Diuretic Treatment for the Sodium Retention of Congestive Heart Failure

Abstract

The use of diuretics for the treatment of sodium retention in congestive heart failure was evaluated. Particular focus was given to the altered renal response to diuretics in patients with heart failure and adverse responses to diuretic therapy. Highlighted information included historical aspects of the development of diuretics, mechanisms of sodium retention, the physiologic and clinical response to diuretics, and the altered pharmacokinetics and pharmacodynamics of diuretics in congestive heart failure. Despite more than 60 years of empiric diuretic use in heart failure, the actual database regarding the long-term efficacy, adverse effects, and altered mortality outcome in heart failure is relatively small. Existent pharmacokinetic and pharmacodynamic data are typically not collected within the context of heart failure efficacy trials. In addition to altered electrolyte transport and total-body electrolyte depletion, diuretics may be associated with adverse neurohormonal activation. Thus, guidelines for acute and long-term therapy with diuretics in heart failure remain somewhat empiric. Diuretics will remain a mainstay for the treatment of edema in congestive heart failure but must be accompanied by moderate sodium restriction. However, large clinical trials of diuretics would be necessary to demonstrate that improved clinical efficacy with edema reduction is not offset by adverse effects, which include electrolyte depletion, ventricular arrhythmias, and subsequent increased mortality.

2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults

“…Bumetanide, furosemide, and torsemide act at the loop of Henle (thus, they are called loop diuretics), whereas thiazides, metolazone, and potassium-sparing agents (e.g., spironolactone) act in the distal portion of the tubule. 263,264 These 2 classes of diuretics differ in their pharmacological actions. The loop diuretics increase sodium excretion up to 20% to 25% of the filtered load of sodium, enhance free water clearance, and maintain their efficacy unless renal function is severely impaired.…”

Combination of high-dose furosemide and hydrochlorothiazide in the treatment of refractory congestive heart failure

“…day -*) and in most of these studies renal function was fair. While thiazides used as monotherapy are thought to be no longer effective when the glomerular filtration rate falls below approximately 25 to 30 m l. min -1 [14,15], there are nevertheless limited data showing that addition of a thiazide to a loop diuretic increases natriuresis in patients with advanced renal failure110,161.…”

Influence of diuretic therapy on the features of heart rhythm variability changes in chronic heart failure patients

“…Эти свойства определяют его повышенную эффективность у пациентов с ХСН, которая продемонстрирована в ряде контролируемых клинических исследо-ваний [4][5][6][7][8][9][10][11][12][13]. Эффективность торасемида обусловлена не только диуретическим эф-фектом, но и антиальдостероновыми меха-низмами.…”