Assessing and grading congestion in acute heart failure: a scientific statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine

Abstract

Patients with acute heart failure (AHF) require urgent in-hospital treatment for relief of symptoms. The main reason for hospitalization is congestion, rather than low cardiac output. Although congestion is associated with a poor prognosis, many patients are discharged with persistent signs and symptoms of congestion and/or a high left ventricular filling pressure. Available data suggest that a pre-discharge clinical assessment of congestion is often not performed, and even when it is performed, it is not done systematically because no method to assess congestion prior to discharge has been validated. Grading congestion would be helpful for initiating and following response to therapy. We have reviewed a variety of strategies to assess congestion which should be considered in the care of patients admitted with HF. We propose a combination of available measurements of congestion. Key elements in the measurement of congestion include bedside assessment, laboratory analysis, and dynamic manoeuvres. These strategies expand by suggesting a routine assessment of congestion and a pre-discharge scoring system. A point system is used to quantify the degree of congestion. This score offers a new instrument to direct both current and investigational therapies designed to optimize volume status during and after hospitalization. In conclusion, this document reviews the available methods of evaluating congestion, provides suggestions on how to properly perform these measurements, and proposes a method to quantify the amount of congestion present.--

Reasons for Guideline Nonadherence at Heart Failure Discharge

“…Even between these studies, the rates of decongestion varied, depending on the definition of decongestion that was used. At present, there is no standard definition for decongestion 29. In this study, we operationalized a simple, 4‐part definition based on history and examination.…”

The Value of a Simplified Lung Ultrasound Protocol in the Pre-Discharge Evaluation of Patients Hospitalized with Acute Heart Failure

“…This includes the obtaining of a congestion-free status at discharge, which has to be objectively demonstrated. The presence of clinical or subclinical congestion could be tested in various ways, the level of NT-proBNP being the gold standard, however LUS could be considered as an emerging, bedside tool of assessment [1,5].…”

“…However, due to the cost and lack of general availability there is a trend to use other, more simple tools to evaluate congestion. Lung ultrasound has emerged as one of the most promising method in this regard [5,6].…”

Focused echocardiography and lung ultrasound protocol for guiding treatment in acute heart failure

“…There is to date virtually no evidence‐based therapy existing for AHF, hospitalizations are lengthy and expensive,2, 3 and post‐discharge prognosis often remains poor,4, 5 underlining the need for better evidence‐based therapy. How to optimally monitor decongestive treatment in AHF, however, is vaguely defined in the guidelines,6, 7 which might partly explain the lack of effective therapies 8, 9, 10…”

“…According to some authorities, tailored therapy based on individual patient characteristics could also be a way to achieve more effective therapy in AHF 8, 9, 10…”