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A Personalized Approach to the Management of Congestion in Acute Heart Failure
Gustavo R Moreira1, Humberto Villacorta1
1Cardiology Division, Fluminense Federal University, Niterói, Rio de Janeiro State, Brazil.
Insights
Diuretics are crucial for managing fluid overload in acute decompensated heart failure (ADHF). Temporary increases in creatinine during treatment are not harmful; focus on personalized diuretic strategies and post-discharge care to prevent readmissions.
Area of Science:
- Cardiology
- Nephrology
- Pharmacology
Background:
- Heart failure (HF) involves neurohumoral pathway hyperactivation.
- Cardiorenal interactions are critical in HF progression.
- Diuretics are essential for managing hypervolemia in acute decompensated heart failure (ADHF).
Purpose of the Study:
- To clarify the complex management of congestion in ADHF.
- To emphasize the importance of understanding cardiorenal interactions in ADHF.
- To guide the effective use of diuretics and post-discharge care.
Main Methods:
- Review of cardiorenal interactions in ADHF.
- Analysis of diuretic use and impact on renal function.
- Assessment of volemia and guideline-directed medical therapy (GDMT).
Main Results:
- Congestion can impair renal function and requires aggressive treatment.
- Transient serum creatinine elevations during decongestion do not predict worse outcomes.
- Maintaining diuretics in hypervolemic patients is recommended.
- Urinary sodium monitoring can personalize diuretic therapy.
- Adequate volemia assessment and GDMT titration are vital before discharge.
Conclusions:
- Aggressive decongestion is necessary in ADHF, even with temporary creatinine increases.
- Personalized diuretic management, including urinary sodium monitoring, improves response.
- Comprehensive pre-discharge assessment and early post-discharge follow-up are crucial to prevent readmissions.
Abstract:
Heart failure (HF) is the common final pathway of several conditions and is characterized by hyperactivation of numerous neurohumoral pathways. Cardiorenal interaction plays an essential role in the progression of the disease, and the use of diuretics is a cornerstone in the treatment of hypervolemic patients, especially in acute decompensated HF (ADHF). The management of congestion is complex and, to avoid misinterpretations and errors, one must understand the interface between the heart and the kidneys in ADHF. Congestion itself may impair renal function and must be treated aggressively. Transitory elevations in serum creatinine during decongestion is not associated with worse outcomes and diuretics should be maintained in patients with clear hypervolemia. Monitoring urinary sodium after diuretic administration seems to improve the response to diuretics as it allows for adjustments in doses and a personalized approach. Adequate assessment of volemia and the introduction and titration of guideline-directed medical therapy are mandatory before discharge. An early visit after discharge is highly recommended, to assess for residual congestion and thus avoid readmissions.
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