Administration of loop diuretics in acutely decompensated heart failure

Evidence Summaries

Level of Evidence = C

Loop diuretics given as continuous infusion in acutely decompensated heart failure may provide greater diuresis and a better safety profile as compared to single intravenous bolus administration, but good quality evidence is lacking.

A Cochrane review 1 included eight studies with a total of 254 subjects. In seven studies which reported on urine output, the output (as measured in cc/24 hours) was noted to be greater in patients given continuous infusion with a weighted mean difference (WMD) of 271 cc/24 hour (95%CI 93.1 to 449; p<0.01). Electrolyte disturbances (hypokalemia, hypomagnesemia) were not significantly different in the two treatment groups with a relative risk (RR) of 1.47 (95%CI 0.52 to 4.15; p=0.5). Less adverse effects (tinnitus and hearing loss) were noted when continuous infusion was given, RR 0.06 (95%CI 0.01 to 0.44; p=0.005). Based on a single study, the duration of hospital stay was significantly shortened by 3.1days with continuous infusion WMD -3.1 (95%CI -4.06 to -2.20; p<0.0001) while cardiac mortality was not significantly different in the two treatment groups, RR 0.47 (95% CI 0.33 to 0.69; p<0.0001). Based on two studies, all cause mortality was not significantly different in the two treatment groups, RR 0.52 (95%CI 0.38 to 0.71; p<0.0001). The existing data does not allow definitive recommendations for clinical practice.

Comment: The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment) and by imprecise results (few patients and wide confidence intervals).

References

1. Salvador DR, Rey NR, Ramos GC, Punzalan FE. Continuous infusion versus bolus injection of loop diuretics in congestive heart failure. Cochrane Database Syst Rev 2005 Jul 20;(3):CD003178.  [PMID:16034890]


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