Decongestion in acute heart failure

Robert J. Mentz*, Keld Kjeldsen, Gian Paolo Rossi, Adriaan A. Voors, John G.F. Cleland, Stefan D. Anker, Mihai Gheorghiade, Mona Fiuzat, Patrick Rossignol, Faiez Zannad, Bertram Pitt, Christopher O'Connor, G. Michael Felker

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

108 Scopus citations


Congestion is a major reason for hospitalization in acute heart failure (HF). Therapeutic strategies to manage congestion include diuretics, vasodilators, ultrafiltration, vasopressin antagonists, mineralocorticoid receptor antagonists, and potentially also novel therapies such as gut sequesterants and serelaxin. Uncertainty exists with respect to the appropriate decongestion strategy for an individual patient. In this review, we summarize the benefit and risk profiles for these decongestion strategies and provide guidance on selecting an appropriate approach for different patients. An evidence-based initial approach to congestion management involves high-dose i.v. diuretics with addition of vasodilators for dyspnoea relief if blood pressure allows. To enhance diuresis or overcome diuretic resistance, options include dual nephron blockade with thiazide diuretics or natriuretic doses of mineralocorticoid receptor antagonists. Vasopressin antagonists may improve aquaresis and relieve dyspnoea. If diuretic strategies are unsuccessful, then ultrafiltration may be considered. Ultrafiltration should be used with caution in the setting of worsening renal function. This review is based on discussions among scientists, clinical trialists, and regulatory representatives at the 9th Global Cardio Vascular Clinical Trialists Forum in Paris, France, from 30 November to 1 December 2012.

Original languageEnglish (US)
Pages (from-to)471-482
Number of pages12
JournalEuropean Journal of Heart Failure
Issue number5
StatePublished - May 2014


  • Acute heart failure
  • Decongestion
  • Outcomes
  • Strategies
  • Volume overload

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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