The Congestion "Pandemic" in Acute Heart Failure Patients

Abstract

Congestion not only represents a cardinal sign of heart failure (HF) but is also now recognized as the primary cause of hospital admissions, rehospitalization, and mortality among patients with acute heart failure (AHF). Congestion can manifest through various HF phenotypes in acute settings: volume overload, volume redistribution, or both. Recognizing the congestion phenotype is paramount, as it implies different therapeutic strategies for decongestion. Among patients with AHF, achieving complete decongestion is challenging, as more than half still experience residual congestion at discharge. Residual congestion is one of the strongest predictors of future cardiovascular events and poor outcomes. Through this review, we try to provide a better understanding of the congestion phenomenon among patients with AHF by highlighting insights into the pathophysiological mechanisms behind congestion and new diagnostic and management tools to achieve and maintain efficient decongestion.

Keywords: biomarkers; congestion; heart failure; volume overload; volume redistribution.

Figure 1

Schematic representation illustrating the interplay between volume overload and volume redistribution in congestion.

Figure 2

An overview of hemodynamic, organ, and clinical congestion with diagnostic tools. This figure presents a comprehensive view of hemodynamic, organ, and clinical congestion, illustrating their interrelation in congestive states. Several diagnostic tools, such as biomarkers, echocardiography, lung ultrasound, vena cava dimension, and various scoring systems for assessing congestion, are illustrated around each type of congestion. This visual representation elucidates the multifaceted approach to detect and assess congestion, highlighting the importance of integrating multiple diagnostic modalities for comprehensive evaluation and management. Abbreviations: NT-proBNP = N-terminal pro-brain natriuretic peptide. CD146 = cluster of differentiation 146; SST2 = Soluble suppression of tumorigenicity 2. ADM = Adrenomedullin. ET-1 = Endothelin 1. CA125 = cancer antigen 125. ↑ = increase. ↓ = decrease.

Figure 3

Phenotypes of heart failure. Diastolic dysfunction, characterizing HF with preserved ejection fraction (HFpEF), leads to pulmonary congestion through volume redistribution. HF with reduced ejection fraction (HFrEF) entails volume overload, resulting in systemic congestion, and involves both systolic and diastolic dysfunction.

Figure 4

Therapeutic strategy in heart failure. A concise description of drugs, their mechanisms of action, and their effects. Additionally, a representative trial for each drug is presented.