Natural History, Complications and Long-Term Prognosis of Patients with Cardiac Ascites

Introduction and Objectives: The natural history of patients with cardiac ascites (CA) due to congestive heart failure (CHF) remains poorly documented. This study aims were to characterize the natural history of patients with CA including its complications and long-term prognosis, in comparison to patients with ascites secondary to metabolic dysfunction-associated steatotic liver disease (MASLD). Patients and Methods: We conducted a retrospective evaluation of 98 patients presenting with ascites due to either CHF (N = 51) or MASLD (N = 47). Results: Patients with CHF exhibited a higher prevalence of cardiac-specific pathology compared to patients with MASLD. Throughout the study period, both groups presented a decline in serum and ascitic total protein and albumin levels. In patients with CHF, the decline in ascitic total protein was so substantial that levels dropped below 25 g/L in 16 patients. Furthermore, Fibrosis-4 Index (FIB-4) values increased during the study, with a more significant rise observed in the patients with MASLD. Patients with CHF had a significantly longer mean survival time compared to those with MASLD (25.0 ± 3.5 vs. 17.0 ± 2.1 months, p = 0.041). Independent predictors of shorter survival included a higher monthly frequency of paracentesis and rising FIB-4 scores during the study period. Conversely, higher admission levels of ascitic fluid albumin were associated with improved survival. Conclusions: Patients with CA demonstrate better survival outcomes than those with ascites secondary to MASLD. As cardiac disease progresses, serum and ascitic albumin and total protein levels typically decline. These findings suggest that the utility of ascitic fluid analysis in the differential diagnosis of ascites may be limited in cases of advanced CHF.