The Degree of the Predischarge Pulmonary Congestion in Patients Hospitalized for Worsening Heart Failure Predicts Readmission and Mortality

Abstract

<b><i>Background:</i></b> Prediction of readmission and death after hospitalization for heart failure (HF) is an unmet need. <b><i>Aim:</i></b> We evaluated the ability of clinical parameters, NT-proBNP level and noninvasive lung impedance (LI), to predict time to readmission (TTR) and time to death (TTD). <b><i>Methods and Results:</i></b> The present study is a post hoc analysis of the IMPEDANCE-HF extended trial comprising 290 patients with LVEF ≤45% and New York Heart Association functional class II–IV, randomized 1:1 to LI-guided or conventional therapy. Of all patients, 206 were admitted 766 times for HF during a follow-up of 57 ± 39 months. The normal LI (NLI), representing the “dry” lung status, was calculated for each patient at study entry. The current degree of pulmonary congestion (PC) compared with its dry status was represented by ΔLIR = ([measured LI/NLI] – 1) × 100%. Twenty-six parameters recorded during HF admission were used to predict TTR and TTD. To determine the parameter which mainly impacted TTR and TTD, variables were standardized, and effect size (ES) was calculated. Multivariate analysis by the Andersen-Gill model demonstrated that ΔLIR<sub>admission</sub> (ES = 0.72), ΔLIR<sub>discharge</sub> (ES = –3.14), group assignment (ES = 0.2), maximal troponin during HF admission (ES = 0.19), LVEF related to admission (ES = –0.22) and arterial hypertension (ES = 0.12) are independent predictors of TTR (<i>p</i> < 0.01, <i>χ</i><sup>2</sup> = 1,206). Analysis of ES showed that residual PC assessed by ∆LIR<sub>discharge</sub> was the most prominent predictor of TTR. One percent improvement in predischarge PC, assessed by ∆LIR<sub>discharge</sub>, was associated with a likelihood of TTR increase by 14% (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.13–1.15, <i>p</i> < 0.01) and TTD increase by 8% (HR 1.08, 95% CI 1.07–1.09, <i>p</i> < 0.01). <b><i>Conclusion:</i></b> The degree of predischarge PC assessed by ∆LIR is the most dominant predictor of TTR and TTD.

Evaluation of Common Clinical and Hemodynamic Parameters to Pulmonary Capillary Wedge Pressures in Patients Undergoing Right Heart Catheterization

“…6 Persistent signs of congestion on hospital discharge correlate with increased risk of readmission and death. 7 Systemic signs of congestion are the first to resolve with diuresis and afterload reduction, while pulmonary and hemodynamic congestion can linger and be difficult to detect in chronic heart failure patients. 8 Hemodynamic congestion is the elevation of left ventricular end diastolic pressures (often represented by the pulmonary capillary wedge pressure [PCWP]) and generally precedes exam findings as well as weight and vital sign changes in decompensated heart failure.…”

Adequate Decongestion Is Still the Question in Heart Failure

“…In this issue of Cardiology , Kleiner Shochat et al [8] attempt to address this need using the measurement of noninvasive lung impedance (LI), a strategy they introduced in the IMPEDANCE-HF trial [9]. In the parent trial, the investigators used a novel high-sensitivity monitor based on an algorithm that derived net LI by subtracting the calculated chest wall impedance from the total transthoracic impedance.…”