Elsevier

Journal of Cardiac Failure

Volume 29, Issue 8, August 2023, Pages 1150-1162
Journal of Cardiac Failure

Prognostic Value of the Severity of Clinical Congestion in Patients Hospitalized for Decompensated Heart Failure: Findings From the Japanese KCHF Registry

https://doi.org/10.1016/j.cardfail.2023.01.003Get rights and content

Highlights

  • In Japan, the median length of heart failure hospitalization was 16 days.

  • Of hospitalized patients, 85% were discharged with complete decongestion.

  • Admission and discharge Composite Congestion Score (CCS) correlated with outcomes.

  • Admission CCS correlated with postdischarge outcomes even when the CCS was 0 at discharge.

Abstract

Background

Congestion is a leading cause of hospitalization and a major therapeutic target in patients with heart failure (HF). Clinical practice in Japan is characterized by a long hospital stay, which facilitates more extensive decongestion during hospitalization. We herein examined the time course and prognostic impact of clinical congestion in a large contemporary Japanese cohort of HF.

Methods and Results

Peripheral edema, jugular venous pressure, and orthopnea were graded on a standardized 4-point scale (0–3) in 3787 hospitalized patients in a Japanese cohort of HF. Composite Congestion Scores (CCS) on admission and at discharge were calculated by summing individual scores. The primary outcome was a composite of all-cause death or HF hospitalization. The median admission CCS was 4 (interquartile range, 3–6). Overall, 255 patients died during the median hospitalization length of 16 days, and 1395 died or were hospitalized for HF over a median postdischarge follow-up of 396 days. The cumulative 1-year incidence of the primary outcome increased at higher tertiles of congestion on admission (32.5%, 39.3%, and 41.0% in the mild [CCS ≤3], moderate [CCS = 4 or 5], and severe [CCS ≥6] congestion groups, respectively, log-rank P < .001). The adjusted hazard ratios of moderate and severe congestion relative to mild congestion were 1.205 (95% confidence interval [CI], 1.065–1.365; P = .003) and 1.247 (95% CI, 1.103–1.410; P < .001), respectively. Among 3445 patients discharged alive, 85% had CCS of 0 (complete decongestion) and 15% had a CCS of 1 or more (residual congestion) at discharge. Although residual congestion predicted a risk of postdischarge death or HF hospitalization (adjusted hazard ratio, 1.314 [1.145–1.509]; P < .001), the admission CCS correlated with the risk of postdischarge death or HF hospitalization, even in the complete decongestion group. No correlation was observed for postdischarge death or HF hospitalization between residual congestion at discharge and admission CCS (P for the interaction = .316).

Conclusions

In total, 85% of patients were discharged with complete decongestion in Japanese clinical practice. Clinical congestion, on admission and at discharge, was of prognostic value. The severity of congestion on admission was predictive of adverse outcomes, even in the absence of residual congestion.

Section snippets

Population

The KCHF registry is a prospective, multicenter, observational cohort study, that is designed as an all-comer registry to capture recent trends in clinical characteristics, socioeconomic factors, management, and prognosis of patients with ADHF in a super-aging society in Japan.15, 16, 17 Therefore, the KCHF registry enrolled, without exclusion and regardless of left ventricular ejection fraction, all consecutive patients hospitalized for acute congestive HF between October 2014 and March 2016

Patient Characteristics

Among 3787 study patients, the median CCS on admission was 4 (IQR 3–6). We classified the study population into 3 groups according to CCS on admission (mild congestion group [CCS of ≤3]: 1263 patients [33%]; moderate congestion group [CCS of 4 or 5]: 1247 patients [33%]; and the severe congestion group [CCS of ≥6]: 1277 patients [34%)] (Fig. 1, 2A). Patients with a higher admission CCS were more likely to have a hypertensive heart disease as the etiology for HF (Table 1). The proportions of

Discussion

The KCHF registry provided the unique features of current clinical practice for HF in an era of a super-aging society in Japan. The present study confirmed that, in current clinical practice for HF in Japan, clinical congestion completely improved in 85% of patients during the median hospital stay of 16 days. Nevertheless, the severity of congestion on admission was related to long-term adverse outcomes. Patients with residual congestion had a markedly higher risk of postdischarge death and

Limitations

There are several limitations in the present study. We used a semiquantitative tool composed of physical signs and symptoms to assess clinical congestion. By using the same scale as that used previously, the present study provides a unique snapshot of a change in the congestion status in Japanese clinical practice. However, physical signs and symptoms are inherently subjective, prone to variation, and dependent on a physician's skills.33,34 Nevertheless, physical signs and symptoms remain the

Conclusions

In current Japanese clinical practice, 85% of patients were discharged with complete decongestion and the median hospitalization length of 16 days. Clinical congestion, both on admission and at discharge, was associated with clinical outcomes. The severity of congestion on admission was predictive of adverse outcomes, even in the absence of residual congestion.

Lay Summary

Congestion is a major therapeutic target in patients with heart failure. Clinical practice in Japan is characterized by a long hospital stay, which would facilitate extensive decongestion during hospitalization. The present study in a large contemporary cohort of Japanese patients with heart failure confirmed that clinical decongestion with complete relief of peripheral edema, jugular venous distension, and orthopnea was achieved in 85% of the patients during a median hospitalization length of

Declaration of Competing Interest

None declared.

Acknowledgments

The authors thank the staff of the KCHF study and the members of the participating centers.

References (35)

  • W. Mullens et al.

    The use of diuretics in heart failure with congestion — a position statement from the Heart Failure Association of the European Society of Cardiology

    Eur J Heart Fail

    (2019)
  • A. Lala et al.

    Relief and recurrence of congestion during and after hospitalization for acute heart failure insights from diuretic optimization strategy evaluation in acute decompensated heart failure (DOSE-AHF) and cardiorenal rescue study in acute decompensated heart failure (CARESS-HF)

    Circ Heart Fail

    (2015)
  • T.A. McDonagh et al.

    2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure

    Eur Heart J

    (2021)
  • A.P. Ambrosy et al.

    Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial

    Eur Heart J

    (2013)
  • R.D. Kociol et al.

    Markers of decongestion, dyspnea relief, and clinical outcomes among patients hospitalized with acute heart failure

    Circ Heart Fail

    (2013)
  • Y. Shiraishi et al.

    9-year trend in the management of acute heart failure in Japan: A report from the national consortium of acute heart failure registries

    J Am Heart Assoc

    (2018)
  • S. Hamaguchi et al.

    Effects of atrial fibrillation on long-term outcomes in patients hospitalized for heart failure in Japan: a report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD)

    Circ J

    (2009)
  • Cited by (0)

    View full text