Torasemide Inhibits Transcardiac Extraction of Aldosterone in Patients With Congestive Heart Failure

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Correspondence
5. Marchlinski FE, Callans DJ, Gottlieb CD, et al. Linear ablation lesions for
control of unmappable ventricular tachycardia in patients with ischemic and
nonischemic cardiomyopathy. Circulation 2000;101:1288 96.
6. Josephson ME, Waxman HL, Cain ME, et al. Ventricular activation
during ventricular endocardial pacing. II. Role of pace-mapping to
JACC Vol. 44, No. 11, 2004

December 7, 2004:224758
localize origin of ventricular tachycardia. Am J Cardiol 1982;50:1122.
7. Leclercq C, Faris O, Tunin R, et al. Systolic improvement and
mechanical resynchronization does not require electrical synchrony in
the dilated failing heart with left bundle-branch block. Circulation
2002;106:1760 3.
Torasemide Inhibits Transcardiac Extraction of Aldosterone in Patients

With Congestive Heart Failure
To the Editor: Loop diuretics such as furosemide and torasemide
are important for the symptomatic treatment of congestive heart
failure (CHF). Recently, in the TOrasemide In Congestive Heart
Failure (TORIC) study, torasemide had a more beneficial effect on
the mortality and morbidity of patients with CHF than furosemide
(1). The mechanism by which torasemide provides a greater
benefit than furosemide remains unknown, but experimental
studies indicate that torasemide may inhibit the binding of
aldosterone (ALD) to its receptor in the cytoplastic fraction of the
rat kidney (2,3). Therefore, in the present study, we evaluated the
transcardiac extraction of ALD, as a potential marker of ALD
action in the heart (4,5), in torasemide therapy compared with
furosemide therapy in the treatment of patients with CHF.
The subjects were 60 consecutive patients with CHF (left
ventricular ejection fraction 45%). Patients receiving spironolactone were excluded. Informed consent was obtained from all
patients before participation in the study, and the protocol was
approved by the Human Investigations Committee of our institution. Sixty patients were divided randomly into two groups that
were treated with either furosemide (n 30) or torasemide (n
30) for one month. In the furosemide group, the same dose of
furosemide was continued. In the torasemide group, furosemide
was changed to torasemide at a dose with comparable diuretic
efficacy (furosemide 40 mg/day changed to torasemide 8 mg/day).
After one month, blood samples for measuring plasma ALD
were collected simultaneously from the aortic root (AO) and
coronary sinus (CS), and measurements of neurohumoral factors
were performed as previously reported (4,5).
All results are expressed as mean values SEM. Univariate
analyses were performed using the Student t test. Linear regression
analysis was used to determine the relationship between continuous variables. A p value 0.05 was regarded as significant.
There was no difference in patient characteristics between the

two groups (Table 1). In the torasemide group, the mean dose of
torasemide was 10.1 0.7 mg/day (range, 4 to 16 mg/day).
One month after randomization, there were no differences in
hemodynamic parameters. In the furosemide group, the plasma ALD
level in the CS was significantly lower than that in the AO (73.1
10.0 pg/ml vs. 56.9 6.5 pg/ml; p 0.001). In contrast, there was
no difference in plasma ALD levels between the AO and the CS in
the torasemide group (85.4 10.5 pg/ml vs. 83.1 11.6 pg/ml) (Fig.
1). Plasma procollagen type III aminoterminal peptide in the CS
concentration was significantly lower in the torasemide group than
that in the furosemide group (0.52 0.03 U/ml vs. 0.67 0.06
U/ml; p 0.05). There was a significant negative correlation between
the dose of torasemide and the transcardiac gradient (AOCS) of
ALD in the torasemide group (r 0.56, p 0.01).
We evaluated the transcardiac extraction of ALD as a potential
marker of ALD action in the heart (4,5) in patients with CHF. In
the furosemide group, the plasma ALD level in the CS was
significantly lower than that in the AO. In contrast, there was no
difference in plasma ALD level between the AO and the CS in the
torasemide group. The transcardiac gradient (AOCS) of ALD
and the extraction ratio of ALD in the AO were significantly lower
in the torasemide group than those in the furosemide group.
Plasma procollagen type III aminoterminal peptide concentration,
a biochemical marker of fibrosis, was significantly lower in the
torasemide group than in the furosemide group. These findings
may indicate that unlike furosemide, torasemide has an ALD
receptor antagonist in the heart. Experimental studies indicate that
torasemide inhibits the binding of ALD to its receptor in the
cytoplastic fraction of rat kidney (2,3). Moreover, the serum
potassium level was significantly higher in the torasemide group
than in the furosemide group in a large series (i.e., TORIC study).
Table 1. Clinical Characteristics of Patients in the Furosemide and Torasemide Groups at

Randomization
Age (yrs)
Gender (male/female)
Etiology of left ventricular dysfunction
Dilated cardiomyopathy
Ischemic cardiomyopathy
NYHA functional class
II
III to IV
Left ventricular ejection fraction by echocardiography (%)
Treatment
Dose of furosemide (mg)
Digitalis
ACE inhibitors or ARB
Beta-blockers
Furosemide
(n 30)
Torasemide
(n 30)
p Value
63.7 1.8
23/7
61.5 2.5
22/8
NS
NS
19
11
15
15
NS
NS
17
13
34.9 1.7
16
14
33.5 1.6
NS
NS
NS
46.7 3.1
19
21
13
50.7 3.5
15
22
14
NS
NS
NS
NS
ACE angiotensin-converting enzyme; ARB angiotensin receptor blocker; NS not significant; NYHA New York
Heart Association.
Correspondence
JACC Vol. 44, No. 11, 2004

December 7, 2004:224758
2253
REFERENCES
1. Cosin J, Diez J, on behalf of the TORIC investigators. Torasemide in
chronic heart failure: results of the TORIC study (erratum in Eur
J Heart Fail 2002;4:667). Eur J Heart Fail 2002;4:50713.
2. Uchida T, Yamanaga K, Nishikawa M, Ohtani Y, Kido H, Watanabe
M. Anti-aldosterone effect of torasemide. Eur J Pharmacol 1991;205:
14550.
3. Uchida T, Yamanaga K, Kido H, Ohtani Y, Watanabe M. Diuretic and
vasodilating actions of torasemide. Cardiology 1994;84:14 7.
4. Tsutamoto T, Wada A, Maeda K, et al. Spironolactone inhibits the
transcardiac extraction of aldosterone in patients with congestive heart
failure. J Am Coll Cardiol 2000;36:838 44.
5. Hayashi M, Tsutamoto T, Wada A, et al. Relationship between
transcardiac extraction of aldosterone and left ventricular remodeling in
patients with first acute myocardial infarction: extracting aldosterone
through the heart promotes ventricular remodeling after acute myocardial infarction. J Am Coll Cardiol 2001;38:1375 82.
Letters to the Editor

Depression and Heart Failure
Figure 1. Plasma aldosterone (ALD) concentrations in the aortic root

(AO) and coronary sinus (CS) in patients with congestive heart failure. (A)
furosemide group; (B) torasemide group.
Taken together with our results, the mechanism of the beneficial

effect of torasemide in comparison with those of furosemide in the
TORIC study may be due to the presence of mineralocorticoid
receptor blocker in torasemide.
*Takayoshi Tsutamoto, MD
Hiroshi Sakai, MD
Atsuyuki Wada, MD
Chitose Ishikawa, MD
Keijin Ohno, MD
Masanori Fujii, MD
Takashi Yamamoto, MD
Tomoyuki Takayama, MD
Tomohiro Dohke, MD
Minoru Horie, MD
We read with great interest the recent study by Gottlieb

et al. (1) and its related editorial (2) about the important problem
of depression in outpatients with heart failure (HF) evaluating its
prevalence and the impact of age, race, and gender. We would like
to add two comments.
First, we believe that the duration of evolution of HF symptoms
is a simple and important parameter that should have been taken
into account. A depression is likely to occur with time when the
patient realizes the true chronicle aspect of its disease, its severity,
and the overall limitation in physical activity and well-being. The
number of hospitalizations across the years may also play a role,
and these aspects of the disease might have been included in the
prediction model of Gottlieb et al. (1).
Second, the diagnosis of depression should particularly be
addressed when one considers the implantation of a cardioverterdefibrillator (ICD). Although the device is usually well accepted
despite fear of being shocked, patients with an ICD have high levels
of anxiety and depressive symptoms (3). The ICD shocks might have
the potential to cause psychological disorders. This may become a
relatively frequent problem considering the preliminary results of the
Sudden Cardiac Death-Heart Failure Trial (SCD-HeFT) in which
treatment with an ICD compared with placebo and amiodarone was
associated with a reduction in all-cause mortality in a large population
of patients with heart failure of all etiologies and with a left ventricular
ejection fraction 35% (4).
Thus, considering the potential association among ICD placement, electrical shock from the ICD, and depression, we should
probably collect information regarding this association in the
evaluation of such patients.
*Laurent Fauchier, MD, PhD
*Department of Cardiovascular and Respiratory Medicine

Shiga University of Medical Science
Tsukinowa, Seta
Otsu 520-2192, Japan
E-mail: tutamoto@belle.shiga-med.ac.jp
doi:10.1016/j.jacc.2004.09.009
*Service de Cardiologie B
Centre Hospitalier Universitaire Trousseau
37044 Tours
France
E-mail: lfau@med.univ-tours.fr
doi:10.1016/j.jacc.2004.09.014

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2252

JACC Vol. 44, No. 11, 2004

Torasemide Inhibits Transcardiac Extraction of Aldosterone in Patients

There was no difference in patient characteristics between the

Table 1. Clinical Characteristics of Patients in the Furosemide and Torasemide Groups at

JACC Vol. 44, No. 11, 2004

Letters to the Editor

Figure 1. Plasma aldosterone (ALD) concentrations in the aortic root

Taken together with our results, the mechanism of the beneficial

We read with great interest the recent study by Gottlieb

*Department of Cardiovascular and Respiratory Medicine

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