title: Can we improve the treatment of congestion in heart failure?
abstract: BACKGROUND
  Dyspnoea and peripheral oedema, caused by fluid redistribution to the lungs and/or by fluid overload, are the main causes of hospitalization in patients with heart failure and are associated with poor outcomes. Treatment of fluid overload should relieve symptoms and have a neutral or favorable effect on outcomes.
  
  
  METHODS
  We first consider the results obtained with furosemide administration, which is still the mainstay of treatment of congestion in patients with heart failure. We then discuss important shortcomings of furosemide treatment, including the development of resistance and side effects (electrolyte abnormalities, neurohormonal activation, worsening renal function), as well as the relationship of furosemide - and its doses - with patient prognosis. Finally, the results obtained with potential alternatives to furosemide treatment, including different modalities of loop diuretic administration, combined diuretic therapy, dopamine, inotropic agents, ultrafiltration, natriuretic peptides, vasopressin and adenosine antagonists, are discussed.
  
  
  CONCLUSIONS
  Relief of congestion is a major objective of heart failure treatment but therapy remains based on the administration of furosemide, an agent that is often not effective and is associated with poor outcomes. The results of the few controlled studies aimed at the assessment of new treatments to overcome resistance to furosemide and/or to protect the kidney from its untoward effects have been mostly neutral. Better treatment of congestion in heart failure remains a major unmet need.
authors.affiliation: University of Brescia, Cardiology, Department of Experimental and Applied Medicine Spedali Civili , Piazzale Spedali Civili, Italy. metramarco@libero.it
authors.forename: Marco
authors.initials: M
authors.lastname: Metra
authors.forename: Silvia
authors.initials: S
authors.lastname: Bugatti
authors.forename: Luca
authors.initials: L
authors.lastname: Bettari
authors.forename: Valentina
authors.initials: V
authors.lastname: Carubelli
authors.forename: Rossella
authors.initials: R
authors.lastname: Danesi
authors.forename: Valentina
authors.initials: V
authors.lastname: Lazzarini
authors.forename: Carlo
authors.initials: C
authors.lastname: Lombardi
authors.forename: Livio Dei
authors.initials: LD
authors.lastname: Cas
mesh_terms: D000818:Animals; D004232:Diuretics / Q000008:administration & dosage* / Q000009:adverse effects; D004417:Dyspnea / Q000188:drug therapy* / Q000209:etiology*; D004487:Edema / Q000188:drug therapy* / Q000209:etiology*; D005665:Furosemide / Q000008:administration & dosage* / Q000009:adverse effects; D006333:Heart Failure / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D008168:Lung / Q000473:pathology
chemical_list: D004232:Diuretics; D005665:Furosemide