We recommend a loop diuretic, such as furosemide, for most patients with HF and congestive symptom. Once acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms. (Recommendation Strong, Quality Low).

We recommend that for patients with persistent volume overload despite optimal medical therapy and increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low dose metolazone) may be considered as long as it is possible to closely monitor morning weight, renal function and serum potassium. (Recommendation Weak, Quality Moderate).

Values and Preferences These recommendations place a high value on the understanding that diuretics have not been shown to improve survival like the ACEi and beta-blockers but are frequently required to relieve congestion.