TY - JOUR
T1 - Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction
T2 - Findings from the EVEREST trial
AU - Ambrosy, Andrew P.
AU - Pang, Peter S.
AU - Khan, Sadiya
AU - Konstam, Marvin A.
AU - Fonarow, Gregg C.
AU - Traver, Brian
AU - Maggioni, Aldo P.
AU - Cook, Thomas
AU - Swedberg, Karl
AU - Burnett, John C.
AU - Grinfeld, Liliana
AU - Udelson, James E.
AU - Zannad, Faiez
AU - Gheorghiade, Mihai
N1 - Funding Information:
Conflict of interest: P.S.P. is or has been a consultant for Astellas, Bayer, EKR Therapeutics, J & J, the Medicines Company, Medtronic, Novartis, Otsuka, Palatin Technologies, PDL BioPharma, Pericor Therapeutics, SigmaTau, Solvay Pharmaceuticals, Trevena. He has received honoraria from Alere, Beckman-Coulter, BiogenIdec, Corthera, Ikaria, Nile Therapeutics, Momentum Research, Overcome. He has received research support from Abbott, Merck and PDL BioPharma. He has received travel support from MyLife. He has received equipment support from Sonosite. G.C.F. reports receiving research support from Medtronic (Modest), Gambro (Significant), and Novartis (Significant). B.T. has received compensation through a contract between Otsuka and the University of Wisconsin. T.C. has received research grants and honoraria from Otsuka. M.G. is a consultant for and/or has received research support from Abbott Labs, Astellas, AstraZe-neca, Bayer Schering PharmaAG, CorThera, Inc., Cytokinetics, Inc., DebioPharm SA, ErrekappaTerapeutici (Milan, Italy), Glaxo Smith Kline, JNJ, Medtronic, Novartis Pharma AG, Otsuka, Sigma Tau, Solvay Pharmaceuticals, and Pericor Therapeutics. Dr. Marvin A. Konstam has been a consultant for and/or received research support from Merck, Amgen, Otsuka, Johnson and Johnson, Novartis, and Car-diokine. The other authors declare no conflicts of interest.
PY - 2013/3/14
Y1 - 2013/3/14
N2 - AimsSigns and symptoms of congestion are the most common cause for hospitalization for heart failure (HHF). The clinical course and prognostic value of congestion during HHF has not been systemically characterized.Methods and resultsA post hoc analysis was performed of the placebo group (n 2061) of the EVEREST trial, which enrolled patients within 48 h of admission (median ∼24 h) for worsening HF with an EF ≤40 and two or more signs or symptoms of fluid overload [dyspnoea, oedema, or jugular venous distension (JVD)] for a median follow-up of 9.9 months. Clinician-investigators assessed patients daily for dyspnoea, orthopnoea, fatigue, rales, pedal oedema, and JVD and rated signs and symptoms on a standardized 4-point scale ranging from 0 to 3. A modified composite congestion score (CCS) was calculated by summing the individual scores for orthopnoea, JVD, and pedal oedema. Endpoints were HHF, all-cause mortality (ACM), and ACM HHF. Multivariable Cox regression models were used to evaluate the risk of CCS at discharge on outcomes at 30 days and for the entire follow-up period. The mean CCS obtained after initial therapy decreased from the mean ± SD of 4.07 ± 1.84 and the median (25th, 75th) of 4 (3, 5) at baseline to 1.11 ± 1.42 and 1 (0, 2) at discharge. At discharge, nearly three-quarters of study participants had a CCS of 0 or 1 and fewer than 10 of patients had a CCS >3. B-type natriuretic peptide (BNP) and amino terminal-proBNP, respectively, decreased from 734 (313, 1523) pg/mL and 4857 (2251, 9642) pg/mL at baseline to 477 (199, 1079) pg/mL, and 2834 (1218, 6075) pg/mL at discharge/Day 7. A CCS at discharge was associated with increased risk (HR/point CCS, 95 CI) for a subset of endpoints at 30 days (HHF: 1.06, 0.95-1.19; ACM: 1.34, 1.14-1.58; and ACM HHF: 1.13, 1.03-1.25) and all outcomes for the overall study period (HHF: 1.07, 1.01-1.14; ACM: 1.16, 1.09-1.24; and ACM HHF 1.11, 1.06-1.17). Patients with a CCS of 0 at discharge experienced HHF of 26.2 and ACM of 19.1 during the follow-up.ConclusionAmong patients admitted for worsening signs and symptoms of HF and reduced EF, congestion improves substantially during hospitalization in response to standard therapy alone. However, patients with absent or minimal resting signs and symptoms at discharge still experienced a high mortality and readmission rate.
AB - AimsSigns and symptoms of congestion are the most common cause for hospitalization for heart failure (HHF). The clinical course and prognostic value of congestion during HHF has not been systemically characterized.Methods and resultsA post hoc analysis was performed of the placebo group (n 2061) of the EVEREST trial, which enrolled patients within 48 h of admission (median ∼24 h) for worsening HF with an EF ≤40 and two or more signs or symptoms of fluid overload [dyspnoea, oedema, or jugular venous distension (JVD)] for a median follow-up of 9.9 months. Clinician-investigators assessed patients daily for dyspnoea, orthopnoea, fatigue, rales, pedal oedema, and JVD and rated signs and symptoms on a standardized 4-point scale ranging from 0 to 3. A modified composite congestion score (CCS) was calculated by summing the individual scores for orthopnoea, JVD, and pedal oedema. Endpoints were HHF, all-cause mortality (ACM), and ACM HHF. Multivariable Cox regression models were used to evaluate the risk of CCS at discharge on outcomes at 30 days and for the entire follow-up period. The mean CCS obtained after initial therapy decreased from the mean ± SD of 4.07 ± 1.84 and the median (25th, 75th) of 4 (3, 5) at baseline to 1.11 ± 1.42 and 1 (0, 2) at discharge. At discharge, nearly three-quarters of study participants had a CCS of 0 or 1 and fewer than 10 of patients had a CCS >3. B-type natriuretic peptide (BNP) and amino terminal-proBNP, respectively, decreased from 734 (313, 1523) pg/mL and 4857 (2251, 9642) pg/mL at baseline to 477 (199, 1079) pg/mL, and 2834 (1218, 6075) pg/mL at discharge/Day 7. A CCS at discharge was associated with increased risk (HR/point CCS, 95 CI) for a subset of endpoints at 30 days (HHF: 1.06, 0.95-1.19; ACM: 1.34, 1.14-1.58; and ACM HHF: 1.13, 1.03-1.25) and all outcomes for the overall study period (HHF: 1.07, 1.01-1.14; ACM: 1.16, 1.09-1.24; and ACM HHF 1.11, 1.06-1.17). Patients with a CCS of 0 at discharge experienced HHF of 26.2 and ACM of 19.1 during the follow-up.ConclusionAmong patients admitted for worsening signs and symptoms of HF and reduced EF, congestion improves substantially during hospitalization in response to standard therapy alone. However, patients with absent or minimal resting signs and symptoms at discharge still experienced a high mortality and readmission rate.
KW - Heart failure
KW - Hospitalization
KW - Morbidity
KW - Mortality
KW - Outcomes
KW - Signs and symptoms
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U2 - 10.1093/eurheartj/ehs444
DO - 10.1093/eurheartj/ehs444
M3 - Article
C2 - 23293303
AN - SCOPUS:84875165977
SN - 0195-668X
VL - 34
SP - 835
EP - 843
JO - European heart journal
JF - European heart journal
IS - 11
ER -