Congestion and Diuretic Resistance in Acute or Worsening Heart Failure

Abstract

Hospitalisation for acute heart failure (AHF) is associated with high mortality and high rehospitalisation rates. In the absence of evidence-based therapy, treatment is aimed at stabilisation and symptom relief. The majority of AHF patients have signs and symptoms of fluid overload, and, therefore, decongestion is the number one treatment goal. Diuretics are the cornerstone of therapy in AHF, but the treatment effect is challenged by diuretic resistance and poor diuretic response throughout the spectrum of chronic to worsening to acute to post-worsening HF. Adequate dosing and monitoring and evaluation of diuretic effect are important for treatment success. Residual congestion at discharge is a strong predictor of worse outcomes. Therefore, achieving euvolaemia is crucial despite transient worsening renal function.

A comprehensive characterization of acute heart failure with preserved versus mildly reduced versus reduced ejection fraction – insights from the ESC‐HFA EORP Heart Failure Long‐Term Registry

“…It should be noted, however, that emerging data suggest that worsening eGFR during hospitalization, if associated with effective diuresis, may not be harmful in the long-run but in contrast a marker of effective in-hospital diuresis. 29 Haemoglobin (both at admission and discharge) was lower with higher EF, similar to what was described in previous registries, which might be related to increasing age. 15,17,[19][20][21] Haemoconcentration was greater in HFpEF which together with greater worsening renal function may reflect more effective diuresis and explain the greater reduction in natriuretic peptides.…”

“…On the other hand, HFrEF patients were more often hypotensive on admission, more often required inotropic support, and thus most probably had more renal hypoperfusion at admission which might have resolved during hospital treatment. It should be noted, however, that emerging data suggest that worsening eGFR during hospitalization, if associated with effective diuresis, may not be harmful in the long‐run but in contrast a marker of effective in‐hospital diuresis 29 . Haemoglobin (both at admission and discharge) was lower with higher EF, similar to what was described in previous registries, which might be related to increasing age 15,17,19–21 .…”

Predictors of 1-year outcome in very old patients managed in a Heart Failure Unit after an acute decompensation

“…We demonstrated in our octogenarians continuously managed in multidisciplinary HFU, that persistent congestion influences the long-term prognosis independently from ejection fraction phenotype, and HF etiology. Even recently, clinical data demonstrate that residual congestion at discharge rather than the timing of decongestion predicted a worse prognosis in patients with acute HF [ 26 ] and incomplete decongestion at discharge is one of the main causes of early re-hospitalization during 30-day follow-up after acute decompensated HF [ 27 ]. Thus, an accurate evaluation of sign of congestion is mandatory during the transition phase and different scores of congestion are elaborated for patients with HF and tested in different clinical settings [ 28 ] with the aim to intercept residual congestion; among these, one of most frequently used is the EVEREST score [ 13 ].…”

Toward quantification of loop diuretic responsiveness for congestive heart failure

“…Interest in diuretic resistance is piqued by the fact that human patients with resistance suffer from worse outcomes, such as higher rehospitalization and mortality as compared to patients without resistance 35,56 . Diuretic resistance is pertinent to both acute and chronic heart failure.…”