the idea


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the idea


Heart failure has advanced along only a few avenues over the last 20 years.

  • The first therapy shown to extend life was ACEi.
  • Then we had beta-blockers (metoprolol, carvedilol, bisprolol), but not all of them (atenolol).
  • Both aldosterone antagonists (spironiolactone and eplerenone) extend life.
  • ARBs too (valsartan, candesartan), but only some of them (cozaar).
  • Digoxin failed.
  • ICDs succeeded.
  • There was Niseritide. Then there wasn't.
  • If you're black you can use nitrates and hydrazine.
  • Statins failed.
  • Darbepoetin failed.
  • I'm not aware of revascularization data, but there might be.
  • Coenzyme Q and L-carnitine have some data but I have not seen anything compelling.

I think that is about it.

The obvious omission from that paragraph are loop diuretics. No thiazides either. That should be shocking because its the standard therapy for acute and chronic heart failure.

The obvious reason is the immediate symptomatic benefit these patients receive. A bit of Lasix and the edema goes away, the oxygen requirement melts. The patient tells you she can sleep in a bed again. You find a stable dose of Lasix, ACEi, beta-blocker and you send her home. And sometime in the next year or three she'll die because mortality is advanced heart failure is terrible.

We use it and rarely question it because it is so essential in managing symptoms. Is there any reason to suspect it might not be beneficial to patients. Well, using diuretics increases sympathetic outflow to the kidneys and heart, and up-regulates the renin-angiotensin-aldosterone system. Our successful drugs suppress sympathetic stimulation, angiotensin and aldosterone. So its not hard to imagine diuretics being harmful. 

Look at the heart failure guidelines from Heart Failure Association of America. Strongest recommendation with the weakest evidence, shouldn't it be opposite. A study on unanswered questionsin the management of acute decompensated heart failure found that diuretic related questions were the most common.

 The strogest recommendation, the weakest weight of evidence. That ain't right.

The strogest recommendation, the weakest weight of evidence. That ain't right.