Do chronic heart failure patients receive optimal decongestive interventions in a real‐life setting? Letter regarding the article ‘Association between loop diuretic dose changes and outcomes in chronic heart failure: observations from the ESC‐EORP Heart Failure Long‐Term Registry’

Abstract

We read with interest the recent investigation by Kapelios et al.1 concerning the analysis of the European Society of Cardiology Heart Failure Long-Term (ESC-HF-LT) registry. It underscores the widespread inertia in congestion management, as only 24% of patients underwent loop diuretic (LD) dose modification in ESC-HF-LT registry. Also, guideline-directed medication was better up-titrated in patients receiving LD dose adjustment, presuming that physician's discretion may be a stronger predictor of individualised therapy than patient's clinical status. The authors also found that successful decongestion is unlikely for patients with peripheral oedema.1 Still, peripheral oedema is not the best parameter to guide decongestion, given the high prevalence of causes other than chronic heart failure (CHF). In daily practice, clinical signs and symptoms remain the cornerstone of congestion assessment, but an extensive clinical investigation is crucial.2 Given the low rate of LD adjustments, it may be speculated that clinical assessment was not sufficiently extensive, at least in some patients.1 In contrast to down-titration, up-titration was related to worse outcome. The authors noted that extensive adjustment was done to prove the independence of up-titration as a risk factor. However, (de)congestion and CHF outcome interact by means of complex and incompletely investigated mechanisms, making full adjustment almost impossible. In addition, registries contain a limited number of variables, limiting the extent of adjustment. Theoretically, LD treatment can trigger various mechanisms of harm,3 but the adaptability of the human body is likely to counterbalance these effects,4 meaning that the effective impact of LD therapy remains unclear. Also, down-titration in patients with no clinical congestion might worsen the already existing haemodynamic congestion. The ESC-HF-LT registry revealed that de-escalation was unsuccessful in 52% of the cases although it only took place in 8.3% of all patients, questioning whether the right intervention was chosen for the right patient. Despite little support by the literature and effective down-titration in only roughly 4%, the Authors suggest to attempt LD de-escalation more often. We are convinced that the target should not be the reduction of LD dose per se but the achievement of euvolaemia with full decongestion. This is supported by the findings of the CHAMPION trial, where adjustment of therapy based on invasively measured filling pressures improved outcome. Importantly, LD therapy was the most common adjustment of therapy and, in the majority, it was LD up-titration.5 Therefore, comprehensive clinical assessment is crucial, which may include additional exams, such as cardiothoracic or long ultrasound to achieve euvolaemia. Unfortunately, clinical inertia is highly prevalent,1 resulting in suboptimal treatment.