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Spironolactone in congestive heart failure refractory to high-dose loop diuretic and low-dose angiotensin-converting
A A van Vliet1, A J Donker, J J Nauta
1Department of Internal Medicine, Free University Hospital, Amsterdam, The Netherlands.
Insights
Adding spironolactone to high-dose loop diuretics and ACE inhibitors effectively treats diuretic-resistant congestive heart failure (CHF). This triple therapy significantly improves fluid retention and CHF symptoms in most patients.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Severe congestive heart failure (CHF) patients (NYHA class III-IV) often have diuretic resistance.
- Low-dose angiotensin-converting enzyme (ACE) inhibitors are used due to hypotension risks with higher doses.
Purpose of the Study:
- To evaluate the efficacy of high-dose loop diuretics combined with maximum tolerable ACE inhibitors in diuretic-resistant CHF.
- To assess the added benefit of spironolactone in patients with insufficient response to initial therapy.
Main Methods:
- A baseline-controlled study involving 21 patients with diuretic resistance and fluid retention.
- Initial 5-day therapy: high-dose bumetanide (10 mg oral) + maximum tolerable ACE inhibitor.
- Subsequent therapy for non-responders: addition of spironolactone (100 mg daily) for 7 days.
Main Results:
- 24% of patients responded to the initial double therapy (bumetanide + ACE inhibitor).
- 81% of the remaining patients responded to the addition of spironolactone (triple therapy), showing marked natriuresis, diuresis, and symptom regression.
- Patients requiring spironolactone had significantly higher baseline plasma aldosterone levels.
Conclusions:
- Combined high-dose loop diuretic and ACE inhibitor therapy is a viable option for some diuretic-resistant CHF patients.
- Spironolactone is highly effective in patients with persistent diuretic resistance, particularly those with elevated aldosterone levels.
- Triple therapy (bumetanide, ACE inhibitor, spironolactone) offers a significant benefit for refractory CHF.
Abstract:
Patients with severe congestive heart failure (New York Heart Association [NYHA] functional classes III-IV) often can tolerate only low doses of angiotensin-converting enzyme (ACE) inhibitors because pronounced hypotension caused by additional ACE inhibitor increments may decrease renal perfusion. The use of high-dose loop diuretics is currently advised to overcome diuretic resistance in refractory congestive heart failure (CHF). In a baseline controlled study, we evaluated 21 patients with diuretic resistance and evident fluid retention for the responses to 5 days of double drug therapy consisting of high-dose loop diuretic (10 mg oral bumetanide) in combination with the maximum tolerable dose of an ACE inhibitor (individualized to blood pressure and kidney function). Five patients (24%) showed a gross natriuresis and reduction in excess weight > 25% in response to this therapy. The remaining 16 patients (76%) with insufficient responses (i.e., < 25% reduction in excess weight) subsequently received 100 mg spironolactone once a day for 7 days in addition to the double therapy. Spironolactone coadministration was highly effective in 13 of 16 patients (81%). Marked natriuresis and diuresis were achieved within the next week of treatment, and CHF symptoms regressed or disappeared. The clinical course was similar in the bumetanide-ACE inhibitor and the bumetanide-ACE inhibitor-spironolactone treatment (triple therapy) groups. Plasma aldosterone was significantly higher (p < 0.05) in the patients who needed spironolactone. The 3 patients who were considered refractory to triple therapy exhibited the highest baseline plasma aldosterone concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)