Target GDMT Doses Tied to Lower Loop Diuretic Needs in Heart Failure

Patients with heart failure (HF) who reached target doses of all guideline-directed medical therapy (GDMT) classes had substantially lower loop diuretic requirements at day 90, and loop diuretic dose did not modify the benefit of high-intensity care, according to a post hoc analysis of the STRONG-HF trial published in European Journal of Heart Failure.

The investigators noted that loop diuretics are central to managing congestion in HF but that it has been unknown whether optimizing disease-modifying therapy can reduce the need for them. The analysis included 1,075 patients with post-randomization loop diuretic data, grouped by furosemide-equivalent dose. Change in dose at day 90 was compared according to whether patients achieved 100% of target GDMT doses.

Higher loop diuretic doses were a marker of more severe HF. Among patients who reached 100% of target doses of all three GDMT classes assessed (RASi, beta-blockers, and MRAs), the furosemide-equivalent dose fell by 21.94mg at day 90, compared with 1.55mg among those who did not reach targets (P < .001). Among individual classes, beta-blockers showed the largest effect, with a reduction of 18.42mg (P < .001).

Loop diuretic dose category was not independently associated with the primary endpoint of all-cause death or HF rehospitalization at 180 days, or with its components. Doubling of the loop diuretic dose was associated with higher all-cause mortality (adjusted hazard ratio, 1.47; 95% CI, 1.04-2.09) but not with the primary endpoint or rehospitalization. The benefit of high-intensity care was consistent across loop diuretic dose groups, with no treatment-by-dose interaction.

The authors concluded that GDMT optimization acted as diuretic-sparing therapy, with target doses, particularly of all three classes, associated with markedly lower loop diuretic requirements. They said loop diuretic dose reflected HF severity but did not consistently predict outcomes or alter the benefit of up-titration.

Source: Biegus J, Davison B, Cotter G, et al. GDMT is associated with reduced loop diuretic requirements, whereas diuretic dose does not modify GDMT benefit in heart failure: STRONG-HF. Eur J Heart Fail. Published online October 9, 2026. doi:10.1093/ejhf/xuag309