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Comprehensive and Safe Decongestion in Acutely Decompensated Heart Failure

  • Decompensated Heart Failure (P. Banerjee, Section Editor)
  • Published:
Current Heart Failure Reports Aims and scope Submit manuscript

Abstract

Purpose of the Review

Progressive intravascular, interstitial, and alveolar fluid overload underlies the transition from compensated to acutely decompensated heart failure and loop diuretics are the mainstay of treatment. Adverse effects and resistance to loop diuretics received much attention while the contribution of a depressed cardiac output to diuretic resistance was downplayed.

Recent Findings

Analysis of experience with positive inotropic agents, especially dobutamine, indicates that enhancement of cardiac output is not consistently associated with increased renal blood flow. However, urinary output and renal sodium excretion increase likely due to dobutamine-mediated decrease in renal and systemic reduced activation of sympathetic nervous- and renin–angiotensin–aldosterone system. Mechanical circulatory support with left ventricular assist devices ascertained the contribution of low cardiac output to diuretic resistance and the pathogenesis and progression of kidney disease in acutely decompensated heart failure.

Summary

Diuretic resistance commonly occurs in acutely decompensated heart failure. However, failure to resolve fluid overload despite high doses of loop diuretics should alert to the presence of a low cardiac output state.

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Abbreviations

ACE:

Angiotensin converting enzyme

ADHF:

Acute decompensated heart failure

AF:

Atrial fibrillation

BMI:

Body mass index

BNP:

B-type natriuretic peptide

BUN:

Blood urea nitrogen

CI:

Cardiac index

CO:

Cardiac output

CRT:

Cardiac resynchronization therapy

DLCO:

Diffusion capacity of carbon monoxide

eGFR:

Estimated glomerular filtration rate

FEV1:

Forced expiratory volume over the first second

FVC:

Forced vital capacity

HF:

Heart failure

HFrEF:

Heart failure with reduced ejection fraction

LA:

Left atrial

LV:

Left ventricular

LVAD:

Left ventricular assist device

LVDD:

Left ventricular diastolic dysfunction

LVOT:

Left ventricular outflow tract

LVSD:

Left ventricular systolic dysfunction

NGAL:

Neutrophil gelatinase–associated lipocalin

OSA:

Obstructive sleep apnea

PAC:

Pulmonary artery catheterization

PAP:

Pulmonary artery pressure

PAWP:

Pulmonary artery wedge pressure

Pcap:

Pulmonary capillary pressure

PH:

Pulmonary hypertension

RBF:

Renal blood flow

RV:

Right ventricle

SGLT2:

Sodium glucose co-transporter 2

SIRS:

Systemic inflammatory response syndrome

WRF:

Worsening renal function

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Authors and Affiliations

  1. Tulane University School of Medicine, New Orleans, LA, USA

    Jason Stencel & Thierry Le Jemtel

  2. Thomas Jefferson University Hospitals, Philadelphia, PA, USA

    Indranee Rajapreyar

  3. Rudd Heart and Lung Center, University of Louisville Health, Louisville, KY, USA

    Rohan Samson

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  1. Jason Stencel
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Stencel, J., Rajapreyar, I., Samson, R. et al. Comprehensive and Safe Decongestion in Acutely Decompensated Heart Failure. Curr Heart Fail Rep 19, 364–374 (2022). https://doi.org/10.1007/s11897-022-00573-y

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