A reappraisal of loop diuretic choice in heart failure patients.
The health and economic burden of heart failure is significant and continues to grow each year. Loop diuretics are an integral part of symptom management in heart failure. Furosemide is used disproportionately compared with other loop diuretics, and there is currently no guidance for physicians regarding which agent to choose. However, there exist pharmacologic differences as well as other mechanistic differences that appear to favor torsemide use over furosemide. Compared with furosemide, torsemide improves surrogate markers of heart failure severity such as left ventricular function, plasma brain natriuretic peptide levels, and New York Heart Association functional class and may also reduce hospitalizations, readmissions, and mortality. Data suggest that these benefits could be mediated through torsemide's ability to positively affect the renin-angiotensin-aldosterone system. Specifically, torsemide has been shown to inhibit aldosterone secretion, synthesis, and receptor binding in vitro, as well as decrease transcardiac extraction of aldosterone, myocardial collagen production, and cardiac fibrosis in patients with heart failure. We identified pertinent literature using keyword MEDLINE searches and cross-referencing prior bibliographies. We summarize the available data suggesting potential benefits with torsemide over furosemide, and call attention to the need for a reappraisal of diuretic use in heart failure patients and also for a well-powered, randomized control trial assessing torsemide versus furosemide use.
Duke University Medical Center, Durham, NC. Electronic address: jonathan.buggey@duke.edu.
Jonathan
J
Buggey
Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
Robert J
RJ
Mentz
University of Michigan Health System, Ann Arbor, MI.
Bertram
B
Pitt
Duke Clinical Research Institute, Durham, NC.
Eric L
EL
Eisenstein
Duke Clinical Research Institute, Durham, NC.
Kevin J
KJ
Anstrom
Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
Eric J
EJ
Velazquez
Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
Christopher M
CM
O'Connor
D002755:Choice Behavior; D005355:Fibrosis; D005665:Furosemide / Q000494:pharmacology / Q000627:therapeutic use; D006321:Heart / Q000187:drug effects; D006333:Heart Failure / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D009206:Myocardium / Q000473:pathology; D010818:Practice Patterns, Physicians'; D012084:Renin-Angiotensin System / Q000187:drug effects / Q000502:physiology*; D049994:Sodium Potassium Chloride Symporter Inhibitors / Q000494:pharmacology / Q000627:therapeutic use*; D013449:Sulfonamides / Q000494:pharmacology / Q000627:therapeutic use; D000077786:Torsemide; D015854:Up-Regulation / Q000502:physiology; D018487:Ventricular Dysfunction, Left / Q000188:drug therapy
D049994:Sodium Potassium Chloride Symporter Inhibitors; D013449:Sulfonamides; D005665:Furosemide; D000077786:Torsemide