Intended for healthcare professionals

Clinical Review ABC of heart failure

Management: diuretics, ACE inhibitors, and nitrates

BMJ 2000; 320 doi: (Published 12 February 2000) Cite this as: BMJ 2000;320:428
  1. M K Davies,
  2. C R Gibbs,
  3. G Y H Lip

    In the past 15 years several large scale, randomised controlled trials have revolutionised the management of patients with chronic heart failure. Although it is clear that some drugs improve symptoms, others offer both symptomatic and prognostic benefits, and the management of heart failure should be aimed at improving both quality of life and survival.

    Aims of heart failure management

    To achieve improvement in symptoms



    ACE inhibitors

    To achieve improvement in survival

    ACE inhibitors

    βblockers (for example, carvedilol and bisoprolol)

    Oral nitrates plus hydralazine


    Diuretics and angiotensin converting enzyme (ACE) inhibitors, when combined with non-pharmacological measures, remain the basis of treatment in patients with congestive heart failure. Digoxin has a possible role in some of these patients, however, and the potential benefits of β blockers and spironolactone (an aldosterone antagonist) in chronic heart failure are now increasingly recognised.


    Diuretics are effective in providing symptomatic relief and remain the first line treatment, particularly in the presence of oedema. Nevertheless, there is no direct evidence that loop and thiazide diuretics confer prognostic benefit in patients with congestive heart failure.

    In general, diuretics should be introduced at a low dose and the dose increased according to the clinical response. There are dangers, however, in either undertreating or overtreating patients with diuretics, and regular review is necessary

    Loop diuretics

    Loop diuretics—frusemide (furosemide) and bumetanide—have a powerful diuretic action, increasing the excretion of sodium and water via their action on the ascending limb of the loop of Henle. They have a rapid onset of action (intravenously 5 minutes, orally 1–2 hours; duration of action 4–6 hours). Oral absorption of frusemide may be reduced in congestive heart failure, although the pharmacokinetics of bumetanide may allow improved bioavailability.

    How to use diuretics in advanced heart failure

    • Optimise diuretic dose

    • Consider combination diuretic treatment with a loop and thiazide (or thiazide-like) diuretic

    • Consider combining a low dose of spironolactone with an ACE inhibitor, provided that there is no evidence of hyperkalaemia …

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