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

Abstract

Aims Patients with acute heart failure (AHF) are included into clinical trials regardless of differences in baseline clinical characteristics. The aim of this study was to assess patients with AHF according to the presence of central and/or peripheral congestion at hospital admission and evaluate treatment response and outcomes in studied phenotypes. Methods and results We investigated retrospectively 352 patients (mean age: 68 ± 13 years, 77% men) hospitalized due to AHF with the signs of congestion on admission. Patients were divided according to the type of signs of congestion into three groups: A, isolated pulmonary congestion (n = 52, 15%); B, isolated peripheral congestion (n = 31, 9%); and C, signs of mixed (peripheral and central) congestion (n = 269, 76%). Patients from Group A had lower concentration of urea, bilirubin, and gamma-glutamyl transferase whereas higher level of haematocrit, albumin, and leukocytes on admission. The highest baseline N-terminal pro-B-type natriuretic peptide level (median: 4113 vs. 3634 vs. 6093 pg/mL) and percentage of patients with chronic heart failure (56 vs. 58 vs. 74%; A vs. B. vs. C, respectively, all P < 0.01) were observed in Group C. There were no differences in terms of demographics, co-morbidities, left ventricular ejection fraction, and applied treatment between studied groups. Patients from Group A had the highest systolic blood pressure on admission (145 ± 37 vs. 122 ± 20 vs. 130 ± 29 mmHg) and the biggest decrease in systolic blood pressure [À22 (À45 to À4) vs. À2 (À13 to 2) vs. À10 (À25 to 0) mmHg] and heart rate [À16 (À35 to À1.5) vs. À1 (À10 to 5) vs. À7 (À20 to 0) b.p.m.] with the lowest weight change [À1.0 (À1.0 to 0) vs. À2.9 (À3.8 to À0.9) vs. À2.0 (À3.0 to À1.0) kg; all P < 0.01] after 48 h of hospitalization. There were differences in short-term and long-term outcomes with favourable results in Group A. Group A experienced less frequent in-hospital heart failure worsening during the first 48 h (4 vs. 23 vs. 7%), had shorter length of hospital stay [6 (5-8) vs. 7 (5-11) vs. 7 (6-11) days], and had lower 1 year all-cause mortality (12 vs. 28 vs. 29%; all P < 0.05). Presence of peripheral congestion on admission was independent predictor for all-cause mortality within 1 year [hazard ratio (95% confidence interval): 2.68 (1.06-6.79); P = 0.04]. Conclusions Patterns of congestion in AHF are associated with differences in clinical characteristics, treatment response, and outcomes. It needs to be considered once planning clinical trials in AHF.

Prognosis of Advanced Heart Failure Patients according to Their Hemodynamic Profile Based on the Modified Forrester Classification

“…Surprisingly, an association with one-year waitlist death, urgent HT, or LVAD implantation was found only with systemic congestion in our cohort. Interestingly, this is concordant with a recent study of Sokolska et al [26] on patients admitted for acute decompensated heart failure. Contrary to isolated pulmonary congestion, presence of systemic congestion on admission was an independent predictor for all-cause mortality within 1 year.…”

Different Renal Function Patterns in Patients With Acute Heart Failure: Relationship With Outcome and Congestion

“…Although our findings may be influenced by the intravenous diuretic amount during the hospitalization period and population heterogeneity, they highlight the relevance of the concomitant measurements of hydro-saline retention and diuretic efficiency monitorization in the context of RF trajectories. Probably, in these groups, the persistence of congestion and in particular the presence of clinical signs of both pulmonary and peripheral congestion are the main driver of worse outcome but should be related also to diuretic resistance which was confirmed by the higher dosage of intravenous diuretics used during hospitalization ( 36 ). A proof of these theories appears to be confirmed by two post hoc analyses from PROTECT and RELAX-AHF trials, evaluating diuretic response during the hospitalization phase ( 37 , 38 ).…”

Not all fluid overloads are the same: some practical considerations for better decongestion

“…Additionally, patterns of congestion in decompensated HF patients are associated with different treatment response, and short-term and long-term outcomes. 8 Such clinical heterogeneity seems to be the result of the relative predominance of one type of congestion -either in the intravascular or in the interstitial compartments (Figure 1B and 1C, respectively). Typically, the former presents as rapid involvement of venous blood reservoir with an increase in intracardiac filling pressure (haemodynamic congestion) and sudden development of symptoms (Figure 1B).…”