Tackling Early Heart Failure Deaths and Readmissions by Estimating Congestion.

SEE PAGE 886 P atients who are discharged after a hospital admission for heart failure enter a vulnerable phase with a very high risk for early death or heart failure readmission (1). This is a major problem for patients, doctors, and society. The underlying cause for high readmission rates is still incompletely understood, although incomplete decongestion at discharge is frequently suggested to play an important role. Heart failure guidelines recommend a detailed and careful assessment of congestion pre-discharge (2,3). This includes assessing signs and symptoms and performing a chest radiograph, but the sensitivity and specificity of thesemethods to accurately estimate congestion are limited (4). Unfortunately, standardized metrics or (de)congestion scores are currently lacking. Several papers were recently published on multiple surrogates used to assess decongestion during hospitalization for acute heart failure. A frequently described surrogate is a rise in hemoglobin during a heart failure admission, indicated as hemoconcentration. Three large studies showed that hemoconcentration was associated with greater weight and fluid loss, greater reductions in filling pressures, and less residual congestion (5–7). A consistent finding among these 3 trials was a clear association between a greater hemoconcentration and a reduction in early post-discharge events and heart failure readmission in particular. Diuretic response during hospitalization was recently proposed as another surrogate for decongestion (8–10). A good diuretic response was associated with greater weight and fluid loss and less use of inotropes during hospitalization. Moreover, diuretic response