Refocus on diuretics in the treatment of heart failure

Diuretics have long been accepted as the traditional first-line treatment of the patient with symptomatic heart failure whatever its aetiology or dysfunctional stage. Their acceptance in this role is based on the rapid improvement in congestive symptoms experienced by most patients, which is arguably greater than that induced by any other currently available anti-heart failure drug. This symptomatic efficacy and their universal clinical acceptance as first-step treatment for the patient with symptoms of heart failure has precluded formal examination of their impact on prognosis. Evidence from indirect studies suggests that when used alone they may not be able to prevent clinical deterioration, possibly due to excitation of the renin-angiotensin-aldosterone system. When such excitation is suppressed by concomitant administration of angiotensin-converting enzyme inhibitors, relief of congestive symptoms is enhanced and the morbidity and mortality risk of heart failure significantly reduced. Studies on the mechanisms of diuretic resistance have demonstrated the synergy of diuretic activity when low doses of diuretics acting at different sites of the nephron are used in combination. Diuretics remain the cornerstone of treatment for symptoms in congestive heart failure but their overall efficacy is substantially improved when combined with ACE inhibitors.