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Congestion in heart failure: a contemporary look at physiology, diagnosis and treatment

Nature Reviews Cardiology volume 17, pages 641–655 (2020)Cite this article

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Abstract

Congestion is the main reason for hospitalization in patients with acute decompensated heart failure and is an important target for therapy. However, achieving complete decongestion can be challenging. Furthermore, residual congestion before discharge from hospital is associated with a high risk of early rehospitalization and death. An improved understanding of the pathophysiology of congestion is of great importance in finding better and more personalized therapies. In this Review, we describe the two different forms of congestion — intravascular congestion and tissue congestion — and hypothesize that differentiating between and specifically treating these two different forms of congestion could improve the outcomes of patients with acute decompensated heart failure. Although the majority of these patients have a combination of both intravascular and tissue congestion, one phenotype can dominate. Each of these two forms of congestion has a different pathophysiology and requires a different diagnostic approach. We provide an overview of novel and established biomarkers, imaging modalities and mechanical techniques for identifying each type of congestion. Treatment with loop diuretics, the current cornerstone of decongestive treatment, reduces circulating blood volume and thereby reduces intravascular congestion. However, the osmolality of the circulating blood decreases with the use of loop diuretics, which might result in less immediate translocation of fluid from the tissues (lungs, abdomen and periphery) to the circulation when the plasma refill rate is exceeded. By contrast, aquaretic drugs (such as vasopressin antagonists) predominantly cause water excretion, which increases the osmolality of the circulating blood, potentially improving translocation of fluid from the tissues to the circulation and thereby relieving tissue congestion.

Key points

  • Congestion is the main reason for hospitalization in patients with acute decompensated heart failure.

  • Residual congestion at discharge from hospital is associated with higher rates of death and hospital readmission for heart failure.

  • Congestion can be present predominantly in the vascular system (intravascular congestion) or in the interstitium (tissue congestion), although the majority of patients have a combination of both intravascular and tissue congestion.

  • Intravascular congestion and tissue congestion can be identified and differentiated with the use of specific diagnostic assessments, such as physical examination, biomarkers and imaging techniques.

  • Loop diuretic therapy reduces circulating blood volume, thereby improving intravascular congestion; however, these therapies increase plasma osmolality, which might impede translocation of fluid from the tissues to the circulation.

  • Aquaretic drugs, such as vasopressin antagonists, reduce plasma volume and lower plasma osmolality, which might stimulate translocation of fluid from the tissues to the circulation.

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Fig. 1: Pathophysiology of tissue congestion.
Fig. 2: Hypothesized differences between tissue congestion and intravascular congestion.
Fig. 3: Sites of action of natriuretic and aquaretic drugs in the nephrons.
Fig. 4: Treatment algorithm for intravascular congestion and tissue congestion.

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Authors and Affiliations

  1. University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, Netherlands

    Eva M. Boorsma, Jozine M. ter Maaten, Kevin Damman & Adriaan A. Voors

  2. Center for Clinical Medicine, University Faculty of Health, University of Witten Herdecke, Witten, Germany

    Wilfried Dinh

  3. Department of Clinical Science, BAYER AG, Research and Development, Wuppertal, Germany

    Wilfried Dinh

  4. Department of Cardiology and Clinical Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark

    Finn Gustafsson

  5. Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA

    Steven Goldsmith

  6. Division of Cardiovascular Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA

    Steven Goldsmith

  7. Division of Cardiology, Tufts Medical Center, Boston, MA, USA

    Daniel Burkhoff & James E. Udelson

  8. Cardiovascular Research Foundation, New York, NY, USA

    Daniel Burkhoff

  9. Universite de Lorraine, Inserm, Centre d’Investigations Cliniques- Plurithematique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France

    Faiez Zannad

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Contributions

E.M.B. researched data for the article. E.M.B., J.M.t.M., K.D., S.G., F.Z. and A.A.V. discussed the content of the article. E.M.B. wrote the manuscript, and all the other authors reviewed and edited the manuscript before submission.

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Correspondence to Adriaan A. Voors.

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Competing interests

W.D. reports full-time employment at Bayer. F.G. receives advisor fees from Abbott, Bayer, Carmat, Impulse Dynamics, Novartis and Pfizer and speaker fees from AstraZeneca, Boehringer Ingelheim and Orion Pharma. S.G. has received consultancy fees and/or research grants from Abbott Laboratories, Bayer and Otsuka Pharmaceuticals. J.E.U. reports research funding for trial activities from Bayer. A.A.V. has received consultancy fees and/or research grants from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Myokardia, Novartis and Roche Diagnostics. The other authors declare no competing interests.

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Boorsma, E.M., ter Maaten, J.M., Damman, K. et al. Congestion in heart failure: a contemporary look at physiology, diagnosis and treatment. Nat Rev Cardiol 17, 641–655 (2020). https://doi.org/10.1038/s41569-020-0379-7

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