Prognostic impact of an extravascular congestion score and its interaction with SGLT2 inhibitor therapy in patients hospitalized for acute heart failure.

INTRODUCTION AND OBJECTIVES: Congestion is the main driver of hospitalization and adverse outcomes in acute heart failure (AHF), with tissue-predominant volume expansion frequently persisting despite loop diuretic therapy. We evaluated whether an extravascular congestion score (ECS) identifies high-risk patients and modifies the prognostic effect of sodium-glucose cotransporter 2 inhibitors (SGLT2i). METHODS: We prospectively studied 821 patients hospitalized for AHF. ECS at discharge was defined as the sum of 3 variables: antigen carbohydrate 125 > 35 U/mL, peripheral edema, and pleural effusion (range 0-3). The primary endpoint was a composite of all-cause mortality or heart failure rehospitalization at 1 year. Multivariable Cox models assessed associations between ECS and outcomes and tested the interaction with SGLT2i use at discharge. RESULTS: During follow-up, the primary endpoint occurred in 436 patients (53.5%). Higher ECS was associated with a stepwise increase in risk. Compared with ECS 0, adjusted HRs were 1.72 (95%CI, 1.04-2.85; P = .034) for ECS 1 and 2.39 (95%CI, 1.29-4.43; P = .006) for ECS 2. A significant interaction was observed between ECS and SGLT2i use (P for interaction = .029). SGLT2i use was not associated with improved outcomes in ECS 0 (HR, 1.21; P = .462) but was associated with numerically lower risk in ECS 1 (HR, 0.76; P = .065), and with a marked risk reduction in ECS 2 (HR, 0.45; P = .003). CONCLUSIONS: ECS identifies AHF patients at high risk due to residual tissue congestion. The association between SGLT2i use and improved outcomes was more pronounced with increasing extravascular congestion burden.