The struggle is real! Measuring and managing heart failure congestion in the outpatient setting

This invited commentary refers to ‘Oedema index trajectories at heart failure nurse clinics over 6 months after acute heart failure predict patient outcomes: a retrospective cohort study’ by M.H. Liu et al., https://doi.org/10.1093/eurjcn/zvae181. Despite improvements in guideline-directed medical therapy (GDMT) for heart failure (HF),1 the risk of death or rehospitalization after acute decompensated HF remains high. Early detection of acute and worsening congestion is essential for timely interventions, such as modifying diuretic dose or titrating GDMT, which may prevent worsening decompensation in this vulnerable patient population. Residual congestion at hospital discharge is associated with rehospitalization,2 and proactive prevention of worsening congestion post-hospitalization may improve quality of life, while concurrently decreasing cost and burden for patients and healthcare systems. Predicting post-hospitalization events due to congestion has historically been limited to patients monitoring their body weight and symptom recognition—late indicators of decompensation.3 However, multiple strategies to objectively and non-invasively assess congestion in HF patients, including leveraging wearable technology, are being developed and tested.4 Nurses and other HF clinicians will be instrumental in effective implementation of congestion measurements and subsequent clinical guidance. Integrating congestion monitoring into wearable devices for consumers is not yet available,5 but research measuring congestion through clinician-controlled devices,6 wearable patch systems,7 and bioimpedance scales8 shows decreased incidence of rehospitalization in patients with HF. Current research demonstrates the promise of non-invasive wearable technology as a tool to guide HF care. Oedema indices measured by nurses in Liu et al.’s,9 ‘Oedema index trajectories at heart failure nurse clinics over 6 months after acute heart failure predict patient outcomes: a retrospective cohort study’ provide an additional tool that may help reduce the incidence of rehospitalization or death after HF hospitalization. In their study, Liu et al.9 measured oedema in patients discharged from the hospital after acute HF exacerbation over six time points. The authors describe four patterns of oedema over time, no oedema, transient oedema, fluctuating oedema, and worsening oedema. Compared with patients with no oedema, patients with transient, fluctuating, and worsening oedema were at higher risk for all-cause hospitalization, HF hospitalization, and death. Although statistically significant, the changes in the edema index (EI) over time within each EI group were quite small, suggesting that the absolute differences in the mean EI for each group may be more informative than the EI trajectories in predicting risk. The results of Lui et al. are consistent with the literature demonstrating residual oedema at discharge is associated with increased risk for hospitalization or death.10–14 However, questions remain about the value in non-invasive monitoring of oedema over time post-HF hospitalization. Notably, none of the subgroups with elevated oedema in Liu and colleagues’ study had substantial improvements in oedema below the 0.39 cut-off the authors use as ‘high vs. normal’ oedema.9 The sustained ‘high’ levels of oedema in over 30% of the participants suggest challenges to outpatient congestion management given the authors state the EI measurements were used to ‘provide home care suggestions’ from clinicians rather than protocolized pharmacologic intervention. Previous studies have shown that both absolute and trajectories of congestion are important to guiding prognosis,15 yet clinician and patient responses to indicators of congestion may influence patient outcomes more than changes in congestion over time. Timeliness of congestion measurement and treatment decisions based on non-invasive congestion measurement are factors that must be considered when managing patients with hospital outside of the hospital. When patients with HF receive regular post-hospitalization care monitoring, congestion guidelines recommend treating high and increasing levels of oedema with diuretics and low-sodium diet.1 Although diet and medication treatment regimens and patient adherence to provider recommendations are important indicators of health outcomes in HF;1,16if clinicians are unable to respond promptly to early signs of increasing congestion, then patients risk decompensation. Thus, including data on diet and diuretic treatment and adherence in non-invasive measurement of congestion research studies may provide important clinical context for oedema and congestion management after discharge. Perhaps nurses empowered with an affordable measure of real-time congestion, such as the EI used by Liu et al., and paired with treatment protocols will prove to be one successful approach to the continued struggle of avoiding post-HF hospitalization events. Mary Roberts Davis (Conceptualization [equal], Resources [equal], Software [lead], Writing—original draft [lead], Writing—review & editing [lead]), Christopher V. Chien (Writing—original draft [supporting], Writing—review & editing [equal]), and Jonathan Auld (Writing—original draft [supporting], Writing—review & editing [supporting]) The writing of this invited commentary was not supported by any grant support. No data was used in the writing of this invited commentary.