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Diuretic therapy in heart failure: current controversies and new approaches for fluid removal

Brandimarte, Filippo; Mureddu, Gian Francesco; Boccanelli, Alessandro; Cacciatore, Giuseppe; Brandimarte, Camillo; Fedele, Francesco; Gheorghiade, Mihai

Journal of Cardiovascular Medicine: August 2010 - Volume 11 - Issue 8 - p 563–570
doi: 10.2459/JCM.0b013e3283376bfa
Review articles

Hospitalization for heart failure is a major health problem with high in-hospital and postdischarge mortality and morbidity. Non-potassium-sparing diuretics (NPSDs) still remain the cornerstone of therapy for fluid management in heart failure despite the lack of large randomized trials evaluating their safety and optimal dosing regimens in both the acute and chronic setting. Recent retrospective data suggest increased mortality and re-hospitalization rates in a wide spectrum of heart failure patients receiving NPSDs, particularly at high doses. Electrolyte abnormalities, hypotension, activation of neurohormones, and worsening renal function may all be responsible for the observed poor outcomes. Although NPSD will continue to be important agents to promptly resolve signs and symptoms of heart failure, alternative therapies such as vasopressine antagonists and adenosine blocking agents or techniques like veno-venous ultrafiltration have been developed in an effort to reduce NPSD exposure and minimize their side effects. Until other new agents become available, it is probably prudent to combine NPSD with aldosterone blocking agents that are known to improve outcomes.

aDepartment of Cardiovascular, Respiratory and Morphological Sciences, Sapienza University and Department of Cardiovascular Diseases, Italy

bEcho Lab and Cardiovascular Prevention Unit, Department of Cardiovascular Diseases, Italy

cDepartment Cardiovascular Diseases, Italy

dHeart Failure Unit, Department of Cardiovascular Diseases, Italy

eDepartment of Internal Medicine, Sapienza University and Division of Internal Medicine, San Giovanni - Addolorata Community Hospital, Italy

fDepartment of Cardiovascular, Respiratory and Morphological Sciences, Sapienza University, Rome, Italy

gDivision of Cardiology, NorthWestern University, Feinberg School of Medicine, Chicago, Illinois, USA

Received 2 October, 2009

Revised 22 December, 2009

Accepted 11 January, 2010

Correspondence to Filippo Brandimarte, MD, Department Cardiovascular Diseases, San Giovanni –Addolorata Hospital, Rome, Italy Tel: +39 067 705 5975; e-mail:

© 2010 Italian Federation of Cardiology. All rights reserved.