With volume reduction using diuretics, care must be taken to avoid excessive diuresis, which may lead to orthostatic hypotension and worsening renal function. This easily occurs in HF-PEF because of the steep curve for LV diastolic pressure in relation to volume. In addition, electrolytes must be carefully monitored and replaced to avoid symptoms such as muscle cramps and dangerous arrhythmias. If there is an inadequate response to initial diuretic therapy, the Heart Failure Society of America recommends dose escalation, continuous infusion of loop diuretics, or the addition of a second type of diuretic.93 An alternative to diuretic therapy that has recently been evaluated is ultrafiltration, which removes more sodium than diuretics.
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