A Narrative Review of Loop Diuretic Potentiating Agents in Patients with Acute Heart Failure

Authors

• Michael D. Skroupa, University of LynchburgFollow

Specialty

Hospital Medicine

Advisor

Thomas P. Colletti, DHSc, MPAS, PA-C Emeritus, DFAAPA

Abstract

This narrative review evaluates the safety and efficacy of four loop diuretic potentiating agents—thiazides, acetazolamide, tolvaptan, and sodium–glucose cotransporter 2 (SGLT2) inhibitors—in patients hospitalized with acute heart failure (HF). PubMed and CINAHL databases were searched for studies assessing these agents' impact on symptom relief, decongestion, diuresis, safety profiles, and hospital length of stay (LOS). The literature indicates that while thiazides effectively improved diuresis, they carried a higher risk of worsening renal function and electrolyte derangements. Conversely, acetazolamide improved congestion and potentially shortened hospital LOS while maintaining a favorable safety profile. Tolvaptan effectively improved diuresis and corrected hyponatremia while preserving kidney function in patients with concurrent chronic kidney disease (CKD), though more studies are needed to firmly establish its efficacy and safety. Finally, SGLT2 inhibitors offered modest diuretic potentiation while fulfilling a crucial component of guideline-directed medical therapy (GDMT). Because clinical guidelines have not yet established an optimal loop diuretic potentiating agent, a gap remains in the literature regarding the best combinations for patients with HF and diuretic resistance. This review suggests that acetazolamide is the preferred loop diuretic potentiating agent due to its ability to improve diuresis, maintain a favorable side-effect profile, and potentially reduce hospital LOS.

Recommended Citation

Skroupa MD. A Narrative Review of Loop Diuretic Potentiating Agents in Patients with Acute Heart Failure. University of Lynchburg Doctoral Project Assignment Repository. 2026; 8(2).