Evaluation and optimization of volume status is an essential component of treatment in patients with systolic or diastolic heart failure (HF) . Removal of excess extracellular fluid with diuretics to treat peripheral and/or pulmonary edema is one of the mainstays of volume management. In contrast to other HF therapies such as angiotensin inhibitors, beta blockers, and aldosterone antagonists, limited outcomes data are available for diuretic therapy.
Issues related to the use of diuretics in patients with HF will be reviewed here. The evaluation, including assessment of volume status, and overall management of HF are discussed separately. (See "Evaluation of the patient with suspected heart failure" and "Evaluation of acute decompensated heart failure" and "Overview of the therapy of heart failure due to systolic dysfunction" and "Treatment and prognosis of diastolic heart failure" and "Treatment of acute decompensated heart failure: General considerations".)
EFFICACY AND SAFETY
Diuretics are the cornerstone of treatment of volume overload in patients with heart failure (HF). However, few clinical trials have studied the impact of diuretic therapy on clinical outcomes.
A meta-analysis of diuretic treatment in chronic HF demonstrated a beneficial effect on clinical outcomes, although only small trials were available . Three trials with a total of 202 patients with chronic HF found a reduction in mortality with diuretic use compared to placebo (OR 0.24, 95% CI 0.07 to 0.83). Admission for worsening HF was reduced by diuretics compared to placebo in two trials with a total of 169 patients (OR 0.07, 95% CI 0.01 to 0.52). These results are consistent with data from observational studies as well as diuretic trials demonstrating rapid improvement in dyspnea in patients treated largely with diuretic therapy [3,4].
However, observational data have raised safety concerns about diuretic treatment of HF. Several uncontrolled studies have found that higher diuretic doses are associated with worse outcomes, including mortality . Use of nonpotassium sparing diuretics to treat HF has been associated with arrhythmic death . However, these observations are confounded by the indications for high dose diuretic use (ie, the need for higher doses of loop diuretics is likely a marker of more severe HF with increased mortality risk).