Diuretic therapy in elderly heart failure patients with and without left ventricular systolic dysfunction

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.