Most elderly patients will require a loop diuretic such as furosemide or bumetanide. Remember that diuretics can quickly lead to volume depletion and hypotension in an elderly patient with poor cardiovascular reflexes who is sodium restricted. Check postural blood pressures frequently and BUN/creatinine ratios at intervals to monitor volume depletion. Check serum electrolytes AND MAGNESIUM, and replace when necessary. Most patient will require regular K supplements and more frequent magnesium supplementation than one might realize.

Patients sometimes refuse to take diuretics because of diuretic-related incontinence. Schedule diuretics at times when the patient will not be socially active or be in a situation where the patient can't get to the bathroom. Bumetanide has a shorter duration of action than furosemide, so the period of intense need to void may be shorter.

Be careful not to over diurese patients with CHF and diastolic dysfunction. They have stiff ventricules that require significant pressure to fill. Over diuresis can result in lowering of ventricular filling pressure which in turn can lead to hypotension.

Do what you can to keep the patient in regular sinus rhythm because atrial contraction is critical to allowing the ventricle to fill adequately without a major increase in mean atrial pressure. Even if the patient is in sinus rhythm, keep the heart rate as slow as feasible. Patients 100 years old with diastolic dysfunction may go into heart failure with exercise heart rates above 96/minute.

Commonly Used Drugs in the Management of CHF