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Decongestion and Outcomes in Patients Hospitalized With Acute HF
Quick Takes
- In a post hoc analysis of the RELAX-AHF-2 trial, 57% of patients had some signs of congestion present at day 5.
- Predictors of persistent congestion at day 5 included baseline exam suggesting more severe decompensation and change in eGFR and hemoglobin at day 5.
- Any congestion at day 5 was associated with increased risk for CV death or rehospitalization for HF or renal failure at 180 days.
Study Questions:
What is the prevalence and prognostic impact of decongestion in patients with acute heart failure (HF)?
Methods:
This was a post hoc analysis of the RELAX-AHF-2 trial that randomized adults hospitalized with acute HF between 2013–2017 to placebo or intravenous serelaxin for 48 hours in addition to standard care. All patients were pooled for this analysis as serelaxin had no effect on outcomes. Congestion was assessed using a composite congestion score (0-8 points) based on the sum of scores for orthopnea, pedal edema, and jugular venous pressure (JVP). Congestion score was assessed at day 5. The primary endpoint was composite of cardiovascular (CV) death and rehospitalization for HF or renal failure at 180 days.
Results:
This study included 5,900 patients with congestion score available at day 5 and 57% had at least one sign of congestion at day 5. Congested patients at day 5 were more likely to be male, have more comorbidities, prior HF hospitalization, and higher New York Heart Association class. Congested patients at day 5 received higher doses of loop diuretic through day 5 and length of hospital stay was longer with higher likelihood of worsening renal function. Predictors of any congestion at day 5 included N-terminal pro–B-type natriuretic peptide, estimated glomerular filtration rate (eGFR), peripheral edema 3+, JVP >10, orthopnea, rales in >2/3 lung fields all assessed at baseline and diuretic response, change in hemoglobin, and change in eGFR at day 5. Baseline congestion score was not associated with the primary endpoint after multivariable adjustment. Congestion score at day 3 was associated independently with the primary endpoint. Any congestion at day 5 was associated with higher risk for the primary endpoint (hazard ratio, 1.32; 95% confidence interval, 1.15-1.51). This association persisted irrespective of age, sex, and left ventricular ejection fraction (LVEF).
Conclusions:
In a post hoc analysis of hospitalized acute HF patients, congestion was noted in 57% of patients at day 5 and associated with increased risk for CV death or rehospitalization for HF or renal failure at 180 days.
Perspective:
Decongestion is central to treatment of hospitalized HF patients. In this large cohort of hospitalized HF patients, persistent congestion was noted at day 5 in 57% of patients. Since randomized trials often select patients that are distinct from real-world practice, these numbers are likely higher in real-world settings. Furthermore, any congestion at day 5 was associated with increased risk for CV death or rehospitalization for HF or renal failure. Importantly, baseline congestion score did not have a similar prognostic association suggesting that persistent congestion at day 5 marks a higher-risk subgroup, regardless of demographics or LVEF.
While existing trials including DOSE-AHF and ADVOR suggest that upfront high dose or combination diuretic therapies are effective at decongestion, these trials did not show a significant difference in post-discharge outcomes, but they were not powered to assess these post-discharge outcomes, as the primary endpoints were in-hospital measures. With an increasing push towards reducing length of stay, additional trials are needed to assess if complete decongestion during AHF is associated with improved post-discharge outcomes.
Clinical Topics: Acute Heart Failure
Keywords: Acute Heart Failure, Renal Insufficiency
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