Decongestion in acute heart failure: Is it time to change diuretic-centred paradigm?

Congestion is a common cause of clinical deterioration and the most common clinical presentation at admission in acute heart failure (HF). Therefore, finding effective and sustainable ways to alleviate congestion has become a crucial goal for treating HF patients. Congestion is a result of complex underlying pathophysiology; therefore, it is not a direct cause of the disease but its consequence. Any therapy that directly promotes sodium/water removal only, thus targeting only clinical symptoms, neither modifies the natural course of the disease nor improves prognosis. This review aims to provide a comprehensive evaluation of the current decongestive therapies and propose a new (not diuretic-centred) paradigm of long-term congestion management in HF that attempts to correct the underlying pathophysiology, thus improving congestion, preventing its development, and favourably altering the natural course of the disease rather than merely treating its symptoms. Guideline directed medical therapy (GDMT)-centred decongestion in heart failure (HF). ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; CVP, central venous pressure; MRA, mineralocorticoid receptor antagonist; PCWP, pulmonary capillary wedge pressure; RAAS, renin-angiotensin-aldosterone system; SGLT-2i, sodium-glucose cotransporter 2 inhibitor; SNS, sympathetic nervous system. image