Use of diuretics and ace-inhibitors in heart failure
Date First Published:
July 5, 2005
Last Updated:
July 14, 2005
Report by:
Shiraz Hussain, Medical student (University of Manchester)
Three-Part Question:
In [adults with moderate to severe acute left ventricular failure] are [diuretics and ace-inhibitors together better than diuretics alone] at [reducing mortality]?
Clinical Scenario:
A 20 year old patient presents to the A & E department with severe pulmonary oedema of cardiac origin. You wonder whether diuretic and ace-inhibitor combination therapy is better than either of them alone.
Search Strategy:
Medline 1966 to June 2005 week 4
Search Details:
(exp Heart Failure, Congestive/ OR exp Adult/ OR exp Cardiac Output, Low/ OR cardiac failure.mp/ OR ccf.mp/ OR exp Pulmonary Edema/ OR exp Cardiotonic Agents/ OR exp Acute Disease/ OR exp Natriuretic Peptide, Brain/ OR pulmonary edema.mp/ OR pulmonary oedema.mp/ OR exp Ventricular Dysfunction, Left/ OR acute systolic failure.mp/ OR shortness of breath.mp/ OR exp Dyspnea/ OR dyspnoea.mp/ OR exp Morphine/ OR left ventricular failure.mp/ OR lv failure.mp/ OR left ventricular heart failure.mp/ OR lvf.mp.) AND (diuretics.mp. OR exp DIURETICS, OSMOTIC/ OR exp DIURETICS, THIAZIDE/ OR exp DIURETICS/ OR exp DIURETICS, SULFAMYL/ OR frusemide.mp. OR exp Furosemide/ OR furosemide.mp.) AND (ace inhibitors.mp. OR exp Angiotensin-Converting Enzyme Inhibitors/ OR angiotensin converting enzyme inhibitors.mp. OR captopril.mp. OR exp CAPTOPRIL/)
Outcome:
273 papers were found
4 were deemed relevant
3 were of sufficient quality and are included in the BET
4 were deemed relevant
3 were of sufficient quality and are included in the BET
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Diuretic Treatment and Diuretic Resistance in Heart Failure Krämer B K, Schweda F, Riegger G A J, 1998 Germany | Various depending on particular study being reviewed | Review of diuretic therapy in congestive heart failure and discussion of mechanisms underlying diuretic resistance | Serum sodium level | Reduced when spironolactone was added to diuretic and ace-inhibitor combination therapy (exact values not given). | Details are not included of how searching for studies was done or inclusion/exclusion criteria, hence not reproducible. Quality assessment of studies not included hence reliability uncertain. Results not always presented clearly enough to allow reader to reach own conclusions (although well referenced). No sensitivity analysis. |
| Spironolactone in Congestive Heart Failure Refractory to High-Dose Loop Diuretic and Low-Dose Angiotensin-Converting Enzyme Inhibitor van Vliet A A, Donker Ab J M, Nauta Jos J P et al 1993 The Netherlands | 21 patients all treated with diuretic and ace-inhibitor. 5 responded. 16 did not and were given additional spironolactone therapy. |
Baseline controlled study | Excess fluid lost after treatment began | 5/21 patients lost (mean values) 62% (0.9±0.5kg per day) excess fluid when treated with a loop diuretic and ace-inhibitor over 5 days. With spironolactone addition, 13/16 patients lost (mean values) 64% excess fluid within a week (0.61±0.2kg per day). | Small numbers used in study. Results may have been influenced by previous medication. |
| ACE Inhibitors Versus Diuretics: When to Choose Which Drug Sharpe N 1993 New Zealand | Varied depending on studies used | Review | Benefit of combination therapy of ace-inhibitors and diuretics | Reduced mortality (more detailed measeurements not included in paper) | Paper lacks detail. Results are not present. Although references are given for theory, more needs to be presented within the paper itself. |
Bottom Line:
Ace-inhibitors and diuretics are more effective for treating acute heart failure when they are combined rather than only using one. The addition of spironolactone is useful in patients resistant to this combination.
References:
- Krämer B K, Schweda F, Riegger G A J,. Diuretic Treatment and Diuretic Resistance in Heart Failure
- van Vliet A A, Donker Ab J M, Nauta Jos J P et al. Spironolactone in Congestive Heart Failure Refractory to High-Dose Loop Diuretic and Low-Dose Angiotensin-Converting Enzyme Inhibitor
- Sharpe N. ACE Inhibitors Versus Diuretics: When to Choose Which Drug