Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Use of diuretics in patients with heart failure

INTRODUCTION

Evaluation and optimization of volume status is an essential component of treatment in patients with systolic or diastolic heart failure (HF) [1]. 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 [2]. 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 [4]. Use of nonpotassium sparing diuretics to treat HF has been associated with arrhythmic death [5]. 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).

                   

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jun 2014. | This topic last updated: Apr 28, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391.
  2. Faris R, Flather MD, Purcell H, et al. Diuretics for heart failure. Cochrane Database Syst Rev 2006; :CD003838.
  3. Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011; 364:797.
  4. Felker GM, O'Connor CM, Braunwald E, Heart Failure Clinical Research Network Investigators. Loop diuretics in acute decompensated heart failure: necessary? Evil? A necessary evil? Circ Heart Fail 2009; 2:56.
  5. Cooper HA, Dries DL, Davis CE, et al. Diuretics and risk of arrhythmic death in patients with left ventricular dysfunction. Circulation 1999; 100:1311.
  6. Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:e1.
  7. Brater DC. Diuretic therapy. N Engl J Med 1998; 339:387.
  8. Vargo DL, Kramer WG, Black PK, et al. Bioavailability, pharmacokinetics, and pharmacodynamics of torsemide and furosemide in patients with congestive heart failure. Clin Pharmacol Ther 1995; 57:601.
  9. Murray MD, Deer MM, Ferguson JA, et al. Open-label randomized trial of torsemide compared with furosemide therapy for patients with heart failure. Am J Med 2001; 111:513.
  10. Müller K, Gamba G, Jaquet F, Hess B. Torasemide vs. furosemide in primary care patients with chronic heart failure NYHA II to IV--efficacy and quality of life. Eur J Heart Fail 2003; 5:793.
  11. Wargo KA, Banta WM. A comprehensive review of the loop diuretics: should furosemide be first line? Ann Pharmacother 2009; 43:1836.
  12. Young M, Plosker GL. Torasemide: a pharmacoeconomic review of its use in chronic heart failure. Pharmacoeconomics 2001; 19:679.
  13. Cosín J, Díez J, TORIC investigators. Torasemide in chronic heart failure: results of the TORIC study. Eur J Heart Fail 2002; 4:507.
  14. Brater DC, Day B, Burdette A, Anderson S. Bumetanide and furosemide in heart failure. Kidney Int 1984; 26:183.
  15. Brater DC. Update in diuretic therapy: clinical pharmacology. Semin Nephrol 2011; 31:483.
  16. Salvador DR, Rey NR, Ramos GC, Punzalan FE. Continuous infusion versus bolus injection of loop diuretics in congestive heart failure. Cochrane Database Syst Rev 2005; :CD003178.
  17. Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:e1.
  18. Testani JM, Chen J, McCauley BD, et al. Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival. Circulation 2010; 122:265.
  19. Bock HA, Stein JH. Diuretics and the control of extracellular fluid volume: role of counterregulation. Semin Nephrol 1988; 8:264.
  20. Ikram H, Chan W, Espiner EA, Nicholls MG. Haemodynamic and hormone responses to acute and chronic frusemide therapy in congestive heart failure. Clin Sci (Lond) 1980; 59:443.
  21. Loon NR, Wilcox CS, Unwin RJ. Mechanism of impaired natriuretic response to furosemide during prolonged therapy. Kidney Int 1989; 36:682.
  22. Schrier RW. Use of diuretics in heart failure and cirrhosis. Semin Nephrol 2011; 31:503.
  23. Chaudhry SI, Wang Y, Concato J, et al. Patterns of weight change preceding hospitalization for heart failure. Circulation 2007; 116:1549.
  24. Wolfel EE. Can we predict and prevent the onset of acute decompensated heart failure? Circulation 2007; 116:1526.
  25. Grinstead WC, Francis MJ, Marks GF, et al. Discontinuation of chronic diuretic therapy in stable congestive heart failure secondary to coronary artery disease or to idiopathic dilated cardiomyopathy. Am J Cardiol 1994; 73:881.
  26. Stampfer M, Epstein SE, Beiser GD, Braunwald E. Hemodynamic effects of diuresis at rest and during intense upright exercise in patients with impaired cardiac function. Circulation 1968; 37:900.
  27. Francis GS, Benedict C, Johnstone DE, et al. Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure. A substudy of the Studies of Left Ventricular Dysfunction (SOLVD). Circulation 1990; 82:1724.
  28. Wang DJ, Gottlieb SS. Diuretics: still the mainstay of treatment. Crit Care Med 2008; 36:S89.
  29. Rose BD, Post TW. Clinical Physiology of Acid-Base and Electrolyte Disorders, 5th ed, McGraw-Hill, New York 2001. p.504.
  30. Mullens W, Abrahams Z, Skouri HN, et al. Elevated intra-abdominal pressure in acute decompensated heart failure: a potential contributor to worsening renal function? J Am Coll Cardiol 2008; 51:300.
  31. Dikshit K, Vyden JK, Forrester JS, et al. Renal and extrarenal hemodynamic effects of furosemide in congestive heart failure after acute myocardial infarction. N Engl J Med 1973; 288:1087.
  32. Bourland WA, Day DK, Williamson HE. The role of the kidney in the early nondiuretic action of furosemide to reduce elevated left atrial pressure in the hypervolemic dog. J Pharmacol Exp Ther 1977; 202:221.
  33. Johnston GD, Hiatt WR, Nies AS, et al. Factors modifying the early nondiuretic vascular effects of furosemide in man. The possible role of renal prostaglandins. Circ Res 1983; 53:630.
  34. Fujimura A, Ebihara A. Role of angiotensin II in renal prostaglandin E2 production after furosemide administration. Hypertension 1988; 11:491.
  35. Pickkers P, Dormans TP, Russel FG, et al. Direct vascular effects of furosemide in humans. Circulation 1997; 96:1847.
  36. Jhund PS, Davie AP, McMurray JJ. Aspirin inhibits the acute venodilator response to furosemide in patients with chronic heart failure. J Am Coll Cardiol 2001; 37:1234.
  37. Francis GS, Siegel RM, Goldsmith SR, et al. Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Activation of the neurohumoral axis. Ann Intern Med 1985; 103:1.
  38. Daskalopoulos G, Laffi G, Morgan T, et al. Immediate effects of furosemide on renal hemodynamics in chronic liver disease with ascites. Gastroenterology 1987; 92:1859.