A spotlight on congestion in acute heart failure: a joint session with the Romanian Society of Cardiology (part I).

Heart failure (HF) is a leading cause of hospitalizations, with over 1 million admissions annually in the USA and Europe due to signs and symptoms of congestion. Congestion in HF is now understood to result from both an absolute increase in total body fluid volume and a relative redistribution of fluid from capacitance vessels to the effective circulation. While guideline-directed medical therapy (GDMT) has greatly improved the outlook for stable HF patients, there has been little progress in managing acute HF (AHF) over the past 50 years. To address this unmet need, a group of expert clinicians met at the 63rd Annual Romanian Society of Cardiology Meeting on September 20th, 2024. They critically evaluated current evidence and identified knowledge gaps in three key areas of AHF management: (1) enhancing diuresis beyond standard therapy; (2) targeting fluid redistribution with intravenous vasodilators; and (3) applying hemodynamic profiling for personalized care. The first part of the discussion centered on enhanced diuresis strategies, covering contemporary real-world practice patterns, the relationship between residual congestion and hospital readmissions, findings from clinical trials of diuretic strategies, and recent insights into the role of GDMT in the acute setting. The panel also highlighted the limitations of existing evidence and proposed a research roadmap to optimize diuretic strategies in conjunction with GDMT in AHF, with the ultimate goal of facilitating decongestion in order to restore euvolemia and improve post-discharge outcomes.