TRANSFORM-HF

Torsemide vs furosemide after hospitalization for heart failure
TRANSFORM-HF found no significant mortality advantage with torsemide compared with furosemide after hospitalization for heart failure. Choice of loop diuretic should therefore be driven primarily by clinical response, tolerability, and practical considerations rather than an expected survival benefit.

Study design

  • Open-label, pragmatic randomized trial
  • N = 2,859
  • Patients hospitalized with heart failure
  • Included patients regardless of ejection fraction
  • Randomized to torsemide vs furosemide at discharge
  • Median follow-up 17.4 months
  • Primary outcome: all-cause mortality in a time-to-event analysis
Pragmatic trial Open label N = 2,859 Any EF Post-hospitalization HF

Population

Included
  • Hospitalized with worsening or new-onset heart failure
  • Planned treatment with an oral loop diuretic after discharge
  • Heart failure across the full range of ejection fraction
Clinical setting
  • Randomization occurred before hospital discharge
  • Real-world pragmatic treatment strategy
  • Loop diuretic dose was selected and adjusted by the treating clinician

Interventions

Torsemide

Torsemide-based loop diuretic strategy after discharge.

n = 1,431
Furosemide

Furosemide-based loop diuretic strategy after discharge.

n = 1,428

Primary outcome

All-cause mortality
26.1% with torsemide vs 26.2% with furosemide
HR 1.02, 95% CI 0.89–1.18, P = 0.76

Torsemide vs furosemide

All-cause mortality

30% 20% 10% 0%
26.1%
Torsemide
373 / 1,431
26.2%
Furosemide
374 / 1,428
26.1% vs 26.2%  |  HR 1.02  |  95% CI 0.89–1.18  |  P = 0.76

Torsemide did not reduce all-cause mortality compared with furosemide over a median follow-up of 17.4 months.

Secondary outcomes

  • Death or hospitalization at 12 months occurred in 47.3% of patients assigned to torsemide and 49.3% assigned to furosemide.
  • HR 0.92, 95% CI 0.83–1.02.
  • Total hospitalizations over 12 months were also similar between groups.
  • There was no clear evidence that the treatment effect differed according to ejection fraction.

Interpretation

What it showed

Routine use of torsemide after hospitalization for heart failure did not improve survival compared with furosemide.

What it changes

There is no strong outcome-based reason to routinely switch a patient from furosemide to torsemide solely to improve mortality.

What still matters

Loop diuretic choice and dose should be individualized based on congestion, diuretic response, absorption, renal function, tolerance, and patient preference.

Limitations: The pragmatic design allowed crossover and variable adherence to the assigned loop diuretic strategy. Loss to follow-up was also greater than anticipated.

Clinical takeaway

  • Torsemide was not superior to furosemide for all-cause mortality.
  • Either loop diuretic is reasonable after hospitalization for heart failure.
  • Use the agent that produces reliable decongestion and works best for the individual patient.
  • TRANSFORM-HF does not support switching stable patients to torsemide simply for a survival advantage.
Citation: Mentz RJ, Anstrom KJ, Eisenstein EL, et al. Effect of Torsemide vs Furosemide After Discharge on All-Cause Mortality in Patients Hospitalized With Heart Failure: The TRANSFORM-HF Randomized Clinical Trial. JAMA. 2023;329(3):214-223. doi:10.1001/jama.2022.23924. JAMA