Key result
Phased diuretic therapy requires aggressive acute loop decongestion before de-escalating post-euvolaemia in HFrEF.
This narrative review provides a phase-based cardiorenal framework for HFrEF management that balances aggressive acute decongestion with loop diuretics against long-term diuretic de-escalation and foundational therapy optimization once euvolaemia is achieved.
Offers phase-based diuretic framework for acute HFrEF; leaves open prospective validation before practice change.
Loop diuretics remain the cornerstone of decongestion in acute heart failure, yet their use in heart failure with reduced ejection fraction (HFrEF) is obscured by two competing errors: undertreating congestion because serum creatinine rises, and continuing or escalating diuretics after euvolaemia. This narrative review integrates established evidence and contemporary guidance into a phase-based cardiorenal decision framework. Congestion is framed as a continuum generated by sodium retention, redistribution of stressed blood volume, vascular and ventricular compliance, right-sided pressure, and renal sodium avidity—not as a binary distinction between pressure and volume overload. During acute decompensation, intravenous loop diuretics remain first-line therapy; early urine output and spot urinary sodium can identify inadequate response and support protocolized escalation. Acetazolamide or a thiazide-type diuretic can improve decongestion when loop response is insufficient, although renal and electrolyte surveillance is essential. Sodium–glucose cotransporter 2 inhibitors should be initiated for disease modification after stabilization, but their context-dependent natriuretic effect does not replace loop diuretics in marked congestion. A creatinine rise during effective decongestion should be interpreted with residual congestion, haemodynamics, urine output, electrolytes, and evidence of kidney injury rather than through a universal threshold. After stabilization, implementation of foundational HFrEF therapy and reassessment of the minimum effective loop dose become priorities. Studies suggest that dose reduction or withdrawal is feasible in stable, euvolaemic patients, but event-powered evidence and validated outpatient biomarkers are lacking. Diuretics and disease-modifying therapy therefore have complementary, time-dependent roles: remove sodium when congestion is present, protect the kidney while recognizing hypoperfusion and intrinsic kidney injury, and de-escalate only after euvolaemia.
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Tsalouchos et al. (2026) conducted a review in Heart failure with reduced ejection fraction (HFrEF). Diuretic therapy (loop diuretics, acetazolamide, thiazide-type diuretics) and SGLT2 inhibitors was evaluated. Diuretic therapy and foundational HFrEF treatment have complementary, time-dependent roles: actively decongest with loop diuretics acutely and de-escalate only after achieving euvolaemia.
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