REFOCUS ON DIURETICS IN THE TREATMENT OF HEART-FAILURE

Diuretics have long been accepted as the traditional first-line treatm ent of the patient with symptomatic heart failure what ever its aetiol ogy or dysfunctional stage Their acceptance in this role is based on t he rapid improvement in congestive symptoms experienced by most patien ts, which is arguably greater than that induced by any other currently available anti-heart failure drug. This symptomatic efficacy and thei r universal clinical acceptance as first-step treatment for the patien t with symptoms of heart failure has precluded formal examination of t heir impact on prognosis. Evidence from indirect studies suggests that when wed alone they may not be able to prevent clinical deterioration possibly due to excitation af the renin-angiotensin-aldosterone syste m. When such excitation is suppressed by concomitant administration of angiotensin-converting enzyme inhibitors, relief of congestive sympto ms is enhanced and the morbidity and mortality risk of heart failure s ignificantly reduced. Studies on the mechanisms of diuretic resistance have demonstrated the synergy of diuretic activity when low doses of diuretics acting at different sites of the nephron are used in combina tion. Diuretics remain the cornerstone of treatment for symptoms in co ngestive heart failure but their overall efficacy is substantially imp roved when combined with ACE inhibitors.