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  • Review Article
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Decongestion in heart failure: medical and device therapies

Nature Reviews Cardiology volume 22, pages 961–977 (2025)Cite this article

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Abstract

Heart failure is a leading cause of hospitalization worldwide, and congestion is the predominant cause of heart failure symptoms and hospitalization. The primary therapy used to treat and prevent congestion has historically been loop diuretics. However, many patients are discharged from hospital with residual congestion, which is associated with persistent heart failure symptoms, adverse outcomes and hospital readmission. Multiple medical strategies and devices have been and are being investigated with the aim of improving decongestion and subsequent heart failure outcomes. Numerous questions exist about the design of clinical trials to test emerging medical and device therapies, including the magnitude of benefit on congestive, kidney and post-discharge outcomes relative to conventional decongestion practices, and how best to implement novel therapies. In this Review, we discuss emerging medical and device strategies targeting congestion in patients with heart failure.

Key points

  • Various medical and device strategies are under investigation to overcome barriers that limit decongestion in patients with acute decompensated heart failure.

  • Medical strategies that optimize the use of existing diuretic therapies could have immediate, systemic effects on heart failure treatment, with limited risk or cost.

  • Most devices under investigation are designed to improve the diuretic response indirectly by targeting a hypothesized haemodynamic mechanism; however, mechanistic data and clinical trials of drugs indicate that improving haemodynamics might have limited benefit.

  • Barriers to the implementation of invasive devices include increased rates of adverse events from invasive procedures, cost, resource utilization and the requirement for provider expertise, limiting the pool of candidate patients.

  • Randomized, controlled trials are needed to determine whether invasive devices can sufficiently improve decongestion and post-discharge outcomes compared with optimized medical therapy to offset their inherent risks and numerous barriers to widespread implementation.

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Fig. 1: Natriuretic therapies and the nephron.
Fig. 2: Diuretic therapy escalation algorithm.
Fig. 3: Indirect and direct decongestion devices.
Fig. 4: Practical considerations for decongestion devices in acute decompensated heart failure.

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Authors and Affiliations

  1. Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN, USA

    Zachary L. Cox

  2. Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA

    Zachary L. Cox

  3. University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands

    Kevin Damman

  4. Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA

    Jeffrey M. Testani

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  1. Zachary L. Cox
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  2. Kevin Damman
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The authors contributed substantially to all aspects of the article.

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Correspondence to Jeffrey M. Testani.

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Competing interests

Z.L.C. reports grants from AstraZeneca and personal fees from Abiomed, Kestra Medical Technologies, Lexicon Pharmaceuticals, Reprieve Cardiovascular and Vectorious. K.D. reports speaker and consultancy fees to his employer from Abbott, AstraZeneca, Boehringer Ingelheim, Echosense, FIRE1 and Novartis. J.M.T. reports grants and/or personal fees from 3ive Labs, Abbott, AstraZeneca, Bayer, BD, Bristol Myers Squibb, Cardionomic, Corteria, Edwards Lifesciences, FIRE1, Lexicon Pharmaceuticals, Lilly, MagentaMed, Merck, Novartis, Otsuka, Precardia, Regeneron, Relypsa, Reprieve, Sanofi, Sequana Medical, Windtree Therapeutics and W.L. Gore. J.M.T. has a patent relating to the treatment of diuretic resistance issued to Yale University and Corvidia Therapeutics, a patent relating to methods for measuring renalase issued to Yale University, and a patent relating to the treatment of diuretic resistance pending with Reprieve.

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Cox, Z.L., Damman, K. & Testani, J.M. Decongestion in heart failure: medical and device therapies. Nat Rev Cardiol 22, 961–977 (2025). https://doi.org/10.1038/s41569-025-01152-z

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