European Consensus on use of diuretics in chronic heart failure 2019

The article presents the consensus materials of the European Society of Cardiology on the use of diuretics in chronic heart failure (CHF). Diuretics represent an important class of drugs for the treatment of heart failure from the perspective of evidence based medicine. Much attention in the consensus s paid to the algorithm of using diuretics, in particular loop diuretics, in acute decompensation of CHF. Clinical and pharmacological advantages and disadvantages of the main drugs of loop diuretics (furosemide, torasemide, bumetanide) in CHF are discussed. There was analyzed the effectiveness of low and high doses of loop diuretics, the method of administration (bolus or continuous infusion) in terms of effective diuretic therapy and prevention of tolerance to diuretics, as well as the impact on the prognosis of survival during decompensation of heart failure. It also discusses modern approaches to the diagnostic criteria for assessing the effectiveness of diuretic therapy in acute decompensation of CHF, and shows the possibility of determination the level of excretion of Na⁺ ions in the urine as a surrogate marker of the effectiveness of diuretic therapy to optimize the dosage regimen of diuretics. An algorithm of diuretic therapy is proposed (the choice of dosages and regimens for using loop diuretics) for patients with acute decompensation of heart failure, including intravenous use of loop diuretics in an optimal increasing dose for the first 24 hours before stopping stagnation with a further transition to a maintenance dose of loop diuretic for euvolemia status and combined diuretic therapy with thiazides to obtain synergism. The recommendations for correction of electrolyte disturbances against the background of diuretic therapy is considered.

Loop diuretics are recommended for CHF to prevent signs and symptoms of congestion: this is the only group of drugs with a level of recommendation as class I in patients with heart failure with a reduced or preserved ejection fraction.

1. Mullens W., Damman K., Harjola V.P., Mebazaa A., Brunner-La Rocca H.P., Martens P. et al. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019;21(2):137-155. doi: 10.1002/ejhf.1369.

2. Mosterd A., Hoes A.W. Clinical epidemiology of heart failure. Heart. 2007;93:1137-1146. doi: 10.1136/hrt.2003.025270.

3. Ponikowski P., Voors A.A., Anker S.D., Bueno H., Cleland J.G.F., Coats A.J.S. et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;37(27):2129-2200. doi: 10.1093/eurheartj/ehw128.

4. Testani J.M., Chen J., McCauley B.D., Kimmel S.E., Shannon R.P. Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival. Circulation. 2010;122(3):265-272. doi: 10.1161/CIRCULATIONAHA.109.933275.

5. Vaduganathan M., Greene S.J., Fonarow G.C., Voors A.A., Butler J., Gheorghiade M. Hemoconcentration-guided diuresis in heart failure. Am J Med. 2014;127(12):1154-1159. doi: 10.1016/j.amjmed.2014.06.009.

6. Testani J.M., Brisco M.A., Chen J., McCauley B.D., Parikh C.R., Tang W.H. Timing of hemoconcentration during treatment of acute decompensated heart failure and subsequent survival: importance of sustained decongestion. J Am Coll Cardiol. 2013;62(6):516-524. doi: 10.1016/j.jacc.2013.05.027.

7. Damman K., Navis G., Voors A.A., Asselbergs F.W., Smilde T.D., Cleland J.G. et al. Worsening renal function and prognosis in heart failure: systematic review and meta-analysis. J Card Fail. 2007;13(8):599-608. doi: 10.1016/j.cardfail.2007.04.008.

8. Damman K., Valente M.A., Voors A.A., O'Connor C.M., van Veldhuisen D.J., Hillege H.L. Renal impairment, worsening renal function, and outcome in patients with heart failure: an updated meta-analysis. Eur Heart J. 2014;35(7):455-469. doi: 10.1093/eurheartj/eht386.

9. Ellison D.H. Diuretic therapy and resistance in congestive heart failure. Cardiology. 2001;96(3-4):132-143. doi: 10.1159/000047397.

10. Shah N., Madanieh R., Alkan M., Dogar M.U., Kosmas C.E., Vittorio T.J. A perspective on diuretic resistance in chronic congestive heart failure. Ther Adv Cardiovasc Dis. 2017;11(10):271-278. doi: 10.1177/1753944717718717.

11. Testani J.M., Brisco M.A., Kociol R.D., Jacoby D., Bellumkonda L., Parikh C.R. et al. Substantial Discrepancy Between Fluid and Weight Loss During Acute Decompensated Heart Failure Treatment. Am J Med. 2015;128(7):776-783.e4. doi: 10.1016/j.amjmed.2014.12.020.

12. Brinkley D.M. Jr., Burpee L.J., Chaudhry S.P., Smallwood J.A., Lindenfeld J., Lakdawala N.K. et al. Spot urine sodium as triage for effective diuretic infusion in an ambulatory heart failure unit. J Card Fail. 2018;24(6):349-354. doi: 10.1016/j.cardfail.2018.01.009.

13. Luk A., Groarke J.D., Desai A.S., Mahmood S.S., Gopal D.M., Joyce E. et al. First spot urine sodium after initial diuretic identifies patients at high risk for adverse outcome after heart failure hospitalization. Am Heart J. 2018;203:95-100. doi: 10.1016/j.ahj.2018.01.013.

14. Ter Maaten J.M., Valente M.A., Damman K., Hillege H.L., Navis G., Voors A.A. Diuretic response in acute heart failure - pathophysiology, evaluation, and therapy. Nat Rev Cardiol. 2015;12:184-192. doi: 10.1038/nrcar-dio.2014.215.

15. Grodin J.L., Stevens S.R., de Las Fuentes L., Kiernan M., Birati E.Y., Gupta D. et al. Intensification of Medication Therapy for Cardiorenal Syndrome in Acute Decompensated Heart Failure. J Card Fail. 2016;22(1):26-32. doi: 10.1016/j.cardfail.2015.07.007.

16. Bikdeli B., Strait K.M., Dharmarajan K., Partovian C., Coca S.G., Kim N. et al. Dominance of furosemide for loop diuretic therapy in heart failure: time to revisit the alternatives? J Am Coll Cardiol. 2013;61(14):1549-1550. doi: 10.1016/j.jacc.2012.12.043.

17. Casu G., Merella P. Diuretic Therapy in Heart Failure - Current Approaches. Eur Cardiol Rev. 2015;10(1):42-47. doi: 10.15420/ecr.2015.10.01.42.

18. Felker G.M., Lee K.L., Bull D.A., Redfield M.M., Stevenson L.W., Goldsmith S.R. et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011;364:797-805. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1005419.

19. Wu M.Y., Chang N.C., Su C.L., Hsu Y.H., Chen T.W., Lin Y.F. et al. Loop diuretic strategies in patients with acute decompensated heart failure: a metaanalysis of randomized controlled trials. J Crit Care. 2014;29(1):2-9. doi: 10.1016/j.jcrc.2013.10.009.

20. Butler J., Anstrom K.J., Felker G.M., Givertz M.M., Kalogeropoulos A.P., Konstam M.A. et al. Efficacy and safety of spironolactone in acute heart failure: the ATHENA-HF randomized clinical trial. JAMA Cardiol. 2017;2(9):950-958. doi: 10.1001/jamacardio.2017.2198.

21. Ferreira J.P., Rossignol P., Machu J.L., Sharma A., Girerd N., Anker S.D. et al. Mineralocorticoid receptor antagonist pattern of use in heart failure with reduced ejection fraction: findings from BIOSTAT-CHF. Eur J Heart Fail. 2017;19(10):1284-1293. doi: 10.1002/ejhf.900.

22. Verbrugge F.H., Dupont M., Bertrand P.B., Nijst P., Penders J., Dens J. et al. Determinants and impact of the natriuretic response to diuretic therapy in heart failure with reduced ejection fraction and volume overload. Acta Cardiol. 2015;70(3):265-273. doi: 10.1080/ac.70.3.3080630.

23. Mullens W., Verbrugge F.H., Nijst P., Martens P., Tartaglia K., Theunissen E. et al. Rationale and design of the ADVOR (Acetazolamide in Decompensated Heart Failure with Volume Overload) trial. Eur J Heart Fail. 2018;20(11):1591-1600. doi: 10.1002/ejhf.1307.

24. Faris R.F., Flather M., Purcell H., Poole-Wilson P.A., Coats A.J. Diuretics for heart failure. Cochrane Database Syst Rev. 2012;(2):CD003838. doi: 10.1002/14651858.CD003838.pub3.