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............................................................ concomitant administration of other diuretics acting at different sites, namely thiazides or metolazone or acetazolamide, may be considered. However, this combination requires careful monitoring of serum electrolytes and renal function (Figure 13).145,469,470 This strategy, based on early and frequent assessment of diuretic response, allows starting treatment with relatively low doses of loop diuretics, with frequent dose adjustments that may be less likely to cause dehydration and increase in serum creatinine. The loop diuretic dose should be progressively decreased when a significant negative fluid balance has been obtained. However, it should be pointed out that this algorithm is entirely based on expert opinion, to date.145,461

Transition to oral treatment should be commenced when the patient’s clinical condition is stable. It is recommended that, after achievement of congestion relief, oral loop diuretics are continued at the lowest dose possible to avoid congestion.463,471 Care must also be taken to avoid patients being discharged from hospital with persistent congestion, as this is a major predictor of increased deaths and rehospitalizations.462,472 Hence, care should be taken to achieve adequate decongestion and establish an appropriate long-term diuretic dose before discharge.427,473 11.3.4 Vasodilators Intravenous vasodilators, namely nitrates or nitroprusside (Supplementary Table 21), dilate venous and arterial vessels leading to a reduction in venous return to the heart, less congestion, lower afterload, increased stroke volume and consequent relief of symptoms. Nitrates act mainly on peripheral veins whereas nitroprusside is more a balanced arterial and venous dilator.474,475 Because of their mechanisms of action, i.v. vasodilators may be more effective than diuretics in those patients whose acute pulmonary oedema is caused by increased afterload and fluid redistribution to the lungs in the absence or with minimal fluid accumulation.427,476478 However, two recent randomized trials comparing usual care with early intensive and sustained vasodilation failed to show a beneficial effect of i.v. vasodilators vs. high-dose diuretics.479,480 No recommendation favouring a regimen based on vasodilator treatment vs. usual care can thus be given, to date.

Intravenous vasodilators may be considered to relieve AHF symptoms when SBP is >110 mmHg. They may be started at low doses and uptitrated to achieve clinical improvement and BP control. Nitrates are generally administered with an initial bolus followed by

Management of diuretic therapy in patients with acute heart failure

On oral loop diuretic

1–2 times daily oral dose i.v. ≥20–40 mg i.v.

furosemide

Urinary spot sodium     after 2 h ≥50–70 mEq/L Urine output                after 6 h      ≥100–150 mL/h

Double dose i.v. until

maximum i.v. dosea Repeat similar dose

i.v. every 12 h

Check serum creatinine and electrolytes at least

every 24 h

Continue until complete decongestion Combination

diuretic therapiesb

N Y

Y N

≥ Urinary spot sodium     50–70 mEq/L at 2–6 h ≥ Urine output                100–150 mL/h

Y N

Figure 13 Diuretic therapy (furosemide) in acute heart failure. i.v.= intravenous. aThe maximal daily dose for i.v. loop diuretics is generally considered furosemide 400600 mg though up to 1000 mg may be considered in patients with severely impaired kidney function. bCombination therapy is the addition to the loop diuretic of a diuretic with a different site of action, e.g. thiazides or metolazone or acetazolamide. Modified from 145. Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026