Jorge Rubio-Gracia1, Biniyam G Demissei2, Jozine M Ter Maaten2, John G Cleland3, Christopher M O'Connor4, Marco Metra5, Piotr Ponikowski6, John R Teerlink7, Gad Cotter8, Beth A Davison8, Michael M Givertz9, Daniel M Bloomfield10, Howard Dittrich11, Kevin Damman2, Juan I Pérez-Calvo12, Adriaan A Voors13. 1. Servicio de Medicina Interna, Hospital Clínico Universitario "Lozano Blesa", Zaragoza, Spain; Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain; University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands. 2. University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands. 3. Imperial College, London, UK. 4. Inova Heart and Vascular Institute, Falls Church, VA, USA. 5. University of Brescia, Brescia, Italy. 6. Medical University, Clinical Military Hospital, Wroclaw, Poland. 7. University of California at San Francisco, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA. 8. Momentum Research Inc., Durham, NC, USA. 9. Brigham and Women's Hospital, Boston, MA, USA. 10. Merck & Co., Inc. Kenilworth, NJ, USA. 11. Abboud Cardiovascular Research Center, University of Iowa Carver College of Medicine, Iowa, USA. 12. Servicio de Medicina Interna, Hospital Clínico Universitario "Lozano Blesa", Zaragoza, Spain; Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain. 13. University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.. Electronic address: a.a.voors@umcg.nl.
Abstract
BACKGROUND: Congestion is the main reason for hospital admission for acute decompensated heart failure (ADHF). A better understanding of the clinical course of congestion and factors associated with decongestion are therefore important. We studied the clinical course, predictors and prognostic value of congestion in a cohort of patients admitted for ADHF by including different indirect markers of congestion (residual clinical congestion, brain natriuretic peptides (BNP) trajectories, hemoconcentration or diuretic response). METHODS AND RESULTS: We studied the prognostic value of residual clinical congestion using an established composite congestion score (CCS) in 1572 ADHF patients. At baseline, 1528 (97.2%) patients were significantly congested (CCS ≥ 3), after 7 days of hospitalization or discharge (whichever came first), 451 (28.7%) patients were still significantly congested (CCS ≥ 3), 751 (47.8%) patients were mildly congested (CCS = 1 or 2) and 370 (23.5%) patients had no signs of residual congestion (CCS = 0). The presence of significant residual congestion at day 7 or discharge was independently associated with increased risk of re-admissions for heart failure by day 60 (HR [95%CI] = 1.88 [1.39-2.55]) and all-cause mortality by day 180 (HR [95%CI] = 1.54 [1.16-2.04]). Diuretic response provided added prognostic value on top of residual congestion and baseline predictors for both outcomes, yet gain in prognostic performance was modest. CONCLUSION: Most patients with acute decompensated heart failure still have residual congestion 7 days after hospitalization. This factor was associated with higher rates of re-hospitalization and death. Decongestion surrogates, such as diuretic response, added to residual congestion, are still significant predictors of outcomes, but they do not provide meaningful additive prognostic information.
RCT Entities:
BACKGROUND: Congestion is the main reason for hospital admission for acute decompensated heart failure (ADHF). A better understanding of the clinical course of congestion and factors associated with decongestion are therefore important. We studied the clinical course, predictors and prognostic value of congestion in a cohort of patients admitted for ADHF by including different indirect markers of congestion (residual clinical congestion, brain natriuretic peptides (BNP) trajectories, hemoconcentration or diuretic response). METHODS AND RESULTS: We studied the prognostic value of residual clinical congestion using an established composite congestion score (CCS) in 1572 ADHFpatients. At baseline, 1528 (97.2%) patients were significantly congested (CCS ≥ 3), after 7 days of hospitalization or discharge (whichever came first), 451 (28.7%) patients were still significantly congested (CCS ≥ 3), 751 (47.8%) patients were mildly congested (CCS = 1 or 2) and 370 (23.5%) patients had no signs of residual congestion (CCS = 0). The presence of significant residual congestion at day 7 or discharge was independently associated with increased risk of re-admissions for heart failure by day 60 (HR [95%CI] = 1.88 [1.39-2.55]) and all-cause mortality by day 180 (HR [95%CI] = 1.54 [1.16-2.04]). Diuretic response provided added prognostic value on top of residual congestion and baseline predictors for both outcomes, yet gain in prognostic performance was modest. CONCLUSION: Most patients with acute decompensated heart failure still have residual congestion 7 days after hospitalization. This factor was associated with higher rates of re-hospitalization and death. Decongestion surrogates, such as diuretic response, added to residual congestion, are still significant predictors of outcomes, but they do not provide meaningful additive prognostic information.
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