Optimal use of diuretics in patients with heart failure.

Currently, the use of diuretics in heart failure (HF) remains more of an art than a science. Diuretics are the principle means for relieving congestion in patients with decompensated HF. Unfortunately, they persist as the only major therapy in HF that has not been subjected to a large randomized clinical trial, precisely because no comparable therapy exists that can so easily, efficiently, and inexpensively treat fluid overload. Nonetheless, diuretics have many potential drawbacks, including electrolyte abnormalities, neurohormonal activation, hypovolemia, renal dysfunction, and direct myocardial effects. Until definitive answers about mortality are settled, the lowest dose of a diuretic that can produce euvolemia should be employed and these agents should be discontinued when possible. Many outpatients with HF can be managed quite well without diuretics once adequate neurohormonal blockade with angiotensin-converting enzyme inhibitors and beta blockers has been achieved.