DISCONTINUATION OF CHRONIC DIURETIC THERAPY IN STABLE CONGESTIVE-HEART-FAILURE SECONDARY TO CORONARY-ARTERY DISEASE OR TO IDIOPATHIC DILATED CARDIOMYOPATHY

To assess the feasibility of diuretic discontinuation In patients with stable congestive heart failure (CHF) and to identify risk factors fo r subsequent development of congestion, a prospective, 12-week clinica l trial of unmasked diuretic withdrawal was conducted with continuatio n of background CHF therapy and double-blind randomization to placebo or lisinopril. Forty-one patients with a history of CHF and continuous diuretic use for greater than or equal to 3 months had all diuretic t herapy discontinued, and therapy with lisinopril 5 mg (target 20 mg)/d ay (n = 20) or placebo (n = 21) begun the next day. A diuretic was res tarted if new or worsening CHF symptoms and signs developed. Twelve pa tients (29%) did not require diuretic reinitiation at any time during follow-up, whereas 29 (71%) restarted diuretic therapy after a median of 15 days (range 2 to 42). Fourteen patients taking lisinopril and 15 taking placebo required diuretic drugs (p = NS). The baseline daily f urosemide dose of >40 mg a left ventricular ejection fraction less tha n or equal to 0.27, and history of systemic hypertension were independ ently predictive of early diuretic reinitiation by Cox proportional-ha zards analysis. The probability of remaining diuretic-free after 6 wee ks was 71% if none of these criteria were present. This trial demonstr ates the feasibility of discontinuing diuretic drugs in certain patien ts with stable CHF and predicts those patients likely to require reini tiation of therapy. Diuretic withdrawal may be warranted when the furo semide dose is less than or equal to 40 mg/day, left ventricular eject ion fraction is >0.27 and when no history of systemic hypertension is present.