Cardiac failure Info desk : Diuretics never save lives, while Dapagliflozin does it in style !

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An Interaction in IMCU

How is Mr. K, who was shifted from ward 102  ?

Yes sir, It was acute decompensated LV failure, Patient was in impending pulmonary edema.

Yes, how did he come around? He was too sick I thought.

“Just pushed 40 mg Frusemide IV, luckily he also had good BP, so with an infusion of NTG, titrated Carvedilol a little bit, he came out nicely. I guess it is Ischemic DCM”.

“Good, You have done a nice job”

“Don’t make me embarrassed sir. It is such a routine in our ER.

To put him in curiosity, I asked “Which drug do you think that saved him” ?

“Obviously, Frusemide sir. He was frothing out. It was a matter of 20 minutes he passed 500 ml lung fluid through the urine”.

I agree, but as a professor, teaching cardiology for 30 years I need to tell you this. Let me clarify diuretics never save lives. It has no survival benefit in heart failure. 

Sir, I guess you are not joking. Does this statement apply to acute heart failure? I have saved 100s of lives with Frusemide,  both in acute, acute on chronic and even in chronic cardiac failures with metolazone

Hmmm, I agree with you my dear student, Frusemide has saved not hundreds but lakhs of lives in the past decades in all forms of heart failure. It continues to do this fabulous job even now. But, don’t say it in exams or scientific forums, they will laugh at you. You can’t credit a drug without evidence. Also realize, saving lives by unscientific means is not something to boast upon. We need the blessings of RCTs, or Kaplans Mayer curves, or Forrest blobbograms. Unfortunately . that is the current principle of practice of medicine.

But sir, who is preventing whom, to do such studies. Why they are not comparing diuretics one to one with these modern drugs of inotropes, calcium modulators, or SGLTis, etc?

I am not sure. My guess is, there are no good friends in the cardiac failure research community for this old warrior drug. 

Cardiac failure Info desk : Diuretics never save lives, while Dapagliflozin does it in style ! 1

Loop diuretics 

Till 1964, toxic mercurial which were saving lives in refractory heart failures. The Na+/K+ /Cl channel blocker Frusemide, ( in the thick ascending limb of the loop of Henle) is the single most powerful drug that changed the way we manage cardiac failure in both acute and chronic settings. Still, the current evidence creators hesitate to call it a life-saving drug,

The meteoric rise of SGLT-2 Inhibitors 

Meanwhile, a few micrometers down the hairpin bend of Henle, drugs called phlorizin are doing wonders. These Apple root barks derivatives were since been invaded by Glyflozins Industry. They are made into a powerful glycosuric drug that drags water out of the system along with glucose. This seems to be the biggest revolution in cardiac pharmacology ever since DaVinci drew the heart and Harvey made it functional. I think we need a supercomputer to count the number of papers and analyze the data from Dapa & Empaglyflosin. It is now concluded officially as an evidence-based live saver in HF.

I asked one Gen X Pharma-geek, “How do these magic drugs perform this miracle in heart failure”? He said beamingly, It is not merely Glyco-diuresis, as you academicians think, it is some mystery action from heaven, still not decoded. What a revelation I thought.

Cardiac failure Info desk : Diuretics never save lives, while Dapagliflozin does it in style ! 2

Continuing Medical Education desk

Final message

Diuretics are powerful drugs that aid the failing heart to reduce both pre and after-load. It is a fact, indiscriminate use of these drugs leads to some electrolytes and metabolic issues. But, hiding behind a hazy and shaky evidence base, and trying to ridicule these life-sustaining drugs, is the height of senselessness in cardiac failure literature.

Reference 

(There is a tug of war of evidence between benefits and risks. I guess someone will bring out the truth, which is written clearly on the walls)

1. Chris J Kapelios, Konstantinos Malliaras, Elisabeth Kaldara, Stella Vakrou, John N Nanas, Loop diuretics for chronic heart failure: a foe in disguise of a friend?, European Heart Journal – Cardiovascular Pharmacotherapy, Volume 4, Issue 1, January 2018, Pages 54–63, https://doi.org/10.1093/ehjcvp/pvx020

2.Faris R, Flather M, Purcell H, Henein M, Poole-Wilson P, Coats A. Current evidence supporting the role of diuretics in heart failure: a meta-analysis of randomized controlled trials. Int J Cardiol. 2002 Feb;82(2):149-58. doi: 10.1016/s0167-5273(01)00600-3. PMID: 11853901.