What is the treatment for vascular congestion (hypervolemia)?

From the Guidelines

Treating vascular congestion requires the use of loop diuretics, such as furosemide or torsemide, as the preferred diuretic agents for most patients with heart failure (HF) and signs of fluid overload and congestion 1. The goal of diuretic use is to eliminate clinical evidence of fluid retention, using the lowest dose possible to maintain euvolemia.

• Loop diuretics, such as furosemide (20-80mg daily) or torsemide, are the preferred initial treatment for vascular congestion due to their ability to increase renal salt and water excretion and have some vasodilatory effect 1.
• Thiazide diuretics, such as chlorthalidone or hydrochlorothiazide, may be considered in patients with hypertension and HF and mild fluid retention, but should be used with caution to avoid dehydration, hypovolaemia, hyponatraemia, or hypokalaemia 1.
• In patients with refractory edema unresponsive to loop diuretics alone, metolazone or chlorothiazide may be added to enhance diuresis 1.
• It is essential to monitor potassium, sodium, and creatinine levels during diuretic therapy to avoid potential complications such as hypokalaemia, renal dysfunction, and hypovolaemia 1.
• The dose requirement must be tailored to the individual patient’s needs and requires careful clinical monitoring 1.
• In any patient with a history of congestion, maintenance diuretics should be considered to avoid recurrent symptoms, and diuretics should not be used in isolation but always combined with other guideline-directed medical therapy (GDMT) for HF that reduces hospitalizations and prolongs survival 1.

From the FDA Drug Label

The principal signs and symptoms of overdose with furosemide are dehydration, blood volume reduction, hypotension, electrolyte imbalance, hypokalemia and hypochloremic alkalosis, and are extensions of its diuretic action. Treatment of overdosage is supportive and consists of replacement of excessive fluid and electrolyte losses.

Vascular congestion treatment is not directly addressed in the provided drug labels.

• The labels discuss treatment of overdosage with furosemide, which involves replacement of excessive fluid and electrolyte losses 2 3. The FDA drug label does not answer the question.

From the Research

Treatment Options for Vascular Congestion

• Diuretic therapy is a common approach to relieve congestive symptoms of heart failure, including vascular congestion 4, 5, 6.
• Loop diuretics, such as furosemide, are the cornerstone of decongestive treatment and reduce circulating blood volume, thereby reducing intravascular congestion 4.
• Aquaretic drugs, such as vasopressin antagonists, can also be used to increase the osmolality of the circulating blood, potentially improving translocation of fluid from the tissues to the circulation and relieving tissue congestion 4.
• The choice of diuretic should be guided by patient clinical situations and the presence of other co-morbidities 7.

Management of Congestion

• Achieving complete decongestion can be challenging, and residual congestion before discharge from hospital is associated with a high risk of early rehospitalization and death 4.
• An improved understanding of the pathophysiology of congestion is essential in finding better and more personalized therapies 4.
• Differentiating between intravascular congestion and tissue congestion, and specifically treating these two different forms of congestion, could improve the outcomes of patients with acute decompensated heart failure 4.

Alternative Therapies

• ACE inhibitors, such as lisinopril, can provide symptomatic benefits in patients with congestive heart failure and reduce the risk of major clinical events 8.
• The use of high doses of lisinopril has been shown to be more effective than low doses in reducing the risk of all-cause mortality and hospitalization for heart failure 8.