Efficacy of High-Dose Spironolactone for Decompensated HF Resistant to Loop Diuretics

chest xray heart failure
chest xray heart failure
Investigators analyzed the safety and efficacy of high-dose spironolactone to treat select patients with acute decompensated heart failure.

For patients with acute decompensated heart failure who do not respond to loop diuretics, high-dose spironolactone may be a safe, effective alternative, according to results published in the Annals of Internal Medicine.

The study included participants who were recently hospitalized for heart failure with reduced or preserved ejection fraction as well as ≥1 symptom (dyspnea, orthopnea, or peripheral swelling) and ≥1 sign (rales, edema, or radiographic pulmonary edema) of hypervolemia (n=47). Participants were weighed in their hospital gowns every day, using the same scale, and they indicated their dyspnea level on a 7-point Likert scale.

The researchers identified consecutive participants who lost <0.5 kg/d despite receiving intravenous furosemide at a dosage of ≥160 mg/d and participants who lost <0.5 kg/d or had no change in dyspnea at 48 hours after admission, regardless of diuretic dose. These participants were given spironolactone 100 mg/d. If a participant was already receiving spironolactone 25 mg/d, the dose was increased to 100 mg. The next day, the dose was increased to 200 mg/d if participants lost <0.5 kg/d and had an increase in serum creatinine level of <26.52 μmol/L (0.3 mg/dL).

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Of 47 participants, 20 met the criteria for high-dose spironolactone and 1 subsequently withdrew from the study because of mechanical ventilation.

The results indicated that participants who received high-dose spironolactone experienced significant weight loss in the subsequent days.

On day 4 after starting high-dose spironolactone therapy, 14 participants reported significantly improved dyspnea (≥3 levels on the Likert scale). No participants had potassium levels above 5.5 mmol/L.

“[O]ur findings and those of other trials with similar designs indicate that it is time to conduct a randomized controlled trial to examine whether high-dose aldosterone antagonists have a role in managing patients with acute decompensated heart failure who are resistant to loop diuretics,” the researchers wrote.


Bansal S, Munoz K, Brune S, Velagapudi C. High-dose spironolactone when patients with acute decompensated heart failure are resistant to loop diuretics: a pilot study [published online July 16, 2019]. Ann Intern Med. doi:10.7326/M18-3285