Efficacy and safety of loop diuretic therapy in acute decompensated heart failure: a clinical review

Abstract

Intravenous loop diuretics are widely used to treat the symptoms and signs of fluid overload in acute heart failure (AHF). Although diuretic therapy is widely used and strongly recommended by most recent clinical guidelines, prospective studies and randomized clinical trials are lacking and so reliable evidence is missing about the best therapy in terms of doses and methods of administration. In addition, clinical efficacy and safety outcomes are often affected by the presence of contrasting evidence. The efficacy of loop diuretics is impaired by diuretic resistance characterized by a decreased diuretic and natriuretic effect. This review focuses on the current management of AHF with diuretic therapy. Continuous diuretic infusion seems to be a good choice, from a pharmacokinetic point of view, when fluid overload is refractory to conventional therapy. Some available evidence comparing bolus injection to continuous infusion of loop diuretics proved the latter to be an effective and safe method of administration. Continuous infusion seems to produce a constant plasmatic concentration of drug with a more uniform daily diuretic and natriuretic effect and a greater safety profile (fewer adverse events such as worsening renal failure, electrolyte imbalances, ototoxicity). The analyses of the published studies did not provide conclusive data about the effects on clinical outcomes (mortality, rate of hospital readmissions, length of hospital stay and adverse events). Furthermore, recent studies focus their attention on alternative strategies of fluid removal, such as vasopressin antagonists, adenosine antagonists and ultrafiltration but available data are often inconclusive.

A novel soluble guanylate cyclase activator with reduced risk of hypotension by short‐acting vasodilation

“…The pathogenesis of acute heart failure has been previously theorized to be body fluid accumulation to cause congestion; accordingly, the main constituent of treatment has been to control body fluid using diuretics . However, the improper use of diuretics causes renal dysfunction and electrolyte abnormalities during clinical acute heart failure .…”

Ultrafiltration in patients with decompensated heart failure and diuretic resistance: an Asian centre’s experience

“…(7,8) Although to date, there is no consensus on the definition of diuretic resistance, it is often described when there is persistent clinical congestion due to inadequate diuresis and natriuresis after administration of at least 80 mg of furosemide daily or an equivalent dose of diuretics. (9)(10)(11)(12) The prevalence of diuretic resistance among patients with HF is unknown. (10) The concept of extracorporeal removal of fluid using ultrafiltration (UF) has been reported for over 50 years.…”

How May Proton Pump Inhibitors Impair Cardiovascular Health?

“…Severe electrolyte abnormalities can be observed when PPIs are co-prescribed with loop diuretics. The latter are often used to manage hypertension or heart failure [79], and increase renal excretion of calcium and magnesium [80]. Indeed, changes in cardiac rhythm were recorded in 30% of patients with PPI-induced hypomagnesaemia, and the underlying cause of hypomagnesaemia in such patients may be overlooked resulting in recurrent hospitalizations [81].…”