Integrative Assessment of Congestion in Heart Failure Throughout the Patient Journey

Abstract

Congestion is one of the main predictors of poor patient outcome in patients with heart failure. However, congestion is difficult to assess, especially when symptoms are mild. Although numerous clinical scores, imaging tools, and biological tests are available to assist physicians in ascertaining and quantifying congestion, not all are appropriate for use in all stages of patient management. In recent years, multidisciplinary management in the community has become increasingly important to prevent heart failure hospitalizations. Electronic alert systems and communication platforms are emerging that could be used to facilitate patient home monitoring that identifies congestion from heart failure decompensation at an earlier stage. This paper describes the role of congestion detection methods at key stages of patient care: pre-admission, admission to the emergency department, in-hospital management, and lastly, discharge and continued monitoring in the community. The multidisciplinary working group, which consisted of cardiologists, emergency physicians, and a nephrologist with both clinical and research backgrounds, reviewed the current literature regarding the various scores, tools, and tests to detect and quantify congestion. This paper describes the role of each tool at key stages of patient care and discusses the advantages of telemedicine as a means of providing true integrated patient care.

Acute heart failure congestion and perfusion status – impact of the clinical classification on in‐hospital and long‐term outcomes; insights from the ESC‐EORP‐HFA Heart Failure Long‐Term Registry

“…Acute heart failure (AHF) includes a wide spectrum of clinical conditions with varied aetiologies and triggers . The pathophysiology of AHF is also diverse, and involves various haemodynamic abnormalities related to elevated ventricular filling pressure and/or reduced cardiac output, clinically manifesting as congestion and hypoperfusion …”

Daily home monitoring of potassium, creatinine, and estimated plasma volume in heart failure post‐discharge

“…Despite its small sample size and related limitation, such home monitoring study was already able to capture a substantial number of clinically relevant cardiorenal and electrolytic changes which are otherwise undiagnosed in routine daily practice with no monitoring . Additionally, given that (i) undiagnosed residual congestion is a major driver of post‐discharge early readmission; (ii) excessive decongestion and use of diuretic therapy is associated with dehydration, hypotension, WRF, and poor prognosis; (iii) dyskalaemia is associated with poor outcome; and hyperkalaemia and WRF are the main reasons for the underuse, underdosing and frequent discontinuation of RAASi, and mineralocorticoid antagonists; and (iv) use of the newly available potassium binders warrants proper biological monitoring, we believe that concomitant monitoring of plasma volume, blood potassium, and renal function is a relevant strategy for assessing congestion and the delicate cardiorenal balance . Plasma volume, blood potassium, and renal function are potentially the most clinically actionable variables for the dynamic optimization of diuretic therapy and of life‐saving RAASi therapy.…”

“…However, in daily practice, patients receive suboptimal doses of RAASi mostly due to concerns of worsening renal function (WRF) and hyperkalaemia . In addition, undiagnosed residual congestion is a major driver of post‐discharge early readmission …”

Figures of the Heart Failure Association: Dr. Ovidiu Chioncel, HFA Board Member, 2018–2020

“…A: A recent review manuscript describes the role of various tools to detect and quantify congestion, at key stages of patient care and assessed from a multidisciplinary perspective.…”