What is the most effective diuretic for an African American patient with heart failure with reduced ejection fraction?

From the Guidelines

Diuretic Choice for African American Patient with Heart Failure

The most effective diuretic for an African American patient with heart failure with reduced ejection fraction is typically a loop diuretic, such as torsemide or furosemide 1. Considering the patient's ethnicity and heart failure status, torsemide may be preferred due to its potential benefits in patients with resistant hypertension and heart failure.

Key Considerations

• A reasonable starting dose for torsemide is 20-50 mg orally once daily, with the option to increase as needed and tolerated, up to a maximum dose of 200 mg daily 1.
• Alternatively, furosemide can be initiated at a dose of 40-80 mg orally once or twice daily, with similar titration options 1.
• Close monitoring of the patient's volume status, electrolytes, and renal function is essential to guide diuretic therapy and minimize potential adverse effects 1.
• Diuretic resistance can be overcome by escalating the loop diuretic dose, using intravenous administration, or combining different diuretic classes 1.

Additional Guidance

• The treatment of hypertension in patients with heart failure should include behavioral modification, such as sodium restriction, and a closely monitored exercise program 1.
• Thiazide diuretics may be considered in hypertensive patients with heart failure and mild fluid retention because they confer more persistent antihypertensive effects 1.
• The use of inappropriately low doses of diuretics will result in fluid retention, while inappropriately high doses will lead to volume contraction, increasing the risk of hypotension and renal insufficiency 1.

From the FDA Drug Label

The antihypertensive effects of torsemide are, like those of other diuretics, on the average greater in black patients (a low-renin population) than in nonblack patients. The most effective diuretic for an African American patient with heart failure with reduced ejection fraction is torsemide, as it has been shown to have greater antihypertensive effects in black patients compared to nonblack patients 2.

• Key points:
  • Torsemide has been studied in controlled trials in patients with New York Heart Association Class II to Class IV heart failure
  • Patients who received 10 mg to 20 mg of daily torsemide achieved significantly greater reductions in weight and edema than did patients who received placebo
  • The antihypertensive effects of torsemide are greater in black patients than in nonblack patients 2

From the Research

Diuretic Options for African American Patients with Heart Failure

• The most effective diuretic for an African American patient with heart failure with reduced ejection fraction (HFrEF) is not explicitly stated in the provided studies.
• However, the use of hydralazine-isosorbide dinitrate (H-ISDN) therapy is recommended for African American patients with moderate to severe HFrEF 3.
• A study found that only 22.4% of eligible African American patients received H-ISDN therapy at discharge, suggesting underutilization of this treatment option 3.
• Another study highlighted the importance of identifying and addressing racial disparities in care to ensure health equity for African American patients with HFrEF 4.

Racial Disparities in Heart Failure Management

• African American patients have a higher incidence of heart failure and are more likely to suffer serious consequences from the disease 4, 5.
• Black patients are more likely to be admitted for heart failure than white patients, with a 2.9 times higher likelihood of admission 4.
• The use of guideline-directed medication therapy (GDMT) is similar between white and black patients, but there is still a need to optimize GDMT to reach recommended doses 4.

Treatment Considerations

• The treatment of heart failure with preserved ejection fraction (HFpEF) is primarily symptomatic, with no survival benefit seen in randomized controlled trials 5.
• Mechanisms postulated for the worse prognosis in African Americans with HFpEF include greater incidence of hypertension and diastolic dysfunction, undefined race-driven genetic predispositions, or relative resistance to medications that treat heart failure in general 5.
• Further studies are required to determine the best management strategies for African American patients with heart failure, including those with improved ejection fraction 6.