Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
J Am Coll Cardiol. 2010 Nov 2;56(19):1527-34. doi: 10.1016/j.jacc.2010.06.034.
Volume overload is an important clinical target in heart failure management, typically addressed using loop diuretics. An important and challenging subset of heart failure patients exhibit fluid overload despite significant doses of loop diuretics. One approach to overcome loop diuretic resistance is the addition of a thiazide-type diuretic to produce diuretic synergy via "sequential nephron blockade," first described more than 40 years ago. Although potentially able to induce diuresis in patients otherwise resistant to high doses of loop diuretics, this strategy has not been subjected to large-scale clinical trials to establish safety and clinical efficacy. We summarize the existing literature evaluating the combination of loop and thiazide diuretics in patients with heart failure in order to describe the possible benefits and hazards associated with this therapy. Combination diuretic therapy using any of several thiazide-type diuretics can more than double daily urine sodium excretion to induce weight loss and edema resolution, at the risk of inducing severe hypokalemia in addition to hyponatremia, hypotension, and worsening renal function. We provide considerations about prudent use of this therapy and review potential misconceptions about this long-used diuretic approach. Finally, we seek to highlight the need for pragmatic clinical trials for this commonly used therapy.
容量超负荷是心力衰竭管理的一个重要临床目标，通常采用袢利尿剂来解决。尽管给予了大剂量的袢利尿剂，心力衰竭患者中仍有一个重要且具有挑战性的亚组存在液体超负荷。克服袢利尿剂抵抗的一种方法是添加噻嗪类利尿剂，通过“顺序肾单位阻滞”产生利尿协同作用，这一策略早在 40 多年前就有描述。尽管这种策略有可能诱导对大剂量袢利尿剂抵抗的患者利尿，但尚未进行大规模临床试验来确定其安全性和临床疗效。我们总结了现有的评估心力衰竭患者中袢利尿剂和噻嗪类利尿剂联合应用的文献，以描述这种治疗方法相关的可能获益和风险。联合使用几种噻嗪类利尿剂进行利尿剂治疗可以使每日尿钠排泄量增加一倍以上，从而导致体重减轻和水肿消退，但除了低钠血症、低血压和肾功能恶化外，还会引起严重的低钾血症。我们提供了关于谨慎使用这种治疗方法的考虑因素，并回顾了这种长期使用的利尿剂方法的潜在误解。最后，我们强调需要对此种常用治疗方法进行实用的临床试验。
