Water and Sodium in Heart Failure: A Spotlight on Congestion.

Despite all available therapies, the rates ofhospitalization and death from heart failure (HF) remainunacceptably high. The most common reasons for hospitaladmission are symptoms related to congestion. Duringhospitalization, most patients respond well to standardtherapy and are discharged with significantly improvedsymptoms. Post-discharge, many patients receive diligentand frequent follow-up. However, rehospitalization ratesremain high. One potential explanation is a persistentfailure by clinicians to adequately manage congestion inthe outpatient setting. The failure to successfully managethese patients post-discharge may represent an unmet needto improve the way congestion is both recognized andtreated. A primary aim of future HF management may be toimprove clinical surveillance to prevent and managechronic fluid overload while simultaneously maximizingthe use of evidence-based therapies with proven long-termbenefit. Improvement in cardiac function is the ultimategoal and maintenance of a ‘‘dry’’ clinical profile isimportant to prevent hospital admission and improveprognosis. This paper focuses on methods for monitoringcongestion, and strategies for water and sodium managementin the context of the complex interplay between the cardiacand renal systems. A rationale for improving recognition andtreatment of congestion is also proposed.