Rethinking Fluid Management in Congestive Heart Failure: Cardiovascular-Renal Regulation, Fluid Management and Diuretics

Despite substantial advances in guideline-directed medical therapy, recurrent hospitalization remains a persistent challenge in the management of congestive heart failure (CHF). Fluid overload is commonly treated as the primary driver of decompensation, with chronic diuretic therapy serving as the cornerstone of outpatient management. However, many patients admitted with CHF exacerbation are already receiving escalating doses of diuretics, raising important questions regarding the underlying mechanisms of recurrent decompensation. This perspective proposes a systems-based, hypothesis-generating framework that reframes congestion as a downstream manifestation of impaired cardiovascular-renal regulation rather than a primary disorder of fluid excess. We examine how rigid, protocol-driven approaches to diuretic use may disrupt physiological equilibrium in susceptible patients and contribute to instability, neurohormonal overactivation, and readmission. We further discuss practice gaps in outpatient fluid management, including inconsistent application of fluid restriction and limited attention to individual tolerance. Finally, we outline the rationale for an individualized, patient-centered approach to fluid management that complements existing guideline-based therapies and warrants prospective investigation.