Diuretic usage in Chronic Heart

Failure patient without Edema: A

Case
Report
M Yusuf Fathoni, Farial Indra, Cut Azlina, Niken Anthea S, Paskariatne
Yamin, Muhammad Husin, Teuku Thoriq, Nabilla Gusrina, Ismi
Purnawan
Department of Cardiology, Gatot Soebroto Central Army Hospital,
Jakarta
Introduction
Diuretic therapy remains the
cornerstone of heart failure wth
volume
overload
treatment.
Recently, there are tendency of
diuretics prescription to heart
failure patients with or without
hypervolemic state
Case Description
A 53-year-old male patient with
history
of
recurring
acute
decompensated
heart
failure
episode came to outpatient clinic
for monthly evaluation. For one
month
Patients
has
taken
Furosemide
40
mg,
Spironolactone 25 mg, Bisoprolol
2.5 mg, Ramipril 5 mg, and
Amlodipine 5 mg, patient have no
history of pretibial edema before
this medication. His current
symptoms were dyspnea on mild
activities, as he could only walk
less than 300 meters with
shortness of breath. The patients
blood pressure was 140/80 mmHg
and heart rate was 98 bpm.
Echocardiography
examination
showed eccentric left ventricular
hypertrophy and reduced left
ventricular ejection fraction (EF
16%)
with
global
systolic
hypokinesis. The diuretic was
stopped and Ramipril was up
titrated to optimal dosage of 10
mg. Patients evaluation in the
following month showed an
improvement in his physical
activity. He was able to walk more
Keywords: heart failure, diuretics, congestion,
than
2
kilometers
without
ACE-inhibitors

Discussion
Diuretic consumption in normovolemic heart
failure paient will stimulate renin angiotensin
aldosterone system may lead into increased
angiotensin 2. Angiotensin 2 is a potent
peripheral
vasoconstrictor
with
increased
adrenergic activity would increase systemic
vascular resistance (SVR). The increased SVR
would decrease stroke volume and cardiac
output that would eventually lead to a vicious
cycle of worsening heart failure. Meanwhile, ACEinhibitors
would
reduce
Angiotensin
II,
diminished afterload and thereby elevated
cardiac output. The diuretic was stopped
because the patient was on a euvolemic state.
Optimization in ACE-inhibitor dosage leads to
Conclusion
improvement of patients
physical capabilities
Although
therapy
the main treatment
and morediuretic
controlled
heartisrate.
for heart failure with volume overload, however it
shouldnt be given in heart failure patient with
euvolemic state.

Figure 1: After 2 month of follow up, patient LVEF

increased to 23.4%
Reference
1. Clyde et al, 2013 ACC/AHA Guideline for the management of
heart failure
2. Dickstein Kenneth et al, ESC Guidelines for the diagnosis and
treatment of acute and chronic heart failure
3. Douglas et al, Braunwald Heart Disease: A Textbook of
cardiovascular Medicine