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Letter

Letter We would like to thank Dr Satchithananda, Sister Ingram and Dr Hookey for their interest in our editorial. We welcome this opportunity to respond. We framed our discussion in the setting of left ventricular systolic dysfunction as this is where the robust evidence base for heart failure therapy has evolved. The evidence base for effective therapy for the clinical syndrome of heart failure with preserved systolic function is much weaker, with very few randomised controlled clinical trials. However, we accept that the symptomatic burden and mortality risk for those with heart failure with preserved systolic function is comparable, and loop diuretic therapy for the associated dyspnoea and congestion is no less applicable to that clinical cohort. Indeed, differentiating between such subpopulations may be largely irrelevant as many heart failure patients exhibit demonstrable abnormalities of both systolic and diastolic function. While there are differences in the assignment of weighting in terms of the class of recommendation and hierarchy of evidence on the conventional use of loop diuretics over the range of acute and chronic heart failure treatment guidelines, and randomised controlled trials may be hard to justify ethically, we have an experiential repository of about 40 years of clinical practice with the use of oral and intravenous furosemide across the clinical spectrum of heart failure. Accumulation of this experience underpins clinical judgement and is consistent with the development of so called ‘tacit knowledge’ which has been proposed as fundamental to evidence base development.1 Certainly, individualising patients’ dosing regimens with appropriate clinical monitoring is mandated for this therapy to be effective and safe, irrespective of the route of furosemide administration as demonstrated in the Diuretic Optimisation Strategies Evaluation (DOSE) trial. 2 The successful use of this approach specifically for the prescription of subcutaneous (SC) furosemide was apparent in the Scarborough study cited in our editorial in which a wide dosing range was employed. 3 This study also demonstrated the effectiveness of multidisciplinary team working, widely accepted as beneficial across the entire heart failure disease trajectory, and no less relevant at the end of life.4 Indeed, the recently published National Institute for Health and Clinical Excellence heart failure quality standards require such an approach, integrating the complementary clinical skills of both heart failure and palliative care professionals to support those with moderate to severe heart failure. 5 The main driver behind our editorial was concern about the largely empirical adoption of SC furosemide by the

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palliative care community for the treatment of patients dying with heart failure as the primary terminal illness, or as a comorbidity, without addressing the need for systematic assessment of effectiveness or clinical risk. This use of SC furosemide for some of the sickest heart failure patients challenges the accepted treatment paradigm, but also provides opportunity for formal clinical evaluation, and we welcome the authors’ potential contribution to development of the evidence base for this form of therapy. James M Beattie,1 Miriam J Johnson2 1 Department of Cardiology, Heart of England NHS Foundation Trust, Birmingham, UK 2 Hull York Medical School, University of Hull, St Catherine’s Hospice, Scarborough, UK

Accepted 11 April 2012 BMJ Supportive & Palliative Care 2012;2:84. doi:10.1136/bmjspcare-2012-000267

REFERENCES 1. 2. 3.

4.

5.

Thornton T. Tacit knowledge as the unifying factor in evidence based medicine and clinical judgement. Philos Ethics Humanit Med 2006;1:E2. Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011;364:797–805. Zacharias H, Raw J, Nunn A, et al. Is there a role for subcutaneous furosemide in the community and hospice management of end-stage heart failure? Palliat Med 2011;25:658–663. Ryder M, Beattie JM, O’Hanlon R, et al. Multidisciplinary heart failure management and end of life care. Curr Opin Support Pall Care 2011;5:317–21. NHS National Institute for Health and Clinical Excellence. Heart failure quality standard, June 2011. http://www.nice.org.uk/guidance/ qualitystandards/chronicheartfailure/home.jsp (accessed 4 April 2012).

BMJ Supportive & Palliative Care June 2012 Vol 2 No 2

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Letter James M Beattie and Miriam J Johnson BMJ Support Palliat Care 2012 2: 84

doi: 10.1136/bmjspcare-2012-000267 Updated information and services can be found at: http://spcare.bmj.com/content/2/2/84.1

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Left ventricular systolic dysfunction is where the robust evidence base for heart failure therapy has evolved.

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