Pharmacotherapeutic principles of fluid management in heart failure

ABSTRACT

Introduction: Heart failure is a major public health concern that is expected to increase over the decades to come. Despite significant advances, fluid overload and congestion remain a major therapeutic challenge. Vascular congestion and neurohormonal activation are intricately linked and the goal of therapy fundamentally aims to reduce both.

Areas covered: The authors briefly review a number of core concepts that elucidate the link between fluid overload and neuro-hormonal activation. This is followed by a review of heart–kidney interactions and the impact of diuresis in this setting. Following an in-depth review of currently available pharmacological agents, the rationale and evidence behind their use, the authors end with a brief note on novel agents/approaches to aid volume management in HF.

Expert opinion: A number of non-pharmacological advances in the management of volume overload in heart failure, though promising – are associated with a number of shortcomings. Pharmacological therapy remains the cornerstone of volume management. A number of novel approaches, utilizing existing therapies as well as the emergence of new agents over the past decade bode well for the vulnerable HF population.

KEYWORDS:

• congestion
• diuretics
• fluid overload
• heart failure
• pharmacology
• sglt-2 inhibitors
• volume management

Article highlights

• Congestion and resulting neurohormonal activation play a key role in disease progression.

• Early recognition and management of these phenomena is essential for successful treatment of heart failure.

• Worsening renal function is often a limiting factor to effective diuresis and volume optimization. This is however increasingly recognized as a transient phenomenon that often does not reflect true renal compromise.

• Loop diuretics are the most commonly employed agents in the management of fluid overload. Other traditional diuretics each have unique characteristics that may be employed in specific clinical circumstances.

• Non-Pharmacological approaches have been met with mixed results, but remain effective tools in select clinical settings.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One reviewer has received honoraria from Otsuka Pharmaceuticals and has served as consultant for Bayer Healthcare. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.