Clinical Question

For patients discharged after hospitalization for acute heart failure, does long-term torsemide decrease all-cause mortality more than furosemide?

Bottom Line

There was no difference in all-cause mortality when comparing torsemide with furosemide in patients after hospitalization for acute heart failure. However, interpretation of the study results is limited because of loss to follow-up, crossover of trial participants, and nonadherence to study drugs. New changes in guideline-directed medical therapy for heart failure, specifically the addition of angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter-2 inhibitors, may have affected outcomes and diuretic requirements over the course of the trial. (Level of Evidence = 1b−)

Synopsis

In this multicenter trial in the United States, investigators randomized patients hospitalized with acute heart failure (either a new diagnosis or worsening of chronic heart failure) to treatment with torsemide (n = 1,431) or furosemide (n = 1,428) before discharge. Dosing and frequency of the study drugs were determined by the primary team in the hospital and then managed by outpatient clinicians at discharge. Data on outcomes were obtained via patient or proxy telephone interviews, medical record queries, death records, and the National Death Index. The two groups had similar baseline characteristics: median age was 65 years, 40% were women, 34% were Black, and 70% had a left ventricular ejection fraction of 40% or less. The median duration of follow-up was 17 months. Approximately 4% of patients in each group were lost to follow-up before completing the trial. There was a 7% crossover rate from torsemide to furosemide and 4% from furosemide to torsemide at hospital discharge. Almost 10% of patients were not taking any loop diuretic at the six-month follow-up. There was no significant difference detected in the primary outcome of all-cause mortality between the two groups (26% in both groups). All-cause mortality and hospitalization over 12 months were similar, with a rate of almost 50% for both groups.