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Controversies in Heart Failure

Should Ultrafiltration Be Used Preferentially Instead of Diuretics for the Initial Treatment of ADHF Patients?

Treatment of Congestion in Congestive Heart Failure: Ultrafiltration Is the Only Rational Initial Treatment of Volume Overload in Decompensated Heart Failure

Bradley A. Bart, MD

From the Division of Cardiology, Hennepin County Medical Center, and the University of Minnesota, Minneapolis, Minn.

Correspondence to Bradley A. Bart, MD, Division of Cardiology, O5 HCMC, 701 Park Ave S, Minneapolis, MN 55415. E-mail bartx006@umn.edu

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
"If you have always done it that way, it is probably wrong."

—Charles F. Kettering, 1876–1958

The morbidity of decompensated heart failure is due to volume overload, a consequence of increased total body sodium.^1,2 Failure to adequately reduce total body sodium contributes to progressive ventricular dysfunction, worsening heart failure, and excess morbidity. Ultrafiltration is the gold standard for sodium-volume removal and is the only intervention shown to improve outcomes in a randomized controlled trial of patients hospitalized with decompensated heart failure.³ Diuretics are inherently inferior because they produce hypotonic urine^4,5and undesirable hemodynamic and neurohormonal changes.^6,7 Therefore, ultrafiltration is the preferred initial treatment for patients hospitalized with decompensated heart failure and sodium-volume overload.

Response by Shin and Dec on p 499

	Sodium is the Major Determinant of Extracellular Fluid Volume

 
The earliest descriptions of heart failure date back more than 3500 years to the Egyptian civilization. Even then, symptoms were correctly attributed to volume excess.⁸ It was not until the early 20th century that researchers recognized the role of salt in the formation of edema. In 1901, researchers found that salt fed to patients with congestive heart failure could not be recovered as chloride in the urine.⁸ This represents one of the earliest descriptions of heart failure as a sodium avid state. Later, it was demonstrated that liberal salt intake increased congestive symptoms and pulmonary edema in patients with heart failure whereas patients on salt-restricted diets could tolerate large amounts of water without any further increases in congestion or edema.⁸ Other studies confirmed the primary role of salt, . . . [Full Text of this Article]