Cardiovascular center, Osaka Red Cross Hospital, Osaka, Japan.
Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
J Card Fail. 2023 Aug;29(8):1150-1162. doi: 10.1016/j.cardfail.2023.01.003. Epub 2023 Jan 21.
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.
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.
https://clinicaltrials.gov/ct2/show/NCT02334891 (NCT02334891) https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000017241 (UMIN000015238).
充血是导致心力衰竭（HF）患者住院的主要原因，也是主要的治疗靶点。日本的临床实践以住院时间长为特点，这有利于在住院期间更广泛地消除充血。我们在此研究了在日本 HF 大当代队列中充血的时间过程和预后影响。
3787 名住院 HF 患者的外周水肿、颈静脉压和端坐呼吸均按标准化的 4 分制（0-3 分）分级。入院和出院时计算的综合充血评分（CCS）是通过将个体评分相加得出的。主要结局是全因死亡或 HF 住院的复合终点。入院时的中位 CCS 为 4 分（四分位间距，3-6）。总的来说，16 天的中位住院期间有 255 名患者死亡，中位出院后随访 396 天有 1395 名患者死亡或因 HF 住院。入院时充血程度较高的患者，1 年累积发生率更高（轻度[CCS≤3]组为 32.5%，中度[CCS=4 或 5]组为 39.3%，重度[CCS≥6]组为 41.0%，log-rank P<0.001）。与轻度充血相比，中度和重度充血的调整后的危险比分别为 1.205（95%置信区间[CI]，1.065-1.365；P=0.003）和 1.247（95% CI，1.103-1.410；P<0.001）。在 3445 名出院存活的患者中，85%的患者出院时 CCS 为 0（完全消除充血），15%的患者出院时 CCS 为 1 或更高（残留充血）。尽管残留充血预测出院后死亡或 HF 住院的风险（调整后的危险比，1.314[1.145-1.509]；P<0.001），但入院时的 CCS 与出院后死亡或 HF 住院的风险相关，即使在完全消除充血组中也是如此。出院时残留充血与入院 CCS 之间与出院后死亡或 HF 住院无相关性（P 交互=0.316）。
在日本的临床实践中，85%的患者出院时完全消除了充血。入院和出院时的临床充血具有预后价值。入院时充血的严重程度即使在没有残留充血的情况下，也可以预测不良结局。
