By Dr. Susanne Heinzl
In heart failure patients treated with torasemide or with after discharge from hospital, overall mortality and hospitalization rates are similar. The primary endpoint of all-cause mortality did not differ between the two treatment groups in all predefined subgroups.
This was the result of the open, pragmatic TRANSFORM-HF study ((ToRsemide compArisoN with furoSemide FOR Management of Heart Failure), which Prof.Dr. Robert J. MentzDuke University School of Medicine, Durham) at the 2022 Scientific Sessions of the American Heart Association (AHA).
«We were initially disappointed because we hoped that based on previous studies and clinical experience, there would be a significant clinical difference between these two loop diuretics. Although we haven’t seen better results with torasemide, these results help us better care for people with heart failure,» Mentz said at an AHA news conference.
«Instead of worrying about which loop diuretic to take, we can now focus on prescribing the right dose of the loop diuretic, and we can focus our efforts on guideline-compliant therapy that improves outcomes for our patients.»
Panelist Prof. Dr. Biykem BozkurtBaylor College of Medicine, Houston) described the primary endpoint of all-cause mortality as a very high challenge, especially during the COVID-19 pandemic.Outcomes such as heart failure-related hospitalization and cardiovascular death might have been better.
Meta-analyses of smaller studies have shown that torasemide improved more than cardiovascular mortality and heart failure-related hospitalization as well as the NYHA classes.
Studies with new therapeutic approaches such as the EMPEROR-Reduced and EMPEROR-Preserved studies with empagliflozin, the DAPA-HF and DELIVER studies with dapagliflozin have also shown no effect on all-cause mortality.
TRANSFORM-HF did not address the anti-edematosis effect of loop diuretics and did not consider disease-specific cardiovascular or heart failure-specific outcomes and safety. «TRANSFORM is unlikely to change practice: Doctors will continue to use torasemide at their discretion, especially if they want better bioavailability and diuretic potency,» Bozkurt said.
Loop diuretics for heart failure
Loop diuretics are routinely used in heart failure patients to improve congestion symptoms.is one of the most widely used substances. Torasemide is said to be more effective – among other things due to higher bioavailability, a longer half-life and higher potency. It is also said to have aldosterone-antagonistic and antifibrotic myocardial effects. Until now, however, it was unclear whether torasemide improved the clinical course compared to patients with heart failure.
In 61 centers in the United States, hospitalized patients with heart failure were enrolled in the study as of June 2018. Randomized, 1432 patients received torasemide and 1428 patients . Subsequently, patients were treated with a centralized follow-up procedure without special face-to-face visits. 30 days, 6 and 12 months after randomization, they were interviewed by telephone. Information on hospitalizations was verified by the call center using hospital records.
The Data Safety Monitoring Board recommended in February 2022 that recruitment be terminated because there was enough data to assess the primary endpoint.The primary endpoint was total mortality. Secondary endpoints included the combination of total mortality rate and hospitalization rate, as well as hospitalization rate.
Effects of the two loop diuretics comparable
The demographic parameters of the two groups were well comparable. The patients were about 65 years old, 35 to 39% were women. In around 65%, the left ventricular ejection fraction was below 40%. 82% were treated with beta-blockers, 68% with ACE inhibitors or ARB (angiotensin receptor blockers) and 44% with mineralocorticoid antagonists. Around 67% had already received a loop diuretic before hospitalization, mostly .
In the primary endpoint, both groups showed a high and comparable event rate. After a median follow-up of 17 months, 347 patients (26.2%) and torasemide 373 patients (26.1%) had died (hazard ratio [HR] 1.02, p=0.77).
After 12 months, 704 patients (49.3%) had died or been re-hospitalized in the furosemide group and 677 (47.3%) in the torasemide group (HR 0.92, p=0.11).
A predefined on-treatment analysis after 30 days yielded consistent results with the primary analysis.
The results of the study may have been influenced by cross-over and discontinuation of the diuretics, according to Mentz.The dosage, which was left to the attending physician, could also have played a role. The all-cause mortality endpoint may have been too imprecise, especially in the context of the COVID-19 pandemic.
On the other hand, this pragmatic study has shown that broad inclusion criteria and a protocol embedded in daily practice made it possible to include a broad patient population, e.g. with a relatively high proportion of women and black people.
This article originally appeared on Medscape.de.
This full text is unfortunately reserved for medical professionals
You have reached the maximum number of articles for unregistered visitors
Source — https://www.univadis.de/viewarticle/mortalitat-bei-herzinsuffizienz-furosemid-und-torasemid-gleichwertig