Prognostic impact of isolated right-sided congestion assessed by pre-discharge right heart catheterization in heart failure

Background/Introduction Residual congestion at discharge is a key determinant of outcomes in heart failure (HF). Although pulmonary capillary wedge pressure (PCWP) is commonly used to guide management, the prognostic significance of isolated right-sided congestion in stable HF patients remains unclear. Purpose To investigate the prognostic impact of isolated right-sided congestion, defined as elevated right atrial pressure (RAP) with non-elevated PCWP, in patients hospitalized for HF who underwent pre-discharge right heart catheterization. Methods We analyzed consecutive patients hospitalized for HF between December 2015 and April 2022 who underwent right heart catheterization within 7 days before discharge. Patients were classified into four groups using established cut-off values: Group 1 (RAP <10 mmHg and PCWP <22 mmHg), Group 2 (RAP ≥10 mmHg and PCWP <22 mmHg), Group 3 (RAP <10 mmHg and PCWP ≥22 mmHg), and Group 4 (RAP ≥10 mmHg and PCWP ≥22 mmHg). The clinical endpoints were HF readmission, analyzed using competing-risk regression with death as a competing event. Cumulative incidence curves were compared using Gray’s test. The composite of HF readmission or all-cause death was analyzed using Cox regression. Results Among 344 patients who underwent pre-discharge right heart catheterization, 265 were classified as Group 1, 19 as Group 2, 34 as Group 3, and 16 as Group 4. During a median follow-up of 714 days, patients with isolated right-sided congestion (Group 2) had a smaller left ventricular size, a larger left atrial diameter, and more frequent moderate-to-severe tricuspid regurgitation than the other groups. Compared with patients without congestion (Group 1), isolated right-sided congestion (Group 2) was independently associated with an increased risk of HF readmission (subdistribution hazard ratio [sHR] 3.50, 95% confidence interval [CI] 1.85–6.64; P < 0.001) and the composite of HF readmission or all-cause death (hazard ratio [HR] 2.63, 95% CI 1.40–4.97; P = 0.003). Conclusion(s) Isolated right-sided congestion assessed by pre-discharge right heart catheterization was significantly associated with adverse outcomes in HF patients. Residual right-sided congestion before discharge identifies patients at high risk of HF readmission despite non-elevated left-sided filling pressure and may represent an important therapeutic target.