Congestion and volume overload are the hallmarks of acute decompensated heart failure (ADHF), and loop diuretics have historically been the cornerstone of treatment. However, the use of loop diuretics is also associated with neurohormonal activation, diuretic resistance, and the risk of acute kidney injury.

In a new study published on June 4 in the Journal of the American College of Cardiology (JACC), G. Michael Felker, MD, FACC, and Robert J. Mentz, MD, review the pathophysiology and recently published clinical trials of both diuretics and peripheral veno-venous ultrafiltration (UF) as alternative strategies to managing volume overload and identifying challenges and unresolved questions for each approach.

Additional Resources Full Study Journal Scan DOSE Trial Summary RAPID-CHF (JACC) UNLOAD Trial Summary New ACCF/AHA/AMA-PCPI Performance Measures Designed to Improve Care for HF Patients ACCF Heart Failure Practice Solutions Toolkit CardioSmart Patient Fact Sheet: Diuretics

Ultimately, the study found that while many questions about the best approach to diuretics remain unanswered, they will likely continue to remain an option for treating ADHF. Both Felker and Mentz note that the recent DOSE trial results suggest that "previous concerns about the safety of high-dose diuretics may not be valid, especially if more effective decongestion can be achieved."

However, of the new treatment options available, peripheral venovenous UF is one of the most promising novel approaches to volume management in ADHF, according to the paper. Currently, UF therapy is recommended only for patients who have not responded to initial medical therapy. But, the impacts of UF on symptoms, renal function, and post-discharge outcomes were recently examined in the RAPID-CHF (Relief for Acutely Fluid-Overloaded Patients with Decompensated Congestive Heart Failure) and UNLOAD (Ultrafiltration vs. Intravenous Diuretics for Patients Hospitalized with Acute Decompensated Heart Failure) trials.

"Potentially, UF may allow or more effective removal of sodium and fluid without the electrolyte abnormalities or neurohormonal activation seen with diuretics, with improved quality of life and reduced rehospitalization rates," the paper states. However, larger studies will need to occur before guidelines could be updated to recommend UF therapy as a first-line treatment.

Moving forward, Felker and Mentz say that more research is needed on the best method for achieving successful decongestion while minimizing changes in renal function and neurohormonal activation. Research already underway, like the National Institutes of Health–sponsored CARRESS study (Effectiveness of Ultrafiltration in Treating People With Acute Decompensated Heart Failure and Cardiorenal Syndrome), should provide greater insight into the best practices for the management of ADHF in the nearer future.

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