Introduction: Hemoconcentration during hospitalization for acute heart failure (HF) correlates with superior decongestion and improved post-discharge outcomes. However, the relationship between early post-discharge hemodilution, markers of congestion, and clinical outcomes is unknown.
Methods: The EVEREST trial randomized hospitalized HF patients with ejection fraction (EF) ≤40% to tolvaptan or placebo, in addition to standard care, with median follow-up of 9.9 months. This post-hoc analysis included 1,598 (78%) patients assigned to placebo with available data. Post-discharge hematocrit change was calculated as the absolute difference between discharge (or hospital day 7 if occurred first) and 1-month post-discharge hematocrit. Outcome analyses were landmarked at 1-month post-discharge.
Results: Mean absolute post-discharge hematocrit change was -1.5% (standard deviation 4.0%) and ranged from -21.0% to +14.0% (Table). Overall, 452 (26%) patients had evidence of hemodilution (≥4% absolute decrease in hematocrit). During the 1-month post-discharge period, hemodilutors were less likely to have worsening renal function, but experienced more weight gain and greater increases in natriuretic peptide level. After adjustment for patient characteristics at 1-month, every 5% decrease in post-discharge hematocrit change was associated with an increased risk of all-cause death (hazard ratio [HR] 1.03, 95% confidence interval [CI], 1.00-1.06, p=0.045), but not the composite of cardiovascular mortality or HF hospitalization (HR 1.01, 95% CI 0.99-1.03, p=0.388).
Conclusions: In this large cohort of patients hospitalized for HF with reduced EF, early post-discharge hemodilution was associated with worsening congestion and higher mortality despite a lower risk of worsening renal function.