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Diuretics for heart failure

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Abstract

Background

Chronic heart failure is a major cause of morbidity and mortality worldwide. Diuretics are regarded as the first‐line treatment for patients with congestive heart failure since they provide symptomatic relief. The effects of diuretics on disease progression and survival remain unclear.

Objectives

To assess the harms and benefits of diuretics for chronic heart failure

Search methods

Updated searches were run in the Cochrane Central Register of Controlled Trials in The Cochrane Library (CENTRAL Issue 1 of 4, 2011), MEDLINE (1966 to 22 February 2011), EMBASE (1980 to 2011 Week 07) and HERDIN database (1990 to February 2011). We hand searched pertinent journals and reference lists of papers were inspected. We also contacted manufacturers and researchers in the field. No language restrictions were applied.

Selection criteria

Double‐blinded randomised controlled trials of diuretic therapy comparing one diuretic with placebo, or one diuretic with another active agent (e.g. ACE inhibitors, digoxin) in patients with chronic heart failure.

Data collection and analysis

Two authors independently abstracted the data and assessed the eligibility and methodological quality of each trial. Extracted data were analysed by determining the odds ratio for dichotomous data, and difference in means for continuous data, of the treated group compared with controls. The likelihood of heterogeneity of the study population was assessed by the Chi‐square test. If there was no evidence of statistical heterogeneity and pooling of results was clinically appropriate, a combined estimate was obtained using the fixed‐effects model.

Main results

This update has not identified any new studies for inclusion. The review includes 14 trials (525 participants), 7 were placebo‐controlled, and 7 compared diuretics against other agents such as ACE inhibitors or digoxin. We analysed the data for mortality and for worsening heart failure. Mortality data were available in 3 of the placebo‐controlled trials (202 participants). Mortality was lower for participants treated with diuretics than for placebo, odds ratio (OR) for death 0.24, 95% confidence interval (CI) 0.07 to 0.83; P = 0.02. Admission for worsening heart failure was reduced in those taking diuretics in two trials (169 participants), OR 0.07 (95% CI 0.01 to 0.52; P = 0.01). In four trials comparing diuretics to active control (91 participants), diuretics improved exercise capacity in participants with CHF, difference in means WMD 0.72 , 95% CI 0.40 to 1.04; P < 0.0001.

Authors' conclusions

The available data from several small trials show that in patients with chronic heart failure, conventional diuretics appear to reduce the risk of death and worsening heart failure compared to placebo. Compared to active control, diuretics appear to improve exercise capacity.

Plain language summary

Diuretics for heart failure in adults

Chronic heart failure (CHF) (also called congestive heart failure, cardiac and heart failure) is a disorder in which the heart loses its ability to pump blood efficiently throughout the body. The oxygen and nutrients in the blood provide the body with the energy it needs to operate efficiently. CHF causes breathlessness and fatigue because the heart cannot function as it should. Heart failure may affect the left, right, or both sides of the heart. If the left half of the heart fails, fluid will build up in the lungs due to congestion of the veins of the lungs. If the left half of the heart fails, general body vein pressure will increase and fluid will accumulate in the body, especially the tissues of the legs and abdominal organs. Often left heart failure leads to right heart failure causing biventricular failure. Fluid may build up in the lungs and legs. Coronary artery disease, a heart attack, or high blood pressure are some of the causes of heart failure. Drug treatments include digitalis, angiotensin‐converting enzyme (ACE) inhibitors, beta‐blockers and diuretics. Diuretics are important as they relieve symptoms quickly and control fluid retention. Some of the diuretics used are furosemide, bumetanide and chlorothiazide. The available data from several small controlled trials show that in patients with CHF, conventional diuretics appear to reduce the risk of death and worsening heart failure when compared to an inactive sugar pill (placebo). About 80 deaths may be avoided for every 1000 people treated. Diuretics also increase the ability to exercise, by about 28% to 33% more than with other active drugs. These conclusions were based on 14 controlled trials (525 people), of which three trials noted deaths in 202 people randomised to receive either diuretic or placebo, and two trials, a total of 169 people, looked at hospitalisation for worsening heart failure. Of the seven trials comparing diuretic treatment with another drug, the effects on exercise were studied in four trials where 91 people were randomised to receive either a diuretic or an ACE inhibitor or digoxin. Most of the trials had small numbers and lasted from 4 to 24 weeks, a short time for a chronic disease. The age of the participants was 59 years, which is relatively young, and the use of diuretic drug was not standardised across the studies. More research would be needed to further confirm the long term benefits of diuretic treatment for CHF patients because these studies were small.