Decongestion in acute heart failure: a contemporary clinical review

Heart failure (HF) management has witnessed significant advances over the past decade. Nevertheless, the management of diuretics remains less evidence-based and poses significant challenges for clinicians. Diuretics are crucial for treating signs and symptoms of fluid retention in patients with HF. There is a significant amount of literature surrounding the various diuretic classes and therapies. However, in clinical practice, the indications of these medications, appropriate dose adjustment, and combination therapies are not always grounded in scientific evidence. Consequently, certain diuretics and escalation patterns are favored over others due to familiarity and institutional practice patterns. This paper delves into the mechanisms that cause congestion in HF and the complex relationship between the heart and kidneys. It will review the evidence supporting current therapies, discuss the gaps in the literature, and propose a stepwise approach to diuretic utilization.