Torsemide Versus Furosemide in Patients With Acute Heart Failure (from the ASCEND-HF Trial)

Abstract

Furosemide is the most commonly used loop diuretic in heart failure (HF) patients despite data suggesting potential pharmacologic and anti-fibrotic benefits with torsemide. We investigated HF patients in ASCEND-HF who were discharged on either torsemide or furosemide. Using inverse probability weighting to account for the non-random selection of diuretic, we assessed the relation between choice of diuretic at discharge with 30-day mortality or HF hospitalization and 180-day mortality. Of 7,141 patients in the trial, 4,177 patients were included in this analysis, of which 87% (n=3,620) received furosemide and 13% (n=557) received torsemide. Torsemide-treated patients had lower ejection fraction and blood pressure, and higher creatinine and natriuretic peptide level compared with furosemide. Torsemide was associated with similar outcomes on unadjusted analysis and nominally lower events on adjusted analysis [30–day mortality/HF hospitalization OR 0.89, 95% CI: 0.62–1.29, P=0.55 and 180-day mortality HR 0.86, 95% CI: 0.63–1.19, P=0.37]. In conclusion, these data are hypothesis-generating and randomized comparative-effectiveness trials are needed to investigate the optimal diuretic choice.

Can Torsemide and Combination of Loop Diuretics Improve Mortality in Patients with Chronic Heart Failure After Discharge?

“…In recent years, two retrospective studies with large sample sizes suggested that torsemide was associated with similar outcomes compared with furosemide. 12,13) We did not observe significantly improved outcomes with torsemide use in our HF cohort, the specific reason for which remains unclear. Compared with previous studies 6,7) that were conducted decades ago, our study cohort had higher usage rates for ACEI/ARB, beta blockers, and spirolactone, which could inhibit the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system.…”

“…Importantly, while the associations between decreased mortality and torsemide in two retrospective studies and our study were not statistically significant, after adjustment the value of point estimation continued to trend towards a better outcome with torsemide in these 3 studies. 12,13) In our logistic analysis, we found that a higher NYHA classification and higher UA were associated with combination treatment. There are several potential reasons for the preference of combination treatment.…”

“…This was different from the reports of previous studies. [11][12][13] Both the torsemide and combination groups had higher NYHA classification, more hyponatremia, and higher furosemide equivalent compared with the furosemide group. Combination-treated patients had higher Cr and BUN compared with furosemide.…”

“…[18][19][20][21] The furosemide equivalent dose in our study cohort was lower than those of the PROTECT trial and ASCEND-HF trial, 11,12) and this finding expanded the understanding of diuretic use in patients with chronic heart failure in China. Diuretics stimulate the RAAS and sympathetic nervous system by depleting the circulating blood volume, contributing to further HF progression.…”

Torasemide

“…Post‐hoc analyses of trials conducted on patients admitted with acute heart failure and discharged on either furosemide or torasemide have also been performed. As an example the ASCEND‐HF trial examined the effects of nesiritide in heart failure . A recent post‐hoc analysis examined patients discharged on either torasemide or furosemide and suggested a tendency for a reduction in mortality in torasemide‐treated patients, but this did not reach statistical significance.…”