Fluid overload?
★ Noticeable swelling in the legs and arms (peripheral edema)
★ Fluid in the abdomen (ascites)
★ Extreme generalized edema / swelling of the skin (anasarca)
★ Accumulation in the fluid-filled space that surrounds the lungs (pleural effusion)
Fluid overload(volume overload)가 없다면, diuretics를 사용할 필요가 없고 ACEI → β-blocker를 사용합니다.
HFrEF
Diuretic — For patients with HFrEF and volume overload, we recommend diuretic therapy, typically with a loop diuretic. The goal of relieving signs and symptoms of volume overload (such as dyspnea and peripheral edema) should be pursued while adverse effects are monitored. Improvement in symptoms can occur within hours to days. In comparison, the clinical effects of digoxin, angiotensin converting enzyme (ACE) inhibitors, and beta blockers may require weeks or months to become fully apparent.
The most commonly used loop diuretic for the treatment of HF is furosemide, but some patients respond better to bemetanide or torsemide because of superior and more predictable absorption. The usual starting dose in outpatients with HF is 20 to 40 mg of furosemide or its equivalent; the maximum suggested total daily dose of furosemide is 400 mg (though some use higher doses).
HFpEF
Diuretics — Diuretic therapy is used in patients with HFpEF to treat volume overload. Diuretic therapy should be administered with caution to avoid excessive preload reduction and hypotension. The beneficial effect of diuretics was suggested by an ancillary study from the CHAMPION trial (mentioned above), in which medical treatment decisions driven by knowledge of pulmonary artery pressure data were associated with a significant reduction in hospitalizations for HF. The majority of medication changes were in diuretic usage, and mean diuretic dose increased significantly more in the pulmonary artery pressure-guided treatment group. These data provide indirect evidence supporting the efficacy of diuretics to reduce morbidity in HFpEF
REF. UpToDate 2019.08.09
