[Pharmacological decongestion: from loop diuretics to sequential nephron blockade]

Congestion management is a key therapeutic target in heart failure, closely linked to both prognosis and quality of life. Loop diuretics play an important role in the management of decongestive therapy, but their efficacy is often limited by diuretic resistance and empiric dosing strategies. In this context, the concept of sequential nephron blockade - combining agents acting on different tubular segments, such as thiazide diuretics - has gained relevance. More recently, sodium-glucose co-transporter 2 inhibitors have emerged as effective decongestive agents, offering modest but sustained osmotic-diuretic effects, synergistic with loop diuretics, and a favorable safety profile with low impact on electrolytes, blood pressure, or renal function. Optimal decongestion, however, requires a tailored and dynamic approach, guided by clinical and laboratory markers (e.g. early spot urinary sodium), aimed at enhancing diuretic response while minimizing risks such as worsening renal function, electrolyte disturbances, or metabolic alkalosis. Patient education and home-based monitoring - potentially supported by point-of-care technologies - are critical to improve adherence and reduce inappropriate diuretic use in the chronic management of heart failure.