The use of diuretics in heart failure with congestion—a position statement from the Heart Failure Association of the European Society of Cardiology
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The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of diuretic therapy. The appropriate use of diuretics however remains challenging, especially when worsening renal function, diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic diuretic strategies, based upon diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.
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Device therapies (implantable cardioverter defibrillator, cardiac resynchronization therapy, and CRT with an implantable defibrillator) have similar efficacies and risks in patients with HFrEF with or without diabetes.
“Device therapies (implantable cardioverter defibrillator [ICD], cardiac resynchronization therapy [CRT], and CRT with an implantable defibrillator [CRT-D]) have similar efficacies and risks in patients with HFrEF with or without diabetes.[522][523][524][525]”
From 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes. (2023) · cites this paper as [523]
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Compensatory Distal Reabsorption Drives Diuretic Resistance in Human Heart Failure
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Self-citationNon-Invasive Assessment of Left Ventricular Filling Pressure
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Self-citationSequential Nephron Blockade Breaks Resistance to Diuretics in Edematous States
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Self-citationUrinary Composition During Decongestive Treatment in Heart Failure With Reduced Ejection Fraction
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Self-citationMineralocorticoid receptor antagonism in acutely decompensated chronic heart failure
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Promise of SGLT2 Inhibitors in Heart Failure: Diabetes and Beyond
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Self-citationThiazide diuretics in advanced chronic kidney disease
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Renal dysfunction and heart failure: things are seldom what they seem
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Self-citationSplanchnic Nerve Block for Acute Heart Failure
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An introduction to acute heart failure syndromes: definition and classification
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Self-citationThe Effects Of Short-Term Omission of Daily Medication on the Pathophysiology of Heart Failure
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Self-citationSpot Urine Sodium as Triage for Effective Diuretic Infusion in an Ambulatory Heart Failure Unit
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Dominance of Furosemide for Loop Diuretic Therapy in Heart Failure
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Self-citationCurrent Approach to Decongestive Therapy in Acute Heart Failure
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Self-citationIntensification of Medication Therapy for Cardiorenal Syndrome in Acute Decompensated Heart Failure
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Self-citationSoluble CD146, a new endothelial biomarker of acutely decompensated heart failure
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Self-citationInsights Into Implementation of Sacubitril/Valsartan Into Clinical Practice
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Are Serial BNP Measurements Useful in Heart Failure Management?
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Hemoconcentration-guided Diuresis in Heart Failure
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Pharmacokinetics of loop diuretics in congestive heart failure
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Water and Sodium in Heart Failure: A Spotlight on Congestion
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A Study on Regulating Factors of Plasma Refilling during Hemodialysis
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Prognostic Value of the Physical Examination in Patients With Heart Failure and Atrial Fibrillation
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Liberal Versus Restricted Fluid Administration in Heart Failure Patients
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Kinetics of Plasma Refilling During Hemodialysis Sessions with Different Initial Fluid Status
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Self-citationUse of B-type natriuretic peptide outside of the emergency department
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Self-citationPrediction of 30-Day Heart Failure-Specific Readmission Risk by Echocardiographic Parameters
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Self-citationSpironolactone to increase natriuresis in congestive heart failure with cardiorenal syndrome
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Self-citationTransient Hyponatremia During Hospitalization for Acute Heart Failure
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Self-citationHow to tackle congestion in acute heart failure
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Self-citationSalt in the diet in patients with heart failure
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2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure
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Self-citation2023 ESC Guidelines for the management of acute coronary syndromes
Byrne, R. A., Rossello, X., Coughlan, J. J., Barbato, E., Berry, C., Chieffo, A., Claeys, M. J., Dan, G.-A., Dweck, M. R., Galbraith, M., et al. (2023) · European Heart Journal · doi:10.1093/eurheartj/ehad191 · Cited by 5,333 · see citing works
2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure
Authors/Task Force Members:, McDonagh, T. A., Metra, M., Adamo, M., Gardner, R. S., Baumbach, A., Böhm, M., Burri, H., Butler, J., Čelutkienė, J., et al. (2022) · European Journal of Heart Failure · doi:10.1002/ejhf.2333 · Cited by 2,273 · see citing works
Self-citation2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes.
Marx, N., Federici, M., Schütt, K., Müller-Wieland, D., Ajjan, R. A., Antunes, M. J., Christodorescu, R. M., Crawford, C., Di Angelantonio, E., Eliasson, B., et al. (2023) · European Heart Journal · doi:10.1093/eurheartj/ehad192 · Cited by 1,642 · see citing works
Self-citationAcetazolamide in Acute Decompensated Heart Failure with Volume Overload
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Self-citationArrigo, M., Jessup, M. L., Müllens, W., Reza, N., Shah, A. M., Sliwa, K. S., & Mebazaa, A. (2020) · Nature Reviews Disease Primers · doi:10.1038/s41572-020-0151-7 · Cited by 592 · see citing works
Self-citationDiuretic Therapy for Patients With Heart Failure
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Self-citationDynamic mechanical analysis of polymeric material
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Combining loop with thiazide diuretics for decompensated heart failure: the CLOROTIC trial
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2023 ESC Guidelines for the management of acute coronary syndromes
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Impact of empagliflozin on decongestion in acute heart failure: the EMPULSE trial
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Self-citation2024 Clinical practice guidelines for Chronic heart failure
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JCS/JHFS 2025 Guideline on Diagnosis and Treatment of Heart Failure
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Diuretic Strategies for Loop Diuretic Resistance in Acute Heart Failure
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Self-citationRight Ventricular Failure: Pathophysiology, Diagnosis and Treatment
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Self-citationEfficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure
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‘Time is Prognosis’ in Heart Failure: Time-to-Treatment Initiation as a Modifiable Risk Factor
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Self-citationGuía ESC 2021 sobre el diagnóstico y tratamiento de la insuficiencia cardiaca aguda y crónica
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Self-citationClinical Role of CA125 in Worsening Heart Failure
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Self-citationDapagliflozin vs. metolazone in heart failure resistant to loop diuretics
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Clinical Importance of Urinary Sodium Excretion in Acute Heart Failure
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Self-citationRelationship of Nonalcoholic Fatty Liver Disease and Heart Failure With Preserved Ejection Fraction
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Self-citationChronic disease management in heart failure: focus on telemedicine and remote monitoring
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Diuretic Resistance in Heart Failure
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Self-citationStratifying Disease Progression in Patients With Cardiac ATTR Amyloidosis
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Cardiac biomarkers of heart failure in chronic kidney disease
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Edema formation in congestive heart failure and the underlying mechanisms
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VExUS Nexus: Bedside Assessment of Venous Congestion
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Daidzein alleviates doxorubicin-induced heart failure via the SIRT3/FOXO3a signaling pathway
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Self-citationCardiorenal Syndrome and Heart Failure—Challenges and Opportunities
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Acute heart failure: More questions than answers
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Hyponatremia in Infectious Diseases—A Literature Review
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The Use of β-Blockers in Heart Failure with Reduced Ejection Fraction
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Tricuspid Regurgitation Management for Heart Failure
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Multiparametric approach to congestion for predicting long-term survival in heart failure
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Practical outpatient management of worsening chronic heart failure
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2026 ESC Guidelines for the management of heart failure
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Self-citationPre-treatment bicarbonate levels and decongestion by acetazolamide: the ADVOR trial
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Self-citationPrevalence and outcome of diuretic resistance in heart failure
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Loop diuretic resistance complicating acute heart failure
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Self-citationModern trends in diuretics development
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Diuretics: a contemporary pharmacological classification?
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Self-citationChinese Guidelines for the Diagnosis and Treatment of Heart Failure 2024
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Conceptual Considerations for Device-Based Therapy in Acute Decompensated Heart Failure
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Self-citationElevated intra-abdominal pressure: A review of current knowledge
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Diuretic Treatment in Heart Failure: A Practical Guide for Clinicians
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JCS/JHFS 2025 Guideline on Diagnosis and Treatment of Heart Failure
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The role of the kidney in acute and chronic heart failure
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PoCUS in nephrology: a new tool to improve our diagnostic skills
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Self-citationThe Role of Serum Chloride in Acute and Chronic Heart Failure: A Narrative Review
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Núñez‐Marín, G., de la Espriella, R., Santas, E., Lorenzo, M., Miñana, G., Núñez, E., Bodı́, V., González, M., Górriz, J. L., Bonanad, C., et al. (2021) · European Heart Journal Acute Cardiovascular Care · doi:10.1093/ehjacc/zuab022 · Cited by 45 · see citing works
- Authors
- Mullens, W., Damman, K., Harjola, V.-P., Mebazaa, A., Brunner-La Rocca, H.-P., Martens, P., Testani, J. M., Tang, W. H. W., Orso, F., Rossignol, P., Metra, M., Filippatos, G., Seferovic, P. M., Ruschitzka, F., & Coats, A. J.
- Affiliations
- Ziekenhuis Oost Limburg , Genk ,
- University Medical Center Groningen (NL)
- University of Helsinki (FI)
- Inserm (FR)
- Maastricht University Medical Center , Maastricht ,
- Ziekenhuis Oost-Limburg (BE)
- Yale University (US)
- Cleveland Clinic (US)
- University of Florence (IT)
- University of Brescia (IT)
- National and Kapodistrian University of Athens (GR)
- University of Belgrade (RS)
- University Hospital Zurich (CH)
- IRCCS San Raffaele Roma (IT)
- ORCID
- Venue
- European Journal of Heart Failure
- Publisher
- Oxford University Press (OUP)
- Published
- 2019-01-01
- Volume
- 21
- Issue
- 2
- Pages
- 137-155
- ISSN
- 1388-9842 (ISSN-L)
- 1879-0844
- OpenAlex
- W2907983377
- Cited by
- 1,119
- References
- 145
- Citations by year
- 2026: 136 · 2025: 156 · 2024: 177 · 2023: 206 · 2022: 145 · 2021: 130 · 2020: 111 · 2019: 56
- FWCI
- 79.82
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- European Journal of Heart Failure (publishedVersion)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- Document Server@UHasselt (UHasselt) (submittedVersion)
- Institutional Research Information System (Università degli Studi di Brescia) (submittedVersion)
- Archivio Istituzionale della Ricerca - Università Vita-Salute San Raffaele (submittedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion)
- INFM-OAR (INFN Catania) (submittedVersion, other-oa)
- Zenodo (CERN European Organization for Nuclear Research) (cc-by)
- Funders
- National Heart, Lung, and Blood Institute (R01HL103931)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Electrolyte and hormonal disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
- Keywords
- diuretics, acute heart failure, fluid overload, diuretic resistance, diuretic response, electrolyte imbalance, renal function, fluid status assessment
- MeSH terms
- Cardiology, Diuretics, Europe, Heart Failure, Humans, Societies, Medical, Stroke Volume, Consensus
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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