Decongestion in Acute Heart Failure

SEE PAGE 580 F luid overload and the resultant signs and symptoms, such as dyspnea, are the predominant factors precipitating a hospitalization for acute heart failure. The first-line treatment to relieve this congestion are loop diuretic agents, which are administered to more than 90% of patients hospitalized for acute heart failure (1). Heart failure guidelines recommend treatment with escalating doses of diuretic agents until decongestion is achieved (2,3). These practice patterns and recommendations are intriguing because there are biologically plausible mechanisms through which loop diuretic agents could directly worsen outcomes, and appropriately powered efficacy and safety studies are lacking. The available data on the risk profile of loop diuretic agents are inconsistent. The majority of studies have indeed found an association between diuretic dose and negative outcome (4,5). However, several studies have found that only certain subgroups are negatively affected, and other studies found no association after extensive adjustment for confounding factors (6,7). Importantly, the DOSE-AHF (Determining Optimal Dose and Duration of Diuretic Treatment in People With Acute Heart Failure) trial found that randomization to a high-dose loop diuretic strategy resulted in modestly greater weight and fluid loss but no apparent worsening in post-discharge outcomes (8). Although not all studies have linked higher diuretic doses to adverse events, signs of improved decongestion have consistently and strongly been associated with better outcomes. Notably, across multiple studies and different metrics such as physical examination,