Theodore E. Woodward Award: Coming in out of the rain. Relieving congestion in heart failure.

Heart failure decompensation is dominated by congestive symptoms from elevated pulmonary and systemic venous pressures. In dilated heart failure, forward flow is optimal at near-normal filling pressures, with minimized mitral regurgitation. Tailored therapy to reduce filling pressures improves symptoms acutely. However, monitored reduction of filling pressures during hospitalization did not translate into improved outcome during the ESCAPE trial. Data recently analyzed from the COMPASS trial indicates that 1) ambulatory filling pressures are far higher than clinically suspected, 2) filling pressures begin to increase over 3 weeks before heart failure events, and 3) events occurring during weight-based management show mismatch between changes in weight and changes in filling pressures. Accumulated days of high filling pressures increases risk continuously above left-sided filling pressures of 15 mmHg. The challenge is to intensify not only acute management of heart failure but ambulatory surveillance to allow early intervention and reduce re-hospitalization.