COMBINATION DIURETIC TREATMENT IN SEVERE HEART-FAILURE - A RANDOMIZEDCONTROLLED TRIAL

Objectives-(a) To test the hypothesis that a fixed 3 day course of the combination of a thiazide and loop diuretic is as effective as more p rolonged treatment in the management of severe resistant cardiac failu re. (b) To compare two thiazide diuretics (bendrofluazide and metolazo ne) in combination with loop diuretics in the treatment of severe resi stant cardiac failure. Design-Randomised study with a 2 x 2 factorial design. Setting-Provincial teaching hospital. Patients-33 consecutive patients (40 episodes) admitted with severe congestive cardiac failure (New York Heart Association class III or IV) unresponsive to intraven ous loop diuretics for 48 hours. Main outcome measures-Change in daily weight and serum electrolytes and clinical improvement in heart failu re. Results-Diuresis was established during 37 of 40 episodes; of the rest two patients died in hospital. On 36 occasions improvement was su fficient to allow discharge from hospital. Median (range) maximal weig ht loss was -5.05 (-11.3 to 1.6) kg after the addition of bendrofluazi de and -5.6 (-12.2 to 4.8) kg after the addition of metolazone (NS). A rea under the body weight loss against time curves showed no significa nt difference between the two thiazide diuretics. Median (range) maxim al weight loss after three days of treatment was -5.4 (-12.2 to 4.8) k g and -5.5 (-10.3 to 1) kg after a more prolonged course of median (ra nge) 5.6 (1 to 13) days (NS). Area under the body weight loss time cur ves showed no significant difference between the two durations of trea tment. Bendrofluazide was associated with fewer electrolyte disturbanc es. Conclusions-Bendrofluazide and metolazone were equally effective i n establishing a diuresis in patients with severe congestive cardiac f ailure resistant to loop diuretics. A fixed three day course of the co mbination was as effective as a longer course.