Clinical phenotypes of acute heart failure based on signs and symptoms of perfusion and congestion at emergency department presentation and their relationship with patient management and outcomes

Abstract

Objective To compare the clinical characteristics and outcomes of patients with acute heart failure (AHF) according to clinical profiles based on congestion and perfusion determined in the emergency department (ED). Methods and results Overall, 11 261 unselected AHF patients from 41 Spanish EDs were classified according to perfusion (normoperfusion = warm; hypoperfusion = cold) and congestion (not = dry; yes = wet). Baseline and decompensation characteristics were recorded as were the main wards to which patients were admitted. The primary outcome was 1‐year all‐cause mortality; secondary outcomes were need for hospitalisation during the index AHF event, in‐hospital all‐cause mortality, prolonged hospitalisation, 7‐day post‐discharge ED revisit for AHF and 30‐day post‐discharge rehospitalisation for AHF. A total of 8558 patients (76.0%) were warm + wet, 1929 (17.1%) cold + wet, 675 (6.0%) warm + dry, and 99 (0.9%) cold + dry; hypoperfused (cold) patients were more frequently admitted to intensive care units and geriatrics departments, and warm + wet patients were discharged home without admission. The four phenotypes differed in most of the baseline and decompensation characteristics. The 1‐year mortality was 30.8%, and compared to warm + dry, the adjusted hazard ratios were significantly increased for cold + wet (1.660; 95% confidence interval 1.400–1.968) and cold + dry (1.672; 95% confidence interval 1.189–2.351). Hypoperfused (cold) phenotypes also showed higher rates of index episode hospitalisation and in‐hospital mortality, while congestive (wet) phenotypes had a higher risk of prolonged hospitalisation but decreased risk of rehospitalisation. No differences were observed among phenotypes in ED revisit risk. Conclusions Bedside clinical evaluation of congestion and perfusion of AHF patients upon ED arrival and classification according to phenotypic profiles proposed by the latest European Society of Cardiology guidelines provide useful complementary information and help to rapidly predict patient outcomes shortly after ED patient arrival.

Distinct clinical phenotypes of congestion in acute heart failure: characteristics, treatment response, and outcomes

“…[3][4][5] Therefore, accurate profiling of patients admitted with AHF generates considerable interest in terms of designing clinical trials in the clinical settings of AHF. [6][7][8][9][10] Current European Society of Cardiology (ESC) Guidelines for diagnosis and treatment of acute and chronic heart failure (HF) recommend to classify patients with AHF according to clinical profiles, based on the presence or absence of congestion ('wet' vs. 'dry') and peripheral hypoperfusion ('cold' vs. 'warm') during bedside physical examination. 1,11,12 Prognostic value of the aforementioned clinical profiling has been recently confirmed.…”

November 2019 at a glance. Chronic and acute heart failure: from epidemiology to treatment

“…Chioncel et al . and Javaloyes et al . reported prevalence and prognostic impact of clinical phenotypes based on perfusion and congestion status.…”

“…Clinical profile of acute HF patients affects outcomes. 12 Chioncel et al 13 and Javaloyes et al 14 reported prevalence and prognostic impact of clinical phenotypes based on perfusion and congestion status. The phenotype 'wet-warm' was the most commonly observed.…”

The CRAS-EAHFE study: Characteristics and prognosis of acute heart failure episodes with cardiorenal-anaemia syndrome at the emergency department

“…[4][5][6][7] In addition, RD is usually presented together with other clinical situations which also worsen the prognosis. For example, there is the case of persistent congestion (which increases mortality, hospitalisation, hospital stay, rehospitalisation and resistance to loop diuretics) [8][9][10][11] or hyperpotassaemia (which, in addition to increasing mortality, limits the use of diseasemodifying drugs, such as renin-angiotensin-aldosterone system (RAAS) blockers or mineralocorticoid-receptor antagonists (MRAs). 12,13 Another comorbidity usually present is anaemia, thereby adding complexity to diagnostic and therapeutic management since it may be due to multiple conditions such as deficit in iron, cobalamins or folates, altered renal perfusion, reduced erythropoietin production or a situation of haemodilution due to congestion, all of which may be isolated occurrences or in combination.…”