Diuretic treatment in heart failure

How to plan diuretic treatment in patients with heart failure to prevent volume overload? Should the treatment be based on the presence of edema or other symptoms or on B-type natriuretic peptide (BNP) levels?

Harriette Van Spall, MD: Changes in BNP can suggest hemodynamic perturbations that typically precede clinical symptoms of heart failure. We have meta-analysis data that indicate that BNP-guided treatment can improve both mortality risk and rehospitalization risk in patients with heart failure.

Typically, clinical trials that tested this mechanism of optimization of therapies have primarily recruited patients with reduced ejection fraction (EF). For example, BNP-guided therapy is recommended in patients with reduced EF, in particular in younger patients with reduced EF, since there are data that the improved outcomes are primarily in patients under the age of 72.

That is one way that you can optimize therapies without relying on symptoms, which typically can lag behind changes in your cardiac biomarkers. That said, symptoms and close follow-up should be used as an importance guide in assessing volume status. You do not need the presence of right-sided edema, but signs of left ventricular (LV) filling pressure elevation—so symptoms of dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND)—can suggest that you are volume overloaded and you can titrate diuretics to effect. The dosing of the diuretics often depends on a variety of different things. If the patient has been naive to diuretics, they can be more responsive. If they have kidney disease, they might be less responsive. So it is a matter of titrating it to the person.

Your question about BNP is important because there is no one BNP level that is normal for a patient. There are ranges of BNP that are considered in the normal range, but for any one patient, their resting BNP level when they are in compensated heart failure might be different from another patient. It is the changes in BNP that are used as a guide versus an absolute number.