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Are diuretics overused in the treatment of chronic heart failure?

Nature Clinical Practice Cardiovascular Medicine volume 5, pages 238–239 (2008)Cite this article

Diuretics constitute one of the drug classes most commonly used for the treatment of chronic heart failure (CHF). These agents rapidly relieve symptoms, and diminish pulmonary and peripheral edema, while fluid retention seems to be adequately controlled by long-term therapy. The use of non-potassium-sparing diuretics (denoted 'diuretics' hereafter) is a class I recommendation in the ACC/AHA guidelines for acutely decompensated CHF or severe cases of persistent fluid retention.1 This recommendation is, however, based on level C evidence; no randomized trial has proven a positive long-term effect of diuretics on clinically relevant end points in patients with stable CHF who are receiving optimum medical therapy. We would, therefore, like to question the inferred long-term benefit of chronic diuretic therapy, because we believe there are no data on which to base these assumptions. We hypothesize that, in clinically stable patients with CHF, diuretics should not be used as the cornerstone of long-term medical treatment. We also emphasize the urgent need for a randomized trial to establish the long-term effectiveness of diuretics for CHF.

Intermediate-term studies have reported improvements in cardiac function and symptoms, exercise tolerance, and patients' overall wellbeing with the use of diuretics.2 A Cochrane systematic review of data from 14 trials concluded that diuretics reduce the risk of death and worsening CHF.2 In this analysis, the mortality in three small placebo-controlled trials, with a total of 221 participants, was found to be lower in patients receiving diuretics than among those in the placebo group (2.7% vs. 10.9%; P = 0.02). These trials, however, had small sample sizes and recorded only 15 deaths. They enrolled individuals with clinically diagnosed CHF from 1977 to 1986 and did not include standardized assessments of left ventricular ejection fraction. Furthermore, the trials were performed at a time when angiotensin-converting enzyme (ACE) inhibitors, β-blockers, and spironolactone were not available for routine use. In all the studies, follow-up was short (4–24 weeks), the average age of the participants was 59 years, the diagnosis of CHF was not clearly defined, and the conclusions were limited by poor statistical power.2 The results of these trials are, therefore, unlikely to be relevant to patients with CHF today.

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Authors and Affiliations

  1. SD Anker is Head of the Division of Applied Cachexia Research, all at the Department of Cardiology at the Charité Medical School, A Vaz Pérez is a doctoral student, R Dietz is the Medical Director, and M Rauchhaus is the Scientific Director of the Competence Network Heart Failure, Berlin, Germany.,

    Amalia Vaz Pérez, Stefan D Anker, Rainer Dietz & Mathias Rauchhaus

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  1. Amalia Vaz Pérez
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  2. Stefan D Anker
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  3. Rainer Dietz
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  4. Mathias Rauchhaus
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Correspondence to Mathias Rauchhaus.

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Vaz Pérez, A., Anker, S., Dietz, R. et al. Are diuretics overused in the treatment of chronic heart failure?. Nat Rev Cardiol 5, 238–239 (2008). https://doi.org/10.1038/ncpcardio1152

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