Spironolactone as an Adjuvant to the Treatment of Congestive Cardiac Failure.

THE co-administration of an aldosterone antagonist and a thiazide diuretic has been consistently effective in the treatment of cirrhotic edema and ascites (Gantt and Dyniewicz, I959; Ogden, Scherr, Spritz and Rubin, I96I; Shaldon, I96I). In renal (edema too, success has attended the use of spironolactone (Manning and Behrle, I96I). In both of these conditions independent evidence implicates secondary hyperaldosteronism in the causation of the cedema. In the treatment of congestive heart failure, however, spironolactone has frequently disappointed and it has been suggested that it is less likely to be successful here because aldosterone probably plays an unimportant role in this condition (British Medical Journal, 196I). Our own clinical impression regarding the efficacy of spironolactone as a diuretic seemed to accord with published reports such as those of Edmonds (I960), Farrelly, Howie and North (I960), and Stewart and Constable (I96I): it seemed that the addition of spironolactone to thiazide or chlorthalidone therapy regularly resulted in a diminution of urinary potassium loss, and often increased sodium excretion to some extent, but only occasionally helped appreciably in the removal of cedema. Exceptionally, however, we had seen striking responses to the addition of spironolactone, with rapid disappearance of (edema and ascites which had previously been accumulating steadily in spite of thiazide, chlorthalidone or mercurial therapy. The observation that some of these cases began to respond four, or even five days after starting spironolactone led us to believe that its 'latent period' might be much longer than the 24 to 48 hours usually quoted (Thomas and Bartter, I96I; Brit. med. 7., 196I). It therefore appeared that spironolactone might not have been given a fair trial when used for less than a week at a time and we decided to review our results with this in mind. Relatively few cases were found in which spironolactone had been given continuously for a week, after a similar control period during which they had gained weight on standard diuretic therapy; but comparison of their weight changes before and after the commencement of spironolactone caused us some surprise.