One-Year Mortality After Intensification of Outpatient Diuretic Therapy

Background Mortality is increased following a hospitalization for decompensated heart failure (HF), during which diuretics are usually intensified. It is unclear how risk is affected after outpatient intensification of diuretic therapy forHF. Methods and Results From nationwide administrative registers, we identified all Danish patients who were diagnosed withHFfrom 2001 to 2016 and received angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta blocker within 120 days. Subsequent follow-up tracked progressive events of diuretic intensification andHFhospitalization. Intensification events were defined as new addition or doubling of loop diuretic or addition of thiazide to loop diuretic. These events were included in multivariable Cox regression models, calculating 1-year mortality hazard after each year since inclusion. Patients with an intensification event or hospitalization were risk set matched to 2 nonworsenedHFcontrols and absolute 1-year mortality risks were calculated using Kaplan-Meier estimates. We included 74 990 patients, their median age was 71 years, and 36% were women. Intensification events were associated with significantly increased mortality at all times during follow-up. One-year mortality was 18.0% after an intensification event, 22.6% afterHFhospitalization, and 10.4% for matched controls with neither. In a multivariable Cox model adjusted for age, sex, ischemic heart disease, atrial fibrillation, chronic obstructive pulmonary disease, and diabetes mellitus, the hazard ratio for 1-year death after an intensification event was 1.75 (95%CI, 1.66-1.85), and it was 2.28 (95%CI, 2.16-2.41) afterHFhospitalization. Conclusions In a nationwide cohort of patients withHF, outpatient intensification events were associated with almost 2-fold risk of mortality during the next year. AlthoughHFhospitalization was associated with a higher risk, the need to intensify diuretics in the outpatient setting is a signal to review and intensify efforts to improveHFoutcomes.