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Review
. 2009 Jan;2(1):56-62.
doi: 10.1161/CIRCHEARTFAILURE.108.821785.

Loop diuretics in acute decompensated heart failure: necessary? Evil? A necessary evil?

G Michael Felker  1 , Christopher M O'Connor, Eugene Braunwald; Heart Failure Clinical Research Network Investigators
Collaborators, Affiliations
Review

Loop diuretics in acute decompensated heart failure: necessary? Evil? A necessary evil?

G Michael Felker et al. Circ Heart Fail. 2009 Jan.

Abstract

Acute decompensated heart failure (ADHF) is a common and highly morbid cardiovascular disorder. Most hospitalizations for ADHF are related to symptoms of congestion, and the vast majority of ADHF patients are treated with intravenous loop diuretics. Despite this nearly ubiquitous use, data supporting the safety and efficacy of loop diuretics in ADHF are limited, and controversy exists about the best way to use loop diuretics with regard to both dosing and means of administration (continuous infusion vs. intermittent boluses). We reviewed the data supporting the safety and efficacy of loop diuretics in patients with ADHF. A large body of observational literature suggests that loop diuretics, especially at higher doses, may be associated with increased mortality in patients with heart failure even after detailed adjustment for other measures of disease severity. Additionally, multiple small underpowered trials suggest that continuous infusion may be equivalent or superior to intermittent bolus dosing. In summary, there is a critical need to develop more robust data on the use of loop diuretics in ADHF. In that context, the NIH Heart Failure Clinical Research Network has begun the Diuretics Optimization Strategies Evaluation (DOSE) study, a multi-center, double-blind, randomized controlled trial that will enroll 300 patients with ADHF. The DOSE study will randomize patients using a 2 × 2 factorial design to low dose vs. high dose furosemide, and intermittent bolus vs. continuous infusion. Successful completion of the DOSE study will provide important data on the optimal clinical use of loop diuretics in ADHF.

Keywords: acute decompensated heart failure; clinical trials; diuretics.

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Conflict of interest statement

Conflict of Interest Disclosures: None

Figures

Figure 1
Figure 1
Relationship between maximum in-hospital diuretic dose and mortality in the ESCAPE study (Reprinted from reference , with permission from Elsevier).
Figure 2
Figure 2
Study Schema for DOSE Study. ADHF=acute decompensated heart failure. PGA=patient global assessment, VAS=visual analog scale, AUC=area under the curve
See this image and copyright information in PMC

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