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


In this comprehensive systematic review of randomized controlled trials, which included a total number of 471 patients, torsemide significantly reduced HF and CV-related hospital readmissions compared with furosemide. However, the results have some limitations. Of particular note, trials were randomized but not double-blind. Both trials were multicentered and included a few hundred patients. This systematic review evaluated 471 patients, encompassing 89, 137 and 57 HF and CV readmissions and deaths, respectively (Figure 5).

In 2006, the annual US healthcare cost for treating patients with HF was US$29.6 billion.[49] At least 70% of this cost was due to HF readmissions, with an estimated cost of $20.72 billion.[50] Taking into account the results of this meta-analysis (RR: 59% reduction in HF readmissions), switching patients on furosemide to torsemide could save the US healthcare system approximately $12.22 billion/year in HF readmissions alone.[49–51] This does not include the money that would be saved from a reduction in CV readmissions, which would be expected to be substantial.

HF results in a decrease in cardiac output with subsequent activation of the renin–angiotensin–aldosterone system in order to maintain target-organ blood flow.[52] Furthermore, arginine vasopressin (antidiuretic hormone) is released by the posterior pituitary gland causing free water retention by the kidneys.[53] Thus, many HF patients are placed on loop diuretics to prevent pulmonary and peripheral edema, which helps to keep them out of the hospital.

Furosemide is the most commonly used loop diuretic for systolic HF patients. However, torsemide has distinct features giving additional benefits beyond a natriuretic and diuretic effect.[18–22] These pleiotropic effects seem to give torsemide an advantage compared with furosemide, such as a significant reduction in HF and CV hospitalizations compared with furosemide.[36,48] More importantly, the TORIC trial showed that torsemide is more efficacious at improving NYHA functional class and is associated with a greater than 50% reduction in mortality compared with furosemide and other diuretics.[53] The results of this systematic review and the TORIC trial should encourage a large multicentered clinical trial to confirm that torsemide improves morbidity and mortality in patients with systolic HF.

HF consensus guidelines do not distinguish one loop diuretic from another.[54,55] However, it is clear that torsemide is a different loop diuretic compared with furosemide with greater evidence to support its use.[36,48,53] Compared with furosemide, the 10.5-month number needed to prevent one HF or CV readmission with torsemide was six and nine, respectively (Table 5).

Loop diuretics such as torsemide and furosemide are used for the symptomatic treatment of CHF,[53] and are currently recommended for the treatment of chronic HF.[53–55] Compared with furosemide, torsemide has a longer half-life, longer duration of action and a higher and less variable bioavailability.[1] This article demonstrates that compared with furosemide, torsemide improves hard outcomes as well as cardiac function and humoral factors. Thus, torsemide should be the loop diuretic of choice in patients with HF compared with furosemide.

In direct randomized comparison trials, torsemide improves fatigue, hospitalizations for HF and CV causes, decreases hospital stay, improves exercise tolerance, quality of life, urinations, urinary urgency, left ventricular function, humoral factors, cardiac sympathetic nerve activity, myocardial fibrosis, left ventricular remodeling, hypokalemia, diuresis, natriuresis, pulmonary congestion, edema, blood pressure and weight compared with furosemide, yet furosemide is the most prescribed loop diuretic. Taking into account the previously mentioned benefits, torsemide not furosemide should be the loop diuretic of choice in patients with HF.