Congestive heart failure diuretics

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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]

Overview

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.

Diuretics

Indications for Diuretics Use

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

Background

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

• Inhibit the Na+/Cl- co transporter in the distal convoluted tube.
• Although thiazide diuretics are effective in mild heart failure they are usually inadequate for the treatment of severe heart failure.
• Thiazide diuretics have also been associative with hyponatremia.

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.

Complications

• Azotemia
• Hypokalemia
• Contraction or metabolic alkalosis
• Increaes in the levels of neurohormones
• Hyponatremia (with thiazides diuretics)

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)

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)

External Links

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

• 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