Congestion in heart failure patients is associated with increased mortality risk

Patients with acute decompensated heart failure who had severe congestion during and after hospitalization had an increased risk of mortality and morbidity, according to a post-hoc analysis of two clinical trials.

Anuradha Lala, MD, of Mount Sinai Hospital in New York City, and colleagues published their findings online in the Journal of the American College of Cardiology: Heart Failure on June 3.

They noted the following symptoms are associated with congestion: dyspnea on minimal exertion or orthopnea, fatigue and peripheral edema. To determine the relationship between congestion and postdischarge outcomes, they evaluated the DOSE-AHF (Diuretic Optimization Strategy Evaluation) and CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) studies, which were both prospective, double-blind, randomized trials.

The studies enrolled patients from March 2008 to January 2012. In DOSE-AHF, 308 patients were randomized to receive low-dose vs. high-dose furosemide therapy and continuous versus intermittent bolus administration of furosemide. In CARRESS-HF, 188 patients were randomized to pharmacologic therapy or ultrafiltration.

At enrollment, 65 percent of patients had high-grade orthodema. Patients with high-grade orthodema had lower use of ACE or ARB inhibitors, higher body mass index (BMI), worse renal function and lower hemoglobin compared with patients with low-grade orthodema.

Lala et al measured congestion by analyzing orthodema scores. They defined no congestion as a score of 0, low-grade orthodema as a score of 1 or 2 and high-grade orthodema as a score of 3 or 4.

For 357 patients, there were orthodema scores at baseline, hospital discharge and 60 days after discharge. At discharge, 52 percent of patients had no congestion, 32 percent had low-grade orthodema and 16 percent had high-grade orthodema. All patients were treated with diuretic therapy and/or ultrafiltration.

Patients who were decongested at discharge had lower 60-day rates of death, hospitalization or unscheduled hospital visits compared with patients with low-grade or high-grade orthodema. In addition, 27 percent of patients who were decongested at discharge had low-grade orthodema and 38 percent had high-grade orthodema at 60 days postdischarge.

The researchers also found that there was no correlation between weight loss and congestion status. Patients who had high-grade orthodema at baseline and were decongested at discharge lost a mean of 14.6 pounds, while patients who remained with high-grade orthodema at baseline and discharge lost a mean of 14.2 pounds.

At 60 days postdischarge, adverse events were found in 50 percent of patients who were decongested at discharge, 52 percent of patients who had low-grade orthodema at discharge and 68 percent of patients who had high-grade orthodema at discharge.