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The role of diuretics in the treatment of heart failure.

TRADITIONALLY, nephrologists have focused on a defect in the salt-excreting capacity of the kidney as pivotal to edema formation in heart failure. 1 Furthermore, based on the concept of "effective central blood volume," they have argued that the renal response is appropriate to the afferent stimuli impacting the kidney, ie, "relative hypoperfusion of the kidneys." Thus, it seems logical that the first order for therapeutic management of congestive heart failure (CHF) would involve elimination of the excess salt and water contained principally in the extracellular volume (ECV). To accomplish this, pharmacologically active diuretic compounds have been employed with both substantial success and recognized imperfections. One might inquire as to the logic of causing a diureticinduced volume depletion that will cause a fall in cardiac output through a reduction in left ventricular end-diastolic pressure. It would be more logical to either add an ionotropic agent that would improve cardiac performance through