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enhance urinary sodium excretion, only few patients with HF can maintain sodium balance without the use of diuretic drugs. Attempts to substitute ACE inhibitors for diuretics can lead to pulmonary and peripheral congestion.

3. Diuretics should not be used alone in the treatment of HF. Even when diuretics are successful in controlling symptoms and fluid retention, diuretics alone are unable to maintain the clinical stability of patients with HF for long periods of time19. The risk of clinical decompensation can be reduced, however, when diuretics are combined with digoxin, an ACE inhibitor, and a beta-blocker20.

4. Appropriate use of diuretics is a key element in the success of other drugs used for the treatment of HF. The use of inappropriately low doses of diuretics will cause fluid retention, which can diminish the response to ACE inhibitors and increase the risk of treatment with beta-blockers21. Conversely, the use of inappropriately high doses of diuretics will lead to volume contraction, which can increase the risk of hypotension with ACE inhibitors and vasodilators and the risk of renal insufficiency with ACE inhibitors and angiotensin II receptor antagonists22. Optimal use of diuretics is the cornerstone of any successful approach to the treatment of HF.

Practical use of diuretic therapy

Selection of patients

Diuretics should be prescribed to all patients who have evidence of, and to most patients with a prior history of, fluid retention. Diuretics should generally be combined with an ACE inhibitor and a beta-blocker (and usually digoxin). Few patients with HF will be able to maintain dry weight without the use of diuretics.

Initiation and maintenance

The most commonly used loop diuretic for the treatment of HF is furosemide, but some patients respond favorably to newer agents in this category (e.g., torsemide) because of their superior absorption. One study has suggested that torsemide may reduce the risk of

19 Richardson A, Bayliss J, Scriven AJ, Parameshwar J, Poole-Wilson PA, Sutton GC. Double-blind comparison of captopril alone against frusemide plus amiloride in mild heart failure. Lancet 1987;2:709-11.

20 Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. The Captopril-Digoxin Multicenter Research Group. JAMA 1988;259:539-44.

21 Cody RJ, Covit AB, Schaer GL, Laragh JH, Sealey JE, Feldschuh J. Sodium and water balance in chronic congestive heart failure. J Clin Invest 1986;77:1441-52.

22 Packer M, Lee WH, Medina N, Yushak M, Kessler PD. Functional renal insufficiency during long-term therapy with captopril and enalapril in severe chronic heart failure. Ann Intern Med 1987;106:346-54.

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