Discordance Between Hemoconcentration and Clinical Assessment of Decongestion in Acute Heart Failure

• Hemoconcentration has been proposed as a surrogate for successful decongestion in acute heart failure. We studied the relationship between hemoconcentration and clinical measures of decongestion.
• There was a poor correlation between the magnitude of hematocrit changes and the degree of improvement in congestion score as assessed by clinical examination.
• Persistent clinical congestion at hospital discharge was present in a significant proportion of patients despite hemoconcentration (23.9%) and was associated with increased risk for mortality and heart failure rehospitalizations.
• Furthermore, hemoconcentration was absent in many patients (71.0%) without clinical evidence of congestion at hospital discharge.

IntroductionHemoconcentration has been proposed as a surrogate for successful decongestion in acute heart failure (AHF). The aim of the present study was to evaluate the relationship between hemoconcentration and clinical measures of congestion.Methods and ResultsWe studied 704 patients with AHF and volume overload. A composite congestion score was calculated at admission and discharge, with a score >1 denoting persistent congestion. Hemoconcentration was defined as any increase in hematocrit and hemoglobin levels between baseline and discharge. Of 276 patient with hemoconcentration, 66 (23.9%) had persistent congestion. Conversely, of 428 patients without hemoconcentration, 304 (71.0%) had no clinical evidence of congestion. Mean hematocrit changes were similar with and without persistent congestion (0.18 ± 3.4% and −0.19 ± 3.6%, respectively; P = .17). There was no correlation between the decline in congestion score and the change in hematocrit (P = .93). Hemoconcentration predicted lower mortality (hazard ratio 0.70, 95% confidence interval 0.54–0.90; P = .006). Persistent congestion was associated with increased mortality independent of hemoconcentration (Ptrend = .0003 for increasing levels of congestion score).ConclusionsHemoconcentration is weakly related to congestion as assessed clinically. Persistent congestion at discharge is associated with increased mortality regardless of hemoconcentration. Hemoconcentration is associated with better outcome but cannot substitute for clinically derived estimates of congestion to determine whether decongestion has been achieved.