Diuretics in heart failure

The majority of patients with chronic congestive cardiac failure will need diuretics to control their symptoms and signs of pulmonary and systemic venous congestion (1)

• in general a loop diuretics, such as furosemide, are most commonly used in moderate or severe HF
• in patients with mild symptoms of HF, diuretics should usually be used together with an ACEI/ARB
• patients should be observed for development of any side effects especially in combination therapy - hypovolaemia, hyponatraemia, or hypokalaemia, renal failure (1)
• should begin with a low dose and titrate the dose upwards until symptoms and signs of congestion are improved
• self adjustment of the dose should be encouraged in HF patients based on daily weight measurements and other signs of fluid retention (1)

The combination of a thiazide, such as bendrofluazide or metolazone, with a loop diuretic promotes an intense diuresis which may be required for patients with severe heart failure

• careful monitoring of electrolyte levels should be undertaken in this context, especially when using the thiazide diuretic metolazone
• NICE recommends that diuretics should be used to treat symptoms of heart failure and be up and down-titrated according to symptomatic effects of subsequent therapies

Spironolactone is a potassium-sparing diuretic which improve prognosis when given to patients with chronic heart failure.

In HF patients with preserved left ventricular ejection fraction (HFPEF), low to medium dose of loop diuretics (e.g. – less than 80mg of furosemide per day) has shown to be helpful. People whose heart failure does not respond to this treatment will need further specialist advice (4)

Reference:

• (1) European Society of Cardiology (ESC) 2008. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008
• (2) Geriatric Medicine (2005); 35 (1):37-42.
• (3) NICE (2003). Clinical Guideline5; Chronic heart failure
• (4) NICE (September 2018).Chronic heart failure in adults: diagnosis and management