Recommendations from others
The American College of Cardiology recommends using diuretics in the setting of left ventricular systolic dysfunction and fluid retention (level of evidence [LOE]: A), and recommends using diuretics in diastolic dysfunction to control pulmonary congestion and peripheral edema (LOE: C).9
The European Society of Cardiology notes that no randomized controlled trials have assessed survival effects of diuretics in congestive heart failure, but recommends using diuretics for symptomatic treatment of volume overload (LOE: A). This society also cites evidence that diuretic use improves exercise tolerance (LOE: B). They recommend that diuretics be used always in addition to an ACE inhibitor, that loop diuretics be used if symptoms are more than mild and if glomerular filtration rate (GFR) <30 cc/min, and that thiazide diuretics can be used with loop diuretics for synergistic effects in severe congestive heart failure. 10
Clinical Commentary
Helpful in the acute setting, diuretics shouldn’t be used alone chronically
Jon Neher, MD
Valley Medical Center, Renton, Wash
Furosemide and the other loop diuretics are very satisfying to use clinically. The patient in heart failure arrives at the hospital dypsneic, cyanotic, and terrified. After a single large dose of medication, the patient diureses and begins to feel good again quite quickly.
The practitioner, however, needs to be wary of the resulting impression that diuretics are “good” for heart failure. ACE inhibitors, beta blockers, and (in severe cases) spironolactone are “good” for heart failure because they prolong lives. One must not allow diuretic therapy—started for acute decompensation— to prevent use of more important long-term medications by causing dehydration, hypotension, or electrolyte disturbances.