From the Guidelines
Loop diuretics are the preferred diuretic agents for use in most patients with heart failure, including those with diastolic dysfunction, and should be prescribed to eliminate clinical evidence of fluid retention, using the lowest dose possible to maintain euvolemia. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, loop diuretics such as bumetanide, furosemide, and torsemide are recommended for use in patients with heart failure. These medications work by inhibiting reabsorption of sodium or chloride at the loop of Henle, promoting diuresis and reducing preload, which can alleviate symptoms of pulmonary congestion and peripheral edema.
In the context of diastolic dysfunction, the heart's ability to relax and fill properly is impaired, leading to increased filling pressures. Loop diuretics help reduce these pressures by decreasing intravascular volume. The treatment goal of diuretic use is to eliminate clinical evidence of fluid retention, using the lowest dose possible to maintain euvolemia, as stated in the guideline 1.
Some key points to consider when using loop diuretics in patients with diastolic dysfunction include:
- Regular monitoring of electrolytes, renal function, and blood pressure is essential to avoid complications such as hypotension, electrolyte abnormalities, and worsening renal function.
- Loop diuretics should be used as part of a comprehensive treatment approach that may include blood pressure control, heart rate management, and addressing underlying causes of diastolic dysfunction such as hypertension or coronary artery disease.
- The effects of diuretics on morbidity and mortality are uncertain, and as such, diuretics should not be used in isolation but always combined with other guideline-directed medical therapy (GDMT) for heart failure that reduces hospitalizations and prolongs survival, as recommended by the guideline 1.
From the Research
Diastolic Dysfunction and Loop Diuretics
- Diastolic dysfunction is a condition where the heart's ability to relax and fill with blood is impaired, and it is a predictor for the development of heart failure (HF) and confers a higher risk of mortality 2.
- Loop diuretics, such as furosemide and torsemide, are commonly used to treat heart failure, including diastolic dysfunction, by reducing volume overload 3.
- However, the choice of loop diuretic can affect outcomes, with torsemide potentially having advantages over furosemide in terms of reduced inter- and intra-individual variation in bioavailability and a longer duration of action 4, 5.
Comparison of Torsemide and Furosemide
- Studies have compared the effects of torsemide and furosemide in patients with heart failure, including those with diastolic dysfunction, and found that torsemide may be associated with reduced heart failure readmissions and improved symptoms 5, 6.
- However, the evidence is not consistent, and some studies have found no significant difference in outcomes between torsemide and furosemide 4, 6.
- A meta-analysis of 14 studies found that torsemide was associated with a reduction in intermediate-term heart failure readmissions and improvement in New York Heart Association class compared with furosemide, but not with a reduced mortality risk 6.
Treatment Considerations
- When treating diastolic dysfunction with loop diuretics, it is essential to carefully consider the choice of diuretic and the potential benefits and risks of each option 3.
- Echocardiography is a crucial tool for diagnosing diastolic heart dysfunction and guiding therapy 3.
- Caution is advised when using diuretics in patients with diastolic dysfunction, as aggressive diuresis can decrease stroke volume more in diastolic dysfunction than in systolic dysfunction 3.