Wilson Ben J, Bates Duane
, MD, FRCPC, is a Clinical Assistant Professor with the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta.
, BScPharm, ACPR, is a Clinical Pharmacist with the Calgary Zone, Alberta Health Services, Calgary, Alberta.
Can J Hosp Pharm. 2024 Jan 10;77(1):e3323. doi: 10.4212/cjhp.3323. eCollection 2024.
Heart failure is a common condition with considerable associated costs, morbidity, and mortality. Patients often present to hospital with dyspnea and edema. Inadequate inpatient decongestion is an important contributor to high readmission rates. There is little evidence concerning diuresis to guide clinicians in caring for patients with acute decompensated heart failure. Contemporary diuretic strategies have been defined by expert opinion and older landmark clinical trials.
To present a narrative review of contemporary recommendations, along with their underlying evidence and pharmacologic rationale, for diuretic strategies in inpatients with acute decompensated heart failure.
PubMed, OVID, and Embase databases were searched from inception to December 22, 2022, with the following search terms: heart failure, acute heart failure, decompensated heart failure, furosemide, bumetanide, ethacrynic acid, hydrochlorothiazide, indapamide, metolazone, chlorthalidone, spironolactone, eplerenone, and acetazolamide.
Randomized controlled trials and systematic reviews involving at least 100 adult patients (> 18 years) were included. Trials involving torsemide, chlorothiazide, and tolvaptan were excluded.
Early, aggressive administration of a loop diuretic has been associated with expedited symptom resolution, shorter length of stay, and possibly reduced mortality. Guidelines make recommendations about dose and frequency but do not recommend any particular loop diuretic over another; however, furosemide is most commonly used. Guidelines recommend that the initial furosemide dose (on admission) be 2-2.5 times the patient's home dose. A satisfactory diuretic response can be defined as spot urine sodium content greater than 50-70 mmol/L at 2 hours; urine output greater than 100-150 mL/h in the first 6 hours or 3-5 L in 24 hours; or a change in weight of 0.5-1.5 kg in 24 hours. If congestion persists after the maximization of loop diuretic therapy over the first 24-48 hours, an adjunctive diuretic such as thiazide or acetazolamide should be added. If decongestion targets are not met, continuous infusion of furosemide may be considered.
Heart failure with congestion can be managed with careful administration of high-dose loop diuretics, supported by thiazides and acetazolamide when necessary. Clinical trials are underway to further evaluate this strategy.
心力衰竭是一种常见病症，伴有高昂的相关费用、发病率和死亡率。患者常因呼吸困难和水肿入院。住院期间充血消除不充分是再入院率高的一个重要原因。几乎没有证据可指导临床医生对急性失代偿性心力衰竭患者进行利尿治疗。当代利尿策略是由专家意见和较早的标志性临床试验所定义的。
对急性失代偿性心力衰竭住院患者利尿策略的当代建议及其潜在证据和药理学原理进行叙述性综述。
检索了PubMed、OVID和Embase数据库，检索时间从建库至2022年12月22日，检索词如下：心力衰竭、急性心力衰竭、失代偿性心力衰竭、呋塞米、布美他尼、依他尼酸、氢氯噻嗪、吲达帕胺、美托拉宗、氯噻酮、螺内酯、依普利酮和乙酰唑胺。
纳入至少100例成年患者（>18岁）的随机对照试验和系统评价。排除涉及托拉塞米、氯噻嗪和托伐普坦的试验。
早期积极给予襻利尿剂与症状更快缓解、住院时间缩短以及可能降低死亡率相关。指南对剂量和频率提出了建议，但未推荐某一种襻利尿剂优于另一种；然而，呋塞米是最常用的。指南建议初始呋塞米剂量（入院时）为患者在家剂量的2 - 2.5倍。满意的利尿反应可定义为2小时时随机尿钠含量大于50 - 70 mmol/L；最初6小时尿量大于100 - 150 mL/h或24小时尿量大于3 - 5 L；或24小时体重变化0.5 - 1.5 kg。如果在最初24 - 48小时襻利尿剂治疗最大化后充血仍持续，应加用噻嗪类或乙酰唑胺等辅助利尿剂。如果未达到充血消除目标，可考虑持续静脉输注呋塞米。
充血性心力衰竭可通过谨慎给予高剂量襻利尿剂进行管理，必要时辅以噻嗪类和乙酰唑胺。目前正在进行临床试验以进一步评估该策略。
