A Novel In-hospital Congestion Score to Risk Stratify Patients Admitted for Worsening Heart Failure (from ASCEND-HF)

  • Rajeev Masson
  • Andrew P. AmbrosyEmail author
  • Kevin Kheder
  • Marat Fudim
  • Robert M. Clare
  • Adrian Coles
  • Adrian F. Hernandez
  • Randall C. Starling
  • Justin A. Ezekowitz
  • Christopher M. O’Connor
  • Robert J. Mentz
Original Article
Part of the following topical collections:
  1. Special Issue: Volume Management in Heart Failure
  2. Special Issue: Volume Management in Heart Failure


Patients hospitalized for heart failure (HF) remain at high risk for early readmission. A post hoc analysis was performed of the biomarker substudy of the ASCEND-HF trial. An in-hospital congestion score was derived using orthopnea, pedal edema, and NT-proBNP levels. Its added prognostic value beyond traditional risk factors was assessed by determining the net reclassification index (NRI). Study participants (n = 884) had a median age (years) of 67 (55–77), 68% were male, and the median (25th–75th) ejection fraction (%) was 26 (20–40). After adjustment, increasing congestion score was associated with 30-day all-cause mortality or HF hospitalization (odds ratio = 1.51, 95% confidence interval [CI] 1.28–1.77, p < 0.001) and 180-day all-cause mortality (hazard ratio = 1.48, 95% CI 1.28–1.72, p < 0.001). However, adding the congestion score to the multivariable model did not significantly impact the NRI. A higher in-hospital congestion score portended a poor short-term prognosis but did not significantly reclassify risk.


Congestion Natriuretic peptides Heart failure Readmission Mortality 



Heart failure


Amino-terminal pro-B-type natriuretic peptide




Jugular venous pulsation


Systolic blood pressure


Blood urea nitrogen


Net reclassification index


Integrated discrimination improvement


Clinical congestion score


Odds ratio


Confidence interval


Hazard ratio


Cardiac implantable electronic device


Funding Information

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Scios Inc. (Mountain View, CA, USA) provided financial and material support for the ASCEND-HF trial. Database management and statistical analysis was performed by the Duke Clinical Research Institute.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that there are no conflicts of interest.

Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all patients for being included in the study.


The authors take responsibility for the manuscript’s integrity, and had complete control and authority over its preparation and the decision to publish.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Authors and Affiliations

  • Rajeev Masson
    • 1
  • Andrew P. Ambrosy
    • 1
    • 2
    Email author
  • Kevin Kheder
    • 1
  • Marat Fudim
    • 3
    • 4
  • Robert M. Clare
    • 4
  • Adrian Coles
    • 4
  • Adrian F. Hernandez
    • 3
    • 4
  • Randall C. Starling
    • 5
  • Justin A. Ezekowitz
    • 6
  • Christopher M. O’Connor
    • 7
  • Robert J. Mentz
    • 3
    • 4
  1. 1.Kaiser Permanente San Francisco Medical CenterSan FranciscoUSA
  2. 2.Division of ResearchKaiser Permanente Northern CaliforniaOaklandUSA
  3. 3.Duke University Medical CenterDurhamUSA
  4. 4.Duke Clinical Research InstituteDurhamUSA
  5. 5.Cleveland Clinic FoundationClevelandUSA
  6. 6.The Canadian VIGOUR CentreUniversity of AlbertaEdmontonCanada
  7. 7.INOVA Heart and Vascular InstituteFalls ChurchUSA

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