Diuretic withdrawal in CHF patients on optimal medical therapy

Abstract

Effective management of congestive heart failure (CHF) requires modulation and control of the neurohormonal systems of the body. The cornerstone of CHF therapy includes angiotensin converting enzyme inhibition (ACE-I), beta blockade (BB) of sympathetic nervous system and blockade of renin-aldosterone system. It has been shown that patients treated with these therapies are much less prone to exacerbation of CHF. Another aspect in CHF management is that of fluid/volume control, which is achieved by sodium and fluid restriction and administration of diuretic therapy. Although diuretic therapy is effective in controlling volume overload, it can lead to volume depletion, activation of the renin-angiotensin system and contribute to the polypharmacy of CHF therapy. It was our hypothesis that it is clinically feasible to gradually withdraw loop diuretics from CHF patients who do not demonstrate volume overload and are treated with optimal medical therapy. Fifteen consecutive patients with left ventricular systolic dysfunction (mean age 71years, mean ejection fraction 27%, males 47%, ischemic cardiomyopathy 47%) who did not demonstrate volume overload and who were on therapeutic doses of ACE-I and BB had their loop diuretics (mean furosemide 42.7 mg QD with range of 20–80 mg QD) gradually withdrawn. The study cohort received comprehensive education related to recommendations for daily weight monitoring, dietary sodium and fluid restrictions, and sliding scale guidelines for diuretic adjustments. They were followed for evidence of fluid retention requiring re-initiation of diuretic therapy or hospitalization. At the conclusion of the six month study period, six patients (40%) had discontinued their furosemide, three patients (20%) required PRN diuretic admininistration (less than one dose per week) and five patients (33%) had the daily furosemide requirement reduced by one-half. One patient required hospitalization for exacerbation of CHF and re-initiation of daily loop diuretic therapy. Conclusion: Loop diuretics can be safely withdrawn from euvolemic CHF patients who are treated on optimal medical therapy.