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The Effects of a Sliding Scale Diuretic Titration Protocol in Patients With Heart Failure

Prasun, Marilyn A. PhD, RN, CNS; Kocheril, Abraham G. MD, FACC, FACP; Klass, Patricia H. PhD; Dunlap, Stephanie H. DO; Piano, Mariann R. PhD, RN

The Journal of Cardiovascular Nursing: January-February 2005 - Volume 20 - Issue 1 - p 62–70

Patients with heart failure (HF) are often instructed to temporarily adjust their diuretic dose. This approach has become routine in some HF management programs; however, no study has specifically examined the effects of a patient-directed flexible diuretic protocol. For the purposes of this study, patients were randomized into a usual care (UC) group (n = 31) or a flexible diuretic titration (DT) group (n = 35). The DT group completed a 6-item diuretic titration protocol once a day, for 3 months. The 6-minute walk distance, plasma B-type natriuretic peptide (NT-BNP), plasma norepinephrine (NE), and quality of life (QOL) were measured at baseline and at 3 months. Hospitalizations, emergency department (ED) visits, and mortality rates were measured at 3 months. Compared to baseline, at 3 months, there was a significant increase in the DT group's 6-minute walk distance (646 ± 60 ft vs 761 ± 61 ft, P = .01) and total QOL score (53 ± 5 vs 38 ± 5, P = .001), whereas these parameters remained unchanged within the UC group. There were significantly less ED visits in the DT group compared with those in the UC group (3% vs 23%, P = .015). No differences were found between the groups in HF-related hospitalizations or mortality. Within both groups, no differences were found between baseline and 3-month NE or NT-BNP plasma values. Patients with heart failure who used a sliding scale diuretic titration protocol had significant improvements in their exercise tolerance and QOL, had fewer ED visits, and had no change in plasma NE or NT-BNP levels.

Coordinator, Heart Failure Clinic, Carle Clinic, Urbana, Ill.; Clinical Instructor, University of Illinois. (Prasun)

Head of Cardiac Electrophysiology, Carle Heart Center.; Associate Professor of Medicine, University of Illinois, Urbana, Ill. (Kocheril)

Professor of Education & Administration, Illinois State University, Normal, Ill. (Klass)

Assistant Professor of Medicine, Rush University, Chicago, Ill. (Dunlap)

Associate Professor of Medical-Surgical Nursing, University of Illinois at Chicago. (Piano)

Corresponding author Marilyn A. Prasun, PhD, RN, CNS, Carle Clinic, Department of Cardiology, 602 W University Ave, Urbana, IL 61801 (e-mail:

This study was supported by a grant-in-aid from Carle Foundation, Urbana, Ill. We express our thanks to Dr Philip Solter and his staff at the College of Veterinary Medicine, University of Illinois-Champaign, for their assistance in laboratory analysis and Drs Kathleen Grady, Dorie Schwertz, Carol Ferrans, and Julie Zerwic for study design assistance.

© 2005 Lippincott Williams & Wilkins, Inc.