title: Decongestion in acute heart failure.
abstract: Congestion is a major reason for hospitalization in acute heart failure (HF). Therapeutic strategies to manage congestion include diuretics, vasodilators, ultrafiltration, vasopressin antagonists, mineralocorticoid receptor antagonists, and potentially also novel therapies such as gut sequesterants and serelaxin. Uncertainty exists with respect to the appropriate decongestion strategy for an individual patient. In this review, we summarize the benefit and risk profiles for these decongestion strategies and provide guidance on selecting an appropriate approach for different patients. An evidence-based initial approach to congestion management involves high-dose i.v. diuretics with addition of vasodilators for dyspnoea relief if blood pressure allows. To enhance diuresis or overcome diuretic resistance, options include dual nephron blockade with thiazide diuretics or natriuretic doses of mineralocorticoid receptor antagonists. Vasopressin antagonists may improve aquaresis and relieve dyspnoea. If diuretic strategies are unsuccessful, then ultrafiltration may be considered. Ultrafiltration should be used with caution in the setting of worsening renal function. This review is based on discussions among scientists, clinical trialists, and regulatory representatives at the 9th Global Cardio Vascular Clinical Trialists Forum in Paris, France, from 30 November to 1 December 2012.
authors.affiliation: Duke University Medical Center, Durham, NC, USA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Mentz
authors.forename: Keld
authors.initials: K
authors.lastname: Kjeldsen
authors.forename: Gian Paolo
authors.initials: GP
authors.lastname: Rossi
authors.forename: Adriaan A
authors.initials: AA
authors.lastname: Voors
authors.forename: John G F
authors.initials: JG
authors.lastname: Cleland
authors.forename: Stefan D
authors.initials: SD
authors.lastname: Anker
authors.forename: Mihai
authors.initials: M
authors.lastname: Gheorghiade
authors.forename: Mona
authors.initials: M
authors.lastname: Fiuzat
authors.forename: Patrick
authors.initials: P
authors.lastname: Rossignol
authors.forename: Faiez
authors.initials: F
authors.lastname: Zannad
authors.forename: Bertram
authors.initials: B
authors.lastname: Pitt
authors.forename: Christopher
authors.initials: C
authors.lastname: O'Connor
authors.forename: G Michael
authors.initials: GM
authors.lastname: Felker
mesh_terms: D000208:Acute Disease; D002317:Cardiovascular Agents / Q000145:classification / Q000627:therapeutic use; D019468:Disease Management; D004417:Dyspnea / Q000628:therapy; D055317:Evidence-Based Practice; D006333:Heart Failure / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D018570:Risk Assessment
chemical_list: D002317:Cardiovascular Agents
keywords: Acute heart failure; Decongestion; Outcomes; Strategies; Volume overload