Dr. Brandon Varr, an advanced heart failure and transplant cardiologist, provides insight into how heart failure is managed by diuretics and whether or not fluid restriction is important. Heart Failure (HF) RefresherHeart Failure (HF) simple means that the heart is not pumping enough blood to adequately supply organs.Body’s “Short Term Fix”: Kidneys sense that there is not enough blood → salt retention to expand fluid volume in bodyLong Term effect of above “Short Term Fix”: Fluid retention → congestion, breathing discomfort, edema TYPES OF DIURETICS (MAIN 4):Loop “Workhorse” or most commonly known diuretic known time and time again for their effectiveness and safetyFurosemide (Lasix) is the most commonly used loop diuretic in the hospital. Bumetanide (Bumex) is also used.Thiazide Adjunct (aka booster) therapy to loop diuretics in HF (ie augments the effects of loop diuretics when a loop diuretic is not producing the desired effects)Potassium Sparing (Aldosterone Antagonists)Another adjunct diuretic. Notably, as its name implies, does not lower serum potassium levelsPer Dr. Varr, this class of medication is often under-dosed or not given when could be beneficial to stabilize serum potassium levelsMost common: Spironolactone (Aldactone)OtherVasopressin inhibitorsReserved for patients who are experiencing significant hyponatremiaSGLT2 Inhibitors (-FLOZIN) Ex: Empagliflozin Per Dr. Varr: Upcoming blockbuster agent because it not only provides diuresis but also increases cardiac efficiencyAngiotensin Receptor Neprilysin Inhibitor (ARNI) Ex: EntrestoHolding ParametersHow much do diuretics influence BP?Concerned more with combo diuretic therapy with thiazideLoop and aldosterone antagonists with modest effectsWhen are we justified in holding on diuretics?Hypotension due to hypovolemiaHypotension with symptomsSevere electrolyte derangementsImportant Take-AwaysThink critically as to WHY your patient is here in the hospital. For example, a decompensated HF patient is in the hospital to lose weight, salt, and take aggressive diuretics to help them feel better. If a patient is hypotensive, look at their meds and think about which medication to hold (usually NOT the diuretic). Consider adjusting BP meds before holding a diuretic.Nurses should hold other BP meds before holding diuretics if patient is hospitalized for fluid overloadFluid RestrictionsThink about patient’s quality of life and patient happiness when it comes to fluid restriction. Drinking tap water (1800 – 2200 ccs) will not be hugely impactful on HF management, but can be for their quality of life.Keeping people on fluid restrictions as they are nearing their dry weight can lead to adverse effects → low BP, dehydration, worsening kidney function I&Os v. Os & WeightI think that strict intakes are just complete waste of time, from a general telemetry floor level patient who’s getting Lasix BID and responding. What I’m more concerned with is how much urine came out that day, what was their weight yesterday and what was their weight today on the same scale standing up in the morning? Those are the most useful things to me is their overall urine output for the day and how much weight they’ve gained or lost.Dr. Brandon VarrMore useful: Overall output for day and daily weights