ABSTRACT
Diuretics remain pivotal in the treatment of acute and chronic heart failure. Until recently, data from randomized controlled trials assessing the specific effects of diuretics on survival in this condition were totally lacking. However, the landmark studies demonstrating the survival benefit of angiotensin-converting enzyme (ACE) inhibitor treatment in symptomatic heart failure have all been trials of experimental therapy added to background treatment with diuretics. The ability of diuretics to prevent progression to heart failure secondary to hypertension (the single most common cause) is well established. Recently, data from a randomized controlled trial of the aldosterone antagonist spironolactone, added to background treatment with an ACE inhibitor and loop diuretic in severe heart failure, have provided the first evidence of survival benefit. Several withdrawal studies have indicated that these drugs are necessary to avoid decompensation into frank heart failure in most patients established on diuretic therapy for this indication, whether or not ACE inhibitor treatment is concurrently
prescribed. This background clinical evidence, coupled to improved knowledge of the pharmacokinetics and dynamics of diuretics in heart failure, allows their rational prescription in heart failure and guides the approach to diuretic resistance in this condition.
