Diuretic therapy in heart failure: current controversies and new approaches for fluid removal.
Hospitalization for heart failure is a major health problem with high in-hospital and postdischarge mortality and morbidity. Non-potassium-sparing diuretics (NPSDs) still remain the cornerstone of therapy for fluid management in heart failure despite the lack of large randomized trials evaluating their safety and optimal dosing regimens in both the acute and chronic setting. Recent retrospective data suggest increased mortality and re-hospitalization rates in a wide spectrum of heart failure patients receiving NPSDs, particularly at high doses. Electrolyte abnormalities, hypotension, activation of neurohormones, and worsening renal function may all be responsible for the observed poor outcomes. Although NPSD will continue to be important agents to promptly resolve signs and symptoms of heart failure, alternative therapies such as vasopressine antagonists and adenosine blocking agents or techniques like veno-venous ultrafiltration have been developed in an effort to reduce NPSD exposure and minimize their side effects. Until other new agents become available, it is probably prudent to combine NPSD with aldosterone blocking agents that are known to improve outcomes.
Brandimarte
Filippo
F
Department of Cardiovascular, Respiratory and Morphological Sciences, Sapienza University, Rome, Italy. fibrand@hotmail.com
Mureddu
Gian Francesco
GF
Boccanelli
Alessandro
A
Cacciatore
Giuseppe
G
Brandimarte
Camillo
C
Fedele
Francesco
F
Gheorghiade
Mihai
M
D000241:Adenosine / Q000037:antagonists & inhibitors; D002318:Cardiovascular Diseases / Q000139:chemically induced; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D006440:Hemofiltration; D006727:Hormone Antagonists / Q000627:therapeutic use; D006801:Humans; D007674:Kidney Diseases / Q000139:chemically induced; D018570:Risk Assessment; D012307:Risk Factors; D049994:Sodium Potassium Chloride Symporter Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D013997:Time Factors; D016896:Treatment Outcome; D014667:Vasopressins / Q000037:antagonists & inhibitors; D014882:Water-Electrolyte Balance / Q000187:drug effects*
D006727:Hormone Antagonists; D049994:Sodium Potassium Chloride Symporter Inhibitors; D014667:Vasopressins; D000241:Adenosine