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Frusemide strategies in heart failure
While loop diuretics are an acknowledged component of therapy for patients with acute decompensated heart failure, as they were introduced into clinical practice prior to the era of large randomised controlled trials there are few prospective data to guide their use.
To better define the most pertinent strategy for their use, the authors conducted a prospective, double-blind, randomised trial, in which 308 patients with acute decompensated heart failure were assigned to receive furosemide administered intravenously by means of either a bolus every 12 h or continuous infusion at either a low dose (equivalent to the patient's previous oral dose) or a high dose (2.5 times the previous oral dose). Any patients requiring inotropes or vasodilators were excluded. The co-primary end points were patients′ global assessment of symptoms using a visual-analogue scale, and the change in the serum creatinine level from baseline to 72 h.
While previous smaller trials of similar design have generally favoured a continuous infusion strategy, in the comparison of bolus with continuous infusion there was no significant difference in patients' assessment of symptoms (mean AUC, 4236±1440 and 4373±1404, respectively; p=0.47) or in the mean change in creatinine (4.4±26.5 μmol/l and 6.2±26.5 μmol/l, respectively; p=0.45). In the comparison of the high-dose strategy with the low-dose strategy, there was a trend towards greater improvement in patients' symptoms with the high-dose (mean AUC, 4430±1401 vs 4171±1436; p=0.06), while there was no significant difference in change in creatinine (7.1±26.5 μmol/l with the high-dose and 3.5±26.5 μmol/l with the low-dose, p=0.21). The high-dose strategy was associated with greater diuresis and more favourable outcomes in some secondary measures but also with transient worsening of renal function and none of the strategies showed any benefit in reducing length of hospital stay or …