Approaches to diuretic therapy and electrolyte imbalance in congestive heart failure.

This review has summarized the current role of diuretic therapy in heart failure, emphasizing those aspects most relevant to this patient population. Recommended diuretic usage is as follows: Asymptomatic left ventricular dysfunction--establish moderate sodium intake, Mild sodium retention--thiazide-type diuretic or low-dose loop diuretic; continue moderate sodium intake; combine with an ACE inhibitor, Moderate sodium retention--loop diuretic, adjusting for renal function, if necessary; continue moderate sodium intake; combine with an ACE inhibitor, Severe sodium retention--large-dose loop diuretic combined with a thiazide-type diuretic; continue moderate sodium intake; ACE inhibitor, unless contraindicated; consider addition of a potassium-sparing diuretic Treatment measures for refractory sodium retention--intermittent intravenous loop diuretic; short-term infusion of a loop diuretic; intensified combination oral diuretic therapy; intravenous positive inotropic therapy; ultrafiltration or dialysis. In addition, the well-known adverse effect of electrolyte depletion and guidelines for electrolyte replacement have been discussed. It is evident that the diuretic class of pharmacologic therapy has not been as well assessed as both the positive inotrope and vasodilator classes. Limitations in this regard have been summarized recently. Even relatively simple parameters or instruments, such as the sodium retention score, when applied to clinical trials will yield a greater understanding of the utility and limitations of diuretic therapy for heart failure.