Raising loop diuretic dose at discharge does not lower readmission risk
Increasing the dose of loop diuretic at hospital discharge of patients with heart failure (HF) was not associated with a reduced risk of hospital readmission for HF or any cause contrary to previous reports suggesting that such a dosing strategy could reduce readmission, according to a study presented at the 21st Asian Pacific Society of Cardiology Congress (APSC 2017) in Singapore.
“Although a common practice is to increase the loop diuretic dose at discharge with reference to the admission dose, evidence behind this practice is lacking,” according to lead author Dr Grace Chang Shu-Wen from the Department of Pharmacy in Khoo Teck Puat Hospital, Singapore, who noted that there is little guidance available on dosing at discharge.
“We did not find an association between increased discharge diuretic dose and readmissions.”
The study included 134 patients admitted to Khoo Teck Puat Hospital who had HF, ejection fraction ≤40 percent, and were treated with loop diuretic at both hospital admission and discharge. The patients were classified into two groups depending on whether the diuretic dose at admission was maintained/reduced (n=66) or increased (n=68) at discharge, and were followed up for at least 5 months. [APSC 2017, abstract P101]
At 30 days, readmission rates for any cause (25.0 percent vs 33.3 percent; p=0.19) and for HF-related cause (11.8 percent vs 16.7 percent; p=0.29) appeared to be lower with increased loop diuretic dose vs same/reduced dose at discharge, although the association was not statistically significant.
Also, time to first all-cause readmission was delayed in the group using increased dose compared with the same/reduced dose at discharge (hazard ratio [HR], 0.61; p=0.04), but the significance was nullified after adjustment for variations in baseline characteristics (adjusted HR, 0.70; p=0.15).
According to Chang, patients whose diuretic dose were maintained or reduced at discharge were significantly more likely to have cardiovascular-related comorbidities (p=0.03) and atrial fibrillation (p=0.048) at baseline, and use less beta-blocker at discharge (p=0.04) compared with those who had increased dose at discharge.
“An increased discharge diuretic dose trended towards a longer time to first all-cause readmission, though this was not significant after adjusting for baseline factors,” said Chang. “Based on these data, routinely increasing discharge dose may not apply for all patients and it is crucial to tailor doses to clinical status instead.”
“This study provides important statistics for our hospital and aids us in identifying at-risk patients who require closer monitoring to prevent readmissions,” she added.