HFSA ePoster Library

Introduction: The landmark trial for sacubitril/valsartan also showed that about 80% of patients with heart failure receiving sacubitril/ valsartan are on loop diuretic therapy. However, both sacubitril and loop diuretic have diuretic effects and the concomitant therapy of sacubitril/valsartan and loop diuretic therapy may cause over-diuresis which in turn, may cause an increased event rate of hypotension or acute kidney injury. However, no guideline addresses how to manage loop diuretic therapies/doses after initiating sacubitril/ valsartan because of the very limited data available. The primary objective was to investigate the longitudinal trend in loop diuretic therapy use and doses over the initial 6 months after sacubitril/valsartan initiation. The secondary objective was to quantify the effect of loop diuretic dose reduction on the event rate of over-diuresis over 6 months.
Methods: The retrospective cohort study included outpatients who are initiated on sacubitril/valsartan from January 1, 2015 to February 28, 2020. Inclusion criteria were patients aged greater than 18 years old receiving bumetanide, furosemide or torsemide, diagnosed as heart failure with reduced ejection fraction (ejection fraction < 40%), and initiated on sacubitril/ valsartan in outpatient setting at any WVU system institution. For the primary objective, authors investigated the longitudinal trend in the prevalence of loop diuretic use and furosemide equivalent dose at baseline, 2 weeks, 1 month, 3 month and 6 months after sacubitril/ valsartan initiation. For the secondary objective, the primary outcome was the composite event rate of acute kidney injury or hypotension. The secondary outcomes include an individual outcome of acute kidney injury or hypotension.
Results: A total of 427 patients were included for the primary objective. Compared to the baseline loop diuretic use and dose, there was no significant change in longitudinal trend in the prevalence of loop diuretic use and furosemide equivalent dose at baseline, 2 weeks, 1 month, 3 month and 6 months after sacubitril/ valsartan initiation. For the secondary objective, there was no significant difference in hypotension (9.85 vs. 13.04%, p=0.523), AKI (10.95 vs. 17.39%, p= 0.233) and the composite of hypotension or AKI (20.44 vs. 28.26%, p= 0.245) between the loop diuretic home dose continuation (n=274) and dose reduction groups (n=46). Multivariate logistic regression analysis showed no significant differences in hypotension (OR 0.879, 95% CI 0.168, 4.594), AKI (OR 1.488, 95% CI 0.462, 4.797), and the composite of hypotension or AKI (OR 1.427, 95% CI 0.504, 4.041).
Conclusions: The use of sacubitril/valsartan was not associated with reduced use or dose of loop diuretic therapy over 6 months. The loop diuretic dose reduction approach was not associated with a reduced event rate of over-diuresis compared to the home dose continuation approach.