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Advances in Heart Failure

Loop Diuretics in Acute Decompensated Heart Failure

Necessary? Evil? A Necessary Evil?

G. Michael Felker, MD, MHS; Christopher M. O'Connor, MD; Eugene Braunwald, MD for the Heart Failure Clinical Research Network Investigators^*

From the Division of Cardiovascular Medicine (G.M.F., C.M.O.), Duke University Medical Center, Durham, NC; and the Cardiovascular Division (E.B.), Brigham and Women’s Hospital, Boston, Mass.

Correspondence to Michael Felker, MD, MHS, Duke Clinical Research Institute, 2400 Pratt St, Room 0311 Terrace Level, Durham, NC 27705. E-mail michael.felker@duke.edu

Key Words: diuretics • heart failure • trials

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 

"In times of great danger, you are permitted to walk with the devil until you have crossed the bridge."

— —Bulgarian proverb

Acute decompensated heart failure (ADHF) is the most common cause of hospital admission in patients >65 years, accounting for >1 million hospitalizations, 6 million hospital days, and $12 billion in costs annually in the United States alone.^1,2 The prognosis of patients admitted with ADHF is dismal, with rates of rehospitalization or death approaching 50% within 6 months.^3,4 Despite these alarming and oft-cited statistics, the development of new therapies in ADHF has changed little over recent decades,⁵ and short-term and intermediate-term outcomes have remained poor.⁶ In addition to spurring the development of new therapies for ADHF, these data suggest the need for an active reappraisal of current therapy. This review will focus on the data (or lack thereof) supporting the efficacy and safety of loop diuretics in ADHF, discuss the challenges in performing clinical trials of diuretics in ADHF, and describe an ongoing clinical trial designed to rigorously evaluate optimal diuretic use in this syndrome.

Loop diuretics are the foundation of current ADHF therapy. Data from the ADHF National Registry demonstrate that approximately 90% of patients hospitalized with ADHF in the United Sates receive IV loop diuretics during the hospitalization.⁷ This nearly ubiquitous use of loop diuretics in ADHF is understandable given that the majority of ADHF hospitalizations are related to volume overload and congestion,⁸ and decades of clinical observation has shown that IV administration of loop . . . [Full Text of this Article]

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