Heart failure has advanced along only a few avenues over the last 20 years.

• The first therapy shown to extend life was ACEi.
• Then we had beta-blockers (metoprolol, carvedilol, bisprolol), but not all of them (atenolol).
• Both aldosterone antagonists (spironiolactone and eplerenone) extend life.
• ARBs too (valsartan, candesartan), but only some of them (cozaar).
• Digoxin failed.
• ICDs succeeded.
• There was Niseritide. Then there wasn't.
• If you're black you can use nitrates and hydrazine.
• Statins failed.
• Darbepoetin failed.
• I'm not aware of revascularization data, but there might be.
• Coenzyme Q and L-carnitine have some data but I have not seen anything compelling.

I think that is about it.

The obvious omission from that paragraph are loop diuretics. No thiazides either. That should be shocking because its the standard therapy for acute and chronic heart failure.

The obvious reason is the immediate symptomatic benefit these patients receive. A bit of Lasix and the edema goes away, the oxygen requirement melts. The patient tells you she can sleep in a bed again. You find a stable dose of Lasix, ACEi, beta-blocker and you send her home. And sometime in the next year or three she'll die because mortality is advanced heart failure is terrible.

We use it and rarely question it because it is so essential in managing symptoms. Is there any reason to suspect it might not be beneficial to patients. Well, using diuretics increases sympathetic outflow to the kidneys and heart, and up-regulates the renin-angiotensin-aldosterone system. Our successful drugs suppress sympathetic stimulation, angiotensin and aldosterone. So its not hard to imagine diuretics being harmful. 

Look at the heart failure guidelines from Heart Failure Association of America. Strongest recommendation with the weakest evidence, shouldn't it be opposite. A study on unanswered questionsin the management of acute decompensated heart failure found that diuretic related questions were the most common.

1. Clinical Trial: High-dose furosemide plus small-volume hypertonic saline solutions vs. repeated paracentesis as treatment of refractory ascites. Alimentary Pharmacology & Therapeutics.
2. Short-Term Effects of Hypertonic Saline Solution in Acute Heart Failure and Long-Term Effects of a Moderate Sodium Restriction in Patients With Compensated Heart Failure With New York Heart Association Class III (Class C) (SMAC-HF Study). The American Journal of the Medical Sciences • Volume 342, Number 1, July 2011
3. Hypertonic saline: A novel therapy for advanced heart failure? American Heart Journal March 2003
4. Loop Diuretic Therapy in Heart Failure: The Need for Solid Evidence on a Fluid Issue. Clin. Cardiol. 33, 6, 345 – 352 (2010)
5. Acute treatment of uncompensated heart failure with 10% hypertonic saline and its subsequent effect on respiratory patterns. Clinics 2011;66(4):717-718
6. Effects of high-dose furosemide and small-volume hypertonic saline solution infusion in comparison with a high dose of furosemide as a bolus, in refractory congestive heat failure. European Journal of Heart Failure 2 (2000) 305-313
7. Unloading therapy by intravenous diuretic in chronic heart failure: a double-edged weapon? Journal of Cardiovascular Medicine 2010, Vol 11 No 8
8. Intravenous High-Dose Furosemide and Hypertonic Saline Solutions for Refractory Heart Failure and Ascites. Seminars in Nephrology, VOl 31, No 6, November 2011, pp 513-522.

Archive of all of the above