Djw. Van Kraaij et al., Diuretic therapy in elderly heart failure patients with and without left ventricular systolic dysfunction, DRUG AGING, 16(4), 2000, pp. 289-300
Long term prescription of diuretics for heart failure is very prevalent amo
ng elderly patients, although the rationale for such a treatment strategy i
s often unclear, as diuretics are not indicated if volume overload is absen
t. The concept of diastolic heart failure in the elderly might particularly
change the role of diuretic therapy since diuretics may have additional ad
verse effects in these patients. This paper reviews the effects of diuretic
therapy in elderly patients with heart failure, emphasising the difference
s between patients with normal and decreased left ventricular systolic func
tion. Studies on diuretic withdrawal in elderly patients with heart failure
are discussed, with emphasis on issues involved in decision making such as
diuretic dose reduction and withdrawal in elderly patients and factors tha
t have been established to predict successful withdrawal. Existing guidelin
es on the prescription of diuretics in elderly patients with heart failure
with normal and decreased left ventricular systolic function and in those w
ith diastolic heart failure are also discussed. By reducing intravascular v
olume, diuretics may further impair ventricular diastolic filling in patien
ts with diastolic heart failure and thus reduce stroke volume. Indeed, prel
iminary studies demonstrate that diuretics may provoke or aggravate hypoten
sion on standing and after meals in these patients. Therefore, it is sugges
ted that elderly patients with heart failure with intact left ventricular s
ystolic function should not receive long term diuretic therapy, unless prov
en necessary to treat or prevent congestive heart failure. This implies tha
t physicians should carefully evaluate the opportunities for diuretic dose
tapering or withdrawal in all of these patients, and that a cautiously guid
ed intermittent diuretic treatment modality may be critical in the care for
older patients with heart failure with intact left ventricular systolic fu
nction.