1. The document discusses diuretic therapy for treating congestion in acute heart failure. It describes the mechanisms of different types of diuretic drugs and their sites of action in the renal tubules. 2. The goal of diuretic therapy is to achieve thorough decongestion without residual volume overload while maintaining adequate organ perfusion. The document outlines stepped-care pharmacologic approaches using loop diuretics initially followed by thiazide or thiazide-like diuretics if needed. 3. Clinical trials such as DOSE and CLOROTIC evaluated diuretic strategies in acute heart failure and found that higher versus lower diuretic doses achieved greater decongestion but also increased

1. Diuretics in acute heart failure
LÊ HỒNG TUẤN, MD

2. CONTENT
1. Renal tubular physiology & tubular reabsorption.
2. Physiopathologic tubular reabsorption in heart failure.
3. Diuretic drugs: Mecanism of action.
4. Diuretic therapy in congestion heart failure

3. Diagram of the renal tubule showing principal sites of diuretic action
Lant A. Diuretics. Clinical pharmacology and therapeutic use (Part I). Drugs 1985;29:57 –87
Site V

4. THE USE OF DIURETICS IN HEART FAILURE WITH CONGESTION
European J of Heart Fail, Volume: 21, Issue: 2, Pages: 137-155, First published: 01 January 2019, DOI: (10.1002/ejhf.1369)

5. LOOP DIURETIC DRUGS: MECHANISM OF ACTION

6. DIURETIC DOSE-RESPONSE RELATIONSHIP
IN CARDIORENAL SYNDROME.
Zachary L. Cox et al. Kidney360 2022;3:954-967

7. STEPPED-CARE PHARMACOLOGIC APPROACH
The goal of treatment is a daily urine volume of 3 to 5 liters until clinical euvolemia is reached. The initial approach may
involve the intravenous administration (in two doses) of 2.5 times the patient’s previous oral daily dose of furosemide or
alternatively the infusion approach described above. The diuretic level can be increased daily to achieve urinary output
between 3 and 5 liters per day by moving to the next step if the urinary output remains less than 3 liters. NA denotes not
applicable.
† Hydrochlorothiazide (at a dose of 50 mg twice daily) or chlorthalidone (at a dose of 50 mg daily) may be substituted for
metolazone. Adapted from Grodin et al.36 and Bart et al. The full algorithm includes additional considerations for
vasodilator, inotropic, or mechanical therapy in patients who do not have a response within 48 hours.
‡ A dose of 40 mg of furosemide is considered to be equivalent to 1 mg of bumetanide or 20 mg of torsemide.
N engl j med 377;20 nejm.org November 16, 2017

8. THIAZIDE AND THIAZIDE-LIKE DIURETICS.
LOOP DIURETICS
ABC Heart Fail Cardiomyop. 2022; 2(1):86-93

9. DIURECTIC THERAPY IN ACUTE DECOMPENSATED HEART FAILURE
• Before initiating decongestive therapies in acutely decompensated patients, the distinction
should be made if volume overload or volume redistribution is contributing to congestion.
• The goals of therapy in patients presenting with congestion and volume overload consists
of
(i) achieving thorough decongestion without residual volume overload. Nevertheless, the
optimal stopping point of decongestive therapy is often difficult to determine, as alluded to
above.
(ii) Ensuring adequate perfusion pressures to guarantee organ perfusion.
(iii) Maintaining guideline-directed medical therapies as these medications may also
increase diuretic response and improve long-term survival.
• When patients with heart failure with reduced (HFrEF) or preserved ejection fraction
(HFpEF) decompensate, they often can present with a similar profile of congestion.
• Therefore, the goal of decongestive therapy is similar in terms of diuretic use in patients
with HFrEF and HFpEF
Mullens W et al, (2019), "The use of diuretics in heart failure with congestion ", European journal of heart failure, 21 (2), pp. 137-155.

10. THE USE OF DIURETICS IN HEART FAILURE WITH CONGESTION
European J of Heart Fail, Volume: 21, Issue: 2, Pages: 137-155, First published: 01 January 2019, DOI: (10.1002/ejhf.1369)

11. blood volume (BV) plasma volume (PV), red blood mass (RBCM) profiles, UF: ultrafiltration.

12. DIURECTIC USE IN ACUTE HEART FAILURE
Congestion with
volume overload
Mullens W et al, (2019), "The use of diuretics in heart failure with congestion ",
European journal of heart failure, 21 (2), pp. 137-155.

13. DIURECTIC USE IN ACUTE HEART FAILURE (CONTINUE)
Mullens W et al, (2019), "The use of diuretics in heart failure with congestion ", European journal of heart failure, 21 (2), pp. 137-155.
Treatment algorithm
after 24 h.

15. Eur Heart J, ehac680, https://doi.org/10.1093/eurheartj/ehac680
MANAGEMENT OF CONGESTION IN ACUTE HEART FAILURE

16. Diuretic Optimization Strategies Evaluation (DOSE) trial.
Felker et al, Diuretics in Acute Heart Failure, Circ Heart Fail January 2009, DOI: 10.1161/CIRCHEARTFAILURE.108.821785

17. Kaplan–Meier Curves for the Clinical Composite: Death, Rehospitalization,or
Emergency Department Visit.
DOSE TRIAL
Michael Felker et all, Diuretic Strategies in Patients with Acute Decompensated Heart Failure N Engl J Med 2011;364:797-805.

18. Eur Heart J, ehac689, https://doi.org/10.1093/eurheartj/ehac689
GRAPHICAL SUMMARY OF THE DESIGN AND MAIN FINDINGS
OF THE CLOROTIC TRIAL
•Change in weight at 96 hours:
-2.5 kg vs. -1.5 kg (p < 0.001)
•24-hour diuresis quantification:
1775 mL vs. 1400 mL (p = 0.05)
•Hospital length of stay: 7.0 vs. 7.0
(p = 0.17)
•All-cause mortality at 30 days:
9.6% vs. 6.0% (p = 0.44)
•All-cause rehospitalization at 30
days: 23.7% vs. 16.4% (p = 0.22)
•Impaired renal function: 46.5% vs.
17.2% (p < 0.001)
•Increase in creatinine >26.5
μmol/L: 46.5% vs. 17.2% (p <
0.001)
•Potassium levels ≤3.5 mmoL/L:
44.7% vs. 19.0% (p < 0.001)

19. P<0,001

20. ADVOR
TRIAL