Should Torsemide Be the Loop Diuretic of Choice in Systolic Heart Failure?

James J DiNicolantonio


Future Cardiol. 2012;8(5):707-728. 

In This Article

Abstract and Introduction


Furosemide is the most widely prescribed loop diuretic in the setting of systolic heart failure (HF), yet torsemide has been shown to have less inter- and intra-individual variation in bioavailability and a longer duration of action compared with furosemide. Thus, a systematic review and meta-analysis of randomized controlled trials comparing torsemide versus furosemide in patients with systolic HF using OVID MEDLINE, Excerpta Medica (Embase), Web of Science, PubMed and Google Scholar was performed. Extracted data included study design, sample characteristics, intervention, outcomes and control for potential confounding factors. A DerSimonian and Laird random-effects model was used to compute summary risk ratios for HF and cardiovascular (CV) readmission outcomes. Two randomized trials comparing furosemide with torsemide in 471 patients with systolic HF were identified. Compared to furosemide, torsemide significantly reduced total HF readmissions (relative risk [RR]: 0.41, 95% CI: 0.28–0.61, p < 0.0001) and HF readmissions (RR: 0.53, 95% CI: 0.33–0.84, p = 0.008) as well as CV readmissions (RR: 0.77, 95% CI: 0.60–0.98, p = 0.03) in patients with "at least 1 readmission." Moreover, compared with furosemide, torsemide caused a 14% reduction in all-cause mortality (RR: 0.86 [0.53–1.39], p = 0.54). Compared with furosemide, torsemide significantly reduces HF and CV-related hospital readmissions in systolic HF. Furthermore, torsemide is associated with a trend in reducing all-cause mortality.


In heart failure (HF), diminished cardiac output causes a decrease in renal blood flow, activating the renin–angiotensin–aldosterone system and the release of arginine vasopressin. This causes preferential retention of free water resulting in pulmonary and peripheral edema. Loop diuretics, such as torsemide and furosemide, are used for the symptomatic treatment of congestive HF (CHF) and are currently recommended for the treatment of chronic HF. Compared with furosemide, torsemide has a longer half-life, a longer duration of action and a higher bioavailability.[1] These favorable effects of torsemide suggest that this agent would be more beneficial than furosemide in patients with systolic HF. Thus, a systematic review and meta-analysis was performed comparing the effects of torsemide to furosemide in patients with systolic HF.