The Effects of a Sliding Scale Diuretic Titration Protocol in Patients With Heart Failure

Abstract

Patients with heart failure (HF) are often instructed to temporarily adjust their diuretic dose. This approach has become routine in some HF management programs; however, no study has specifically examined the effects of a patient-directed flexible diuretic protocol. For the purposes of this study, patients were randomized into a usual care (UC) group (n = 31) or a flexible diuretic titration (DT) group (n = 35). The DT group completed a 6-item diuretic titration protocol once a day, for 3 months. The 6-minute walk distance, plasma B-type natriuretic peptide (NT-BNP), plasma norepinephrine (NE), and quality of life (QOL) were measured at baseline and at 3 months. Hospitalizations, emergency department (ED) visits, and mortality rates were measured at 3 months. Compared to baseline, at 3 months, there was a significant increase in the DT group's 6-minute walk distance (646 +/- 60 ft vs 761 +/- 61 ft, P = .01) and total QOL score (53 +/- 5 vs 38 +/- 5, P = .001), whereas these parameters remained unchanged within the UC group. There were significantly less ED visits in the DT group compared with those in the UC group (3% vs 23%, P = .015). No differences were found between the groups in HF-related hospitalizations or mortality. Within both groups, no differences were found between baseline and 3-month NE or NT-BNP plasma values. Patients with heart failure who used a sliding scale diuretic titration protocol had significant improvements in their exercise tolerance and QOL, had fewer ED visits, and had no change in plasma NE or NT-BNP levels.

State of the Science

“…Two of the articles focused only on improving self-care. 284,288 In the other 20 articles, self-care was emphasized as a part of a disease-management program. Only 18 of the 22 studies used a randomized design.…”

“…When these 18 studies were reviewed, the effect of self-care interventions on QOL in HF patients was equivocal, with only 10 trials finding greater improvement in QOL in the intervention group than in the control group. In the 2 trials that tested self-care as the primary intervention, 1 reported improved QOL in the intervention group, 288 whereas the other reported no differences in QOL between groups. 284 Interestingly, QOL differences were found in studies that included relatively younger patients, predominantly men, and primarily New York Heart Association class III and IV patients.…”

“…Few prospective longitudinal studies have been conducted in representative samples that characterize the changes in cognitive function over time in HF using valid neuropsychological tests. 170,171,288 Without such longitudinal studies, interventions may not target the problematic areas, which makes them less likely to be efficacious.…”

Role of telephone monitoring in patients with chronic heart failure: theory and practical implications

“…Weaker self-efficacy beliefs are associated with nonadherence to self-care recommendations for HF. 47 The positive effect of such an intervention was seen in two studies: one study tested a sliding scale diuretic titration protocol in HF patients where patients using this self-management strategy had increases in their exercise tolerance, quality of life, and fewer emergency department visits; 48 and the other study admitted HF patients randomized to an HF management group and taught self-management skills compared with usual care. 49 Unfortunately, the majority of patients with HF are not followed in an HF disease management program but by primary care physicians.…”

Remote Monitoring of Heart Failure Patients

“…Earlier smaller studies also have not shown any convincing evidence for self-management. [33][34][35][36] Therefore, a strategy that minimizes patient responsibility in monitoring and care might be more pragmatic. All strategies should still aim at having a patient-centered care plan along with stressing patient education.…”