The Relationship Between Time-to-Target Rate of Urine Volume and Mortality in ADHF

Patients with acute decompensated heart failure (ADHF) and a time-to-target rate of urine volume of less than 24 hours have lower all-cause mortality and readmission rates at 1 year, according to a study in the International Journal of Cardiology.

The multicenter, retrospective, cohort registry study sought to examine the relationship between time-to-target rate of urine volume following treatment initiation and clinical outcomes during hospitalization and after discharge among patients hospitalized for ADHF from January 2011 to December 2016.

Patients treated with intravenous furosemide, oral torasemide, oral azosemide, and oral tolvaptan were included. Time-to-target rate of urine volume was defined as the time from hospitalization to a urine volume rate of 100 mL/h.

The participants were categorized into 3 groups, patients with a time-to-target rate of urine volume of less than 24 hours (n=248; day 1 group), patients with a time-to-target rate of urine volume of 24 to 72 hours (n=172; days 2 to 3 group), and patients with a time-to-target rate of urine volume of more than 72 hours or whose urine output rate did not reach 100 mL/h after admission (n=369; no-target urine volume group). The primary outcome was a 1-year composite of death or heart failure hospitalization.

The no-target urine volume group had the oldest mean age (82.3±10.6 years, P <.01) of the 3 groups, while the day 1 group had the youngest (77.6±12.7 years). Men represented 56.1% of patients in the day 1 group, 59.3% of patients in the days 2 to 3 group, and 51.2% of patients in the no-target urine volume group.

The overall in-hospital mortality rate was 4.3%. The day 1, days 2 to 3, and no-target urine volume groups had 7, 10, and 41 deaths (P =.0007), respectively. A shorter time-to-target rate of urine volume was associated with reduced in-hospital mortality. Event-free survival by time-to-target rate of urine volume was significantly greater for the day 1 group (67.7%; P =.004), compared with the days 2 to 3 (54.1%) and no-target urine volume (56.9%) groups, based on the Kaplan-Meier survival curve for the 1-year composite endpoint. After adjustment, the composite endpoint had a statistically significant association with earlier time-to-target rate of urine volume. Mortality also had a statistically significant association with earlier time-to-target rate of urine volume after adjustment for confounding factors.

No significant difference was observed in event-free survival in the 3 groups (day 1 group, 60.3%; days 2-3 group, 57.1%; no-target urine volume group, 61.1%; P =.71) when the 1-year composite endpoint was compared by time-to-target rate of urine volume (1 mL/kg/h). After adjustment, the composite endpoint was not significantly associated with time-to-target rate of urine volume (1 mL/ kg/h), and only time-to-target rate of urine volume (100 mL/h) was statistically significant for the composite endpoint in the day 1 group.

Multivariate analysis demonstrated that the negative predictors of time-to-target rate of urine volume (100 mL/h) at day 1 were age, prior hospitalization for heart failure, and N-terminal pro-brain natriuretic peptide level. Positive predictors were carperitide use (odds ratio [OR], 0.69; 95% CI, 0.48-0.99; P =.05) and early tolvaptan administration (OR, 0.60; 95% CI, 0.42-0.85; P =.004). This model had an area under the receiver operating characteristic curve of 0.64.

The researchers noted that their study is not a randomized, double-blind, placebo-controlled trial, and there are differences in baseline patient characteristics. Also, acute treatment was guideline-based but was at the discretion of the treating physician, and the association between door-to-diuretic time and prognosis was not evaluated.

“…patients with T2TUV [time-to-target rate of urine volume] (100 ml/h) of less than 24 h had lower all-cause mortality and readmission rates at 1 year and lower WRF [worsening renal function] and hospital length of stay,” the study authors wrote. “Thus, T2TUV (100 ml/h) is effective in determining the efficacy of diuretic therapy in acute heart failure.

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.