Diuretic Strategies in Patients with Acute Decompensated Heart Failure N Engl J Med 2011;364:797-805.

This paper should be kind of a big deal I think.

We treat a lot of heart failure, and we don’t really know how to treat it. We give lots of drugs to make you pee, to “dry” out the lungs but we have no real evidence that it works or does anything.

These guys tried to answer a bit of the question.

Allowing that we’ll give them diuretics even without evidence, what about the dose (high vs low) or the mean by which we give the drug (bolus vs infusion)

Enrolled sickish CHF patients but excluded the real ICU cases. They enrolled them once in the hospital, not from the ED.

Low dose was their daily, chronic dose but in IV form, and high dose was 2.5 times their normal daily dose.

The fascinating thing was that they found diddly-squat of a difference no matter what treatment they got. Not only was there no difference in their primary outcome (a basic “do you feel better at 48 hours” but there wasn’t even any difference in harm! If we gave them 2.5 times the does, the kidneys did pretty much the same.

When I rooted around in the supplementary appendix for the mortality rate (and why wasn’t it in the paper?) it was roughly 15% at 60 days for all 4 groups.

This should really beg the question – if it doesn’t make a difference how or how much we give of it should we be doing it at all?

Of course us empiricists have been asking this for a while, we just don’t have the answer yet.

Over my 6 years working, i’ve changed a lot in my use of diuretics, from low dose, to mega-dose, to almost homeopathic dose these days. It’s hard to admit a patient with CHF without giving some, people look at you funny.

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