Loop diuretic resistance in heart failure: resistance etiology-based strategies to restoring diuretic efficacy

Loop diuretics are a cornerstone of symptom management for nearly all patients with heart failure. Diuretic resistance is a clinical problem with similar presentation despite diverse and multiple etiologies. Although the exact incidence is not known, diuretic resistance occurs frequently and can increase the length of hospitalization. Despite the prevalence of loop diuretic prescription in heart failure and frequency of diuretic resistance, current heart failure guidelines provide nonspecific guidance on strategies to restore diuretic efficacy. Providers are left with many questions regarding the optimum diuretic titration strategy in the setting of diuretic resistance. In light of these highly prevalent uncertainties, we present a case vignette-structured literature review of the mechanisms of diuretic resistance and recommend therapeutic strategies based on the resistance etiology to improve diuretic response in acute decompensated heart failure.