Systemic and pulmonary congestion by ultrasound and prognosis in heart failure: A pooled cohort analysis

Objective: We assessed the prognostic value of the relation between pulmonary and systemic congestion in HF. Background: Increasing congestion, either pulmonary (detected by ultrasound) or systemic (quantified by inferior vena cava (IVC) diameter), is associated with worse outcomes in patients with heart failure (HF). Methods: We performed a pooled analysis on five European cohorts of patients with HF. The primary outcome was a composite of hospitalization for HF and all-cause death. Patients with mild pulmonary congestion (lowest tercile of B-lines, <16 for in-patients, <3 for out-patients) and un-dilated IVC (<21 mm) were considered as the reference group. Results: 835 patients (mean age 75 ± 11 years, 60 % men, 60 % in-patients) were included. Compared to patients with the lowest degree of congestion (n = 124 in-patients, 25 %, and 75 out-patients, 22 %), those with greater congestion were older, had higher natriuretic peptides and lower tricuspid annular plane systolic excursion, but similar left ventricular ejection fraction (LVEF). Among in-patients, 163 (33 %) were re-hospitalized or died during a follow-up of 180 days while 125 (37 %) out-patients were re-hospitalized or died during a median follow-up of 600 days. In models adjusted for age and LVEF, out-patients with the greatest degree of isolated pulmonary congestion (highest tercile) were at higher risk than reference group (HR: 2.34 (1.11–4.91), p = 0.025). A dilated IVC was associated with a greater risk in both in-patients and out-patients when pulmonary congestion was more than mild. Conclusion: Among patients with HF, the combination of both pulmonary and systemic congestion is associated with a worse prognosis than either sign of congestion alone.