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The use of Torsemide versus Furosemide in Patients with Heart Failure, a Systematic Review and Meta Analysis
The 23rd Annual Scientific Meeting HFSA
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Cardiovascular Pharmacology 057 The use of Torsemide versus Furosemide in Patients with Heart Failure, a Systematic Review and Meta Analysis Bishoy Abraham, MD1, Michael Megaly, MD, MS2,3, Mina Fransawyalkomos, MD4, Mina Sous, MD5, Marwan Saad, MD, PhD6,7, Robert Fraser, MD2,3, Joel Topf, MD8, Steven Goldsmith, MD3, Mengistu Simegn, MD3, Bradley Bart, MD3, Zain Azzo, MD9, Nancy Mesiha, MD9, Rajaninder Sharma, MD1; 1Department of Medicine, Ascension Saint John Hospital, Detroit, MI; 2Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN; 3Division of Cardiovascular Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN; 4Department of Internal Medicine, Saint Joseph University Medical Center, Paterson, NJ; 5Department of Internal Medicine, Amita Health Saint Francis Hospital, Evanston, IL; 6Department of Cardiovascular Medicine, University of Arkansas for MedicalSciences, Little Rock, Arkansas; 7Department of Cardiology, Ain Shams University Hospitals, Cairo, Egypt; 8 Division of Nephrology, Department of Medicine, Ascension Saint John Hospital, Detroit, MI; 9Division of Cardiology, Department of Medicine, Ascension Saint John Hospital, Detroit, MI Background: Loop diuretics are recommended by current guidelines for patients with symptomatic heart failure (HF) with NYHA class II-IV. While torsemide’s oral bioavailability and half life theoretically render it a more efficacious drug than furosemide, the clinical outcomes of torsemide compared with furosemide in patients with HF remain unclear. Methods: We performed a meta-analysis including all published randomized control trial (RCTs) and observational studies that compared torsemide and furosemide use in chronic HF patients from inception to February 2019. Results: Fifteen studies (eight RCTs and seven observational studies) including 9758 patients were included. Over a weighted mean follow-up duration of 8§3 months, torsemide was associated with a lower risk of rehospitalization due to HF (8.6% vs. 12.7%, NNT=23) (OR 0.63, 95% CI (0.44, 0.91), p=0.01, I2=8%) and cardiac mortality (1.6% vs. 4.4%, NNT=37) (OR 0.37, 95% CI (0.20, 0.66), p<0.001, I2=0%); and significantly higher improvement in functional status from NYHA class III/IV to I/II (72.5% vs. 58%, NNT=5) (OR 2.34, 95% CI 1.32, 4.15), p=0.004, I2=27%) compared with furosemide. There was no difference in all-cause mortality or medication side effects between both diuretics. In sensitivity analysis including RCTs only, improvement in functional status remained significant between torsemide and furosemide groups; however there was no difference in cardiac mortality between the two groups. With subgroup analysis, there was no difference in rehospitalization due to heart failure when analyzing subgroups of RCTs and observational studies individually. Conclusion: Torsemide use improved functional status and reduced rehospitalization due to HF compared with furosemide in chronic HF patients. Torsemide was also associated with reduced cardiac mortality, but this effect requires further study.
HF program in the Middle East Gulf region. Methods: A retrospective outpatient chart review was conducted on HF patients after initial outpatient clinic enrollment between October 2015 and July 2017. All patients with EF 40 were included. We documented baseline and follow-up evidence based HF medications including beta blockers, RAAS inhibitors, and MRA. Results: Out of 305 enrolled patients, only 186 had a 12 month follow up appointment, out of which 139 had HFrEF and were included in this analysis. At baseline, 25.2%, 13.7%, and 42.4% of patients were receiving target doses of beta-blocker, ACEI/ARB/ARNI, and MRA, respectively. Only 2.9% were on target doses of all 3 classes of evidence based therapies. At 12 months, percentage of patients on target doses significantly increased to 51.8% for beta blockers and 31.7% for ACEI/ARB/ARNI, while there was no significant change in patients on target dose MRA (36.7%). More patients (10.1%) were on target doses of all 3 evidence based therapies (table 1). A significant increase was observed in the rate of adoption of ARNI from baseline to follow-up (10.1% vs 48.9%, p<0.001) as well as those on target dose ARNI (figure 1). Conclusion: Close follow up of patients with HFrEF was associated with statistically significant increase in those on target doses of both beta blockers and ACE/ARB/ARNI and patients on simultaneous target doses of all evidence based medications. Compared to recent western outpatient registries, our study shows that the success of longitudinal titration of evidence based medications and adoption of new ones can be enhanced when patients are followed by a specialized multidisciplinary program. Table 1. Percentage of HFrEF patients on evidence based medications at baseline and 12 months follow-up (n=139).
Figure 1. Percentage of HFrEF patients on sacubitril/valsartan, including target doses, at baseline and 1 months follow-up (n=139).
059 Digoxin Use in Cardiac Amyloidosis Joseph P. Donnelly, Andrej Gabrovsek, Brett W. Sperry, Laura Young, Jerry Estep, W. H. Wilson Tang, Mazen Hanna; Cleveland Clinic Foundation, Cleveland, OH
058 Achieving Successful Longitudinal Titration of Evidence Based Heart Failure Medical Therapy at a Newly Established Multidisciplinary Program in the Middle East Gulf Region Bassam Atallah, Fahad Alajmi, Ziad G. Sadik, Guirgis Gabra, Medhat Soliman, Iman Hamour, Mosaad El Banna, Mohammed Khalil, Feras Bader; Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates Background: The 2017 ACC expert consensus decision pathway for optimization of heart failure (HF) treatment emphasizes the fact that target doses of medications are associated with the best outcomes. It has been reported that a significant portion of HFrEF patients are not on optimal doses of medical therapy, and gaps exist in longitudinal medication titration. The objective of this retrospective study is to describe medical therapy after 12 months of follow up in a newly established multidisciplinary
Introduction: With limited options for rate control of atrial fibrillation in the setting of low-output heart failure (HF), digoxin may appear to be a reasonable option for patients with cardiac amyloidosis (CA). However, current guidelines, based on historical case reports and an in vitro study, state that digoxin should generally be avoided in CA due to increased sensitivity for digoxin toxicity. A recent study of 107 patients with AL amyloidosis given digoxin showed relative safety with cautious use, with 11% of patients developing significant arrhythmias. We describe our institution’s experience with digoxin in patients with CA and the suspected digoxin-related arrhythmias and toxicity. Methods: This is a retrospective examination of patients diagnosed with CA seen between November 1995 and October 2018 at the Cleveland Clinic. CA patients were screened for a history of digoxin use; patients with less than 7 days of digoxin use were excluded, as well as those with incomplete medical records. Suspected digoxin-related arrhythmias and toxicity events were defined as: unexplained altered mental status, use of digoxin immune fab, ventricular tachycardia/fibrillation, paroxysmal atrial tachycardia with 2:1 block, new-onset junctional rhythm, and symptomatic bradycardia. Results: Of 756 patients with CA identified, 71 patients were treated with digoxin for 7 days: 42 with transthyretin (ATTR) CA and 29 with light chain (AL) CA. Median duration of digoxin therapy was 10 months
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Cardiovascular Pharmacology 057 The use of Torsemide versus Furosemide in Patients with Heart Failure, a Systematic Review and Meta Analysis Bishoy Abraham, MD1, Michael Megaly, MD, MS2,3, Mina Fransawyalkomos, MD4, Mina Sous, MD5, Marwan Saad, MD, PhD6,7, Robert Fraser, MD2,3, Joel Topf, MD8, Steven Goldsmith, MD3, Mengistu Simegn, MD3, Bradley Bart, MD3, Zain Azzo, MD9, Nancy Mesiha, MD9, Rajaninder Sharma, MD1; 1Department of Medicine, Ascension Saint John Hospital, Detroit, MI; 2Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN; 3Division of Cardiovascular Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN; 4Department of Internal Medicine, Saint Joseph University Medical Center, Paterson, NJ; 5Department of Internal Medicine, Amita Health Saint Francis Hospital, Evanston, IL; 6Department of Cardiovascular Medicine, University of Arkansas for MedicalSciences, Little Rock, Arkansas; 7Department of Cardiology, Ain Shams University Hospitals, Cairo, Egypt; 8 Division of Nephrology, Department of Medicine, Ascension Saint John Hospital, Detroit, MI; 9Division of Cardiology, Department of Medicine, Ascension Saint John Hospital, Detroit, MI Background: Loop diuretics are recommended by current guidelines for patients with symptomatic heart failure (HF) with NYHA class II-IV. While torsemide’s oral bioavailability and half life theoretically render it a more efficacious drug than furosemide, the clinical outcomes of torsemide compared with furosemide in patients with HF remain unclear. Methods: We performed a meta-analysis including all published randomized control trial (RCTs) and observational studies that compared torsemide and furosemide use in chronic HF patients from inception to February 2019. Results: Fifteen studies (eight RCTs and seven observational studies) including 9758 patients were included. Over a weighted mean follow-up duration of 8§3 months, torsemide was associated with a lower risk of rehospitalization due to HF (8.6% vs. 12.7%, NNT=23) (OR 0.63, 95% CI (0.44, 0.91), p=0.01, I2=8%) and cardiac mortality (1.6% vs. 4.4%, NNT=37) (OR 0.37, 95% CI (0.20, 0.66), p<0.001, I2=0%); and significantly higher improvement in functional status from NYHA class III/IV to I/II (72.5% vs. 58%, NNT=5) (OR 2.34, 95% CI 1.32, 4.15), p=0.004, I2=27%) compared with furosemide. There was no difference in all-cause mortality or medication side effects between both diuretics. In sensitivity analysis including RCTs only, improvement in functional status remained significant between torsemide and furosemide groups; however there was no difference in cardiac mortality between the two groups. With subgroup analysis, there was no difference in rehospitalization due to heart failure when analyzing subgroups of RCTs and observational studies individually. Conclusion: Torsemide use improved functional status and reduced rehospitalization due to HF compared with furosemide in chronic HF patients. Torsemide was also associated with reduced cardiac mortality, but this effect requires further study.
HF program in the Middle East Gulf region. Methods: A retrospective outpatient chart review was conducted on HF patients after initial outpatient clinic enrollment between October 2015 and July 2017. All patients with EF 40 were included. We documented baseline and follow-up evidence based HF medications including beta blockers, RAAS inhibitors, and MRA. Results: Out of 305 enrolled patients, only 186 had a 12 month follow up appointment, out of which 139 had HFrEF and were included in this analysis. At baseline, 25.2%, 13.7%, and 42.4% of patients were receiving target doses of beta-blocker, ACEI/ARB/ARNI, and MRA, respectively. Only 2.9% were on target doses of all 3 classes of evidence based therapies. At 12 months, percentage of patients on target doses significantly increased to 51.8% for beta blockers and 31.7% for ACEI/ARB/ARNI, while there was no significant change in patients on target dose MRA (36.7%). More patients (10.1%) were on target doses of all 3 evidence based therapies (table 1). A significant increase was observed in the rate of adoption of ARNI from baseline to follow-up (10.1% vs 48.9%, p<0.001) as well as those on target dose ARNI (figure 1). Conclusion: Close follow up of patients with HFrEF was associated with statistically significant increase in those on target doses of both beta blockers and ACE/ARB/ARNI and patients on simultaneous target doses of all evidence based medications. Compared to recent western outpatient registries, our study shows that the success of longitudinal titration of evidence based medications and adoption of new ones can be enhanced when patients are followed by a specialized multidisciplinary program. Table 1. Percentage of HFrEF patients on evidence based medications at baseline and 12 months follow-up (n=139).
Figure 1. Percentage of HFrEF patients on sacubitril/valsartan, including target doses, at baseline and 1 months follow-up (n=139).
059 Digoxin Use in Cardiac Amyloidosis Joseph P. Donnelly, Andrej Gabrovsek, Brett W. Sperry, Laura Young, Jerry Estep, W. H. Wilson Tang, Mazen Hanna; Cleveland Clinic Foundation, Cleveland, OH
058 Achieving Successful Longitudinal Titration of Evidence Based Heart Failure Medical Therapy at a Newly Established Multidisciplinary Program in the Middle East Gulf Region Bassam Atallah, Fahad Alajmi, Ziad G. Sadik, Guirgis Gabra, Medhat Soliman, Iman Hamour, Mosaad El Banna, Mohammed Khalil, Feras Bader; Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates Background: The 2017 ACC expert consensus decision pathway for optimization of heart failure (HF) treatment emphasizes the fact that target doses of medications are associated with the best outcomes. It has been reported that a significant portion of HFrEF patients are not on optimal doses of medical therapy, and gaps exist in longitudinal medication titration. The objective of this retrospective study is to describe medical therapy after 12 months of follow up in a newly established multidisciplinary
Introduction: With limited options for rate control of atrial fibrillation in the setting of low-output heart failure (HF), digoxin may appear to be a reasonable option for patients with cardiac amyloidosis (CA). However, current guidelines, based on historical case reports and an in vitro study, state that digoxin should generally be avoided in CA due to increased sensitivity for digoxin toxicity. A recent study of 107 patients with AL amyloidosis given digoxin showed relative safety with cautious use, with 11% of patients developing significant arrhythmias. We describe our institution’s experience with digoxin in patients with CA and the suspected digoxin-related arrhythmias and toxicity. Methods: This is a retrospective examination of patients diagnosed with CA seen between November 1995 and October 2018 at the Cleveland Clinic. CA patients were screened for a history of digoxin use; patients with less than 7 days of digoxin use were excluded, as well as those with incomplete medical records. Suspected digoxin-related arrhythmias and toxicity events were defined as: unexplained altered mental status, use of digoxin immune fab, ventricular tachycardia/fibrillation, paroxysmal atrial tachycardia with 2:1 block, new-onset junctional rhythm, and symptomatic bradycardia. Results: Of 756 patients with CA identified, 71 patients were treated with digoxin for 7 days: 42 with transthyretin (ATTR) CA and 29 with light chain (AL) CA. Median duration of digoxin therapy was 10 months