Diuretic Therapy for Patients with EF 20-25%
Diuretics are strongly recommended for patients with heart failure and an ejection fraction of 20-25% who show signs and/or symptoms of congestion to alleviate symptoms, improve exercise capacity, and reduce heart failure hospitalizations. 1
Rationale for Diuretic Therapy in Low EF
- Diuretics are a cornerstone therapy for symptomatic treatment of heart failure with reduced ejection fraction (HFrEF), particularly when there is evidence of fluid overload 2
- Patients with severely reduced EF (20-25%) commonly experience fluid retention and congestion that requires diuretic therapy to maintain euvolemia 1
- Diuretic therapy should be used to achieve and maintain the patient's "dry weight" (free of symptoms and signs of congestion) 1
Diuretic Dosing Approach
- Start with a low dose of loop diuretic (e.g., furosemide 20-40 mg daily) and titrate based on clinical response 3
- Adjust dose according to symptoms, signs of congestion, blood pressure, and renal function 1
- The dose may need to be increased up to 600 mg/day in patients with clinically severe edematous states 3
- For maintenance therapy, the minimum effective dose should be used to maintain euvolemia 1, 3
Monitoring During Diuretic Therapy
- Check renal function and electrolytes before initiation and 1-2 weeks after starting or increasing dose 1
- Monitor for:
- Hypotension (especially orthostatic)
- Worsening renal function
- Electrolyte abnormalities, particularly hypokalemia and hypomagnesemia 1
- Assess congestion status regularly to determine if diuretic adjustment is needed 1
Diuretic Resistance Management
- For patients who develop diuretic resistance:
- Consider sequential nephron blockade by adding a thiazide diuretic 1
- Addition of a mineralocorticoid receptor antagonist (MRA) can help with diuresis while providing cardiovascular benefits 1
- Consider switching from furosemide to more potent loop diuretics like bumetanide or torsemide 4
- In severe cases, consider intravenous diuretic therapy in an outpatient setting 5
Integration with Other HFrEF Therapies
- Diuretics should always be used in combination with guideline-directed medical therapy (GDMT) for HFrEF, including:
- Initiation of beta-blockers should occur after optimization of volume status and successful discontinuation of intravenous diuretics 1
- Transition from intravenous to oral diuretic therapy should be done with careful attention to oral diuretic dosing and electrolyte monitoring 1
Common Pitfalls to Avoid
- Inadequate diuretic dosing leading to persistent congestion and increased hospitalization risk 4
- Excessive diuretic dosing causing dehydration, hypotension, and worsening renal function 1
- Failure to adjust diuretics when initiating other HF medications that may affect volume status 1
- Not considering diuretic reduction in patients with low blood pressure but no signs of congestion 1
- Using NSAIDs, which can attenuate diuretic effect and worsen renal function 1
Special Considerations
- In patients with low blood pressure, consider reducing diuretic dose if there are no signs of congestion 1
- For patients with worsening renal function, careful evaluation is needed to distinguish between overdiuresis and cardiorenal syndrome 1
- Outpatient escalation of diuretic therapy is associated with increased healthcare resource utilization but not with increased mortality 4
Diuretic therapy remains an essential component of heart failure management in patients with severely reduced ejection fraction, with the primary goal of relieving congestion and improving symptoms while maintaining optimal GDMT for mortality benefit.