What are the key teaching points for rounds on a patient with Heart Failure with preserved Ejection Fraction (Hfpef) regarding the use of diuretics?

From the Guidelines

For patients with Heart Failure with preserved Ejection Fraction (HFpEF), diuretic therapy should be used primarily to manage volume overload and relieve congestive symptoms, with loop diuretics like furosemide being the first-line agents for symptom relief, as recommended by the most recent guidelines 1. When managing HFpEF, it is crucial to prioritize the use of diuretics for symptom relief, focusing on improving quality of life, as there is no evidence that diuretics improve mortality in HFpEF patients 1. Key points for rounds on a patient with HFpEF regarding the use of diuretics include:

• Loop diuretics, such as furosemide (20-40mg daily or twice daily), torsemide (10-20mg daily), or bumetanide (0.5-1mg daily), are the preferred initial treatment for volume overload and congestive symptoms 1.
• Dosing should be individualized based on symptoms, aiming for the lowest effective dose to maintain euvolemia while avoiding excessive diuresis that could lead to hypotension or renal dysfunction.
• In cases of resistant volume overload, adding a thiazide diuretic like metolazone (2.5-5mg) or chlorthalidone (12.5-25mg) can enhance diuresis through sequential nephron blockade.
• Regular monitoring of electrolytes, particularly potassium and sodium, along with renal function, is essential, with assessments recommended within 1-2 weeks of initiation or dose changes.
• Volume status should be assessed clinically through symptoms, physical examination findings (edema, jugular venous distention), and daily weight measurements. It is also important to note that while diuretics are crucial for symptom management in HFpEF, they have not been shown to improve mortality, and their use should be balanced with the potential risks of stimulating the sympathetic nervous system and renin-angiotensin-aldosterone system (RAAS) 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Edema Therapy should be individualized according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response. The key teaching points for rounds on a patient with Heart Failure with preserved Ejection Fraction (HFpEF) regarding the use of diuretics are:

• Individualized dosing: The dose of diuretics, such as furosemide, should be individualized according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response 2.
• Monitoring: Careful clinical observation and laboratory monitoring are particularly advisable when doses exceeding 80 mg/day are given for prolonged periods 2.
• Dose titration: The dose may be raised by 20 or 40 mg and given not sooner than 6 to 8 hours after the previous dose until the desired diuretic effect has been obtained 2. Note that the provided drug labels do not directly address the use of diuretics in patients with HFpEF, but rather provide general guidance on the use of diuretics in patients with edema and hypertension.

From the Research

Key Teaching Points for Rounds on a Patient with Heart Failure with Preserved Ejection Fraction (HFpEF) Regarding the Use of Diuretics

• The primary goal of diuretic therapy in HFpEF is to relieve congestion and improve symptoms, as noted in studies 3, 4, 5.
• Loop diuretics, such as furosemide, are considered the first-line diuretic therapy for HFpEF, with the initial dose being 2-2.5 times the patient's home dose 6, 7.
• The diuretic response should be monitored closely, with a satisfactory response defined as:
  • Spot urine sodium content greater than 50-70 mmol/L at 2 hours
  • Urine output greater than 100-150 mL/h in the first 6 hours or 3-5 L in 24 hours
  • Change in weight of 0.5-1.5 kg in 24 hours 7
• If congestion persists after maximizing loop diuretic therapy, an adjunctive diuretic such as thiazide or acetazolamide may be added 4, 7.
• Continuous infusion of furosemide may be considered if decongestion targets are not met 7.
• The use of aldosterone antagonists, such as spironolactone, may be beneficial in relieving congestive symptoms in combination with furosemide, although the evidence is limited 3, 5.
• Metolazone, a thiazide-like diuretic, can be used in combination with loop diuretics to enhance diuresis, particularly in patients with refractory heart failure 4, 5.
• Close monitoring of serum electrolytes and kidney function is essential during diuretic therapy to minimize the risk of adverse effects 3, 6.