Prognostic Value of Admission-to-Discharge Change in Integral Congestion Assessment for Predicting Adverse Outcomes in Patients with Decompensated Heart Failure

Document Type : Original Articles


People’s Friendship University of Russia, Moscow, Russia


This study was performed to evaluate the prognostic value of relative changes from admission to discharge (Δ%) of integrated congestion assessment to predict adverse outcomes in patients with irreversible heart failure (HF) during a one-year follow-up. The study included 122 patients (60% males, median age of 69 years) with decompensated HF. Most of the patients (92%) had a history of arterial hypertension, 53.3% had coronary heart disease, and 40.2% had type 2 diabetes mellitus. All patients underwent assessments, including NT-proBNP, lung ultrasound (LUS) B-line score, liver stiffness by transient elastography, and resistance and reactance by bioimpedance vector analysis (BIVA). The assessments were performed at admission and discharge, and a relative change from admission (delta percentage, Δ%) was calculated. Long-term clinical outcomes were assessed by a structured interview conducted 1, 3, 6, and 12 months after discharge. The cut-offs for the occurrence of the endpoint events were Δ% NT-proBNP of ≥ -25, Δ% liver stiffness of ≥ -44, Δ% B-line score on lung ultrasound of ≥ -73, Δ% BIVA resistance of ≤ 18, and Δ% BIVA reactance of ≤ 40. It was revealed that 55% of endpoint events, including 22 (18%) deaths and 33 (27%) readmissions, occurred within a median of 74 days (interquartile range: 33-147). Patients with an endpoint event had significantly worse values of all studied parameters in contrast to patients without it. There was a significant direct association between Δ% NT-proBNP and Δ% B-lines (r=0.18; P=0.04), and a highly reliable inverse association was observed between Δ% liver stiffness and Δ% BIVA reactance (r=-0.4; P<0.001). No significant associations were found between the other parameters. Univariate Cox regression analysis demonstrated the independent prognostic value of all congestion markers under study (NT-proBNP, LUS B-lines, liver stiffness, and BIVA reactance) for predicting the combined endpoint. Multivariate Cox regression analysis confirmed the independent prognostic value in predicting the risk of endpoint event for the following parameters: NT-proBNP (hazard rate [HR] 2.5, P=0.001), liver stiffness (HR 2.3, P=0.012), LUS B-line score (HR 2.2, P=0.008). However, it did not find any significant prognostic value for BIVA resistance and reactance. The relative admission-to-discharge change in the integral assessment of congestion had a prognostic value for predicting the risk of adverse outcomes (all-cause mortality and readmission rate) in patients with decompensated HF during a one-year follow-up.


Main Subjects

  1. Stewart D, McPherson ML. Symptom management challenges in heart failure: pharmacotherapy considerations. Heart Fail Rev. 2017;22(5):525-34.
  2. de Boer RA, Meijers WC, van der Meer P, van Veldhuisen DJ. Cancer and heart disease: associations and relations. Eur J Heart Fail. 2019;21(12):1515-25.
  3. Gewirth A. 1. Human Dignity as the Basis of Rights. The Constitution of Rights: Cornell University Press; 2019. p. 10-28.
  4. Shahriari M, Mohammadi E, Abbaszadeh A, Bahrami M, Fooladi MM. Perceived ethical values by Iranian nurses. Nurs Ethics. 2012;19(1):30-44.
  5. Swenne CL, Skytt B. The ward round–patient experiences and barriers to participation. Scand J Caring Sci. 2014;28(2):297-304.
  6. Paul S. Hospital discharge education for patients with heart failure: what really works and what is the evidence? Crit Care Nurse. 2008;28(2):66-82.
  1. Mangolian SP, Shahnazari J, Mahmoodi M, Farokhzadian J. The effect of an educational self-care program on knowledge and performance in patients with heart failure. Iran J Med Edu. 2012; 11(6):609-19.
  2. Nici L, ZuWallack R. An official American Thoracic Society workshop report: the integrated care of the COPD patient. Proc Am Thorac Soc. 2012;9(1):9-18.
  3. Ågren S, Evangelista L, Strömberg A. Do partners of patients with chronic heart failure experience caregiver burden? Eur J Cardiovasc Nurs. 2010;9(4):254-62.
  4. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314-23.
  5. Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345-9.
  6. Kalra AD, Fisher RS, Axelrod P. Decreased length of stay and cumulative hospitalized days despite increased patient admissions and readmissions in an area of urban poverty. J Gen Intern Med. 2010;25(9):930-5.
  7. Horwitz L, Partovian C, Lin Z, Herrin J, Grady J, Conover M, et al. Hospital-wide (all-condition) 30-day risk-standardized readmission measure. New Haven, CT. 2011.
  8. Jakovljevic M, Cupurdija V, Lazic Z. Cost of illness of community-acquired pneumonia. Review of the literature and possible strategies in the Serbian health care setting. Farmeconomia Health economics and therapeutic pathways. 2012;13(3):133-9.
  9. Girerd N, Seronde M-F, Coiro S, Chouihed T, Bilbault P, Braun F, et al. Integrative assessment of congestion in heart failure throughout the patient journey. JACC Heart Fail. 2018;6(4):273-85.
  10. Arrigo M, Jessup M, Mullens W, Reza N, Shah AM, Sliwa K, et al. Acute heart failure. Nat Rev Dis Primers. 2020;6(1):1-15.
  11. Kobalava ZD, Safarova A, Soloveva A, Cabello F, Meray I, Shavarova E, et al. Pulmonary congestion by lung ultrasound in decompensated heart failure: Associations, in-hospital changes, prognostic value. Kardiologiia. 2019;59(8):5-14.
  12. Massari F, Scicchitano P, Iacoviello M, Passantino A, Guida P, Sanasi M, et al. Multiparametric approach to congestion for predicting long-term survival in heart failure. J Cardiol. 2020;75(1):47-52.
  13. Pfister R, Schneider CA. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: application of natriuretic peptides. Eur Heart J. 2008;30(3):382-3; author reply 3.
  14. Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner‐La Rocca HP, Martens P, 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;21(2):137-55.
  15. Pivetta E, Goffi A, Nazerian P, Castagno D, Tozzetti C, Tizzani P, et al. Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial. Eur J Heart Fail. 2019;21(6):754-66.
  16. Platz E, Merz AA, Jhund PS, Vazir A, Campbell R, McMurray JJ. Dynamic changes and prognostic value of pulmonary congestion by lung ultrasound in acute and chronic heart failure: a systematic review. Eur J Heart Fail. 2017;19(9):1154-63.
  17. Coiro S, Porot G, Rossignol P, Ambrosio G, Carluccio E, Tritto I, et al. Prognostic value of pulmonary congestion assessed by lung ultrasound imaging during heart failure hospitalisation: a two-centre cohort study. Sci Rep. 2016;6(1):1-8.
  18. Rubio-Gracia J, Demissei BG, Ter Maaten JM, Cleland JG, O'Connor CM, Metra M, et al. Prevalence, predictors and clinical outcome of residual congestion in acute decompensated heart failure. Int J Cardiol. 2018;258:185-91.
  19. Saito Y, Kato M, Nagashima K, Monno K, Aizawa Y, Okumura Y, et al. Prognostic relevance of liver stiffness assessed by transient elastography in patients with acute decompensated heart failure. Circ J. 2018;17:1344.
  20. Taniguchi T, Ohtani T, Kioka H, Tsukamoto Y, Onishi T, Nakamoto K, et al. Liver stiffness reflecting right-sided filling pressure can predict adverse outcomes in patients with heart failure. Cardiovasc Imaging. 2019;12(6):955-64.
  21. Santarelli S, Russo V, Lalle I, De Berardinis B, Vetrone F, Magrini L, et al. Prognostic value of decreased peripheral congestion detected by Bioelectrical Impedance Vector Analysis (BIVA) in patients hospitalized for acute heart failure: BIVA prognostic value in acute heart failure. Eur Heart J Acute Cardiovasc Care. 2017;6(4):339-47.
  22. Massari F, Iacoviello M, Scicchitano P, Mastropasqua F, Guida P, Riccioni G, et al. Accuracy of bioimpedance vector analysis and brain natriuretic peptide in detection of peripheral edema in acute and chronic heart failure. Heart Lung. 2016;45(4):319-26.