Loop Diuretic Dosing in HFpEF

Evidence-Based Dosing Strategy

The American College of Cardiology and European Society of Cardiology recommend starting with furosemide 20-40 mg once or twice daily for patients with signs of congestion, with a strength of evidence based on clinical guidelines 1, 2, 3, 4, 5
For patients already on chronic oral diuretics, the initial dose should be at least equivalent to their current regimen, as stated by the American College of Cardiology 4, 1, 3, 5

Guidelines do not differentiate loop diuretic dosing between HFpEF and HFrEF, as stated by the American Heart Association and European Society of Cardiology 1, 2, 3
The European Society of Cardiology explicitly states diuretics relieve dyspnea and edema "irrespective of EF" 2
Diuretics remain the only drugs proven to adequately control fluid retention in heart failure regardless of ejection fraction, according to the American College of Cardiology 3

Increase the dose systematically until achieving target response, aiming for weight loss of 0.5-1.0 kg daily, as recommended by the American College of Cardiology 4, 1, 3, 5, 7
If inadequate response after initial dose, increase by 20-40 mg increments, with a maximum daily dose of 600 mg in severe cases, as stated by the American College of Cardiology 4, 1, 3, 5

Bumetanide: 0.5-1.0 mg once or twice daily, with better oral bioavailability, as recommended by the American College of Cardiology 4, 1, 3
Torsemide: 10-20 mg once daily, with a longer duration of action, as stated by the American College of Cardiology 4, 1, 3

The goal is to achieve "dry weight" with the lowest possible dose, as recommended by the European Society of Cardiology 2
Once euvolemia is achieved, reduce the dose to prevent volume depletion, as stated by the European Society of Cardiology and American College of Cardiology 2, 3

Monitor closely for complications, including symptoms, urine output, and daily weights, as recommended by the American College of Cardiology and European Society of Cardiology 6, 7
Check renal function and electrolytes regularly, and aggressively correct electrolyte abnormalities, as stated by the American College of Cardiology and European Society of Cardiology 4, 1, 6, 7

Always combine diuretics with guideline-directed medical therapy, as recommended by the American College of Cardiology and European Society of Cardiology 6, 7
Avoid excessive diuresis in HFpEF, as volume depletion may reduce cardiac output more significantly due to diastolic dysfunction, as stated by the European Society of Cardiology 2