title: Fluid removal in acute heart failure: diuretics versus devices.
abstract: OBJECTIVE
  Fluid removal and relief of congestion are central to treatment of acute heart failure. Diuretics have been the decongestive mainstay but their known limitations have led to the exploration of alternative strategies. This review compares diuretics with ultrafiltration and examines the recent evidence evaluating their use.
  
  
  RESULTS
  Relevant recent studies are the Diuretic Optimization Strategies Evaluation trial (of diuretics) and the Cardiorenal Rescue Study in Acute Decompensated Heart Failure (of ultrafiltration). The Diuretic Optimization Strategies Evaluation study evaluated strategies of loop diuretic use during acute heart failure (continuous infusion versus intermittent bolus and high dose versus low dose). After 72  h, there was no significant difference with either comparison for the coprimary end points. Patients treated with a high-dose strategy tended to have greater diuresis and more decongestion compared with low-dose therapy, at the cost of transient changes in renal function. The Cardiorenal Rescue Study in Acute Decompensated Heart Failure study showed that in acute heart failure patients with persistent congestion and worsening renal function, ultrafiltration, as compared with a medical therapy, was associated with similar weight loss but greater increase in serum creatinine and more adverse events.
  
  
  CONCLUSIONS
  Decongestion remains a major challenge in acute heart failure. Although recent studies provide useful data to guide practice, the relatively poor outcomes point to the continued need to identify better strategies for safe and effective decongestion.
authors.affiliation: aDivision of Cardiology, Department of Medicine bDuke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
authors.forename: Arun
authors.initials: A
authors.lastname: Krishnamoorthy
authors.forename: G Michael
authors.initials: GM
authors.lastname: Felker
mesh_terms: D000208:Acute Disease; D003404:Creatinine / Q000097:blood; D004232:Diuretics / Q000008:administration & dosage* / Q000009:adverse effects; D006333:Heart Failure / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D007262:Infusions, Intravenous; D017410:Practice Guidelines as Topic; D016896:Treatment Outcome; D014462:Ultrafiltration / Q000009:adverse effects / Q000379:methods*; D015431:Weight Loss
chemical_list: D004232:Diuretics; D003404:Creatinine