Practical Applications of Intravenous Diuretic Therapy in Decompensated Heart Failure
Section snippets
Randomized controlled trials of diuretics
Two prospective, randomized trials, both conducted nearly 20 years ago, have evaluated the immediate hemodynamic effects of IV diuretics in patients with heart failure (HF) secondary to myocardial infarction.9, 10 In the first trial, Verma and associates10 compared the effects of an IV diuretic (furosemide, 1 mg/kg), a venodilator (isosorbide dinitrate, 50 to 200 μg/kg per hr), an arteriolar dilator (hydralazine, 0.15 mg/kg), and a positive inotropic agent (prenalterol, 50 to 200 μg/kg per hr)
Standard use of intravenous diuretics
Diuretics differ significantly in their site and mechanism of action.12, 13 Carbonic anhydrase inhibitors inhibit carbonic anhydrase in the proximal tubule. Osmotic agents have an osmotic effect in both the proximal tubule and the thick ascending limb of Henle. Loop diuretics inhibit the Na+-K+-2Cl− reabsorptive pump in the thick ascending limb of the loop of Henle. Thiazide diuretics inhibit electroneutral NaCl reabsorption in the distal convoluted tubule, and potassium-sparing diuretics
Expected response to intravenous diuretics
Loop diuretics enhance the excretion of sodium, chloride, potassium, and other ions, increasing urine volume, decreasing intravascular and extracellular fluid, and reducing total body sodium.20, 22, 28, 29 With bolus therapy, urine output peaks within 1 to 2 hours and declines to baseline level within 6 hours when assessed using urinary catheters, with changes in sodium excretion mirroring those of urine output (Figure 2).12, 29, 30, 31
In healthy volunteers, an IV dose of 40 mg furosemide, 20
Potential deleterious effects of intravenous diuretics
Diuretics, and especially their overuse, produce several deleterious effects that can influence clinical outcomes. A frequent consequence of diuretic therapy is electrolyte disturbances. 4, 6, 13, 20, 22 Loop diuretics increase urinary excretion of potassium, magnesium, and calcium, reducing total body stores of these essential cations, causing secondary hyperparathyroidism, and potentially increasing the risk of arrhythmic mortality.20, 22, 33, 34 Patients with advanced HF and long-term
Failure to respond to standard diuretic doses
Diuretic resistance, i.e., the failure to adequately respond to standard doses of diuretics, is a major issue in the management of patients with advanced HF. It is frequently seen in patients with severe symptoms, hypotension, hyponatremia, renal dysfunction, and/or significant cardiac dysfunction, and it has been associated with increased mortality.23, 47, 48, 50
Currently, the management of patients with diuretic resistance must be guided by the available limited data and theoretical
Summary
IV loop diuretics are considered the standard of care in patients with DHF. They decrease volume overload, improve hemodynamics, and reduce symptoms. However, they also can produce electrolyte abnormalities, neurohormonal activation, intravascular volume depletion, and renal dysfunction, leading to increased morbidity and mortality. In addition, many patients are resistant to the effects of standard doses of loop diuretics. These patients may benefit from the reduction or elimination of factors
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Cited by (37)
Diuretic Response: Clinical and Hemodynamic Predictors and Relation to Clinical Outcome
2016, Journal of Cardiac FailureCitation Excerpt :Loop diuretics must be actively secreted into the urine by proximal tubule cells to reach a therapeutic concentration at the site of action.24,27,28 In the setting of ADHF, the dose–response curve for loop diuretics is shifted to the right and reduced in magnitude owing to renal insufficiency, hypotension, and neurohormonal activation,24,27,29 and higher doses are needed to compensate for the consequent changes in renal blood flow. In the present study, we were unable to demonstrate a plateau in the magnitude of diuretic response even with furosemide equivalent doses >240 mg (Fig. 1, upper quartile of furosemide dose).
The independent association between altered renal arterial resistance and loop diuretic dose in chronic heart failure outpatients
2015, IJC Heart and VasculatureCitation Excerpt :A decreased response of the nephron to diuretic therapy in CHF patients when compared to normal patients has been widely demonstrated. The dose–response curve shows a downward and right shift, thus requiring a higher dose in order to achieve the same level of sodium excretion [21]. However, in CHF patients, there is a high interindividual variability in loop diuretic response.
Efficacy of tolvaptan in a patient with right-sided heart failure and renal dysfunction refractory to diuretic therapy
2014, Journal of Cardiology CasesCitation Excerpt :As a result, he took a dose of 7.5 mg of tolvaptan several times per month, and the HF continues to be well controlled with 160 mg/day of furosemide. Loop diuretics have been shown to reduce renal blood flow and glomerular filtration rate and stimulate the renin–angiotensin–aldosterone system, thereby worsening renal dysfunction [1–4]. Renal dysfunction is associated with a poor prognosis in patients with HF [2,3], and more than 30% of patients hospitalized with HF have renal dysfunction [8].
2013 ACCF/AHA guideline for the management of heart failure: A report of the American college of cardiology foundation/american heart association task force on practice guidelines
2013, Journal of the American College of CardiologyPassive leg movement enhances diuresis and decline of plasma NT-proBNP level in patients with decompensated heart failure treated with furosemide
2013, International Journal of CardiologyManagement of the Patient with Congestive Heart Failure
2012, Nephrology Secrets