- •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.
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).
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.
Clinical Trial Registration
https://clinicaltrials.gov/ct2/show/NCT02334891 (NCT02334891) https://upload.umin.ac.jp/cgi–open–bin/ctr_e/ctr_view.cgi?recptno=R000017241 (UMIN000015238)
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- The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries.J Am Coll Cardiol. 2014; 63 (Preprint at): 1123-1133https://doi.org/10.1016/j.jacc.2013.11.053
- Do patients have worse outcomes in heart failure than in cancer? A primary care-based cohort study with 10-year follow-up in Scotland.Eur J Heart Fail. 2017; 19: 1095-1104
- Acute heart failure congestion and perfusion status – impact of the clinical classification on in-hospital and long-term outcomes; insights from the ESC-EORP-HFA heart failure long-term registry.Eur J Heart Fail. 2019; 21: 1338-1352
- European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT): 1-year follow-up outcomes and differences across regions.Eur J Heart Fail. 2016; 18: 613-625
- Heart failure.JACC: Heart Failure. 2013; 1 (Preprint at): 1-20https://doi.org/10.1016/j.jchf.2012.10.002
- 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; 21: 137-155
- 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; 8: 741-748
- 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure.Eur Heart J. 2021; 42 (Preprint at): 3599-3726https://doi.org/10.1093/eurheartj/ehab368
- 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; 34: 835-843
- Prevalence, predictors and clinical outcome of residual congestion in acute decompensated heart failure.Int J Cardiol. 2018; 258: 185-191
- Markers of decongestion, dyspnea relief, and clinical outcomes among patients hospitalized with acute heart failure.Circ Heart Fail. 2013; 6: 240-245
- The burden of congestion in patients hospitalized with acute decompensated heart failure.Am J Cardiol. 2019; 124: 545-553
- 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; 7e008687
- 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; 73: 2084-2090
- Kyoto Congestive Heart Failure (KCHF) study: rationale and design.ESC Heart Fail. 2017; 4: 216-223
- Demographics, management, and in-hospital outcome of hospitalized acute heart failure syndrome patients in contemporary real clinical practice in Japan: Observations from the prospective, multicenter Kyoto Congestive Heart Failure (KCHF) registry.Circ J. 2018; 82: 2811-2819
- Association of mineralocorticoid receptor antagonist use with all-cause mortality and hospital readmission in older adults with acute decompensated heart failure.JAMA Netw Open. 2019; 2e195892
- The natural history of congestive heart failure: the Framingham study.N Engl J Med. 1971; 285: 1441-1446
- Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991.Circulation. 1998; 98: 2282-2289
Japan's ethical guidelines for epidemiologic research. 2008;2002. Available at: http://www.lifescience.mext.go.jp/files/pdf/n796_01.pdf.
- Risk factors and clinical outcomes of functional decline during hospitalisation in very old patients with acute decompensated heart failure: an observational study.BMJ Open. 2020; 10e032674
- Ischemic stroke in acute decompensated heart failure: from the KCHF registry.J Am Heart Assoc. 2021; 10e022525
- Risk factors and clinical outcomes of nonhome discharge in patients with acute decompensated heart failure: an observational study.J Am Heart Assoc. 2021; 10e020292
- Current use of inotropes according to initial blood pressure and peripheral perfusion in the treatment of congestive heart failure: findings from a multicentre observational study.BMJ Open. 2022; 12e053254
- Integrative assessment of congestion in heart failure throughout the patient journey.JACC Heart Fail. 2018; 6: 273-285https://doi.org/10.1016/j.jchf.2017.09.023
- The role of the clinical examination in patients with heart failure.JACC Heart Fail. 2018; 6: 543-551https://doi.org/10.1016/j.jchf.2018.04.005
- Prognostic implications of congestion on physical examination among contemporary patients with heart failure and reduced ejection fraction: PARADIGM-HF.Circulation. 2019; 140: 1369-1379
- Burden of heart failure signs and symptoms, prognosis, and response to therapy: the PARAGON-HF trial.JACC Heart Fail. 2021; 9: 386-397
- Global differences in characteristics, precipitants, and initial management of patients presenting with acute heart failure.JAMA Cardiol. 2020; 5: 401
- Clinical characteristics and outcomes of hospitalized patients with heart failure from the large-scale Japanese registry of acute decompensated heart failure (JROADHF).Circ J. 2021; 85: 1438-1450
- Do countries or hospitals with longer hospital stays for acute heart failure have lower readmission rates? Findings from ASCEND-HF.Circ Heart Fail. 2013; 6: 727-732
- Length of hospital stay and 30-day readmission following heart failure hospitalization: insights from the EVEREST trial.Eur J Heart Fail. 2015; 17: 1022-1031
- Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial.Circ Heart Fail. 2008; 1: 170-177
- The limited reliability of physical signs for estimating hemodynamics in chronic heart failure.JAMA. 1989; 261: 884
- Congestion in heart failure: a contemporary look at physiology, diagnosis and treatment.Nat Rev Cardiol. 2020; 17: 641-655
Published online: January 20, 2023
Accepted: January 2, 2023
Received in revised form: December 23, 2022
Received: August 8, 2022
Publication stageIn Press Journal Pre-Proof
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