Water and sodium in heart failure: a spotlight on congestion

Gaspare Parrinello, Stephen J Greene, Daniele Torres, Michael Alderman, Joseph Vincent Bonventre, Pietro Di Pasquale, Luna Gargani, Anju Nohria, Gregg C Fonarow, Muthiah Vaduganathan, Javed Butler, Salvatore Paterna, Lynne Warner Stevenson, Mihai Gheorghiade, Gaspare Parrinello, Stephen J Greene, Daniele Torres, Michael Alderman, Joseph Vincent Bonventre, Pietro Di Pasquale, Luna Gargani, Anju Nohria, Gregg C Fonarow, Muthiah Vaduganathan, Javed Butler, Salvatore Paterna, Lynne Warner Stevenson, Mihai Gheorghiade

Abstract

Despite all available therapies, the rates of hospitalization and death from heart failure (HF) remain unacceptably high. The most common reasons for hospital admission are symptoms related to congestion. During hospitalization, most patients respond well to standard therapy and are discharged with significantly improved symptoms. Post-discharge, many patients receive diligent and frequent follow-up. However, rehospitalization rates remain high. One potential explanation is a persistent failure by clinicians to adequately manage congestion in the outpatient setting. The failure to successfully manage these patients post-discharge may represent an unmet need to improve the way congestion is both recognized and treated. A primary aim of future HF management may be to improve clinical surveillance to prevent and manage chronic fluid overload while simultaneously maximizing the use of evidence-based therapies with proven long-term benefit. Improvement in cardiac function is the ultimate goal and maintenance of a "dry" clinical profile is important to prevent hospital admission and improve prognosis. This paper focuses on methods for monitoring congestion, and strategies for water and sodium management in the context of the complex interplay between the cardiac and renal systems. A rationale for improving recognition and treatment of congestion is also proposed.

Conflict of interest statement

Conflict of interest None of the authors have any potential conflict of interest in the submitted manuscript.

Figures

Fig. 1. Pathophysiological course and vicious cycle…
Fig. 1. Pathophysiological course and vicious cycle of HF until clinical congestion, including renal dysfunction by cardio-renal interaction, subdivided in phases of preclinical medical interventions and hospitalization, suggesting a window for earlier intervention on hemodynamic congestion
Fig. 2. The vicious cycle of HF…
Fig. 2. The vicious cycle of HF progression with mutual involvement of left and right sides of the heart and the kidney: key role of congestion
Fig. 3. Key points of congestion assessment
Fig. 3. Key points of congestion assessment
Fig. 4. Congestion-guided clinical approach and decisionmaking…
Fig. 4. Congestion-guided clinical approach and decisionmaking during post-discharge follow-up of patients with HF

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