Treatment Approaches to Congestion Relief in Acute Decompensated HF: Insights After DOSE-AHF and CARRESS-HF.

OPINION STATEMENT: Most patients admitted to the hospital with ADHF do not achieve adequate relief of signs and symptoms of congestion. Patients with inadequate decongestion are known to be at higher risk of readmission for heart failure and mortality, although it is uncertain whether this is a cause or simply a marker of increased risk. Nonetheless, adequate decongestion is critical for improving quality of life. Based on the DOSE-AHF and CARRESS-HF studies, a high-dose diuretic regimen consisting of 2.5 times the daily dose of loop diuretic in furosemide equivalents, administered in twice-daily bolus doses, is reasonable to achieve a goal of 3-5 liters of urine output per day. Transient increases in creatinine in the first 4-5 days of diuresis should not be a limiting factor, but a prolonged progressive increase in creatinine signals a high-risk patient. Current goals for decongestion should be resolution of orthopnea, jugular venous pressure of < 8 cm of water, and trace to no peripheral edema. The hope is that better measures of assessing complete decongestion will reduce the progression to heart failure and mortality. While the best noninvasive method to assess speed of congestion has not been determined, it is clear that hemoconcentration (an increase in hematocrit) reflects a decrease in plasma volume and decongestion. In-line monitoring of hemoconcentration may improve the results of ultrafiltration therapy by preventing too large and/or too rapid a fall in intravascular volume and consequent triggering of neurohormonal activation. Several additional strategies such as serelaxin, high-dose mineralocorticoid receptor antagonists, and new forms and combinations of natriuretic peptides have shown promising results in the relief of congestion in patients with ADHF.