Treating Hemodynamic Congestion Is the Key to Prevent Heart Failure Hospitalizations.

O ne of the greatest challenges in the management of patients with chronic heart failure is forecasting and preventing the development of acute worsening leading to hospitalizations. Despite current best practice guidelines, including management within a heart failure clinic, early follow-up after hospitalizations, measuring daily weights, and frequent patient contact, rehospitalization for heart failure occurs at a rate close to 50% over 6 months (2). The major reason for this unacceptably high event rate is our failure to understand and recognize the dissociation between clinical congestion and hemodynamic congestion. When patients with chronic heart failure are in a compensated state, there is equilibrium between intravascular and extravascular hydrostatic pressure, oncotic pressure, and lymphatic capacity. However, when intravascular hydrostatic pressure exceeds extravascular hydrostatic pressure to an extent that the lymphatic system cannot compensate for this imbalance, patients develop acute hypervolemic decompensated heart failure. Clinical congestion occurs when the increase in the left atrial filling