Background Advanced heart failure patients suffer with dyspnoea and peripheral oedema (Sobanski, Alt-Epping, Currow, et al., 2020. Cardiovasc Res. 116: 12) which are frequently treated with parenteral diuretics (Crespo-Leiro, Metra, Lund , et al., 2018. Eur J Heart Fail. 20: 1505) despite a limited evidence base in this patient population (McDonagh, Metra, Adamo, et al., 2021. Eur Heart J. 42: 3599).

Aim To systematically review and analyse the effectiveness of parenteral diuretics to improve dyspnoea and peripheral oedema in advanced heart failure patients with a significant symptom burden approaching the end of life.

Methods Five databases were searched, as well as hand searching, citation searching and performing a grey literature search. Two independent researchers screened and assessed the studies against set criteria. The RoB2 tool was used to determine study quality and data extraction was undertaken using a standardised pro forma (Higgins, Savović, Page, et al., 2022). Primary outcomes were improvement in dyspnoea and peripheral oedema, reduction in weight and increase in urine output. Secondary outcomes included other measures of heart failure symptomology and adverse effects of diuretic therapy.

Results 4646 records were screened and six studies met the inclusion criteria. Of these six studies, all were RCTs and compared the effectiveness of a continuous vs bolus intravenous diuretic infusion in advanced heart failure patients. Study quality was variable, with two studies having a low overall risk of bias, two with some concerns and two having a high risk. Outcomes with the strongest level of evidence were dyspnoea and peripheral oedema, reduction in weight and urine output, which all favour the continuous intravenous furosemide infusion. Bolus intravenous furosemide infusions also showed outcome improvement, particularly in outcomes corresponding to diuresis.

Conclusions There is strong evidence to suggest that intravenous diuretics improve congestion status in advanced heart failure patients in the short term, with more limited evidence of an associated improvement in dyspnoea and oedema. This review highlights a lack of specific evidence for the administration of diuretics via the subcutaneous route as well as a limited use of relevant palliative care outcome measures. Prospective RCTs are recommended.