Using Combinational Diuretics Across the Spectrum of Renal Function

This article refers to 'Combining loop and thiazide diuret-ics for acute heart failure across the estimated glomeru-lar filtration rate spectrum: A post-hoc analysis of the CLOROTIC trial' by J.C. Trullàs et al., published in this issue on pages 1784-1793. Acute heart failure (AHF) remains one of the most frequent reasons for admissions in patients older than 65 years of age. Worsening of signs and symptoms of congestion are the main reasons why patients with acute heart failure seek urgent care. 1 Congestion is the end-product of an abnormal interaction between the compliance of-and the volume within-the cardiovascular system. Not all congestion is caused by an increase in extracellular volume, as decreases in compliance with fluid shifts resulting in an increased stressed blood volume can also lead to congestion. While vasodilatation might be the preferred medication for the latter, diuretics are predominantly recommended by guidelines to treat signs and symptoms of volume overload. 2 Given the central role of congestion in AHF, it is not surprising that loop diuret-ics are a cornerstone therapy used in AHF. In clinical practice, congestion can often persist despite the use of loop diuretics. Residual congestion at discharge is associated with poor clinical outcome. It is unclear if this congestion itself mediates the poor outcome, or whether other clinical factors (renal dysfunction, frailty, high comorbidity burden) generate an inability to attain decongestion and optimize guideline-directed medical therapy and also influence the poor outcome. Indeed, several recent trials have shown that despite a higher likelihood of attaining deconges-tion in AHF with reductions in length of stay by achieving faster and safe decongestion via cheap and easy to implement diuretic strategies, that this did not necessarily translate into improved longer-term survival. 3-5 Nevertheless, the short-term goal in a patient that seeks urgent care for volume overload is to get rid of the excessive volume as this is the principal complaint of those patients. Every physician intimately involved in patient care will recognize the importance of attaining this goal when the patient presents in one of the most vulnerable phases in their disease trajectory. Achieving this goal in a safe and efficient manner is an important basis for a healthy doctor-patient relationship, The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Heart Failure or of the European Society of Cardiology.