Body Weight Change During and After Hospitalization for Acute Heart Failure: Patient Characteristics, Markers of Congestion, and Outcomes

Abstract

Background Body weight changes during and after hospitalization for acute heart failure (AHF) and the relationships with outcomes have not been well-characterized. Methods A post-hoc analysis was performed of the ASCEND-HF trial, which enrolled patients admitted for AHF regardless of ejection fraction. In-hospital body weight change was defined as the difference between baseline and discharge/day 10, while post-discharge body weight change was defined as the difference between discharge/day 10 and day 30. Spearman rank correlations of weight change, urine output (UOP), and dyspnea relief as assessed by a 7-point Likert scale are described. Logistic and Cox proportional hazards regression was used to evaluate the relationship between weight change and outcomes. Results Study participants with complete body weight data (n = 4,172) had a mean age of 65±14 years and 66% were male. Ischemic heart disease was reported in 60% of patients and the average ejection fraction was 30±13%. The median change in body weight was −1.0 kg (interquartile range [IQR]: −2.1, 0.0) at 24 hr and −2.3 kg (IQR: −5.0, −0.7) by discharge/day 10. At hour 24, there was a weak correlation between change in body weight and UOP (r = −0.381) and minimal correlation between body weight change and dyspnea relief (r = −0.096). After risk adjustment, increasing body weight during hospitalization was associated with a 16% increase per kg in the likelihood of 30-day mortality or HF readmission for patients showing weight loss ≤1 kg or weight gain during hospitalization (Odds Ratio per kg increase 1.16, 95% Confidence Interval [CI] 1.09–1.27; p<0.001). Among the subset of patients experiencing > 1 kg increase in body weight post-discharge, increasing body weight was associated with higher risk of 180-day mortality (Hazard Ratio per kg increase 1.16, 95% CI 1.09–1.23; p<0.001). Conclusion A substantial number of patients experienced minimal weight loss or frank weight gain in the context of an AHF trial, and increasing body weight in this subset of patients was independently associated with a worse post-discharge prognosis.

Optimal Endpoints of Acute Heart Failure Therapy

“…[29] Alternatively, increases in body weight during AHF hospitalization correlate with a 16% per kilogram risk of 30-day mortality and readmission. [30] Further, patients with diastolic HF may have symptoms related to fluid redistribution rather than total body fluid accumulation, and it may not be necessary to target significant weight loss in this patient population. [31] While weight loss appears to be measure of adequate diuresis and has been traditionally used as a tool to evaluate decongestion, data do not support the use of weight loss as a reliable correlative of decongestion or volume loss during inpatient therapy.…”

Predictors of Post-discharge Mortality Among Patients Hospitalized for Acute Heart Failure

“…However, dyspnoea assessments remain imprecise and regardless of how it is measured, the vast majority of resolves or significantly improves in the first 24 to 48 hours of IV standard therapies. 24 In the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF), 25 the relationship between in-hospital dyspnoea improvement and post-discharge outcomes was inconsistent and study medication failed to show any post-discharge outcomes benefit. Furthermore, pathophysiology of congestion is more complex, and the subjective feeling of dyspnoea may poorly correlate with objective measures of decongestion, such as weight change 25 or urine output.…”

“…24 In the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF), 25 the relationship between in-hospital dyspnoea improvement and post-discharge outcomes was inconsistent and study medication failed to show any post-discharge outcomes benefit. Furthermore, pathophysiology of congestion is more complex, and the subjective feeling of dyspnoea may poorly correlate with objective measures of decongestion, such as weight change 25 or urine output. 26 Nonetheless, congestion is the leading cause for AHF readmission, and represents an important therapeutic target of inpatient management, and a major determinant of discharge decision-making.…”

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

“…Most of the costs associated with HF are related to hospitalizations due to decompensated HF, also known as acute HF (AHF), which has become one of the leading causes for hospitalization globally 2, 3. 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…”

“…Of the adjunct monitoring tools, echocardiography (echo) and lung ultrasound (LUS) allow real‐time evaluation of cardiac filling pressures and pulmonary congestion, and these two modalities can be performed sequentially using the same machinery and probe 11, 12, 13, 14. Furthermore, echo can specify the underlying cardiac disease in AHF 4, 5. Echo and LUS might thus be useful for determining haemodynamic and baseline disease phenotype in AHF, as well as for monitoring and individually guiding treatment.…”