Congestive heart failure diuretics

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Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
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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
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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]

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

• Loop diuretics is recommended to reduce the signs and/or symptoms of congestion in patients with HFrEF.
• The effects of diuretics on morbidity and mortality have not been studied in RCTs.
• Loop diuretics and thiazide diuretics appear to reduce the risk of death and worsening HF compared with a placebo.
• Diuretics can improve exercise capacity.
• 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.
• 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.
• MRAs improve symptoms.
• MRAs 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.