Approaches to decongestion in patients with acute decompensated heart failure

Loop diuretics remain a mainstay in the pharmacologic treatment of acute decompensated heart failure (ADHF). Recent randomized trial results have challenged existing clinical dogma about the optimal manner of intravenous diuretic administration in hospitalized patients. The Diuretic Optimization Strategies Evaluation (DOSE) trial, while technically a neutral study, suggested some advantages of a high-dose diuretic strategy as compared with low dose administration without evidence of long term safety concerns. The DOSE study additionally showed no difference in efficacy or safety between continuous infusion or bolus diuretic therapy. Venovenous ultrafiltration (UF) holds promise as an alternative approach to volume removal in ADHF, but significant work remains in characterizing the relative risks and benefits of this technique, as well as the degree to which it can be broadly utilized. This review highlights current approaches and future directions in mitigating congestion and volume overload in the ADHF population, with a particular focus on novel diuretic dosing strategies and on the emerging role of UF.