329. Guidelines: 2022 AHA/ACC/HFSA Guide...

Which of the following sentences regarding diuretics in the management of heart failure is correct?

A

In HF patients with minimal congestive symptoms, medical management with diuretics alone is sufficient to improve outcomes.

B

Prescribing a loop diuretic on discharge after a HF hospitalization may improve short term mortality and HF rehospitalization rates.

C

The combination of thiazide (or thiazide-like) diuretics with loop diuretics is preferred to higher doses of loop diuretics in patients with HF and congestive symptoms.

D

The maximum daily dose of furosemide is 300 mg.

Explanation

Choice B in correct. The guidelines give a Class 1 recommendation for diuretics in HF patients who have fluid retention to relieve congestion, improve symptoms, and prevent worsening heart failure. Recent data from the non-randomized OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry revealed reduced 30-day all-cause mortality and hospitalizations for HF with diuretic use compared with no diuretic use after hospital discharge for HF.

Choice A is incorrect. With the exception of mineralocorticoid receptor antagonists (MRAs), the effects of diuretics on morbidity and mortality are uncertain. As such, diuretics should not be used in isolation, but always combined with other GDMT for HF that reduce hospitalizations and prolong survival.

Choice C is incorrect. The use of a thiazide or thiazide-like diuretic (e.g., metolazone) in combination with a loop diuretic inhibits compensatory distal tubular sodium reabsorption, leading to enhanced natriuresis. In a propensity-score matched analysis in patients with hospitalized HF, the addition of metolazone to loop diuretics was found to increase the risk for hypokalemia, hyponatremia, worsening renal function, and mortality, whereas use of higher doses of loop diuretics was not found to adversely affect survival. The guidelines recommend that the addition of a thiazide (e.g., metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderate- or high-dose loop diuretics to minimize electrolyte abnormalities (Class I, LOE B-NR).

Choice D is incorrect. The guidelines recommend a maximum total daily dose of 600mg of furosemide or 10mg of bumetanide or 200mg of torsemide.

Main Takeaway

In summary, diuretics are recommended in heart failure patients who have fluid retention to relieve congestion, improve symptoms, and prevent worsening heart failure. Maintenance diuretics on HF hospitalization discharge may help prevent recurrent HF hospitalizations. They should be used in combination with other GDMT to improve HF outcomes. Combining loop and thiazide diuretics may cause serious electrolyte abnormalities and should be reserved for patients who do not respond to moderate- or high-dose loop diuretics.

Guideline Loc.

Section 7.2, Table 12