Concomitant administration of ACE inhibitors alone or in combination with potassium- retaining agents (such as spironolactone) can prevent electrolyte depletion in most patients with HF who are taking a loop diuretic. When these drugs are prescribed, long- term oral potassium supplementation is frequently not needed and may be deleterious.
As previously mentioned, excessive use of diuretics can decrease blood pressure and impair renal function and exercise tolerance, but hypotension and azotemia may also occur as a result of worsening HF, which may be exacerbated by attempts to reduce the dose of diuretics. Hence, if there are no signs of fluid retention, hypotension and azotemia are likely to be related to volume depletion and may resolve after a reduction in diuretic dose. If there are signs of fluid retention, hypotension and azotemia are likely to reflect worsening HF and a decline in effective peripheral perfusion. Such patients should be managed by maintaining the dose of diuretic and improving end-organ perfusion, by adding an inotropic agent34.
A summary of the oral diuretics recommended for use in the treatment of fluid retention in HF is presented in the table below:
INHIBITORS OF THE RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM.
Inhibition of the renin-angiotensin-aldosterone system can take place at multiple sites: at the level of the enzyme that converts angiotensin I to angiotensin II (ACEIs), at the
34 Oster JR, Epstein M, Smoller S. Combined therapy with thiazide-type and loop diuretic agents for resistant sodium retention. Ann Intern Med 1983;99:405-6.