Prognostic Value of Integral Assessment of Congestion in Patients Hospitalized with Acute Decompensated Chronic Heart Failure

Abstract

Background: Systemic congestion is the leading pathophysiological mechanism of decompensated heart failure (HF), and hospitalization and poor prognosis. Unfortunately, patients are discharged with residual congestion, possibly due to the lack of a clear strategy for its assessment. The existing criteria for discharge of patients from the hospital are more often based on a subjective assessment and poorly correlate with the state of hemodynamic stabilization, and the search for methods for detecting congestion remains relevant. Objective: The objective is to determine the prognostic value of an integrated assessment of congestion based on novel diagnostic methods in patients hospitalized with acute decompensated chronic HF (ADCHF). Methods: Single-center prospective study in 171 patients hospitalized with ADCHF. All patients underwent physical examination, paraclinical (laboratory and instrumental) investigations-N-terminal pro-brain natriuretic peptide (NT-proBNP) level, lung ultrasound, transient elastography (TE), bioimpedance vector analysis (BIVA) on admission and discharge. Clinical congestion was assessed in accordance with the HF Association consensus document. Clinical outcomes were assessed by structured telephone survey 1, 3, 6, 12 months after discharge. Combined rates of all-cause mortality and re-admissions were used as the study endpoint. Results: Patients hospitalized with ADCHF had the following congestion status at discharge as assessed by individual methods (TE, lung ultrasound, BIVA and NT-proBNP): The incidence of clinical residual Congestion I ranged 33%–39%, the incidence of subclinical congestion was 12%–24%, and patients with euvolemia accounted for 19%–32%. According to the integral assessment of hydration status, the incidences of clinical residual Congestion I, subclinical congestion, and euvolemia were 57%, 31% and 12%, respectively. The study has demonstrated a significant worsening of all congestion parameters with increasing number of methods (1–4) that had detected congestion. Patients with congestion detected at discharge by 2, 3, or 4 methods were at a significantly higher risk of all-cause mortality or readmission. TE + NT-proBNP had a higher prognostic value in regard to the risk of endpoint event, while the combination of all four methods was the most predictive. Conclusions: Patients hospitalized with ADCHF should undergo an integral assessment of residual and subclinical congestion at discharge. The introduction of integral congestion assessment into the routine practice will help identify patients with less favorable prognosis in terms of the risk of death and re-admission, as well as to enhance pharmacologic therapy and follow-up.