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Aims: The use of loop diuretics in pulmonary arterial hypertension (PAH) is less frequent compared with heart failure. The clinical and prognostic characteristics of PAH patients according to loop diuretic use remain unexplored. In this study, we retrospectively analysed the characteristics and survival of PAH patients requiring different doses of loop diuretics. Methods and results: Patients diagnosed with PAH between 2001 and 2022 at seven European centres for the management of PAH. According to the median equivalent dose of furosemide in the overall cohort, patients were divided into two subgroups: no/low‐dose loop diuretic and high‐dose loop diuretic. Primary outcome was 5 year all‐cause mortality. Among the 397 patients included, 227 (57%) were treated with loop diuretics. Median daily furosemide equivalent dose was 25 mg, and accordingly patients were divided in no/low dose (i.e. ≤25 mg, n = 257, 65%) vs. high dose (i.e. >25 mg, n = 140, 35%). Patients in the high‐dose group were older, more likely to have comorbidities, and had a more severe disease according to the ESC/ERS risk category. Crude 5 year survival was significantly shorter in patients in the high‐dose group, but after adjustment for age, sex, and risk category, high loop diuretic dose was not significantly associated with the primary outcome. Conclusions: Use of high dose of loop diuretics in PAH is associated with a higher burden of comorbidities, more severe disease, and worse survival. However, in PAH, the need of high loop diuretic dose is a marker of disease severity and not an independent prognostic factor. [ABSTRACT FROM AUTHOR]

Heart failure (HF) is a leading cause of morbidity and mortality and a major public health problem. Both overhydration and dehydration are non-physiological states of the body that can adversely affect human health. Congestion and residual congestion are common in patients hospitalized for HF and are associated with poor prognosis and high rates of rehospitalization. However, the clinical problem of dehydration is also prevalent in healthcare and community settings and is associated with increased morbidity and mortality. This article provides a comprehensive review of the issue of congestion and dehydration in HF, including HF guidelines, possible causes of dehydration in HF, confirmed and potential new diagnostic methods. In particular, a full database search on the relationship between dehydration and HF was performed and all available evidence in the literature was reviewed. The novel hypothesis of chronic subclinical hypohydration as a modifiable risk factor for HF is also discussed. It is concluded that maintaining euvolemia is the cornerstone of HF management. Physicians have to find a balance between decongestion therapy and the risk of dehydration. [ABSTRACT FROM AUTHOR]

Aims: Maintenance of euvolaemia with diuretics is critical in heart failure (HF) patients with chronic kidney disease (CKD); however, it is challenging because no reliable marker of volume status exists. Fractional excretion of urea nitrogen (FEUN) is a useful index of volume status in patients with renal failure. We aimed to examine whether FEUN is a surrogate marker of volume status for risk stratification in HF patients with CKD. Methods and results: We examined 516 HF patients with CKD (defined as discharge estimated glomerular filtration rate < 60 mL/min/1.73 m2) whose FEUN was measured at discharge (median age, 80 years; 58% male). The patients were divided into four groups according to quartile FEUN value at discharge: low‐FEUN, FEUN ≤ 32.1; medium‐FEUN, 32.1 < FEUN ≤ 38.0; high‐FEUN, 38.0 < FEUN ≤ 43.7; and extremely‐high‐FEUN, FEUN > 43.7. FEUN was calculated by the following formula: (urinary urea × serum creatinine) × 100/(serum urea × urinary creatinine). During the 3 year follow‐up, 131 HF readmissions occurred. Kaplan–Meier analysis showed that the HF readmission rate was significantly lower in the medium‐FEUN group than in the other three groups (log‐rank test, P = 0.029). Multivariate Cox regression analysis identified the low‐FEUN, high‐FEUN, and extremely‐high‐FEUN values as independent factors associated with post‐discharge HF readmission. In the analysis of 130 patients who underwent right heart catheterization during hospitalization, a significant correlation between FEUN value and right atrial pressure was observed (R = 0.243, P = 0.005). Multivariate linear regression analysis revealed that FEUN value at discharge decreased in a dose‐dependent manner with loop diuretics. Conclusions: In HF patients with CKD, FEUN is a potential marker of volume status for risk stratification of post‐discharge HF readmission. Low FEUN value (FEUN ≤ 32.1) may represent intravascular dehydration, whereas high FEUN value (FEUN > 38.0) may represent residual congestion; both of them were independent risk factors for HF readmission. FEUN may be useful to determine euvolaemia and guide fluid management in HF patients with CKD. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to evaluate the outcome and prognostic factors in patients with dilated cardiomyopathy (DCM) and long‐standing heart failure (LDCM) vs. recent‐onset heart failure (RODCM). Methods and results: We compared 2019 patients with RODCM (duration <6 months, mean age 58.6 years, 70.7% male) with 1714 patients with LDCM (duration ≥6 months, median duration 3.5 years, mean age 62.5 years, 73.7% male) included in the Swedish Heart Failure Registry in the years 2003–16. Outcome measures were all‐cause, cardiovascular (CV), and non‐CV death and hospitalizations; heart transplantation; and a combined outcome of all‐cause death, heart transplantation, or heart failure (HF) hospitalization. Multivariable risk factor analyses were performed for the combined endpoint. All outcomes were more frequent in LDCM than in RODCM. The multivariable‐adjusted hazard ratios (HRs) (95% confidence interval) for LDCM vs. RODCM were 1.56 (1.34–1.82), P < 0.0001, for all‐cause death over a median follow‐up of 4.2 and 5.0 years, respectively; 1.67 (1.36–2.05), P < 0.0001, for CV death; 2.12 (1.14–3.91), P < 0.0001, for heart transplantation; 1.36 (1.21–1.53), P < 0.0001, for HF hospitalization; and 1.37 (1.24–1.52), P < 0.0001, for the combined outcome. A propensity score‐matched analysis yielded similar results. CV death was the main cause of mortality in LDCM and was higher in LDCM than in RODCM (P < 0.0001). Almost all co‐morbidities were significantly more frequent in LDCM than in RODCM, and the mean number of co‐morbidities increased significantly with increased duration of disease, also after age adjustment. Age, New York Heart Association functional class, ejection fraction, and left bundle branch block were prognostically adverse. The only co‐morbidity associated with the combined outcome regardless of HF duration was diabetes, in LDCM [HR 1.34 (1.15–1.56), P = 0.0002] and in RODCM [HR 1.29 (1.04–1.59), P = 0.018]. Male sex [HR 1.38 (1.18–1.63), P < 0.0001] and aspirin use [HR 1.33 (1.14–1.55), P = 0.0004] carried increased risk only in RODCM. Heart rate ≥75 b.p.m. [HR 1.20 (1.04–1.37), P = 0.01], atrial fibrillation [HR 1.24 (1.08–1.42), P = 0.0024], musculoskeletal or connective tissue disorder [HR 1.36 (1.13–1.63), P = 0.0014], and diuretic therapy [HR 1.40 (1.17–1.67), P = 0.0002] were prognostically adverse only in LDCM. Conclusions: This nationwide study of patients with DCM demonstrates that longer disease duration is associated with worse prognosis. Co‐morbidities are more common in long‐standing HF than in recent‐onset HF and are associated with worse outcome. With the increased survival seen in the last decades, our results highlight the importance of careful attention to co‐morbid conditions in patients with DCM. [ABSTRACT FROM AUTHOR]

Aims: The outpatient diuretic dose is a marker of diuretic resistance and prognosis in chronic heart failure (HF). Still, the impact of the preadmission dose on diuretic efficiency (DE) and prognosis in acute HF is not fully known. Methods and results: We conducted an observational and prospective study. All patients admitted for acute HF treated with intravenous diuretic and at least one criterion of congestion on admission were evaluated. Decongestion [physical examination, hemoconcentration, N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) change, and lung ultrasound], DE (weight loss and urine output per unit of 40 mg furosemide), and urinary sodium were monitored on the fifth day of admission. DE was dichotomized into high–low based on the median value. A multivariate Cox regression analysis was conducted to find predictors of HF readmission or mortality. A total of 105 patients were included between July 2017 and July 2019. Mean age was 74.5 ± 12.0 years, 64.8% were male, 33.3% had de novo HF, and mean left ventricular ejection fraction was 46 ± 17%. Median follow‐up was 26 [15–35] months. Low DE based on weight loss was associated with a higher previous dose of furosemide (odds ratio [OR] 1.01 [1.00–1.02]), thiazide treatment before admission (OR 9.37 [2.19–40.14]), and lower diastolic blood pressure (OR 0.95 [0.91–0.98]) in the multivariate regression model. Only previous dose of furosemide (OR 1.01 [1.00–1.02]) and haemoglobin at admission (OR 0.76 [0.58–0.99]) were associated with low DE based on urine output in the multivariate analysis. The correlation between the previous dose of furosemide and DE based on weight loss was poor (r = −0.12; P = 0.209) and with DE based on urine output was weak to moderate (r = −0.33; P < 0.001). Low DE based on weight loss and urine output was associated with lesser decongestion measured by NT‐proBNP (P = 0.011; P = 0.007), hemoconcentration (P = 0.006; P = 0.044), and lung ultrasound (P = 0.034; P = 0.029), but not by physical examination (P = 0.506; P = 0.560). Survival and event‐free survival in acute decompensated HF (ADHF) were lower than in de novo HF; a preadmission dose of furosemide > 80 mg in ADHF identified patients with particularly poor prognosis (log‐rank < 0.001). In ADHF, the preadmission dose of furosemide (hazard ratio [HR] 1.34 [1.08–1.67] per 40 mg) and NT‐proBNP at admission (HR 1.03 [1.01–1.06] per 1000 pg/mL) were independently associated with mortality or HF readmission in the multivariate Cox regression analysis. Conclusions: The outpatient dose of furosemide before acute HF admission predicts DE and must be taken into account when deciding on the initial diuretic dose. In ADHF, the outpatient dose of furosemide can predict long‐term prognosis better than DE during hospitalization. [ABSTRACT FROM AUTHOR]