The use of diuretics in heart failure with congestion — a position statement from the Heart Failure Association of the European Society of Cardiology

Abstract

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.

Refractory congestive heart failure: when the solution is outside the heart

“…Many of these patients develop renal failure as the disease progresses, which complicate their management and reduce the therapeutic options, besides accelerating the progression of both diseases . The diuretic treatment represents the first therapeutic option to improve the symptoms caused by venous congestion; however, with its chronic use, resistance may appear …”

“…Pulmonary and systemic congestion is the main cause for most of the symptoms and signs of heart failure (HF), being responsible for the majority of readmissions . Diuretics remain the cornerstone of the pharmacological treatment of congestion in HF patients .…”

“…Pulmonary and systemic congestion is the main cause for most of the symptoms and signs of heart failure (HF), being responsible for the majority of readmissions . Diuretics remain the cornerstone of the pharmacological treatment of congestion in HF patients . However, as the disease progresses, congestion becomes refractory, despite intensive diuretic therapy, a fact that overshadows the clinical prognosis …”

“…Diuretics remain the cornerstone of the pharmacological treatment of congestion in HF patients . However, as the disease progresses, congestion becomes refractory, despite intensive diuretic therapy, a fact that overshadows the clinical prognosis …”

The use of diuretics in heart failure with congestion: we can't judge a book by its cover

“…1 Indeed, no specific guidelines have been previously published on this topic, although congestion assessment and its solution by current depletion treatment are two of the major challenges in the management of acute heart failure (AHF). 1 Indeed, no specific guidelines have been previously published on this topic, although congestion assessment and its solution by current depletion treatment are two of the major challenges in the management of acute heart failure (AHF).…”