Editor,—We read Broadley and Marshall's letter with great interest.1 Diuretic treatment has a well established role in management of some cases of decompensation of heart failure. However, rather more common than worsening contractile function are general illnesses, diuretic resistance, or failure of adherence to prescribed treatment (diuretic or otherwise). The concept of patient self management of diuretic treatment is certainly simple, but is not new, and is already widely used in selected patients. It can work well, usually by titrating up loop diuretic. There are several practical problems that befall the proposed advice when widened to the greater heart failure population.

As is often stated, most heart failure patients are elderly or very elderly and cannot easily cope with the basic multiple prescribed medicines, far less manipulate them further. Second, the change in weight described as being recorded on bathroom scales (1 kg rise) is trivial and certainly close to the variance seen on repetitive measurement in follow up of heart failure. In a previous neurohormonal study we found a 0.5–1.5 kg weight increment in association with delayed dosing of routine frusemide, basically overnight. Third, in a repetitive community follow up of a congestive heart failure cohort (42 patients) over two years, we found huge variation in the prescribed dose of diuretic. The main change was general practitioner initiated increments (doses were almost never reduced) in response to ill defined episodes of breathlessness. As is obvious, even in patients with well documented systolic failure, there are many non-cardiac causes …