Transitioning Patients to Oral Diuretics 24 Hours before Discharge from Heart Failure Hospitalization Does Not Improve 30 Day Outcomes

Abstract

Background Patients hospitalized with acute heart failure (AHF) are at increased risk for clinical events during the 30-day period following discharge. The 2013 ACC/AHA heart failure (HF) guidelines recommend that such patients should be “transitioned to oral diuretic therapy to verify its effectiveness.” Although evidence that this strategy is effective is limited, many institutions transition patients from intravenous to oral diuretic therapy for at least 24 hours based on the premise that it improves outcomes. We investigated the effectiveness of this strategy on post-discharge outcomes in patients hospitalized for AHF at our institution. Methods In a retrospective chart review study, we evaluated all patients with a primary diagnosis of HF, regardless of left ventricular ejection fraction (LVEF), who were hospitalized from 8/1/2016 - 7/31/2017, discharged on an oral diuretic and followed at our institution. Baseline characteristics of patients who were discharged with at least a 24-hour period on oral diuretics and those who were discharged with less than 24 hours of observation on oral diuretics were compared and the effect of these strategies on a composite of all-cause mortality and all-cause rehospitalization, HF rehospitalization and all-cause rehospitalization were assessed. Results Of the 285 consecutive patients who met study entry criteria, 178 were observed for at least 24 hours on oral diuretics prior to discharge and 104 were not. These groups were similar in baseline characteristics including age, gender, co-morbidities, baseline blood chemistries, hemoglobin, BNPP, HF etiology, LVEF and factors triggering HF exacerbation. The group that was observed for 24 hours or more on oral diuretics had longer hospital stays and experienced greater weight and net volume loss than patients observed on oral diuretics for less than 24 hours. The latter group was more likely to have had changes made in their dose of neurohormonal blocking agents and diuretics within the 24-hour period prior to discharge. In contrast to expectations, all-cause mortality or all-cause hospitalization (27.5% vs 15%; p=0.019), all-cause rehospitalization (27% vs 14%; p=0.009) and AHF rehospitalization (12.9% vs 6.5%; p=0.064) occurred more commonly in patients who were observed for 24 hours on oral diuretics than for patients who were not. Conclusion In a population of patients discharged from an academic medical center after an episode of AHF, the strategy of transitioning patients to oral diuretics for at least 24 hours prior to discharge failed to improve 30-day outcomes. While this study has limitations due to the relatively small patient population followed at a single center, the results do not support the recommendation to observe patients on oral diuretics for at least 24 hours prior to discharge and they raise the question of whether providers should be encouraged to follow this practice without prospective studies demonstrating its effectiveness.