consensus regarding best practice principles and the need for an increased focus on care management for LVAD patients with collaborative, multi-institutional studies