Unsolved challenges in diuretic therapy for acute heart failure: a focus on diuretic response

Loop diuretics represent the mainstay of management of patients hospitalized for heart failure (HF). Diuretic resistance is commonly encountered in clinical practice, but limited evidence-based approaches are available to address it. Recent clinical investigations have proposed common definitions of diuretic response: a change in body weight, net fluid loss or total urinary output to 40 mg of furosemide dose equivalents. Poor diuretic response is characterized by features of advanced HF and atherosclerosis and is independently associated with poor in-hospital and post-discharge outcomes. A number of adjunctive or combination decongestion therapies are available to overcome diuretic resistance, but high-quality prospective data supporting these approaches are lacking. Once a definition has been standardized and accepted, diuretic response may represent an important inclusion criteria and end point in upcoming clinical trials in hospitalized HF to help define an optimal, tailored approach to this challenging clinical entity.