Abstract
Background: Patients with heart failure (HF) often display dyspnea associated with pulmonary congestion, along with intravascular congestion, both may result in urgent hospitalization and subsequent death. A combination of radiographic pulmonary congestion and plasma volume might screen patients with a high risk of in-hospital mortality in the emergency department (ED).Methods: In the pathway of dyspneic patients in emergency (PARADISE) cohort, patients admitted for acute HF were stratified into 4 groups based on high or low congestion score index (CSI, ranging from 0 to 3, high value indicating severe congestion) and estimated plasma volume status (ePVS) calculated from hemoglobin/hematocrit.Results: In a total of 252 patients (mean age, 81.9 years; male, 46.8%), CSI and ePVS were not correlated (Spearman rho <0 .10, p > 0.10). High CSI/high ePVS was associated with poorer renal function, but clinical congestion markers (i.e., natriuretic peptide) were comparable across CSI/ePVS categories. High CSI/high ePVS was associated with a four-fold higher risk of in-hospital mortality (adjusted-OR, 95%CI = 4.20, 1.10-19.67) compared with low CSI/low ePVS, whereas neither high CSI nor ePVS alone was associated with poor prognosis (all-p-value > 0.10; Pinteraction = 0.03). High CSI/high ePVS improved a routine risk model (i.e., natriuretic peptide and lactate)(NRI = 46.9%, p = 0.02), resulting in high prediction of risk of in-hospital mortality (AUC = 0.85, 0.82-0.89).Conclusion: In patients hospitalized for acute HF with relatively old age and comorbidity burdens, a combination of CSI and ePVS was associated with a risk of in-hospital death, and improved prognostic performance on top of a conventional risk model.
Highlights
Congestion in heart failure (HF) is defined as a high left ventricular filling pressure associated with signs and symptoms of HF such as dyspnea and edema [1,2,3]
We observed a poor correlation between congestion score index (CSI) and ePVS, which may be partly explained by the fact that fluid accumulation - as expressed by Plasma volume (PV)- and fluid redistribution from splanchnic venous system may contribute to degrees of pulmonary congestion [3, 28,29,30]
Our results showed that only the simultaneous presence of pulmonary and intravascular congestion conferred a higher risk of in-hospital mortality, whereas patients with only one severe congestion marker had a comparable risk of adverse outcome when compared with those without
Summary
Congestion in heart failure (HF) is defined as a high left ventricular filling pressure associated with signs and symptoms of HF such as dyspnea and edema [1,2,3]. Assessment of integrating pulmonary and intravascular congestion might provide better patient risk stratification. Our group reported that increased both ePVS and CSI of AHF patients were associated with a high risk of 90-day post-discharge outcomes [9]. We hypothesized that the combination of elevated CSI and ePVS could potentially identify patients with markedly increased congestion in the ED, and provide important risk-stratification for in-hospital management. Patients with heart failure (HF) often display dyspnea associated with pulmonary congestion, along with intravascular congestion, both may result in urgent hospitalization and subsequent death. A combination of radiographic pulmonary congestion and plasma volume might screen patients with a high risk of in-hospital mortality in the emergency department (ED)
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