Changing views on the place of loop and thiazide diuretics in the treatment of chronic heart failure. Part II. Influence on outcomes and clinical application

摘要

Results of studies of effects of loop and thiazide diuretics on clinical outcomes in patients with chronic heart failure (CHF) are discussed. A number of prospective trials have shown that in patients with CHF not receiving angiotensin converting enzyme inhibitors (ACEI) diuretics lessen considerably probability of decompensation. At the same time retrospective analysis of some large randomized trials revealed elevated mortality among patients with CHF receiving high doses of loop diuretics without potassium sparing diuretics. Especially significant during treatment with high doses of loop diuretics is elevated risk of sudden (or arrhythmic) death which according to data from SOLVD and PRAISE trials increases 30-50%. Current recommendations on the use of loop and thiazide diuretics in complex therapy of patients with CHF are given. An attention is paid to that therapy of CHF should be started with prescription of ACEI and diuretic added in the presence of symptoms and signs of congestion. In moderate and severe CHF as basic therapy it is recommended to use combination of ACEI, b-adrenoblocker and spironolactone, which allow to confine to medium doses of loop diuretics (furosemide not more than 80 mg/day). Mechanisms of diuretic resistance in CHF and methods of its management are also reviewed in detail.