Congestion as a therapeutic target in acute heart failure syndromes

This review begins by discussing the importance of clinical congestion as the dominant presenting manifestation of acute heart failure syndromes (AHFS). The pathophysiology of the cardiorenal syndrome is reviewed, including its relationship to the use of current therapy, that is, loop diuretics. The review then summarizes results from recent clinical trials evaluating therapy for AHFS, with a focus on those studies investigating ultrafiltration and vasopressin antagonists, and also, but more briefly, vasodilators and inotropic agents. Possible reasons for the success and failure of various therapeutic strategies directed at the congested state are discussed. The review concludes with recommendations for possible new strategies and specific investigations designed to benefit from the lessons learned from both the recent successful trials and the more numerous failures.