Fast Five Quiz: Heart Failure With Reduced Ejection Fraction (HFrEF) Treatment Optimization

Alanna Morris, MD; Michael Weber, MD; Jeffrey J. Hsu, MD


November 16, 2023

According to the most recent guidelines from the European Society of Cardiology, diuretics are recommended to maintain or achieve euvolemia at the lowest possible dose. Loop diuretics combined with thiazides may be considered in patients with refractory edema unresponsive to loop diuretics alone. However, this combination might increase the risk for adverse effects, such as hypokalemia and hyponatremia. Loop diuretics generate a diuresis that is more intense but shorter in duration than that produced by thiazides.

Updated ACC guidelines note that lower doses of loop diuretics might be necessary for initiation and/or optimal titration of an ARNI/ACEI/ARB to avoid hypotension in patients with a systolic blood pressure ≤ 100 mmHg. Careful attention to potassium concentrations is necessary because the kaliuretic effects of loop diuretics might no longer be present; this might require restriction of supplemental and/or dietary potassium. Results from a randomized controlled study presented at the ACC 2022 Scientific Sessions report that addition of a potassium-sequestrant patiromer may protect patients sufficiently against hyperkalemia to allow the use of RAS-inhibiting medications at higher doses.

Learn more about the treatment of HFrEF.


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