Table 1.

Strengths and limitations of different decongestion strategies.

Strategy	Strengths	Limitations	Key References
Strategies routinely used for decongestion
Loop diuretics	Ease of clinical use Non-invasive strategy Operator experience is robust Benefits on dyspnea relief	Diuretic resistance Possible neurohormonal activation Side effects including electrolyte disturbances Association with worsening renal function Potential limitations to reaching successful decongestion	DOSE-AHF(44) Felker GM and Mentz RJ, 2012(39) Hasselblad V, et al. 2007(51) Metra M, et al. 2012(58)
Intravenous vasodilators	Dyspnea benefits (modest) Hemodynamic benefits (CVP, PCWP) Blood pressure reduction may be beneficial in certain circumstances	Potential for hypotension Require close monitoring ± ICU Tachyphylaxis (nitroglycerin) Uncertain decongestion benefits	VMAC(65) ASCEND(66)
Ultrafiltration	Fluid removal possible in the setting of diuretic resistance and renal insufficiency Potential for reduced RAAS activation Potential benefits on weight loss (variable effects in different trials) Potential for reduced electrolyte disturbances	Potential for worsening renal function in the setting of cardiorenal syndrome (e.g., CARRESS Trial) Vascular access complications Anticoagulation is required Provider experience may be less Nursing support/training required Potential limitations to reaching successful decongestion Potential cost considerations	UNLOAD(69) CARRESS(29)
Strategies in development or under investigation for decongestion
Vasopressin antagonists	Dyspnea relief (particularly early during AHF) Benefits for body weight, rales, JVD, and orthopnea May allow less loop diuretic use	Benefit appears to be greatest in those with hyponatremia Adverse effect profile includes neurological changes and hepatotoxicity (in the context of prolonged use) Cost considerations	Konstam M, et al. 2007(72) Pang P, et al. 2009(74)
Mineralocorticoid receptor antagonists (natriuretic doses)	Potential additive benefits to loop diuretic on natriuresis Potential strategy to overcome diuretic resistance	Hyperkalemia Empiric data regarding decongestion benefits are limited Provider experience with high dose may be limited	Bansal S, et al. 2009(79)
Gut sequesterants	Potential benefits on weight loss Possible benefits on dyspnea relief and natriuretic peptide levels May allow fluid removal without RAAS activation and potassium abnormalities	Current empiric evidence on these agents is limited Concerns related to mortality in early phase studies Cost considerations	Costanzo MR, et al. 2012(87)
Serelaxin	Dyspnea relief Benefits on natriuretic peptide levels Reduced incidence of worsening HF Potential mortality benefit	Empiric data regarding decongestion benefits are limited Provider experience is less Potential cost considerations	Teerlink, JR et al. 2013(89) Metra M, et al. 2013(90)