Current Approach to Decongestive Therapy in Acute Heart Failure

Congestion, defined by elevated cardiac filling pressures, is the major driver of hospitalization in acute decompensated heart failure. Careful clinical assessment should allow to determine whether volume overload or volume misdistribution is the predominating mechanism of congestion. Differentiation is imperative because therapy differs. If volume overloads prevails, loop diuretics are considered the mainstay therapy. However, early use of combinational therapy with diuretics acting more proximal or distal in the nephron could allow for a more profound natriuresis and diuresis. A stepped guided pharmacological treatment should focus on achieving complete decongestion, because persistent congestion is a major driver of readmission. If diuretic strategies remain unsuccessful, ultrafiltration should be considered. Ultrafiltration should be used with caution in the setting of worsening of renal function. When volume misdistribution and impaired venous capacitance predominate the picture of congestion, unloading-more than diuretics-with arteriolar and venous vasodilators might mitigate the clinical picture of congestion. This review offers a thorough overview and practical insight in the use of current and potential decongestive therapies.