Perspective:

Top 10: This state-of-the art paper summarizes the current data regarding the use of diuretics and ultrafiltration in patients with acute heart failure (HF).

1. Loop diuretics inhibit the Na+/K+/2Cl- transporter in the thick ascending limb of the loop of Henle, causing diuresis and natriuresis. Torsemide has the longest half-life (3-4 hours), and bumetanide and torsemide have a better bioavailability than furosemide.

2. Diuretics have a Class I recommendation for HF therapy, but the level of evidence is based on expert opinion with few clinical studies.

3. Studies suggest that large volume fluxes induced by high-dose diuretics may lead to activation of the renin-angiotensin-aldosterone system and may lead to an increased mortality and renal dysfunction.

4. The DOSE trial was a blinded, randomized trial evaluating furosemide continuous infusion versus high- (2.5x oral) or low-dose (1x oral) diuretic boluses. Patients on a higher diuretic regimen had more net fluid loss and less dyspnea. Serious adverse events were overall lower in the high-dose furosemide group.

5. Diuretic resistances should be considered when a patient requires escalating diuretic doses or have reached maximum recommended dosing without incremental improvement in diuresis.

6. Thiazide diuretics and spironolactone at natriuretic doses can be used to overcome loop diuretic resistance. Thiazides may provoke large volume fluxes and electrolyte disturbances due to brisk diuresis.

7. Ultrafiltration (Uf) allows for rapid and controlled isotonic fluid removal, leading to more Na+ and potassium removal for an equivalent volume compared with that of diuretics.

8. Data suggest that controlled Uf (avoiding intravascular volume depletion) may lead to lower plasma renin, norepinephrine, and aldosterone levels than that following diuretics use.

9. Unblinded trials of Uf versus diuretics have demonstrated greater weight loss, less electrolyte disturbances, and reduced HF rehospitalization with Uf, but larger trials are needed to confirm results and demonstrate cost-effectiveness.

10. Currently, guidelines only recommend Uf for patients who have failed traditional medical therapy (Class IIa, Level of Evidence B).