Loop Diuretics in Acute Decompensated Heart Failure
Necessary? Evil? A Necessary Evil?
“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 diuretics results in prompt diuresis and relief of symptoms in most patients. Despite this breadth of clinical experience, however, high quality data supporting the safety and efficacy of loop diuretics in ADHF are sparse. Accordingly, the most recent practice guidelines for ADHF from the …