Congestive heart failure diuretics: Difference between revisions

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| [[File:Siren.gif|30px|link= Congestive heart failure resident survival guide]]|| <br> || <br>
| [[Acute decompensated heart failure resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{| class="infobox" style="float:right;"
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| [[File:Critical_Pathways.gif|88px|link= Congestive heart failure critical pathways]]|| <br> || <br>
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{{Congestive heart failure}}
{{Congestive heart failure}}
 
{{CMG}}; {{AOEIC}} {{LG}} {{EdzelCo}}
{{CMG}}; {{AOEIC}} {{LG}}


==Overview==
==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 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.


==Mechanism of Benefit==
==Diuretics==
*Reduce intravascular volume
===[[Diuretics]]===
*Lasix reduces preload and relaxes pulmonary venules and thereby reduce the symptoms of [[pulmonary edema]]
*[[Loop diuretics]] is recommended to reduce the signs and/or symptoms of [[congestion]] in [[patients]] with [[ HFrEF]].<ref name="pmid30600580">{{cite journal |vauthors=Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, Testani JM, Tang WHW, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic PM, Ruschitzka F, Coats AJ |title=The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology |journal=Eur J Heart Fail |volume=21 |issue=2 |pages=137–155 |date=February 2019 |pmid=30600580 |doi=10.1002/ejhf.1369 |url=}}</ref>
*Reduce wall stress
* The effects of [[diuretics]] on [[morbidity]] and [[mortality]] have not been studied in [[RCTs]].
*Improve left ventricular remodeling
*[[Loop diuretics]] and [[thiazide diuretics]] appear to reduce the risk of death and worsening [[HF]] compared with a placebo.
*Improve symptoms but not improve 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.
*[[Diuretics]] can improve [[exercise capacity]].<ref name="pmid11853901">{{cite journal |vauthors=Faris R, Flather M, Purcell H, Henein M, Poole-Wilson P, Coats A |title=Current evidence supporting the role of diuretics in heart failure: a meta analysis of randomised controlled trials |journal=Int J Cardiol |volume=82 |issue=2 |pages=149–58 |date=February 2002 |pmid=11853901 |doi=10.1016/s0167-5273(01)00600-3 |url=}}</ref>
* [[Loop diuretics]] and [[thiazides]] act synergistically and may be used to treat [[diuretic resistance]].
* [[ARNI]], [[MRAs]], and [[SGLT2 inhibitors]] may also possess [[diuretic]] properties.
* Maintaining the euvolemia state is the aim of [[diuretic therapy]] with the lowest doses.<ref name="pmid31424503">{{cite journal |vauthors=Rohde LE, Rover MM, Figueiredo Neto JA, Danzmann LC, Bertoldi EG, Simões MV, Silvestre OM, Ribeiro ALP, Moura LZ, Beck-da-Silva L, Prado D, Sant'Anna RT, Bridi LH, Zimerman A, Raupp da Rosa P, Biolo A |title=Short-term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double-blind, multicentre, randomized trial |journal=Eur Heart J |volume=40 |issue=44 |pages=3605–3612 |date=November 2019 |pmid=31424503 |doi=10.1093/eurheartj/ehz554 |url=}}</ref>
* [[Patients]] should be trained to self-adjust their [[diuretic]] dose based on monitoring of symptoms/signs of [[congestion]] and daily [[weight]] measurements.
 
 
 
=== [[MRA]] or [[Mineralocorticoid receptor antagonists]]===
*In all  [[patients]] with [[HFrEF]], [[MRAs]] ([[spironolactone]] or [[eplerenone]]) are recommended, in addition to an [[ACE-I]] and a [[beta-blocker]], to reduce [[mortality]] and the risk of [[heart failure]] hospitalization.<ref name="pmid10471456">{{cite journal |vauthors=Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J |title=The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators |journal=N Engl J Med |volume=341 |issue=10 |pages=709–17 |date=September 1999 |pmid=10471456 |doi=10.1056/NEJM199909023411001 |url=}}</ref>
*[[MRA]]s  improve [[symptoms]].
* [[MRA]]s block receptors that bind [[aldosterone]] and also other [[steroid]] hormones ([[corticosteroid]] and [[androgen]]) receptors.
* [[Eplerenone]] is more specific for [[aldosterone blockade]] and, therefore, causes less [[gynaecomastia]].
*In [[patients]] with impaired [[renal function]] and in those with serum [[potassium]] concentrations >5.0 mmol/L, [[MRA]] should be used with causion.
 
== 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500  }} </ref>==
 
===[[Diuretics]] and [[Decongestion]] Strategies in [[Patients]] with [[HF]] (DO NOT EDIT)<ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500  }} </ref><ref name="pmid23747642">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE et al.| title=2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2013 | volume=  | issue=  | pages=  | pmid=23747642 | doi=10.1016/j.jacc.2013.05.019 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23747642  }} </ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 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. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID:[http://pubmed.gov/19324967 19324967]</ref>===
 
{|class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
 
|-
|bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In [[patients]] with [[HF]] who have fluid retention, [[diuretics]] are recommended to relieve [[congestion]], improve [[symptoms]], and prevent worsening [[HF]]. <ref name="pmid7997385">{{cite journal| author=Patterson JH, Adams KF, Applefeld MM, Corder CN, Masse BR| title=Oral torsemide in patients with chronic congestive heart failure: effects on body weight, edema, and electrolyte excretion. Torsemide Investigators Group. | journal=Pharmacotherapy | year= 1994 | volume= 14 | issue= 5 | pages= 514-21 | pmid=7997385 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7997385  }} </ref><ref name="pmid8111802">{{cite journal| author=Goebel KM| title=Six-week study of torsemide in patients with congestive heart failure. | journal=Clin Ther | year= 1993 | volume= 15 | issue= 6 | pages= 1051-9 | pmid=8111802 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8111802  }} </ref><ref name="pmid7468610">{{cite journal| author=Wilson JR, Reichek N, Dunkman WB, Goldberg S| title=Effect of diuresis on the performance of the failing left ventricle in man. | journal=Am J Med | year= 1981 | volume= 70 | issue= 2 | pages= 234-9 | pmid=7468610 | doi=10.1016/0002-9343(81)90755-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7468610  }} </ref><ref name="pmid8225657">{{cite journal| author=Parker JO| title=The effects of oral ibopamine in patients with mild heart failure--a double blind placebo controlled comparison to furosemide. The Ibopamine Study Group. | journal=Int J Cardiol | year= 1993 | volume= 40 | issue= 3 | pages= 221-7 | pmid=8225657 | doi=10.1016/0167-5273(93)90004-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8225657  }} </ref><ref name="pmid2888942">{{cite journal| author=Richardson A, Bayliss J, Scriven AJ, Parameshwar J, Poole-Wilson PA, Sutton GC| title=Double-blind comparison of captopril alone against frusemide plus amiloride in mild heart failure. | journal=Lancet | year= 1987 | volume= 2 | issue= 8561 | pages= 709-11 | pmid=2888942 | doi=10.1016/s0140-6736(87)91074-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2888942  }} </ref>  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
 
|-
|bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For [[patients]] with [[HF]] and [[congestive symptoms]], addition of a [[thiazide]] (eg, [[metolazone]]) to [[treatment]] with a [[loop diuretic]] should be reserved for [[patients]] who do not respond to moderate or high-dose [[loop diuretics]] to minimize [[electrolyte]] abnormalities. <ref name="pmid26209004">{{cite journal| author=Grodin JL, Stevens SR, de Las Fuentes L, Kiernan M, Birati EY, Gupta D | display-authors=etal| title=Intensification of Medication Therapy for Cardiorenal Syndrome in Acute Decompensated Heart Failure. | journal=J Card Fail | year= 2016 | volume= 22 | issue= 1 | pages= 26-32 | pmid=26209004 | doi=10.1016/j.cardfail.2015.07.007 | pmc=4706474 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26209004  }} </ref>  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>


==Complications==
|}
*[[Azotemia]]
*[[Hypokalemia]]
*Contraction or [[metabolic alkalosis]]
*Elevate neurohormones
*[[Thiazide]] diuretics are associated with [[hyponatremia]]


==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==
=====Mineralocorticoid Receptor Antagonists (MRAs)=====
* Agents in this class include [[Furosemide]] or [[lasix]], [[bumetanide]], [[ethacrynic acid]] and [[torsemide]].
* 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]] lower than that required to initiate diuresis, and for lasix 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==
{|class="wikitable" style="width:80%"
* 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.
| colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
* 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 inhibitor]]s particularly when diabetes or renal disease is present because the patient can become [[hyperkalemic]].


==2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT) <ref name="Hunt"> 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</ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 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. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>==
|-
|bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In [[patients]] with [[HFrEF]] and [[NYHA]] class II to IV [[symptoms]], an [[MRA]] ([[spironolactone]] or [[epleronone]]) is recommended to reduce [[morbidity]] and [[mortality]], if [[eGFR]] is >30 mL/min/1.73 m<sup>2</sup> and [[serum]] [[potassium]] is <5.0 mEq/L. Careful monitoring of [[potassium]], [[renal function]], and [[diuretic]] dosing should be performed at initiation and closely monitored thereafter to minimize risk of [[hyperkalemia]] and [[renal insufficiency]]. <ref name="pmid10471456">{{cite journal| author=Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A | display-authors=etal| title=The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. | journal=N Engl J Med | year= 1999 | volume= 341 | issue= 10 | pages= 709-17 | pmid=10471456 | doi=10.1056/NEJM199909023411001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10471456  }} </ref><ref name="pmid12668699">{{cite journal| author=Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B | display-authors=etal| title=Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. | journal=N Engl J Med | year= 2003 | volume= 348 | issue= 14 | pages= 1309-21 | pmid=12668699 | doi=10.1056/NEJMoa030207 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12668699  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=12899810 Review in: J Fam Pract. 2003 Aug;52(8):598-9]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=12954024 Review in: ACP J Club. 2003 Sep-Oct;139(2):32] </ref><ref name="pmid21073363">{{cite journal| author=Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H | display-authors=etal| title=Eplerenone in patients with systolic heart failure and mild symptoms. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 1 | pages= 11-21 | pmid=21073363 | doi=10.1056/NEJMoa1009492 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21073363  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=21558564 Review in: Evid Based Med. 2011 Aug;16(4):121-2] [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=21814643 Review in: J Fam Pract. 2011 Aug;60(8):482-4] </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>


Diuretics in Patients Presenting With Heart Failure (DO NOT EDIT) <ref name="Hunt"> 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</ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 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. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>==
|}


{|class="wikitable"
{|class="wikitable" style="width:80%"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:White"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Value Statement: High Value]]


|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Diuretics]] and salt restriction are indicated in patients with current or prior symptoms of [[heart failure]] and reduced [[left ventricular ejection fraction]] ([[LVEF]]) who have evidence of fluid retention. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="White"|<nowiki>"</nowiki>'''2.''' In [[patients]] with [[HFrEF]] and [[NYHA]] II to IV [[symptoms]], [[MRA]] [[therapy]] provides high economic value.<ref name="pmid23433562">{{cite journal| author=Banka G, Heidenreich PA, Fonarow GC| title=Incremental cost-effectiveness of guideline-directed medical therapies for heart failure. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 13 | pages= 1440-6 | pmid=23433562 | doi=10.1016/j.jacc.2012.12.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23433562  }} </ref><ref name="pmid12085979">{{cite journal| author=Glick HA, Orzol SM, Tooley JF, Remme WJ, Sasayama S, Pitt B| title=Economic evaluation of the randomized aldactone evaluation study (RALES): treatment of patients with severe heart failure. | journal=Cardiovasc Drugs Ther | year= 2002 | volume= 16 | issue= 1 | pages= 53-9 | pmid=12085979 | doi=10.1023/a:1015371616135 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12085979  }} </ref><ref name="pmid15723981">{{cite journal| author=Weintraub WS, Zhang Z, Mahoney EM, Kolm P, Spertus JA, Caro J | display-authors=etal| title=Cost-effectiveness of eplerenone compared with placebo in patients with myocardial infarction complicated by left ventricular dysfunction and heart failure. | journal=Circulation | year= 2005 | volume= 111 | issue= 9 | pages= 1106-13 | pmid=15723981 | doi=10.1161/01.CIR.0000157146.86758.BC | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15723981  }} </ref><ref name="pmid20104935">{{cite journal| author=Zhang Z, Mahoney EM, Kolm P, Spertus J, Caro J, Willke R | display-authors=etal| title=Cost effectiveness of eplerenone in patients with heart failure after acute myocardial infarction who were taking both ACE inhibitors and beta-blockers: subanalysis of the EPHESUS. | journal=Am J Cardiovasc Drugs | year= 2010 | volume= 10 | issue= 1 | pages= 55-63 | pmid=20104935 | doi=10.2165/11319940-000000000-00000 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20104935  }} </ref>  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
 
|}
|}


==Vote on and Suggest Revisions to the Current Guidelines==
{|class="wikitable" style="width:80%"
*[[The Living Guidelines: Diagnosis and Management of Chronic Heart Failure | The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
|-
| colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
 
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' In [[patients]] taking [[MRA]] whose [[serum]] [[potassium]] cannot be maintained at <5.5 mEq/L, [[MRA]] should be discontinued to avoid life-threatening [[hyperkalemia]]. <ref name="pmid23188026">{{cite journal| author=Hernandez AF, Mi X, Hammill BG, Hammill SC, Heidenreich PA, Masoudi FA | display-authors=etal| title=Associations between aldosterone antagonist therapy and risks of mortality and readmission among patients with heart failure and reduced ejection fraction. | journal=JAMA | year= 2012 | volume= 308 | issue= 20 | pages= 2097-107 | pmid=23188026 | doi=10.1001/jama.2012.14795 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23188026  }} </ref><ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A | display-authors=etal| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047  }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>


==Guidelines Resources==
|}
*[http://circ.ahajournals.org/content/112/12/e154.full.pdf The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult] <ref name="Hunt"> 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</ref>


*[http://content.onlinejacc.org/cgi/reprint/53/15/1343.pdf 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] <ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 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. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>
==External Link==
*[https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000001063.full.pdf 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines]<ref name="pmid35363499">{{cite journal |vauthors=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW |title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=145 |issue=18 |pages=e895–e1032 |date=May 2022 |pmid=35363499 |doi=10.1161/CIR.0000000000001063 |url=}} </ref>


==References==
==References==
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Latest revision as of 15:22, 28 November 2022
Resident
Survival
Guide
File:Critical Pathways.gif

Congestive Heart Failure Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
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HFpEF
HFrEF

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Differentiating Congestive heart failure from other Diseases

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Treatment

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Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
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Surgical Therapy:

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

Congestive heart failure diuretics On the Web

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Risk calculators and risk factors for Congestive heart failure diuretics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2] Edzel Lorraine Co, DMD, MD[3]

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

Diuretics


MRA or Mineralocorticoid receptor antagonists

2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [5]

Diuretics and Decongestion Strategies in Patients with HF (DO NOT EDIT)[5][6][7]

Class I
"1. In patients with HF who have fluid retention, diuretics are recommended to relieve congestion, improve symptoms, and prevent worsening HF. [8][9][10][11][12] (Level of Evidence: B-NR) "
"2. For patients with HF and congestive symptoms, addition of a thiazide (eg, metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderate or high-dose loop diuretics to minimize electrolyte abnormalities. [13] (Level of Evidence: B-NR) "


Mineralocorticoid Receptor Antagonists (MRAs)
Class I
"1. In patients with HFrEF and NYHA class II to IV symptoms, an MRA (spironolactone or epleronone) is recommended to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter to minimize risk of hyperkalemia and renal insufficiency. [4][14][15] (Level of Evidence: A) "
Value Statement: High Value
"2. In patients with HFrEF and NYHA II to IV symptoms, MRA therapy provides high economic value.[16][17][18][19] (Level of Evidence: A) "
Class III (Harm)
"3. In patients taking MRA whose serum potassium cannot be maintained at <5.5 mEq/L, MRA should be discontinued to avoid life-threatening hyperkalemia. [20][21] (Level of Evidence: B-NR) "

External Link

References

  1. ↑ Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, Testani JM, Tang W, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic PM, Ruschitzka F, Coats AJ (February 2019). "The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology". Eur J Heart Fail. 21 (2): 137–155. doi:10.1002/ejhf.1369. PMID 30600580. Vancouver style error: initials (help)
  2. ↑ Faris R, Flather M, Purcell H, Henein M, Poole-Wilson P, Coats A (February 2002). "Current evidence supporting the role of diuretics in heart failure: a meta analysis of randomised controlled trials". Int J Cardiol. 82 (2): 149–58. doi:10.1016/s0167-5273(01)00600-3. PMID 11853901.
  3. ↑ Rohde LE, Rover MM, Figueiredo Neto JA, Danzmann LC, Bertoldi EG, Simões MV, Silvestre OM, Ribeiro A, Moura LZ, Beck-da-Silva L, Prado D, Sant'Anna RT, Bridi LH, Zimerman A, Raupp da Rosa P, Biolo A (November 2019). "Short-term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double-blind, multicentre, randomized trial". Eur Heart J. 40 (44): 3605–3612. doi:10.1093/eurheartj/ehz554. PMID 31424503. Vancouver style error: initials (help)
  4. ↑ 4.0 4.1 Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J (September 1999). "The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators". N Engl J Med. 341 (10): 709–17. doi:10.1056/NEJM199909023411001. PMID 10471456.
  5. ↑ 5.0 5.1 Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check |pmid= value (help).
  6. ↑ Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE; et al. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.
  7. ↑ 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
  8. ↑ Patterson JH, Adams KF, Applefeld MM, Corder CN, Masse BR (1994). "Oral torsemide in patients with chronic congestive heart failure: effects on body weight, edema, and electrolyte excretion. Torsemide Investigators Group". Pharmacotherapy. 14 (5): 514–21. PMID 7997385.
  9. ↑ Goebel KM (1993). "Six-week study of torsemide in patients with congestive heart failure". Clin Ther. 15 (6): 1051–9. PMID 8111802.
  10. ↑ Wilson JR, Reichek N, Dunkman WB, Goldberg S (1981). "Effect of diuresis on the performance of the failing left ventricle in man". Am J Med. 70 (2): 234–9. doi:10.1016/0002-9343(81)90755-5. PMID 7468610.
  11. ↑ Parker JO (1993). "The effects of oral ibopamine in patients with mild heart failure--a double blind placebo controlled comparison to furosemide. The Ibopamine Study Group". Int J Cardiol. 40 (3): 221–7. doi:10.1016/0167-5273(93)90004-z. PMID 8225657.
  12. ↑ Richardson A, Bayliss J, Scriven AJ, Parameshwar J, Poole-Wilson PA, Sutton GC (1987). "Double-blind comparison of captopril alone against frusemide plus amiloride in mild heart failure". Lancet. 2 (8561): 709–11. doi:10.1016/s0140-6736(87)91074-9. PMID 2888942.
  13. ↑ Grodin JL, Stevens SR, de Las Fuentes L, Kiernan M, Birati EY, Gupta D; et al. (2016). "Intensification of Medication Therapy for Cardiorenal Syndrome in Acute Decompensated Heart Failure". J Card Fail. 22 (1): 26–32. doi:10.1016/j.cardfail.2015.07.007. PMC 4706474. PMID 26209004.
  14. ↑ Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B; et al. (2003). "Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction". N Engl J Med. 348 (14): 1309–21. doi:10.1056/NEJMoa030207. PMID 12668699. Review in: J Fam Pract. 2003 Aug;52(8):598-9 Review in: ACP J Club. 2003 Sep-Oct;139(2):32
  15. ↑ Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H; et al. (2011). "Eplerenone in patients with systolic heart failure and mild symptoms". N Engl J Med. 364 (1): 11–21. doi:10.1056/NEJMoa1009492. PMID 21073363. Review in: Evid Based Med. 2011 Aug;16(4):121-2 Review in: J Fam Pract. 2011 Aug;60(8):482-4
  16. ↑ Banka G, Heidenreich PA, Fonarow GC (2013). "Incremental cost-effectiveness of guideline-directed medical therapies for heart failure". J Am Coll Cardiol. 61 (13): 1440–6. doi:10.1016/j.jacc.2012.12.022. PMID 23433562.
  17. ↑ Glick HA, Orzol SM, Tooley JF, Remme WJ, Sasayama S, Pitt B (2002). "Economic evaluation of the randomized aldactone evaluation study (RALES): treatment of patients with severe heart failure". Cardiovasc Drugs Ther. 16 (1): 53–9. doi:10.1023/a:1015371616135. PMID 12085979.
  18. ↑ Weintraub WS, Zhang Z, Mahoney EM, Kolm P, Spertus JA, Caro J; et al. (2005). "Cost-effectiveness of eplerenone compared with placebo in patients with myocardial infarction complicated by left ventricular dysfunction and heart failure". Circulation. 111 (9): 1106–13. doi:10.1161/01.CIR.0000157146.86758.BC. PMID 15723981.
  19. ↑ Zhang Z, Mahoney EM, Kolm P, Spertus J, Caro J, Willke R; et al. (2010). "Cost effectiveness of eplerenone in patients with heart failure after acute myocardial infarction who were taking both ACE inhibitors and beta-blockers: subanalysis of the EPHESUS". Am J Cardiovasc Drugs. 10 (1): 55–63. doi:10.2165/11319940-000000000-00000. PMID 20104935.
  20. ↑ Hernandez AF, Mi X, Hammill BG, Hammill SC, Heidenreich PA, Masoudi FA; et al. (2012). "Associations between aldosterone antagonist therapy and risks of mortality and readmission among patients with heart failure and reduced ejection fraction". JAMA. 308 (20): 2097–107. doi:10.1001/jama.2012.14795. PMID 23188026.
  21. ↑ Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A; et al. (2004). "Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study". N Engl J Med. 351 (6): 543–51. doi:10.1056/NEJMoa040135. PMID 15295047.
  22. ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW (May 2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e895–e1032. doi:10.1161/CIR.0000000000001063. PMID 35363499 Check |pmid= value (help).

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