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Treatment Approaches to Congestion Relief in Acute Decompensated HF: Insights After DOSE-AHF and CARRESS-HF

  • Heart Failure (W Tang, Section Editor)
  • Published:
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Opinion statement

Most patients admitted to the hospital with ADHF do not achieve adequate relief of signs and symptoms of congestion. Patients with inadequate decongestion are known to be at higher risk of readmission for heart failure and mortality, although it is uncertain whether this is a cause or simply a marker of increased risk. Nonetheless, adequate decongestion is critical for improving quality of life. Based on the DOSE-AHF and CARRESS-HF studies, a high-dose diuretic regimen consisting of 2.5 times the daily dose of loop diuretic in furosemide equivalents, administered in twice-daily bolus doses, is reasonable to achieve a goal of 3–5 liters of urine output per day. Transient increases in creatinine in the first 4–5 days of diuresis should not be a limiting factor, but a prolonged progressive increase in creatinine signals a high-risk patient. Current goals for decongestion should be resolution of orthopnea, jugular venous pressure of < 8 cm of water, and trace to no peripheral edema. The hope is that better measures of assessing complete decongestion will reduce the progression to heart failure and mortality. While the best noninvasive method to assess speed of congestion has not been determined, it is clear that hemoconcentration (an increase in hematocrit) reflects a decrease in plasma volume and decongestion. In-line monitoring of hemoconcentration may improve the results of ultrafiltration therapy by preventing too large and/or too rapid a fall in intravascular volume and consequent triggering of neurohormonal activation. Several additional strategies such as serelaxin, high-dose mineralocorticoid receptor antagonists, and new forms and combinations of natriuretic peptides have shown promising results in the relief of congestion in patients with ADHF.

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  1. Lindenfeld J, Albert NM, Boehmer JP, et al. HFSA Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16:e1–194.

    Article  PubMed  Google Scholar 

  2. Adams Jr KF, Fonarow GC, Emerman CL, LeJemtel TH, Costanzo MR, Abraham WT, et al. Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J. 2005;149:209–16.

    Article  PubMed  Google Scholar 

  3. O’Connor CM, Stough WG, Gallup DS, Hasselblad V, Gheorghiade M. Demographics, clinical characteristics, and outcomes of patients hospitalized for decompensated heart failure: observations from the IMPACT-HF registry. J Card Fail. 2005;11:200–5.

    Article  PubMed  Google Scholar 

  4. Gheorghiade M, Abraham WT, Albert NM, Greenberg BH, O’Connor CM, She L, et al. Systolic blood pressure at admission, clinical characteristics, and outcomes inpatients hospitalized with acute heart failure. JAMA. 2006;296:2217–26.

    Article  CAS  PubMed  Google Scholar 

  5. Cleland JG, Swedberg K, Follath F, Komajda M, Cohen-Solal A, Aguilar JC, et al. The EuroHeart Failure survey programme–a survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis. Eur Heart J. 2003;24:442–63.

    Article  CAS  PubMed  Google Scholar 

  6. Tavazzi L, Maggioni AP, Lucci D, Cacciatore G, Ansalone G, Oliva F, et al. Nationwide survey on acute heart failure in cardiology ward services in Italy. Eur Heart J. 2006;27:1207–15.

    Article  PubMed  Google Scholar 

  7. Janssen DJ, Spruit MA, Uszko-Lencer NH, Schols JM, Wouters EF. Symptoms, comorbidities, and health care in advanced chronic obstructive pulmonary disease or chronic heart failure. J Palliat Med. 2011;14:735–43.

    Article  PubMed  Google Scholar 

  8. Stevenson LW, Tillisch JH, Hamilton M, Luu M, Chelimsky-Fallick C, Moriguchi J, et al. Importance of hemodynamic response to therapy in predicting survival with ejection fraction less than or equal to 20 % secondary to ischemic or nonischemic dilated cardiomyopathy. Am J Cardiol. 1990;66:1348–54.

    Article  CAS  PubMed  Google Scholar 

  9. Lucas C, Johnson W, Hamilton MA, Fonarow GC, Woo MA, Flavell CM, et al. Freedom from congestion predicts good survival despite previous class IV symptoms of heart failure. Am Heart J. 2000;140:840–7.

    Article  CAS  PubMed  Google Scholar 

  10. Kociol RD, McNulty SE, Hernandez AF, Lee KL, Redfield MM, Tracy RP, et al. Markers of decongestion, dyspnea relief, and clinical outcomes among patients hospitalized with acute heart failure. Circ Heart Fail. 2013;6:240–5.

    Article  CAS  PubMed  Google Scholar 

  11. Mentz RJ, Hernandez AF, Stebbins A, Ezekowitz JA, Felker GM, Heizer GM, et al. Predictors of early dyspnoea relief in acute heart failure and the association with 30-day outcomes: findings from ASCEND-HF. Eur J Heart Fail. 2013;15:456–64.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Gattis WA, O’Connor CM, Gallup DS, Hasselblad V, Gheorghiade M. Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure: results of the Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial. J Am Coll Cardiol. 2004;43:1534–41.

    Article  CAS  PubMed  Google Scholar 

  13. Gheorghiade M, Konstam MA, Burnett Jr JC, Grinfeld L, Maggioni AP, Swedberg K, et al. Short-term clinical effects of tolvaptan, an oral vasopressin antagonist, in patients hospitalized for heart failure: the EVEREST Clinical Status Trials. JAMA. 2007;297:1332–43.

    Article  CAS  PubMed  Google Scholar 

  14. Konstam MA, Gheorghiade M, Burnett Jr JC, Grinfeld L, Maggioni AP, Swedberg K, et al. Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. JAMA. 2007;297:1319–31.

    Article  CAS  PubMed  Google Scholar 

  15. Massie BM, O’Connor CM, Metra M, Ponikowski P, Teerlink JR, Cotter G, et al. Rolofylline, an adenosine A1-receptor antagonist, in acute heart failure. N Engl J Med. 2010;363:1419–28.

    Article  PubMed  Google Scholar 

  16. O’Connor CM, Starling RC, Hernandez AF, Armstrong PW, Dickstein K, Hasselblad V, et al. Effect of nesiritide in patients with acute decompensated heart failure. N Engl J Med. 2011;365:32–43.

    Article  PubMed  Google Scholar 

  17. Teerlink JR, Cotter G, Davison BA, Felker GM, Filippatos G, Greenberg BH, et al. Serelaxin, recombinant human relaxin-2, for treatment of acute heart failure (RELAX-AHF): a randomised, placebo controlled trial. Lancet. 2013;381:29–39. An important study demonstrating that human recombinant relaxin improves measures of congestion without excess adverse events and with a strong signal of improved mortality in patients with ADHF.

    Article  CAS  PubMed  Google Scholar 

  18. Chen HH, Anstrom KJ, Givertz MM, Stevenson LW, Semigran MJ, Goldsmith SR, et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: the ROSE acute heart failure randomized trial. JAMA. 2013;310:2533–43.

    CAS  PubMed Central  PubMed  Google Scholar 

  19. Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011;364:797–805. A trial comparing high- and low-dose as well as continuous vs. bolus infusion loop diuretics in patients with ADHF is discussed in detail in the manuscript.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  20. Bart BA, Goldsmith SR, Lee KL, Redfield MM, Felker GM, O’Connor CM, et al. Cardiorenal rescue study in acute decompensated heart failure: rationale and design of CARRESS-HF, for the Heart Failure Clinical Research Network. J Card Fail. 2012;18:176–82.

    Article  PubMed Central  PubMed  Google Scholar 

  21. Bart BA, Goldsmith SR, Lee KL, et al. Heart Failure Clinical Research Network. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med. 2012;367:2296–304. A trial comparing stepped pharmacological care using a high-dose diuretic regimen to ultrafiltration in patients with ADHF is discussed in detail in the manuscript.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  22. Amer M, Adomaityte J, Qayyum R. Continuous infusion versus intermittent bolus furosemide in ADHF: an updated meta-analysis of randomized control trials. J Hosp Med. 2012;7:270–5.

    Article  PubMed  Google Scholar 

  23. Butler J, Forman DE, Abraham WT, Gottlieb SS, Loh E, Massie BM, et al. Relationship between heart failure treatment and development of worsening renal function among hospitalized patients. Am Heart J. 2004;147:331–8.

    Article  PubMed  Google Scholar 

  24. Metra M, Davison B, Bettari L, Sun H, Edwards C, Lazzarini V, et al. Is worsening renal function an ominous prognostic sign in patients with acute heart failure? The role of congestion and its interaction with renal function. Circ Heart Fail. 2012;5:54–62.

    Article  PubMed  Google Scholar 

  25. Ronco C, Cicoira M, McCullough PA. Cardiorenal syndrome type 1: pathophysiological crosstalk leading to combined heart and kidney dysfunction in the setting of acutely decompensated heart failure. J Am Coll Cardiol. 2012;60:1031–42. An important discussion of the pathophysiology of cardiorenal syndrome due to acute heart failure (type 1 cardiorenal syndrome).

    Article  PubMed  Google Scholar 

  26. Francis GS, Siegel RM, Goldsmith SR, Olivari MT, Levine TB, Cohn JN. Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Activation of the neurohumoral axis. Ann Intern Med. 1985;103:1–6.

    Article  CAS  PubMed  Google Scholar 

  27. Braunwald E, Plauth Jr HW, Morrow AG. Method for the detection and quantification of impaired sodium excretion. Circulation. 1965;32:223–31.

    Article  CAS  PubMed  Google Scholar 

  28. Schrier RW. Pathogenesis of sodium and water retention in high-output and low-output cardiac failure, nephrotic syndrome, cirrhosis, and pregnancy. N Engl J Med. 1988;319:1127–34.

    Article  CAS  PubMed  Google Scholar 

  29. Anand IS, Ferrari R, Kalra GS, Wahi PL, Poole-Wilson PA, Harris PC. Edema of cardiac origin. Studies of body water and sodium, renal function, hemodynamic indexes, and plasma hormones in untreated congestive cardiac failure. Circulation. 1989;80:299–305.

    Article  CAS  PubMed  Google Scholar 

  30. Anand IS, Florea VG. High Output Cardiac Failure. Curr Treat Options Cardiovasc Med. 2001;3:151–9.

    Article  PubMed  Google Scholar 

  31. Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin Z, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010;363:2301–9.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  32. Lewin J, Ledwidge M, O’Loughlin C, McNally C, McDonald K. Clinical deterioration in established heart failure: what is the value of BNP and weight gain in aiding diagnosis? Eur J Heart Fail. 2005;7:953–7.

    Article  CAS  PubMed  Google Scholar 

  33. Zile MR, Bennett TD, St John Sutton M, Cho YK, Adamson PB, Aaron MF, et al. Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. Circulation. 2008;118:1433–41.

    Article  PubMed  Google Scholar 

  34. Adamson PB, Smith AL, Abraham WT, Kleckner KJ, Stadler RW, Shih A, et al. Continuous autonomic assessment in patients with symptomatic heart failure: prognostic value of heart rate variability measured by an implanted cardiac resynchronization device. Circulation. 2004;110:2389–94.

    Article  PubMed  Google Scholar 

  35. Fallick C, Sobotka PA, Dunlap ME. Sympathetically mediated changes in capacitance: redistribution of the venous reservoir as a cause of decompensation. Circ Heart Fail. 2011;4:669–75. A review of mechanisms in addition to sodium and water retention that contribute to signs and symptoms of congestion in patients with ADHF.

    Article  PubMed  Google Scholar 

  36. Nohria A, Hasselblad V, Stebbins A, Pauly DF, Fonarow GC, Shah M, et al. Cardiorenal interactions: insights from the ESCAPE trial. J Am Coll Cardiol. 2008;51:1268–74.

    Article  PubMed  Google Scholar 

  37. Testani JM, Chen J, McCauley BD, Kimmel SE, Shannon RP. Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival. Circulation. 2010;122:265–72.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Aronson D, Burger AJ. The relationship between transient and persistent worsening renal function and mortality in patients with acute decompensated heart failure. J Card Fail. 2010;16:541–7. A study demonstrating that persistent but not transient worsening renal function predicts 6-month mortality.

    Article  PubMed  Google Scholar 

  39. Givertz MM, Postmus D, Hillege HL, Mansoor GA, Massie BM, Davison BA, et al. Renal function trajectories and clinical outcomes in acute heart failure. Circ Heart Fail. 2014;7:59–67.

    Article  CAS  PubMed  Google Scholar 

  40. Costanzo MR, Ronco C. Isolated ultrafiltration in heart failure patients. Curr Cardiol Rep. 2012;14:254–64.

    Article  PubMed  Google Scholar 

  41. Ronco C, Brendolan A, Bellomo R. Online monitoring in continuous renal replacement therapies. Kidney Int Suppl. 1999 :S8-14.

  42. Ronco C, Haapio M, House AA, Anavekar N, Bellomo R. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52:1527–39.

    Article  PubMed  Google Scholar 

  43. Dupont M, Mullens W, Finucan M, Taylor DO, Starling RC, Tang WH. Determinants of dynamic changes in serum creatinine in acute decompensated heart failure: the importance of blood pressure reduction during treatment. Eur J Heart Fail. 2013;15:433–40. A single-center study demonstrating that the relative decrease in mean blood pressure was more pronounced in patients with worsening renal function when compared with stable patients or those with improved renal function, and larger decreases in mean BP were associated with a greater likelihood of worsening renal function. The degree of change in right atrial pressure or cardiac index did not affect the propensity for developing worsening renal function.

    Article  CAS  PubMed  Google Scholar 

  44. Testani JM, Coca SG, McCauley BD, Shannon RP, Kimmel SE. Impact of changes in blood pressure during the treatment of acute decompensated heart failure on renal and clinical outcomes. Eur J Heart Fail. 2011;13:877–84.

    Article  PubMed Central  PubMed  Google Scholar 

  45. Binanay C, Califf RM, Hasselblad V, O’Connor CM, Shah MR, Sopko G, et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA. 2005;294:1625–33.

    Article  PubMed  Google Scholar 

  46. Gheorghiade M, Follath F, Ponikowski P, Barsuk JH, Blair JE, Cleland JG, et al. Assessing and grading congestion in acute heart failure: a scientific statement from the acute heart failure committee of the heart failure association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine. Eur J Heart Fail. 2010;12:423–33. A comprehensive review of the methods for assessing congestion.

    Article  PubMed  Google Scholar 

  47. Drazner MH, Velez-Martinez M, Ayers CR, Reimold SC, Thibodeau JT, Mishkin JD, et al. Relationship of right- to left-sided ventricular filling pressures in advanced heart failure: insights from the ESCAPE trial. Circ Heart Fail. 2013;6:264–70.

    Article  PubMed  Google Scholar 

  48. Lindenfeld J, Schrier RW. The Kidney in Heart Failure. In: Hosenpud JD, Greenberg BH, editors. Congestive Heart Failure, Third Edition. Philadelphia: Lippincott Williams and Wilkins; 2006. p. 888–941.

    Google Scholar 

  49. Androne AS, Katz SD, Lund L, LaManca J, Hudaihed A, Hryniewicz K, et al. Hemodilution is common in patients with advanced heart failure. Circulation. 2003;107:226–9.

    Article  PubMed  Google Scholar 

  50. Testani JM, Brisco MA, Chen J, McCauley BD, Parikh CR, Tang WH. Timing of hemoconcentration during treatment of acute decompensated heart failure and subsequent survival: importance of sustained decongestion. J Am Coll Cardiol. 2013;62:516–24.

    Article  PubMed  Google Scholar 

  51. van der Meer P, Postmus D, Ponikowski P, Cleland JG, O’Connor CM, Cotter G, et al. The predictive value of short-term changes in hemoglobin concentration in patients presenting with acute decompensated heart failure. J Am Coll Cardiol. 2013;61:1973–81. A post hoc analysis of the PROTECT (Placebo-Controlled Randomized Study of the Selective Adenosine A1 Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function) study in 1,969 patients with AHF and mild-to-moderate impaired renal function, demonstrating the association of hemoconcentration in the first 4 days of hospitalization with improved 180 day survival.

    Article  PubMed  Google Scholar 

  52. Publication Committee for the VMAC Investigators (Vasodilatation in the Management of Acute CHF). Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA. 2002;287:1531–40.

    Google Scholar 

  53. Bansal S, Lindenfeld J, Schrier RW. Sodium retention in heart failure and cirrhosis: potential role of natriuretic doses of mineralocorticoid antagonist? Circ Heart Fail. 2009;2:370–6. A review of the role of aldosterone in diuretic resistance.

    Article  CAS  PubMed  Google Scholar 

  54. Hensen J, Abraham WT, Dürr JA, Schrier RW. Aldosterone in congestive heart failure: analysis of determinants and role in sodium retention. Am J Nephrol. 1991;11:441–6.

    Article  CAS  PubMed  Google Scholar 

  55. VanVliet AA, Donker AJ, Nauta JJ, et al. Spironolactone in congestive heart failure refractory to high-dose loop diuretic and low-dose angiotensin-converting enzyme inhibitor. Am J Cardiol. 1993;71:21A–8.

    Article  CAS  Google Scholar 

  56. Shchekochikhin D, Lindenfeld J, Schrier R. Increased Spironolactone in Advanced Heart Failure: Effect of Doses Greater than 25 mg/Day on Plasma Potassium Concentration. Cardiorenal Med. 2013;3:1–6.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  57. von Lueder TG, Sangaralingham SJ, Wang BH, Kompa AR, Atar D, Burnett Jr JC, et al. Renin-angiotensin blockade combined with natriuretic peptide system augmentation: novel therapeutic concepts to combat heart failure. Circ Heart Fail. 2013;6:594–605.

    Article  Google Scholar 

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Dr. Simon F. Shakar and Dr. JoAnn Lindenfeld each declare no potential conflicts of interest relevant to this article.

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  1. University of Colorado Denver, Box B130, 12631 East 17th Avenue, Aurora, CO, 80045, USA

    Simon F. Shakar MD

  2. Cardiac Transplant Program, University of Colorado Denver, Box B130, 1635 Aurora Court, F749, Box 7063, Aurora, CO, 80045, USA

    JoAnn Lindenfeld MD

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Correspondence to JoAnn Lindenfeld MD.

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Shakar, S.F., Lindenfeld, J. Treatment Approaches to Congestion Relief in Acute Decompensated HF: Insights After DOSE-AHF and CARRESS-HF. Curr Treat Options Cardio Med 16, 330 (2014). https://doi.org/10.1007/s11936-014-0330-5

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