Diuretic resistance in acute heart failure - clinical characteristics and prognostic significance

Abstract

Purpose: Diuretic resistance is common in patients with acute heart failure, although a clinically useful definition is lacking. Little is known about its prevalence, predictors and clinical outcome. Methods: We examined diuretic response (Δ weight kg/40mg furosemide) and diuretic resistance (diuretic response ≥0) in 1745 hospitalized AHF patients from the PROTECT trial. Day 4 response was used for the best signal-to-noise ratio. We investigated predictors of diuretic response and resistance and their relationship with outcome. Results: Mean diuretic response was -0.6±0.8 kg/40 mg furosemide and 226 (13%) patients were resistant. A history of Diabetes (p<0.001), coronary disease (p<0.01) and renal impairment (p<0.001) were more common in poor responders. Multivariable regression showed an inverse association between poor diuretic response and systolic blood pressure, serum potassium and rolofylline use, and an association with diabetes, hypercholesterolemia, smoking, previous PCI or beta blocker use and Blood Urea Nitrogen (all p<0.05). Worse diuretic response independently predicted 180-day mortality (HR 1.42; 95% CI 1.11-1.81, p=0.005), 60-day death or renal or cardiovascular rehospitalization (HR 1.34; 95% CI 1.14-1.59, p<0.001) and 60-day HF rehospitalization (HR 1.57; 95% CI 1.24-2.01, p<0.001) in multivariable models. Diuretic resistance was associated with 180-day mortality (HR 1.45; 95% CI 1.04-1.93, p=0.029). Figure 1. Multivariable adjusted hazard ratio for 180-day all-cause mortality for diuretic response Conclusion: Worse diuretic response was associated with more advanced heart failure, renal impairment, metabolic and atherosclerotic disease, and is a predictor in-hospital worsening heart failure, mortality and rehospitalization. Diuretic resistance predicts mortality.