Decongestion and Outcomes in Patients Hospitalized for Acute Heart Failure: Insights From the RELAX-AHF-2 Trial

Background: The prognostic importance of residual congestion after acute heart failure (AHF) hospitalization is still debated. Objectives: The authors aimed to assess the impact of residual congestion in a large cohort of patients with AHF enrolled in the RELAX-AHF-2 (Relaxin in Acute Heart Failure 2) trial. Methods: Residual congestion was assessed at day 5 after admission among hospitalized patients using an established composite congestion score (CCS) based on the presence of orthopnea, peripheral edema, and increased jugular venous pressure, ranging from 0 to 8 points. The primary endpoint was a composite of cardiovascular death or rehospitalization for heart failure or renal failure at 180 days. Results: Among the 5,900 AHF patients included in this analysis, 3,380 (57.3%) had at least 1 sign of congestion (ie, CCS ≥1) and 1,066 (18.1%) had a CCS ≥3 at day 5 after admission. Patients with residual congestion at day 5 were more symptomatic, had more comorbidities, received higher doses of loop diuretic agents in-hospital, albeit with lower diuretic response, were less likely to have hemoconcentration, and were more likely to have worsening renal function at day 5. After multivariable adjustment for clinically meaningful variables, any sign of residual congestion and CCS ≥3 at day 5 were both independently associated with a higher risk of the primary endpoint (adjusted HR: 1.32 [95% CI: 1.15-1.51]; P < 0.001 and adjusted HR: 1.62 [95% CI: 1.39-1.88]; both P < 0.001). Conclusions: Among patients with AHF who were still hospitalized at day 5, residual congestion was common and independently associated with worse outcome. (Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF [RELAX-AHF-2]; NCT01870778).