Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 2

Abstract

Congestion is the most common manifestation of acute decompensated heart failure (ADHF). Residual congestion despite initial medical therapy is common and is recognized to be associated with worse outcomes; however, there are currently no standardized definition regarding decongestion end point. In the second part of this 2-part review, we provide a critical appraisal of decongestion definitions previously used in ADHF studies, review alternative metrics to define severity of volume overload, and propose a more granular 4-class congestion grading scheme and decongestion end point definitions that could potentially be included in future ADHF trials and consensus definitions.

Keywords: cardiorenal syndrome; congestion; diuretic resistance; end point; heart failure.

Graphical abstract

Central Illustration

Proposed nomenclature and definitions of major end points for future decongestion trials in the context of acute decompensated heart failure: (1) novel standardized 4-class grading of congestion, (2) decongestion end points based on objective and subjective assessment, and (3) safety end points related to worsening kidney function and worsening of heart failure or treatment failure. ∗Refer to Table 3; ^†refer to Table 4; ^‡refer to Table 5. ECMO, extracorporeal mechanical circulatory support; VAD, ventricular assist device; WRF, worsening renal function.