The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of diuretic therapy. The appropriate use of diuretics however remains challenging, especially when worsening renal function, diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic diuretic strategies, based upon diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.

Appropriate interpretation of changes in markers of kidney function is essential during the treatment of acute and chronic heart failure. Historically, kidney function was primarily assessed by serum creatinine and the calculation of estimated glomerular filtration rate. An increase in serum creatinine, also termed worsening renal function, commonly occurs in patients with heart failure, especially during acute heart failure episodes. Even though worsening renal function is associated with worse outcome on a population level, the interpretation of such changes within the appropriate clinical context helps to correctly assess risk and determine further treatment strategies. Additionally, it is becoming increasingly recognized that assessment of kidney function is more than just glomerular filtration rate alone. As such, a better evaluation of sodium and water handling by the renal tubules allows to determine the efficiency of loop diuretics (loop diuretic response and efficiency). Also, though neurohumoral blockers may induce modest deteriorations in glomerular filtration rate, their use is associated with improved long‐term outcome. Therefore, a better understanding of the role of cardio–renal interactions in heart failure in symptom development, disease progression and prognosis is essential. Indeed, perhaps even misinterpretation of kidney function is a leading cause of not attaining decongestion in acute heart failure and insufficient dosing of guideline‐directed medical therapy in general. This position paper of the Heart Failure Association Working Group on Cardio‐Renal Dysfunction aims at improving insights into the interpretation of renal function assessment in the different heart failure states, with the goal of improving heart failure care.

Резюме. Для більшості епізодів гострої серцевої недостатності характерне посилення симптомів та ознак застійних явищ з об'ємним перенавантаженням. Мета терапії в таких пацієнтів полягає в полегшенні застійних явищ шляхом досягнення нормоволемії, головним чином за допомогою терапії діуретиками. Проте належне застосування діуретиків залишається складним, особливо при погіршенні функції нирок, резистентності до діуретиків та порушеннях балансу електролітів. У цій офіційній заяві розглядається застосування діуретиків при застійній серцевій недостатності. У роботі розглядаються поширені проблеми, такі як: 1) оцінка застійних явищ та клінічної нормоволемії; 2) оцінка відповіді на діуретики/резистентності до діуретиків при лікуванні гострої серцевої недостатності; 3) підхід до поетапних фармакологічних стратегій застосування діуретиків на основі відповіді на діуретики; 4) лікування поширених порушень балансу електролітів. Рекомендації наведені відповідно до доступних настанов, свідчень та експертних висновків.

Aims Patients with heart failure (HF) randomized in controlled trials are generally selected and do not fully represent the ‘real world’. The purpose of this study is to better describe the characteristics of HF by analysing administrative data of a population of nearly 2 500 000 subjects. Methods and results Data came from the ARNO Observatory including inhabitants of five Local Health Units of the Italian National Health Service (INHS). Patients were selected when discharged for HF (1 January 2008–31 December 2012) and prescribed at least one HF treatment. Clinical characteristics, pharmacological treatments, rehospitalization, and direct costs for the INHS were described during 1‐year follow‐up (FU). Of the 2 456 739 subjects included in the database, 54 059 (2.2%) were hospitalized for HF: 41 413 were discharged alive and prescribed HF treatments. Mean age was 78 ± 11 years and 51.4% were females. Just 26.6% were managed in a cardiology setting. The most frequent co‐morbidities were diabetes (30.7%), COPD (30.5%), and depression (21%). ACE inhibitors/ARBs, beta‐blockers, and mineralocorticoid antagonists were prescribed in 65.8, 49.7, and 42.1% of patients, respectively. During 1‐year FU, at least one rehospitalization occurred in 56.6% of patients, 49% of them due to non‐cardiovascular causes. The direct cost per patient per year to the INHS was €11 867, of which 76% was related to hospitalizations. Conclusions Real‐world evidence provides a description of patient characteristics and treatment patterns that are different from those reported by randomized clinical trials. Costs for the INHS are mainly driven by hospitalizations, which are often due to non‐cardiovascular reasons.