[The diuretic in chronic cardiac failure: a clumsy partner]

Ever since the publication of the large scale clinical trials of morbid-mortality, the recommendations concerning the medical treatment of cardiac failure are clear with respect to ACE inhibitors, betablockers, angiotensin receptor antagonists and aldosrerone antagonists with established target doses. As far as the prescription of diuretics go, drugs which are effective in a condition associated with a poor quality of life, it is important to use the minimal dosage because of their deleterious stimulant effects on the rennin-angiotensin-aldosterone system and their metabolic side effects. A review of the clinical trials shows that almost all patients were prescribed diuretics; in over 80% of cases, the drugs are loop diuretics with a preference for furosemide, with increasing doses during the follow-up, infrequently associated with thiazide diuretics. In the short term, diuretics reduce the circulating volume and the BNP. In the long term, high doses are associated with a poor prognosis. The clinician then has to decide on the basis of few objective criteria, especially for the reduction of dosage, despite the introduction of the BNP whose role as an aid to prescription remains to be defined. In addition to the simple prescription of drugs, a global approach to patient management is necessary in cardiac failure; in this context, concerning salt- water equilibrium and diuretics, therapeutic education may have a solid role to play to provide an acceptable quality of life including the reduction of the number of frequent hospital admissions.