Congestive heart failure diuretics

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Congestive Heart Failure Microchapters


Patient Information


Historical Perspective



Systolic Dysfunction
Diastolic Dysfunction


Differentiating Congestive heart failure from other Diseases

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Medical Therapy:

Acute Pharmacotherapy
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Chronic Pharmacotherapy in HFrEF
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Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]


Diuretics reduce circulating volume, improve symptoms and are a mainstay of therapy for congestive heart failure. While these agents improve symptoms, they have not been associated with a reduction in mortality and are associated with electrolyte imbalances.


Indications for Diuretics Use

  • Diuretics are indicated for the treatment of all patients with previous or current congestive heart failure symptoms.


Benefits of Diuretics

  • Reduction of the intravascular volume
  • Reduction of the preload and relaxation of the pulmonary venules
  • Reduction of the wall stress
  • Improvement of the left ventricular remodeling
  • Improvement of symptoms but not survival
    • In fact higher doses of lasix are associated with higher mortality, likely as a results of higher doses being a marker of more severe disease.

Thiazide Diuretics

Loop Diuretics

  • Agents in this class include Furosemide or lasix, bumetanide, ethacrynic acid and torsemide.
  • Loop diuretics inhibit the Na+/K+/Cl- transporter.
  • Fluid retention usually responds best to furosemide (Lasix)
    • If there is no response to the initial dose then it can be increased by at least 50%.
  • The maintenance dose of the diuretics is lower than that required to initiate diuresis, and for lasix it is usually 10 to 20 mg per day.
  • The patient should be told to return to their physician in the next three to seven days after initiation for further assessment including assessment of their potassium concentration.
  • Weight loss should not exceed 1 to 2 pounds/day.
  • If the patient gains more than two pounds and they are instructed to double the dose of their loop diuretic.
  • Once the baseline weight has been re-established than they can resume their previous status.
  • Higher lasix doses are associated with higher mortality, likely as a surrogate of disease severity rather than part of a causal pathway.
  • Intermittent use of metolazone into dose of 2.5 or 5 mg can be given if the patient is refractory to furosemide Lasix. Metolazone should be given in the inpatient setting.

Potassium Sparing Diuretics

  • The role of potassium sparing diuretics such as spironolactone (Aldactone), amiloride, or triamterene remains the subject of controversy.
  • Spironolactone is currently recommended only as third line therapy for congestive heart failure.
  • These agents inhibit Na reabsorbtion and Potassium secretion in the distal convoluted tubule and cortical collecting duct.
  • Their significant side effect is hyperkalemia.
  • Extreme caution is necessary when adding a potassium sparing agent to the regiment that includes ACE inhibitors particularly when diabetes or renal disease is present because the patient can become hyperkalemic.


2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Diuretics in Patients Presenting With Heart Failure (DO NOT EDIT) [1][2]

Class I

1. Diuretics should be used for relief of symptoms due to volume overload in patients with HFpEF. (Class I, Level of Evidence: B)

Vote on and Suggest Revisions to the Current Guidelines

External Links


  1. 1.0 1.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
  2. 2.0 2.1 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA 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 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967

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