Long term prescription of
diuretics for
heart failure is very prevalent among elderly patients, although the rationale for such a treatment strategy is often unclear, as
diuretics are not indicated if volume overload is absent. The concept of
diastolic heart failure in the elderly might particularly change the role of
diuretic therapy, since
diuretics may have additional adverse effects in these patients. This paper reviews the effects of
diuretic therapy in elderly patients with
heart failure, emphasising the differences between patients with normal and decreased left ventricular systolic function. Studies on
diuretic withdrawal in elderly patients with
heart failure are discussed, with emphasis on issues involved in decision making such as
diuretic dose reduction and withdrawal in elderly patients and factors that have been established to predict successful withdrawal. Existing guidelines on the prescription of
diuretics in elderly patients with
heart failure with normal and decreased left ventricular systolic function and in those with
diastolic heart failure are also discussed. By reducing intravascular volume,
diuretics may further impair ventricular diastolic filling in patients with
diastolic heart failure and thus reduce stroke volume. Indeed, preliminary studies demonstrate that
diuretics may provoke or aggravate
hypotension on standing and after meals in these patients. Therefore, it is suggested that elderly patients with
heart failure with intact left ventricular systolic function should not receive long term
diuretic therapy, unless proven necessary to treat or prevent
congestive heart failure. This implies that physicians should carefully evaluate the opportunities for
diuretic dose tapering or withdrawal in all of these patients, and that a cautiously guided intermittent
diuretic treatment modality may be critical in the care for older patients with
heart failure with intact left ventricular systolic function.