What is the treatment for a patient with heart failure and fluid retention?

From the Guidelines

The treatment for heart failure with fluid retention typically involves diuretics as first-line therapy, particularly loop diuretics like furosemide (20-80mg daily), bumetanide (0.5-2mg daily), or torsemide (10-20mg daily) 1. These medications increase urine output to reduce fluid overload by inhibiting sodium reabsorption in the kidneys. Additional medications include ACE inhibitors (such as lisinopril 2.5-40mg daily) or ARBs (such as losartan 25-100mg daily) to reduce afterload and improve cardiac remodeling, and beta-blockers (such as carvedilol 3.125-25mg twice daily or metoprolol succinate 12.5-200mg daily) to reduce heart rate and workload. For moderate to severe heart failure, aldosterone antagonists like spironolactone (12.5-25mg daily) may be added 1. Some key points to consider when using diuretics in patients with heart failure include:

• Diuretics produce symptomatic benefits more rapidly than any other drug for heart failure, relieving pulmonary and peripheral edema within hours or days 1.
• Diuretics are the only drugs used for the treatment of heart failure that can adequately control the fluid retention of heart failure 1.
• Diuretics should not be used alone in the treatment of Stage C heart failure, and should be combined with an ACE inhibitor and a beta-blocker to reduce the risk of clinical decompensation 1.
• Appropriate use of diuretics is a key element in the success of other drugs used for the treatment of heart failure, and the use of inappropriately low doses of diuretics will result in fluid retention, while the use of inappropriately high doses of diuretics will lead to volume contraction and increase the risk of hypotension and renal insufficiency 1. Sodium restriction (2000mg daily) and fluid restriction (1.5-2L daily) are important lifestyle modifications. Daily weight monitoring helps track fluid status, with patients advised to contact their healthcare provider if they gain more than 2-3 pounds in a day or 5 pounds in a week. Physical activity should be maintained as tolerated, and in advanced cases, oxygen therapy or mechanical circulatory support may be necessary. This multi-faceted approach addresses both the cardiac dysfunction and the resulting fluid retention.

From the FDA Drug Label

Patients had to have been clinically stable for at least 4 weeks on an optimized and stable clinical regimen, which included maximally tolerated doses of beta-blockers and, in most cases, ACE inhibitors or ARBs, spironolactone, and diuretics, with fluid retention and symptoms of congestion minimized.

The treatment for a patient with heart failure and fluid retention includes an optimized and stable clinical regimen with:

• Beta-blockers
• ACE inhibitors or ARBs
• Spironolactone
• Diuretics This regimen should be maximally tolerated and aim to minimize fluid retention and symptoms of congestion. Additionally, ivabradine may be considered to reduce the risk of hospitalization for worsening heart failure, as demonstrated in the SHIFT trial 2.

From the Research

Treatment for Heart Failure and Fluid Retention

The treatment for a patient with heart failure and fluid retention typically involves the use of diuretics to relieve congestion symptoms.

• Loop diuretics are the preferred diuretic and have been given a class I recommendation by clinical guidelines for the relief of congestion symptoms 3.
• The first therapeutic strategy in HF patients with fluid overload is optimization of diuretic intervention to maximize water and sodium excretion 4.
• Diuretic resistance is a major challenge to decongestion therapy for patients with heart failure and is associated with a poor clinical prognosis 3.

Diuretic Therapy

Diuretic therapy is the backbone of the contemporary management of heart failure.

• Loop diuretics possess a unique pharmacology and pharmacokinetics that lay the ground for different strategies to increase diuretic efficiency 3.
• A stepped and protocolized diuretics dosing has been suggested to have superior benefits over an individual clinician-based strategy 3.
• Recommended diuretic usage includes:
  • Asymptomatic left ventricular dysfunction: establish moderate sodium intake
  • Mild sodium retention: thiazide-type diuretic or low-dose loop diuretic
  • Moderate sodium retention: loop diuretic, adjusting for renal function if necessary
  • Severe sodium retention: large-dose loop diuretic combined with a thiazide-type diuretic 5.

Additional Therapies

Additional therapies may be considered for patients with heart failure and fluid retention.

• Salt and fluid restriction can be effective in patients with chronic heart failure 6.
• Renal replacement therapy represents an alternative option for fluid removal and a way to restore diuretic responsiveness when diuretic therapy fails to relieve congestion 4.
• Loop diuretic prescription has been associated with improved 30-day clinical outcomes in older patients with heart failure 7.