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

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


March 13, 2023

According to the 2021 guidelines from the European Society of Cardiology, diuretics are recommended to maintain or achieve euvolemia with the lowest possible dose. Loop diuretics combined with thiazides may be considered in patients with refractory edema unresponsive to loop diuretics alone. This combination should be used with care because it may increase the risk for adverse effects, such as hypokalemia, hyponatremia, and worsening renal function. Although they act synergistically in combination, 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 may be necessary for initiation and/or optimal titration of an ARNI/ACEI/ARB to avoid hypotension in patients with a systolic blood pressure ≤ 100 mm Hg. Careful attention to potassium concentrations is necessary because the kaliuretic effects of loop diuretics may no longer be present, and restriction of supplemental and/or dietary potassium may be required. A recent randomized controlled study concluded that the addition of a potassium-sequestrant patiromer may protect patients against hyperkalemia enough that they can take RAS-inhibiting therapy at higher doses.

Learn more about the treatment of HFrEF.


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