Signs of congestion on physical exam accurately predict heart failure hospitalizations, death

Physical exam of patients with heart failure (HF) and reduced ejection fraction provided significant, independent prognostic value even beyond symptoms, natriuretic peptides, and risk scores, a study found.

Researchers analyzed participants from the PARADIGM-HF (Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in HF) trial to determine the association between physical signs of congestion (jugular venous distention, edema, rales, and S3) at baseline and quality of life (assessed by the Kansas City Cardiomyopathy Questionnaire) and clinical outcomes (cardiovascular death, HF hospitalization, and all-cause mortality), as well as to assess the treatment effects of sacubitril/valsartan (the trial drug) on congestion. PARADIGM-HF was sponsored by Novartis Pharmaceuticals. Results were published by Circulation on Sept. 12.

Among 8,380 participants, 70% had no signs of congestion, 21% had one sign, 7% had two signs, and 2% had three or four signs. Patients with baseline congestion were older, were more often women, and had higher Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk scores and lower quality-of-life scores (P<0.05). After adjustment for baseline natriuretic peptides, time-updated MAGGIC score, and time-updated New York Heart Association class, increasing time-updated congestion was associated with all outcomes (P<0.001).

Reducing congestion in the outpatient setting was independently associated with improved quality of life and reduced cardiovascular events, including death, even after adjustment for baseline congestion (P<0.001). Sacubitril/valsartan reduced the risk of the primary outcome compared to enalapril irrespective of clinical signs of congestion at baseline (P=0.16 for interaction), and it improved congestion to a greater extent than enalapril (P=0.011). Each reduction in a sign of congestion was independently associated with a 5.1-point improvement in the quality-of-life score (95% CI, 4.7 to 5.5 points).

“Our findings reinforce the significant, ongoing clinical relevance of the physical exam in HF, reducing congestion as assessed by serial physical exams (which was independently associated with improved quality of life and reduced risk for adverse cardiovascular events), and the notion that measuring [natriuretic peptides] does not substitute for a comprehensive physical exam for risk stratification,” the authors wrote.