A reappraisal of loop diuretic choice in heart failure patients

Abstract

The health and economic burden of heart failure is significant, and continues to grow each year. Loop diuretics are an integral part of symptom management in heart failure. Furosemide is used disproportionately compared to other loop diuretics and there is currently no guidance for physicians regarding which agent to choose. However, there exist pharmacologic differences as well as other mechanistic differences that appear to favor torsemide use over furosemide. Compared to furosemide, torsemide improves surrogate markers of heart failure severity such as left ventricular function, plasma brain natriuretic peptide levels, and New York Heart Association functional class and may also reduce hospitalizations, readmissions, and mortality. Data suggest these benefits could be mediated through torsemide’s ability to positively affect the renin-angiotensin-aldosterone system. Specifically, torsemide has been shown to inhibit aldosterone secretion, synthesis, and receptor binding in vitro, as well as decrease transcardiac extraction of aldosterone, myocardial collagen production and cardiac fibrosis in patients with heart failure. We identified pertinent literature using keyword MEDLINE searches and cross-referencing prior bibliographies. We summarize the available data suggesting potential benefits with torsemide over furosemide, and call attention to the need for a reappraisal of diuretic use in heart failure patients and also for a well powered, randomized control trial assessing torsemide versus furosemide use.

Diuretic Treatment in Heart Failure

“…18 A systematic analysis of torsemide versus furosemide comparative effectiveness suggested that torsemide reduced heart failure readmissions, 19 but available data are limited and the question is well-suited for definitive clinical trials. 20 …”

Torsemide Versus Furosemide in Patients With Acute Heart Failure (from the ASCEND-HF Trial)

“…Previous studies suggested that torsemide may be associated with better outcomes than furosemide in chronic HF patients 22 . A small (N=234) open-label, randomized study by Murray et al compared chronic HF with reduced EF patients receiving torsemide vs. furosemide 5 .…”

A Clinical Perspective of Anti-Fibrotic Therapies for Cardiovascular Disease

“…They further reported the ability of torsemide to correct both lysyl oxidase overexpression and enhanced collagen cross-linking leading to normalization of LV chamber stiffness in patients with heart failure (López et al, 2009). This was supported by preclinical data showing torsemide's effect on RAAS inhibition including decreasing aldosterone secretion, inhibiting aldosterone receptor and Ang II effects (Buggey et al, 2015). However, in the TORAFIC study, a multi-center study of 155 hypertensive patients with chronic heart failure randomized to torsemide or furosemide, investigators did not find significant differences between the two groups in changes of PICP (Group, 2011).…”