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Diuretika bei Herzinsuffizienz

Diuretics in heart failure

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Zusammenfassung

Diuretika sind bei der akuten kardialen Dekompensation notwendige, unersetzliche Medikamente zur Behandlung der pulmonalen und peripheren Überwässerung. Auch der Einsatz von Diuretika bei arterieller Hypertonie in Form von niedrigdosierten Thiaziden ist etabliert. Bei akuter Herzinsuffizienz werden Diuretika zur symptomatischen Therapie der Überwässerung empfohlen. Ein Nutzen von Diuretika bezüglich harter Endpunkte bei chronischer Herzinsuffizienz ist bisher nicht nachgewiesen. Doch evidenzbasiert ist, dass eine suffiziente neurohumorale Blockade des Renin-Angiotensin-Aldosteron-Systems (RAAS) und des Sympathikus (SNS) das Risiko von Natrium- und Flüssigkeitsrestriktion, die Dekompensation und die Mortalität drastisch reduzieren kann. Einsatz finden Schleifen- und Thiaziddiuretika sowie kaliumsparende Diuretika. Nebenwirkungen sind u. a. Elektrolytentgleisungen, Azidose/Alkalose, Insulinresistenz und Ototoxizität. Der Einsatz von Diuretika beim Nierenversagen hat keinen oder sogar einen nachteiligen Einfluss auf die Erholung der Nierenfunktion, nicht kaliumsparende Diuretika führen vermutlich sogar zu einer Erhöhung der Mortalität durch maligne Arrhythmien. Eine sequenzielle Tubulusblockade und/oder eine passagere Ultrafiltration bzw. Nierenersatztherapie können bei renokardialen Syndromen und Resistenz auf die konventionelle Therapie möglicherweise von Nutzen sein, Evidenz aus kontrollierten Studien fehlt bis heute.

Abstract

Diuretics are useful and inevitable in acute congestive heart failure with pulmonary congestion and edema. The use of low-dose thiazide diuretics is well established in arterial hypertension. In acute heart failure, diuretics are recommended for the treatment of fluid overload and pulmonary edema. No evidence is available so far regarding any benefit of diuretics on the outcome of patients with chronic heart failure, whereas evidence-based blockade of the renin-angiotensin system and sympathetic nervous system reduces the risk of congestion and improves survival. Several types of diuretics are relevant: loop diuretics, thiazides, and potassium-sparing diuretics. All diuretics have significant side effects, mainly electrolyte disorders, metabolic acidosis/alkalosis, insulin resistance, and ototoxicity. Diuretics have no benefit in acute or acute-on-chronic renal failure; moreover, they even increase mortality and reduce the chance of renal recovery in these patients. Increased mortality with the use of diuretics also seems to be associated with a higher risk of lethal arrhythmias. Sequential tubular blockade may be useful for the short term in potentiating the natriuresis in renocardiac syndromes. Furthermore, ultrafiltration or renal replacement therapy may have an additional beneficial effect in these patients, although controlled trials are still lacking.

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Interessenkonflikt

Der korrespondierende Autor erhielt in der Vergangenheit Honorare für Vorträge und/oder Consultant-Tätigkeiten von folgenden Firmen: Actelion, Chiesi, Fresenius, Menarini, Speedel, Takeda.

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  1. Abteilung für Innere Medizin, Kardiologie und Nephrologie, Allgemeines öffentliches Krankenhaus Zell am See, Akademisches Lehrkrankenhaus der Paracelsus Universitätsklinik Salzburg, Paracelsusstr. 8, 5700, Zell am See, Österreich

    R.R. Wenzel

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Wenzel, R. Diuretika bei Herzinsuffizienz. Nephrologe 4, 177–191 (2009). https://doi.org/10.1007/s11560-008-0277-1

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