Freedom from congestion predicts good survival despite previous class IV symptoms of heart failure

Background This study determined whether evidence of congestion after 4 to 6 weeks of heart failure management predicted outcome for patients hospital ized with chronic New York Heart Association class IV symptoms. Cross IV sy mptoms predict high mortality rates, but outcome is not known for patients who improve to establish freedom from congestion. Revised estimates at 1 mo nth could facilitate decisions regarding transplantation and other high-ris k interventions. Methods At 4 to 6 weeks after hospital discharge, 146 patients were evaluat ed for congestion by 5 criteria (orthopnea, jugular venous distention, edem a, weight gain, and new increase in baseline diuretics). Heart failure mana gement included inpatient therapy tailored to relieve congestion, followed by adjustments to maintain Fluid balance during the next 4 weeks. Results Freedom from congestion was demonstrated at 4 to 6 weeks in 80 (54% ) patients, who had 87% subsequent 2-year survival compared with 67% in 40 patients with 1 or 2 criteria of congestion and 41% in 26 patients with 3 t o 5 criteria. The Cox proportional hazards model identified left ventricula r dimension, pulmonary wedge pressure on therapy, and freedom from congesti on as independent predictors of survival. Persistence of orthopnea itself p redicted 38% 2-year survival (without urgent transplantation) versus 77% in 113 without orthopnea. Serum sodium was lower and blood urea nitrogen and heart rate higher when orthopnea persisted. Conclusions The ability to maintain freedom From congestion identifies a po pulation with good survival despite previous class IV symptoms. At 4 to 6 w eeks, patients with persistent congestion may be considered for high-risk i ntervention.