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Current Approach to Decongestive Therapy in Acute Heart Failure

  • Decompensated Heart Failure (D Aronso, Section Editor)
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Abstract

Congestion, defined by elevated cardiac filling pressures, is the major driver of hospitalization in acute decompensated heart failure. Careful clinical assessment should allow to determine whether volume overload or volume misdistribution is the predominating mechanism of congestion. Differentiation is imperative because therapy differs. If volume overloads prevails, loop diuretics are considered the mainstay therapy. However, early use of combinational therapy with diuretics acting more proximal or distal in the nephron could allow for a more profound natriuresis and diuresis. A stepped guided pharmacological treatment should focus on achieving complete decongestion, because persistent congestion is a major driver of readmission. If diuretic strategies remain unsuccessful, ultrafiltration should be considered. Ultrafiltration should be used with caution in the setting of worsening of renal function. When volume misdistribution and impaired venous capacitance predominate the picture of congestion, unloading—more than diuretics—with arteriolar and venous vasodilators might mitigate the clinical picture of congestion. This review offers a thorough overview and practical insight in the use of current and potential decongestive therapies.

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Abbreviations

ADHF:

Acute decompensated heart failure

WRF:

Worsening of renal function

PCWP:

Pulmonary capillary wedge pressure

CRT:

Cardiac resynchronization therapy

BID:

Bis in Die

NT-proBNP:

N-terminal pro-brain natriuretic peptide

MRA:

Mineralocorticoid receptor antagonist

SGLT2:

Sodium-glucose linked transporter 2

ISDN:

Isosorbide dinitrate

UF:

Ultrafiltration

AVP:

Arginine vasopressin

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Acknowledgments

Pieter Martens, Petra Nijst and Wilfried Mullens are researchers for the Limburg Clinical Research Program (LCRP) UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk (LSM), Hasselt University, Ziekenhuis Oost-Limburg, and Jessa Hospital.

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  1. Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium

    Pieter Martens, Petra Nijst & Wilfried Mullens

  2. Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium

    Pieter Martens & Petra Nijst

  3. Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium

    Wilfried Mullens

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Martens, P., Nijst, P. & Mullens, W. Current Approach to Decongestive Therapy in Acute Heart Failure. Curr Heart Fail Rep 12, 367–378 (2015). https://doi.org/10.1007/s11897-015-0273-5

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