How to manage fluid overload in heart failure?

From the Guidelines

Diuresis in heart failure patients should begin with loop diuretics, specifically furosemide at 20-40mg IV or oral doses, which can be increased as needed based on response, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.

Key Considerations

• For patients with fluid overload, initial IV bolus administration is preferred, potentially followed by continuous infusion at 5-10mg/hour if bolus therapy is insufficient.
• Add thiazide diuretics like chlorthalidone 12.5-25mg daily or metolazone 2.5-5mg daily for diuretic resistance, as suggested by the 2013 ACCF/AHA guideline for the management of heart failure 1.
• Potassium-sparing diuretics such as spironolactone 25-50mg daily can be added for additional benefit and to prevent hypokalemia.

Monitoring and Adjustments

• During diuresis, monitor daily weights, fluid intake/output, electrolytes (especially potassium and sodium), and renal function.
• Target a weight loss of 0.5-1kg daily, adjusting diuretic doses accordingly.
• Fluid restriction to 1.5-2L daily and sodium restriction to 2-3g daily will enhance diuretic effectiveness, as noted in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1.

Mechanism of Action

• Loop diuretics work by inhibiting sodium reabsorption in the loop of Henle, increasing sodium and water excretion.
• Thiazides block sodium reabsorption in the distal tubule, creating a synergistic effect when combined with loop diuretics in resistant cases.

Additional Considerations

• 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 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
• 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.

From the FDA Drug Label

1. 1 Treatment of Edema Edema associated with heart failure The recommended initial dose is 10 mg or 20 mg oral torsemide tablets once daily. If the diuretic response is inadequate, titrate upward by approximately doubling until the desired diuretic response is obtained.

To diurese a patient with heart failure, the recommended initial dose of torsemide is 10 mg or 20 mg oral tablets once daily. If the diuretic response is inadequate, the dose should be titrated upward by approximately doubling until the desired diuretic response is obtained 2.

• The initial dose can be either 10 mg or 20 mg.
• Doses higher than 200 mg have not been adequately studied.

From the Research

Diuretic Treatment for Heart Failure

To diurese a patient with heart failure, the following options can be considered:

• Loop diuretics are the preferred diuretic and have been given a class I recommendation by clinical guidelines for the relief of congestion symptoms 3
• A stepped and protocolized diuretics dosing has been suggested to have superior benefits over an individual clinician-based strategy 3
• Combination therapy with metolazone and loop diuretics can be effective in outpatients with refractory heart failure, with a low starting dose of metolazone (< or =5 mg) 4

Choice of Loop Diuretic

The choice of loop diuretic may not affect mortality in patients with heart failure:

• A multicenter propensity score matched analysis found no significant association between loop diuretic choice and all-cause mortality 5
• A meta-analysis found no significant difference in intermediate-term mortality among heart failure patients on furosemide compared with torsemide 6
• However, torsemide may be associated with a reduction in intermediate-term heart failure readmissions and improvement in New York Heart Association class compared with furosemide 6

Comparison of Diuretic Regimens

Comparing the efficacy and safety of different diuretic regimens:

• A retrospective study found that combination furosemide plus metolazone and continuous infusion bumetanide were associated with greater increases in urine output compared to continuous infusion furosemide 7
• However, the incidence of worsening renal function was not different between regimens, and electrolyte abnormalities may be more prevalent when furosemide is combined with metolazone or when bumetanide is used 7