Diuretics and their mechanisms of action will be discussed in detail in Chapter 21. Loop diuretics, such as furosemide (Lasix), block the Na+-K+-2Cl~symporter in the ascending limb of the loop of Henle. The resultant effect is delivery of more Na+ to the distal tubule and enhanced urinary loss of Na+ and water. Unfortunately, the resultant increase in urinary excretion of H+ and K+ can lead to arrhythmias. The potential for arrhythmias is exacerbated by the loss of Mg++ and Ca++ and an underlying vulnerability of the myocardium in CHF. However, loop diuretics are still part of the mainstay of therapy for CHF despite these potential problems and the absence of well-controlled multicenter clinical trials. The rationale for their use is so compelling that placebo-controlled studies appear unethical. Moreover, furosemide was accepted as the standard of care in all of the clinical trials that form the basis for recommended therapy for CHF. The use of the potassium-sparing diuretic spironolactone has been shown to improve survival and is discussed below.
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