Loop Diuretics in Acute Decompensated Heart Failure Necessary? Evil? A Necessary Evil?
Loop Diuretics in Acute Decompensated Heart Failure Necessary? Evil? A Necessary Evil?
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DOI：
10.1161/circheartfailure.108.821785
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发表时间：
2009-01-01
影响因子：
9.7
通讯作者：
Braunwald, Eugene
中科院分区：
文献类型：
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作者：
Felker, G. Michael;O'Connor, Christopher A.;Braunwald, Eugene
急性失代偿性心力衰竭（ADHF）是65岁患者住院的最常见原因，仅在美国每年就有100万例住院，600万个住院日和120亿美元的费用。1，2 ADHF患者的预后很差，6个月内再住院或死亡率接近50%。尽管有这些令人担忧且经常被引用的统计数据，但近几十年来ADHF新疗法的发展几乎没有改变，5短期和中期结局仍然很差。6除了刺激ADHF新疗法的开发外，这些数据还表明需要对当前治疗进行积极的重新评估。本文将重点介绍支持袢利尿剂治疗ADHF的有效性和安全性的数据（或缺乏数据），讨论在ADHF中进行利尿剂临床试验的挑战，并描述一项正在进行的临床试验，旨在严格评估利尿剂在该综合征中的最佳使用。来自ADHF国家登记处的数据表明，在美国，约90%的ADHF住院患者在住院期间接受IV袢利尿剂。7考虑到大多数ADHF住院治疗与容量超负荷和充血有关，因此在ADHF中几乎普遍使用袢利尿剂是可以理解的，8并且数十年的临床观察表明，静脉注射袢利尿剂可使大多数患者迅速利尿并缓解症状。尽管有如此广泛的临床经验，但是，支持袢利尿剂治疗ADHF的安全性和有效性的高质量数据很少。因此，美国心力衰竭协会最近的ADHF实践指南推荐袢利尿剂的剂量为“产生足以达到最佳容量状态的利尿速率所需的剂量”。9值得注意的是，本指南具有最强的推荐等级（推荐），但证据等级最低（C，基于
Acute decompensated heart failure (ADHF) is the most common cause of hospital admission in patients 65 years, accounting for 1 million hospitalizations, 6 million hospital days, and $12 billion in costs annually in the United States alone. 1, 2 The prognosis of patients admitted with ADHF is dismal, with rates of rehospitalization or death approaching 50% within 6 months. 3, 4 Despite these alarming and oft-cited statistics, the development of new therapies in ADHF has changed little over recent decades, 5 and short-term and intermediate-term outcomes have remained poor. 6 In addition to spurring the development of new therapies for ADHF, these data suggest the need for an active reappraisal of current therapy. This review will focus on the data (or lack thereof) supporting the efficacy and safety of loop diuretics in ADHF, discuss the challenges in performing clinical trials of diuretics in ADHF, and describe an ongoing clinical trial designed to rigorously evaluate optimal diuretic use in this syndrome.Loop diuretics are the foundation of current ADHF therapy. Data from the ADHF National Registry demonstrate that approximately 90% of patients hospitalized with ADHF in the United Sates receive IV loop diuretics during the hospitalization. 7 This nearly ubiquitous use of loop diuretics in ADHF is understandable given that the majority of ADHF hospitalizations are related to volume overload and congestion, 8 and decades of clinical observation has shown that IV administration of loop diuretics results in prompt diuresis and relief of symptoms in most patients. Despite this breadth of clinical experience, however, high quality data supporting the safety and efficacy of loop diuretics in ADHF are sparse. Accordingly, the most recent practice guidelines for ADHF from the Heart Failure Society of America recommend loop diuretics at “doses needed to produce a rate of diuresis sufficient to achieve an optimal volume status.” 9 Notably, this guideline has the strongest level of recommendation (is recommended) but the lowest level of evidence (C, based on