SOURCE: Ellison DH, Felker GM. Diuretic treatment in heart failure. N Engl J Med 2017;337:1964-1975.

Diuretics are employed in heart failure for symptom control, but they are not disease-modifying; that is, in contrast to angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers, aldosterone antagonists, hydralazine/isosorbide, and valsartan/sacubitril, each of which has demonstrated meaningful reductions in mortality in heart failure clinical trials, diuretics are employed solely for improved patient quality of life. Perhaps that helps explain why there is remarkably less clinical trial data specifically focused on diuretic therapies for heart failure.

Two areas in which knowledge about best diuretic use is particularly important are acute decompensated heart failure and the scenario of diuretic resistance. For patients with acute decompensated heart failure, a trial comparing twice-daily furosemide IV boluses vs. continuous infusion (using low-dose and high-dose regimens) did not demonstrate any statistically significant difference for the coprimary endpoint of the patient’s global assessment of symptoms. However, secondary endpoint outcomes, which must be regarded as hypothesis-generating rather than definitive since the primary outcome was not achieved, tended to favor high-dose regimens regarding dyspnea, weight change, and net fluid loss.

For diuretic resistance, the authors endorsed continuous diuretic infusion with stepwise dose increases to achieve a 3-5 liter/day urine volume until euvolemia is achieved. The modest amount of clinical trial data to assist clinicians in choosing doses of diuretics, mode of administration, and target fluid losses suggests that much more information is needed.