Although this combination is clearly efficacious, it involves dosing three to four times daily and is associated with significant side effects. More studies will be necessary before the angiotensin II receptor blocking agents find a well-defined place in the treatment of heart failure.
Daily diuretics may not be necessary in patients who are on a strict low-sodium diet and have no signs or symptoms of congestion. Furosemide Lasix , a commonly used loop diuretic, is dose-dependent a dose threshold must be reached before a response is seen. If physical examination, weight or symptoms suggest that adequate diuresis has not been achieved, the dosage should be doubled and given as a single dose.
The dosage of loop diuretics may have to be increased if chronic renal insufficiency is present. Furosemide may have variable absorption requiring larger doses or use of other loop diuretics such as bumetanide Bumex or torsemide Demadex.
Twice-daily dosing may be necessary in severe cases because the half-life of loop diuretics is very short. Patients may become refractory to loop diuretics. Metolazone Zaroxolyn may be added if this occurs. Metolazone is a thiazide-like diuretic that affects different sites in the renal tubule, which results in a synergistic diuretic effect. A reasonable strategy in patients who are refractory to loop diuretics is to give 5 mg of metolazone one hour before the morning dose of the loop diuretic.
The Randomized Aldactone Evaluation Study RALES 13 reported lower mortality and a 35 percent lower hospitalization rate in patients given 25 mg spironolactone compared with those who received placebo when the drug was added to the standard treatment for heart failure.
This study suggests that the benefit from spironolactone is derived from an aldosterone-blocking effect and not a diuretic effect. Spironolactone may help correct hypokalemia caused by large doses of diuretics.
Serious hyperkalemia was rare in this trial even though most of the patients were also taking an ACE inhibitor. Patients with serum creatinine levels greater than 2. Spironolactone appears to be a simple and useful therapy, although further studies will be necessary to determine its exact role in heart failure.
Recent studies of bisoprolol, 14 metoprolol Tropol-XL 15 and carvedilol 16 demonstrate lower mortality rates decreased sudden death and hospitalization rates in patients with NYHA class II or class III heart failure who are treated with these agents.
The benefit of beta blockers in class I and class IV patients has not yet been demonstrated. Carvedilol has alpha- and beta-blocking activity and has been labeled by the U. Food and Drug Administration for use in patients with heart failure. Beta blockers should be started at a low dose when the patient is stable. The dosage should be increased slowly with careful attention to hypotension or worsening heart failure. Patience is important, because the benefit of treatment may not be apparent for months.
In addition, reevaluation by a cardiologist should be considered in class IV patients before initiating beta-blocker therapy. Digoxin can improve symptoms of heart failure and reduce hospital admissions but survival benefits have not been proved. Nonsteroidal anti-inflammatory drugs NSAIDs block the effects of diuretics and ACE inhibitors, causing some patients to become refractory to treatment. One study 18 cited a twofold increase in hospitalizations for heart failure in elderly patients taking diuretics and NSAIDS.
Calcium channel blockers, with the exception of amlodipine Norvasc , should be avoided in patients with heart failure.
The results of the Prospective Randomized Amlodipine Survival Evaluation Study Group I and II trials demonstrate a neutral effect on survival in patients with heart failure treated with amlodipine. A single home health visit may significantly decrease hospital readmission for treatment of heart failure. Up to 50 percent of patients are found to be noncompliant in following discharge instructions from a previous hospitalization.
Although patients with heart failure have traditionally been advised not to exercise, recent studies have shown that appropriate exercise programs are safe for patients with mild to moderate heart failure. Patients who exercise may have reduced numbers of hospitalizations and cardiac events and an improved quality of life. Several studies have shown differences between cardiologists and noncardiologists in the understanding of the pathophysiology and treatment of heart failure.
Table 4 summarizes the most important points to remember when managing patients with heart failure. Maintain patient on 2- to 3-g sodium diet. Follow daily weight. Monitor standing blood pressures in the office, as these patients are prone to orthostasis. In order to prevent worsening azotemia, some patients will need to have some edema. Achieving target weight should mean no orthopnea or paroxysmal nocturnal dyspnea. Consider home health teaching.
Avoid all nonsteroidal anti-inflammatory drugs because they block the effect of ACE inhibitors and diuretics. The only proven safe calcium channel blocker in heart failure is amlodipine Lotrel. Use ACE inhibitors in all heart failure patients unless they have an absolute contraindication or intolerance.
Use doses proven to improve survival and back off if they are orthostatic. In those patients who cannot take an ACE inhibitor, use an angiotensin receptor blocker like irbesartan Avapro. For patients who respond poorly to large dosages of loop diuretics, consider adding 5 to 10 mg of metolazone Zaroxolyn one hour before the dose of furosemide once or twice a week as tolerated. Use metoprolol Lopressor , carvedilol Coreg or bisoprolol Zebeta beta blockers in all class II and III heart failure patients unless there is a contraindication.
Start with low doses and work up. Do not start if the patient is decompensated. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Hoyt received his medical degree from Virginia Commonwealth University Medical College of Virginia School of Medicine, Richmond, where he also served a residency in internal medicine.
Bowling received his medical degree from the University of Mississippi School of Medicine, Jackson, and completed a residency in internal medicine and a fellowship in cardiology at Naval Medical Center, San Diego, Calif. Address correspondence to Capt. Robert E. Reprints are not available from the authors. The authors thank Jo Ann Clay for her assistance in the preparation of the manuscript. Heart and Stroke Statistical Update.
Dallas: American Heart Association, Prevalence and mortality rate of congestive heart failure in the United States. J Am Coll Cardiol. Department of Health and Human Services. Heart failure: evaluation and care of patients with left-ventricular systolic dysfunction. Rockville, Md. Drug information provided by: IBM Micromedex. Furosemide belongs to a group of medicines called loop diuretics also known as water pills.
Furosemide is given to help treat fluid retention edema and swelling that is caused by congestive heart failure, liver disease, kidney disease, or other medical conditions. It works by acting on the kidneys to increase the flow of urine. Furosemide is also used alone or together with other medicines to treat high blood pressure hypertension. High blood pressure adds to the workload of the heart and arteries. If it continues for a long time, the heart and arteries may not function properly.
This can damage the blood vessels of the brain, heart, and kidneys, resulting in a stroke, heart failure, or kidney failure. High blood pressure may also increase the risk of heart attacks. These problems may be less likely to occur if blood pressure is controlled. In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make.
For this medicine, the following should be considered:. Tell your doctor if you have ever had any unusual or allergic reaction to this medicine or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully. Appropriate studies performed to date have not demonstrated pediatric-specific problems that would limit the usefulness of furosemide in children.
However, premature babies are more likely to have unwanted effects on the kidney, which may require caution in patients receiving furosemide. Appropriate studies performed to date have not demonstrated geriatric-specific problems that would limit the usefulness of furosemide in the elderly.
However, elderly patients are more likely to have age-related liver, kidney, or heart problems, which may require caution and an adjustment in the dose for patients receiving furosemide. There are no adequate studies in women for determining infant risk when using this medication during breastfeeding.
Weigh the potential benefits against the potential risks before taking this medication while breastfeeding. Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary.
When you are taking this medicine, it is especially important that your healthcare professional know if you are taking any of the medicines listed below.
The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive. Using this medicine with any of the following medicines is not recommended. Your doctor may decide not to treat you with this medication or change some of the other medicines you take. Using this medicine with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.
Using this medicine with any of the following medicines may cause an increased risk of certain side effects, but using both drugs may be the best treatment for you. Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. The presence of other medical problems may affect the use of this medicine.
While loop diuretics are regarded as first-line therapy, the addition of thiazide diuretics may be required in patients with advanced HF. Patients with systolic LV dysfunction with NYHA class III and IV will also benefit from addition of aldosterone antagonists; however, a close monitoring of renal function and serum potassium level is required. Novel agents such as vasopressin antagonists and adenosine antagonists are currently being evaluated, with promising results.
When treating HF with diuretics, care must be taken to not unload too much volume, which may result in cardiac output depression. Heart Disease and Stroke Statistics: Update. Accessed May 8, Heart failure. Who is at risk for heart failure? Hormones and hemodynamics in heart failure. N Engl J Med. Vogl A. The discovery of the organic mercurial diuretics. Am Heart J. Lifetime risk for developing congestive heart failure: the Framingham Heart Study.
Gheorghiade M, Bonow RO. Chronic heart failure in the United States: a manifestation of coronary artery disease. Acute heart failure complicating acute coronary syndromes: a deadly intersection. Evaluation and monitoring of patients with acute heart failure syndromes. Am J Cardiol. Brater DC. Diuretic therapy. Bumetanide and furosemide in heart failure.
Kidney Int. Open-label randomized trial of torsemide compared with furosemide therapy for patients with heart failure. Am J Med. Continuous infusion versus bolus injection of loop diuretics in congestive heart failure. Cochrane Database Syst Rev. Diuretics in congestive heart failure. In: Feldman HM, ed. Heart Failure: Pharmacologic Management. Malden, MA: Blackwell Futura; Ellison DH.
The physiologic basis of diuretics synergism: its role in treating diuretic resistance. Ann Intern Med. Combined therapy with thiazide-type and loop diuretics agents for resistant sodium retention.
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