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Review
. 2025 Sep;30(5):831-841.
doi: 10.1007/s10741-025-10509-y. Epub 2025 Apr 5.

Outpatient worsening heart failure: innovative decongestion strategies and health equity implications

Rami Halaseh  1 , Grace K Sun  2 , Ankeet S Bhatt  2   3 , Alex J Chang  1 , Jana Svetlichnaya  3 , Sirtaz Adatya  4 , Marat Fudim  5   6 , Stephen J Greene  5   6 , Daniel R Bensimhon  7 , Eric D Adler  8 , Tamas Alexy  9 , Jan Biegus  10 , Andrew J Sauer  11   12 , Peter S Pang  13 , Sean P Collins  14 , Ambarish Pandey  15   16 , Javed Butler  16   17 , Andrew P Ambrosy  18   19
Affiliations
Review

Outpatient worsening heart failure: innovative decongestion strategies and health equity implications

Rami Halaseh et al. Heart Fail Rev. 2025 Sep.

Abstract

Worsening heart failure (WHF) is a major clinical and economic challenge, contributing to high rates of hospitalization and significant healthcare costs. While WHF has traditionally been managed through hospitalization, recent approaches are shifting toward outpatient care to maximize patient time spent at home and optimize allocation of hospital resources. Emerging treatments like subcutaneous furosemide and intranasal bumetanide offer promising alternatives for safe, well-tolerated, and effective diuresis outside the hospital. However, these novel strategies face several challenges, including the need for clinician/staff training, patient education, logistical difficulties, and a lack of evidence in diverse populations. To ensure equitable management, it is also essential to address healthcare disparities, particularly in socioeconomically disadvantaged and rural populations. While these new treatments have the potential to improve care delivery, additional research is necessary to assess their comparative effectiveness and overcome current limitations fully.

Keywords: Health Equity; Nasal bumetanide; Subcutaneous furosemide; Worsening heart failure.

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Conflict of interest statement

Declarations. Competing interests: Dr. Bhatt has received research grant support to his institution from National Institutes of Health/National Heart, Lung, and Blood Institute, National Institutes of Health/National Institute on Aging, American College of Cardiology Foundation, The Permanente Medical Group, Northern California Community Benefits Programs, Garfield Memorial Fund and the Centers for Disease Control and Prevention and consulting fees from Heart Health Leaders, Sanofi Pasteur, Merck, Amgen, AstraZeneca and Novo Nordisk. Dr. Fudim was supported by the NIH, Alleviant, Gradient, Reprieve, Sardocor, and Doris Duke; he is a consultant and/or has ownership interest in Abbott, Acorai, Ajax, Alio Health, Alleviant, Artha, Astellas, Audicor, AxonTherapies, Bodyguide, Bodyport, Boston Scientific, Broadview, Cadence, Cardiosense, Cardioflow, Clinical Accelerator, CVRx, Daxor, Edwards LifeSciences, Echosens, EKO, Endotronix, Feldschuh Foundation, Fire1, FutureCardia, Gradient, Hatteras, HemodynamiQ, Impulse Dynamics, ISHI, Lumia Health, Medtronic, NovoNordisk, NucleusRx, Omega, Orchestra, Parasym, Pharmacosmos, Presidio, Procyreon, Proton Intelligence, Puzzle, ReCor, Scirent, SCPharma, Shifamed, Splendo, Summacor, SyMap, Terumo, Vascular Dynamics, Vifor Pharma, Vironix, Viscardia, Zoll. Dr. Greene has received research support from the Duke University Department of Medicine Chair’s Research Award, American Heart Association, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cytokinetics, Merck, Novartis, Otsuka, Pfizer, and Sanofi; has served on advisory boards or as consultant for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Corcept Therapeutics, Corteria Pharmaceuticals, CSL Vifor, Cytokinetics, Lexicon, Lilly, Merck, Novo Nordisk, Otsuka, Roche Diagnostics, Sanofi, scPharmaceuticals, Sumitomo, and Tricog Health; and has received speaker fees from AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Lexicon, Novo Nordisk, and Roche Diagnostics. Dr. Adler is chief medical officer and head of research at Lexeo Therapeutics and a scientific advisor and founder for Papillion Therapeutics and Corstasis Therapeutics. Dr. Alexy receives research support from NIH; he is a consultant for Abbott, Edwards Lifesciences LLC, and scPharmaceuticals; his spouse is an employee of Boston Scientific Inc. Dr. Biegus has received honoraria from Bayer, Boehringer Ingelheim, and AstraZeneca for lectures and from Alleviant Medical, Reprieve Cardiovascular, and WhiteSwell for participation in clinical trial advisory boards. Dr. Sauer has received research funding support from Heart Failure Society of America (HFSA), Astra Zeneca, Boehringer Ingelheim, Bayer, CSL Vifor, Pfizer, Rivus Pharmaceuticals, 35Pharma, Novo Nordisk, Edwards Lifesciences, Story Health, and has served as a consultant for Abbott, Boston Scientific, Edwards Lifesciences, Impulse Dynamics, Acorai, General Prognostics, Story Health, Amgen, Bayer. He owns stock in ISHI, Pulsli (both privately held digital health companies). Dr. Pang is, or has been over the last 36 months, a consultant for Incyte Pharmaceuticals, Chugai Pharmaceuticals, Heart Initiative (DSMB), Roche Diagnostics, Eagle Pharmaceuticals, and Kowa Pharmaceuticals; he has received research support by Abbott, Beckman Coulter, Siemens, and the NIH (where he serves as a consultant for a NIH Project); he owns stock in theHeartCourse, and has received funding for other CME work for WebMD. Dr. Collins receives research support from NIH, PCORI, and DOD and is a consultant for Reprieve Cardiovascular, Prenosis, Abbott, Boehringer Ingelheim and Tosoh. Dr. Pandey has received research support from the National Institute on Minority Health and Disparities (R01MD017529), the National Institute of Heart, Lung, and Blood Institute (R21HL169708), American Heart Association, Ultromics, Anumana, and Roche Diagnostics; serves as a consultant for and/or received honoraria outside of the present study as an advisor/consultant for Northwestern University, Tricog Health Inc, Lilly USA, Rivus, Cytokinetics, Roche Diagnostics, Sarfez Therapeutics, Edwards Lifesciences, Merck, Bayer, Novo Nordisk, Alleviant, Axon Therapies, Kilele Health, Acorai, Ultromics, Kardigan, Novartis, Idorsia Pharma, and Science37; also served as consultant for Palomarin Inc. with stocks compensation. Dr. Butler is a consultant to Abbott, Adaptyx, American Regent, Amgen, AskBio, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardiac Dimension, Cardior, CSL Vifor, CVRx, Cytokinetics, Daxor, Diastol, Edwards, Element Sciences, Faraday, Idorsia, Impulse Dynamics, Imbria, Innolife, Intellia, Inventiva, Levator, Lexicon, Eli Lilly, Mankind, Medtronic, Merck, New Amsterdam, Novartis, NovoNordisk, Pfizer, Pharmacosmos, Pharmain, Prolaio, Pulnovo, Regeneron, Renibus, Reprieve, Roche, Rycarma, Saillent, Salamandra, Salubris, SC Pharma, SQ Innovation, Secretome, Sequanna, Transmural, TekkunLev, Tenex, Tricog, Ultromic, Vera, and Zoll. Dr. Ambrosy has received relevant research support through grants to his institution from the National Heart, Lung, and Blood Institute (K23HL150159 and R01 AG091005), the American Heart Association (2nd Century Early Faculty Independence Award), The Permanente Medical Group, Northern California Community Benefits Programs, Garfield Memorial Fund, Abbott Laboratories, Amarin Pharma, Inc., Bayer, Cordio Medical, Edwards Lifesciences LLC, Esperion Therapeutics, Inc., Merck, and Novartis. Dr. Andrew P. Ambrosy and Dr. Stephen J. Greene are editorial board members for Heart Failure Reviews. All other authors report no relevant disclosures.

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