# Pharmacological options to relieve congestion in acute heart failure

## TL;DR

This paper reviews the best ways to treat congestion in acute heart failure patients using medications like diuretics and other drugs.

## Contribution

The paper provides updated, evidence-based pharmacological strategies for managing congestion in acute heart failure.

## Key findings

- I.v. loop diuretics are recommended as first-line treatment, with dose adjustments based on early diuretic response.
- SGLT2 inhibitors and spironolactone should be initiated early in AHF patients, regardless of diuretic use.
- Changes in serum creatinine during treatment do not necessarily indicate worsening kidney function.

## Abstract

Although congestion is present in the large majority of patients hospitalized with acute heart failure (AHF), the pharmacological options to treat it remain poorly studied, with heterogeneity in real-world practices and outcomes. The best available evidence supports that patients with AHF and congestion should be initially treated with i.v. loop diuretics with their dose tailored to early (within 2–6 h) diuretic response, as assessed by spot urine sodium and/or hourly urine output. If diuretic response is sub-optimal, the next best steps seem to be increases in i.v. loop diuretics and addition of a thiazide and/or i.v. acetazolamide. Irrespective of the above, sodium-glucose co-transporter-2 inhibitors and spironolactone should be started in all patients with AHF as early as possible. Changes in serum creatinine in this scenario do not typically represent true worsening in renal function and should, thus, not lead to de-escalation of decongestion therapy.