Classification of acute HF patients based on congestion and hypoperfusion status in real-world setting

Acute heart failure congestion and perfusion status; impact of the clinical classification on in hospital and long term outcomes; insights from the ESC EORP HFA Heart Failure Long Term Registry

News - May 24, 2019

Presented at ESC Heart Failure 2019 in Athens, Greece, by Ovidiu Chioncel (Bucuresti, Romania)

Introduction and methods

The 2016 ESC HFA Guidelines proposed a classification of acute heart failure patients based on congestion and hypoperfusion status: dry-warm (no congestion, no hypoperfusion), wet-warm (congestion, no hypoperfusion), dry-cold (no congestion, hypoperfusion), wet-cold (congestion, hypoperfusion). However, this classification has never been validated in an unselected real-world population of acute HF patients, including patients from the entire spectrum of clinical severity and all ranges of LVEF.

Therefore, the congestion and hypoperfusion classification was applied to the ESC EORP HFA Heart Failure Long Term Registry and association of baseline characteristics, treatments and outcomes with each profile were assessed in patients at admission and discharge.

The ESC EORP HFA Heart Failure Long-Term Registry included 7865 acute HF patients in 21 countries at 211 centers. Outcomes were in-hospital mortality, and one-year all-cause mortality, one-year HF hospitalizations, and composite of one-year death and HF hospitalizations.

Main results

  • At admission, 19.8% patients were wet-cold, 0.4% were dry-cold, 69.9% were wet-warm and 9.9% were dry-warm.
  • At discharge, patients had changed classifications; 5.6% were wet-cold, 1.6 % were dry-cold, 30.9% were wet-warm and 61.9% were dry-warm.
  • In-hospital outcomes, including all causes of death, time in hospital, admitted in ICCU, time in ICCU, were significantly different for all profiles (P<0.001). Percentage all-cause death increased stepwise from dry-warm (2.0%), wet-warm (3.8%), dry-cold (9.1%) to highest for wet-cold (12.1%) profile (wet-cold: HR 3.45, 95%CI: 1.99-5.97 when compared to dry-warm).
  • All outcomes of all cause death, all-cause hospitalization, HF hospitalization and composite of all-cause death and HF hospitalization after one year were significantly different for all profiles (P<0.001) with worst outcomes in those with wet-cold profile.
  • When comparing patients with congestion at discharge (31.9%) vs. those free of congestion at discharge, all-cause death, all-cause hospitalization, HF hospitalization and composite of death and HF hospitalization were all significantly different (P<0.0001), with higher rates for those with congestion.
  • Main predictors of mortality in those with congestion at discharge were NYHA class IV, mitral regurgitation, and use of IV diuretics.


Classification of acute HF patients in the real-world showed that outcomes during hospital admission and after one year are different for patients with wet-cold, dry-cold, wet-warm and dry-warm profiles. Outcomes were worst for those with wet-cold profile, confirming that hypoperfusion is a marker of HF severity and associated with poor outcomes.

Clinical phenotyping of acute HF patients can help to identify high-risk patients and facilitate in early decision-making for treatment options.


The discussant Mandeep Mehra (Boston, MA, USA) said that this classification system is a practical approach to manage acute HF patients. He noted that this study examined those in a real-world setting, thus including all HF types, also those with preserved EF. As HFpEF patients were also included, he would not have expected to see so many patients with hypoperfusion.

He ended by saying that we should pause and look further into phenotyping acute HF patients, because better characterization of high-risk patients is crucial to improve treatment for these patients and eventually reduce the burden of HF.

Our reporting is based on the information provided at the ESC Heart Failure 2019 congress

This study was published simultaneously in Eur J Heart Fail

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