AIMS:The relief of the symptoms is one of the major purposes in the treatment for acute decompensated heart failure. The aim of this study is to investigate the relationship between patient-reported perception of symptom change of heart failure during hospitalization and subsequent prognosis in patients with acute decompensated heart failure (ADHF). METHODS AND RESULTS:Among 4056 consecutive patients hospitalized due to ADHF from a multicentre cohort study in Japan (Kyoto Congestive Heart Failure study), the study population consisted of 3567 patients who assessed their perception of symptom change during index hospitalization by themselves on 7-point Likert scale. We classified them the study patients into 4 groups: marked improvement group (N = 1602; 44.9%), moderate improvement group (N = 1659; 46.5%), minimal improvement group (N = 240; 6.7%), and no improvement group (N = 66; 1.9%). Primary outcome measures were a composite of all-cause death or HF hospitalization. The cumulative 1-year incidence of the primary outcome was higher in the no, minimal, and moderate improvement groups than in the marked improvement group (56%, 45%, 36%, vs. 29%, log-rank P < 0.001). After adjustment, the hazard ratios of the no, minimal, and moderate improvement groups relative to the marked improvement group were 1.66, 95% confidence interval [CI]: 1.14-2.42; 1.26, 95% CI: 1.01-1.57; 1.08, 95% CI: 0.95-1.21, respectively, for the primary outcome. CONCLUSION:The patient-reported perception of symptom change at discharge was correlated with a composite of all-cause death or HF hospitalization at 1 year after discharge in patients admitted to the hospital for ADHF.

Background The restrictive filling pattern of transmitral inflow has been shown to be associated with a poor prognosis in patients with heart failure (HF) with reduced ejection fraction or myocardial infarction. We aimed to investigate the significance of restrictive filling pattern in patients with HF with preserved ejection fraction (HFpEF).Methods Among 4056 patients with acute decompensated HF in the Kyoto Congestive Heart Failure registry, we analysed 830 patients with HFpEF who had transmitral inflow data available in echocardiography. Patients whose early to late diastolic transmitral flow velocity (E/A ratio) ≥2 were classified as having a restrictive filling pattern of transmitral inflow. The main outcome measures were all-cause death and HF hospitalisation at 1 year.Results Among 830 patients, a restrictive filling pattern was observed in 144 (17.3%) patients, who had higher prevalence of a history of atrial fibrillation and supranormal left ventricular ejection fraction (>65%), and higher brain natriuretic peptide level at discharge. The cumulative 1-year incidence of HF hospitalisation was significantly higher in patients with restrictive filling pattern than those without (31.0% vs 18.1%, p<0.001), while the cumulative 1-year incidence of all-cause death was not different between the two groups (14.2% vs 14.4%, p=0.93). After adjusting for confounding factors, the excess risk of restrictive filling pattern relative to non-restrictive filling pattern remained significant for HF hospitalisation (HR=1.58, 95% CI 1.10 to 2.27, p=0.01), but not for all-cause death (HR=0.92, 95% CI 0.60 to 1.42, p=0.70).Conclusions A restrictive filling pattern of transmitral inflow was associated with an increased risk for HF hospitalisation, but not for all-cause death, in patients with acute decompensated HFpEF.

The clinical trials in low risk patients have clearly demonstrated clinical outcomes of transcatheter aortic-valve replacement (TAVR) comparable to those of surgical aortic-valve replacement (SAVR) in patients with severe aortic stenosis (AS). However, data are lacking on the appropriate treatment selection for patients with severe AS and low surgical risk in Japanese routine clinical practice. Among 3369 patients enrolled in the CURRENT AS Registry-2 between April 2018 and December 2020, the current study population include 826 patients with low Society of Thoracic Surgeons (STS) score and not on hemodialysis who actually underwent TAVR (439 patients) or SAVR (387 patients). After propensity score matching, there remained 162 patients in each group. The primary outcome was a composite of all-cause death, disabling stroke, or heart failure hospitalization. The cumulative 3-year incidence of the primary outcome was not significantly different between the TAVR and SAVR groups (19.5

Background: The residential environment may influence access to care and prognosis in patients with heart failure (HF). Evidence on the impact of geographic factors in Japan is limited. We investigated the association of home-to-hospital distance and residential population density with 1-year clinical outcomes in patients hospitalized for acute decompensated HF. Methods and Results: We used the Kyoto Congestive Heart Failure registry to analyze 3,616 patients who were discharged alive after their first hospitalization. Home-to-hospital distance was calculated using road travel distance and dichotomized by the median (8.0 km). Residential density was classified as urban (densely inhabited districts [DID]) or suburban (non-DID). The primary outcome was all-cause death at 1 year, assessed using hospital-stratified Cox proportional hazards models. The median home-to-hospital distance was 8.0 km (interquartile range 4.1-14.5km); 1,797 (49.7%) patients were in the long-distance group. The long-distance group had a higher risk of all-cause death than the short-distance group (adjusted hazard ratio [HR] 1.19; 95% confidence interval [CI] 1.02, 1.39; P=0.02). As a continuous variable, each doubling of distance was associated with increased all-cause death (HR 1.06; 95% CI 1.02, 1.10). Suburban residence was not significantly associated with the primary outcome compared with urban residence (adjusted HR 1.18; 95% CI 0.99, 1.44; P=0.06). Conclusions: In Japanese patients hospitalized for acute decompensated HF, longer home-to-hospital distance, but not residential population density, was associated with a higher risk of 1-year all-cause death.

BACKGROUND:The overall impact of the introduction of transcatheter aortic valve replacement (AVR) on the prognosis of the entire population with severe aortic stenosis has not been evaluated. METHODS:We analyzed 2 multicenter registries that consecutively enrolled patients with severe aortic stenosis before and after the introduction of transcatheter AVR in Japan (CURRENT AS [CURRENT AS, Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis] Registry-1: 2003-2011; Registry-2: 2018-2020). Data were derived from hospital electronic health records. The primary outcome was 1-year all-cause mortality. Secondary outcomes included hospitalization for heart failure, cardiovascular death, and noncardiovascular death. we Multivariable Cox proportional hazards models were adjusted for age, sex, body mass index, hypertension, current smoking, diabetes on insulin therapy, prior myocardial infarction, prior symptomatic stroke, atrial fibrillation or flutter, aortic or peripheral vascular disease, creatinine level, hemodialysis, anemia, liver cirrhosis (child B or C), malignancy currently under treatment, chronic lung disease (moderate or severe), coronary artery disease, peak aortic jet velocity, any combined moderate or severe valvular disease, and tricuspid regurgitation pressure gradient. RESULTS:A total of 6645 patients (Registry-1: 3448 patients, and Registry-2: 3197 patients) were included. Patients in Registry-2 were older than those in Registry-1 (81.7 versus 77.8 years), and an initial AVR strategy was more frequently selected (49.9% versus 31.3%). The cumulative 1-year incidence and adjusted risk of 1-year all-cause mortality were lower in Registry-2 than in Registry-1 (10.2% versus 16.0%, P<0.001, hazard ratio, 0.55 [95% CI, 0.47-0.63]). In contrast, the incidence and adjusted risk of hospitalization for heart failure did not differ between Registry-2 and Registry-1 (8.5% versus 9.0%, P=0.66, hazard ratio, 0.88 [95% CI, 0.75-1.04]). CONCLUSIONS:The overall 1-year mortality outcome of patients with severe aortic stenosis improved in the posttranscatheter AVR era compared with the pretranscatheter AVR era, with no noticeable improvement in hospitalization for heart failure.

BACKGROUND:A valve syndrome framework (stable valve syndrome [SVS], progressive valve syndrome [PVS], and acute valve syndrome [AVS]) integrates clinical presentation with objective markers, but its prognostic implications remain incompletely characterized. METHODS:Among 3369 consecutive patients with severe aortic stenosis (AS) in the CURRENT AS Registry-2, we analyzed 2824 patients with natriuretic peptide (NP) and left ventricular ejection fraction (LVEF) data. Patients were classified as SVS (no symptoms with low NP), PVS (mild symptoms and/or mildly elevated NP), or AVS (acute deterioration and/or markedly elevated NP or reduced LVEF), and stratified by initial aortic valve replacement (AVR) and conservative strategies. The primary outcome was a composite of death or heart failure hospitalization. Subgroup analyses further classified patients into five phenotypes: SVS, progressive valve signs without symptoms, progressive valve symptoms, acute valve signs without symptoms, and acute valve symptoms. RESULTS:In the initial AVR stratum, AVS was associated with higher risk for the primary outcome compared with SVS (adjusted HR 2.34, 95% CI 1.19-4.59, P=0.01), whereas PVS was not. In the conservative stratum, SVS demonstrated a very low early event rate (1.0% at 6 months), while AVS and PVS had higher risk than SVS. In the five-phenotype analysis, patients with progressive valve signs without symptoms underwent AVR at rates comparable to SVS yet had worse outcomes than SVS in the conservative stratum (adjusted HR 1.89, 95% CI 1.18-3.03, P=0.008). CONCLUSIONS:A valve syndrome framework highlights limitations of symptom-based risk stratification and may refine surveillance and intervention strategies in severe AS.

Data on the impact of cardiac damage based on follow-up echocardiography at 1 year in patients with severe aortic stenosis (AS) are insufficient. The current study included 1991 patients with severe AS who underwent follow-up echocardiography at 1 year after the initial AVR strategy (n = 1211) and conservative management (n = 780) in the CURRENT AS Registry-2. In the initial AVR group, the higher adjusted risk for stage 1, 2, and 3 or 4 relative to stage 0 was not significant for the primary outcome (a composite of all-cause death or hospitalization for heart failure) (hazard ratio [HR] = 0.51, 95% confidence interval [CI] = 0.25-1.04; HR = 0.71, 95% CI = 0.39-1.29; and HR = 0.57, 95% CI = 0.22-1.48). Meanwhile, in the conservative management group, it was significant for the primary outcome (HR = 2.33, 95% CI = 0.99-5.52; HR = 2.89, 95% CI = 1.30-6.40; and HR = 6.44, 95% CI = 2.62-15). A significant association was observed between the initial treatment strategies and effects of cardiac damage stages at 1 year on the primary outcome (P interaction = 0.003). Cardiac damage stages based on follow-up echocardiography at 1 year were useful for prognostic stratification in patients who received conservative management, but not in those who underwent initial AVR. UMINID: UMIN000034169.

Cardiac damage staging is a validated predictor of outcomes in tricuspid aortic valve aortic stenosis (TAV-AS), but its role in bicuspid aortic valve aortic stenosis (BAV-AS) remains unclear. We compared baseline characteristics, cardiac damage stages, and clinical outcomes between BAV-AS and TAV-AS patients. We analyzed 3365 patients with severe aortic stenosis (AS) from the CURRENT AS Registry-2, including 222 with BAV-AS and 3143 with TAV-AS. Cardiac damage stages were classified based on index echocardiographic findings. The primary outcome was a composite of death or heart failure hospitalization. BAV-AS patients were significantly younger and had fewer cardiovascular comorbidities than TAV-AS patients. Despite greater AS severity, BAV-AS patients more often presented with less advanced cardiac damage (stage 0–1: 53

There are limited reports on the prevalence and clinical significance of guideline-directed medical therapy (GDMT) initiation in patients with acute heart failure (HF). We analyzed 2086 patients with acute heart failure with reduced or mildly reduced ejection fraction (HFrEF or HFmrEF) in the KCHF registry. The patients were classified according to the number of GDMT classes at discharge. The primary outcome was a composite of all-cause death or HF hospitalization. There were 181 (8.7

The optimal timing for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS) remains debatable. This study aimed to compare the clinical outcomes of early AVR and clinical surveillance in asymptomatic patients with high-gradient severe AS. Among 3369 patients enrolled in the CURRENT AS Registry-2, which included consecutive patients with severe AS, we identified 596 asymptomatic patients with high-gradient severe AS (initial AVR strategy: 285 patients; clinical surveillance strategy: 311 patients). A propensity score-matched cohort was constructed, comprising 206 patients each in the initial AVR and clinical surveillance groups. The primary outcome measure was a composite of all-cause death, stroke, or hospitalization for heart failure (HF). In the propensity score-matched cohort, the mean age was 79.6 years, and the median Society of Thoracic Surgeons-predicted risk of mortality was 3.2%. In the initial AVR group, surgical and transcatheter AVR were performed in 83 and 123 patients, respectively, whereas in the clinical surveillance group, conversion to AVR occurred in 11.1%, 32.9%, and 69.0% patients at 6 months, 1 year, and 3 years. The cumulative 3-year incidence of the primary outcome was not significantly different between the initial AVR and clinical surveillance groups (26.4% vs 28.4%; log-rank p = 0.46; hazard ratio [HR]: 0.85, 95% confidence interval [CI]: 0.56-1.29). In conclusion, in asymptomatic patients with high-gradient severe AS, the initial AVR strategy compared to clinical surveillance was not associated with a lower risk for a composite of all-cause death, stroke or hospitalization for HF.

BACKGROUND:The prognostic significance of the 6-minute walk distance (6MWD) in patients with severe aortic stenosis (AS) has not been thoroughly investigated. METHODS AND RESULTS:This study evaluated 998 patients with severe AS who underwent a 6-min walk test as part of a large multicenter prospective cohort. Patients were categorized as either fast walkers (6MWD ≥300 m; n=515) or slow walkers (6MWD <300 m; n=483). During a median follow-up of 2.3 years, 861 (86.3%) patients underwent surgical or transcatheter aortic valve replacement (AVR; 87.0% of fast walkers vs. 85.5% of slow walkers). The cumulative 3-year incidence of death was significantly lower among fast walkers than slow walkers (10.9% vs. 31.7%; P<0.001). After adjusting for confounders, slow walkers had a significantly higher risk of all-cause mortality than fast walkers (hazard ratio 2.36; 95% confidence interval 1.55-3.58; P<0.001). Stratified analysis by initial treatment strategy revealed that the cumulative 3-year incidence of all-cause death was consistently lower among fast walkers than slow walkers (initial AVR strategy: 10.1% vs. 28.1% [P<0.001]; conservative strategy: 13.4% vs. 46.7% [P<0.001]). Among asymptomatic patients managed conservatively, fast walkers demonstrated a remarkably low cumulative 3-year incidence of all-cause death (8.1%). CONCLUSIONS:The 6MWD is a reliable prognostic marker for patients with severe AS, regardless of initial treatment strategy.

BACKGROUND:Patients with heart failure (HF) have a significantly higher prevalence of cognitive impairment than those without HF. While the association of dementia with prognosis of patients with HF is well documented in Western populations, data from large, prospective cohorts in East Asia, particularly Japan, remain limited. METHODS:The KCHF (Kyoto Congestive Heart Failure) registry, a prospective cohort study, enrolled consecutive patients admitted for acute decompensated HF in Japan. We evaluated 3728 patients who were alive at discharge and for whom follow-up data were available. We compared 1-year clinical outcomes between patients with and without dementia. RESULTS:Of 3728 participants, 658 (17.6%) were diagnosed with dementia. Patients with dementia were older, more likely to be men, more often had atrial fibrillation and prior stroke with poorer daily life activities and poor adherence to medical therapy, and less often received guideline-directed medications at discharge than those without dementia. After adjustment for confounders, the excess risk of patients with dementia compared with those without dementia remained significant for all-cause death and cardiovascular death (hazard ratio [HR], 1.45 [95% CI, 1.17-1.79]; P=0.0007; HR, 1.48 [95% CI, 1.12-1.95]; P=0.006, respectively). However, the excess risk of patients with dementia compared with those without dementia was no longer significant for noncardiovascular death and HF hospitalization (HR, 1.36 [95% CI, 0.96-1.91]; P=0.08; HR, 1.08 [95% CI, 0.88-1.33]; P=0.45, respectively). CONCLUSIONS:Dementia in patients with HF is associated with the risk for all-cause death as well as cardiovascular death.

BACKGROUND:The prognostic impact of cardiac damage staging in severe aortic stenosis (AS) based on gradient patterns, symptoms, and initial treatment strategies is not well understood. OBJECTIVES:This study aimed to assess the differences in characteristics and clinical outcomes of AS patients according to cardiac damage stage, stratified by gradient patterns, symptoms, and treatment strategies. METHODS:A total of 3,369 consecutive patients with severe AS (high-gradient [HG] AS, n = 1986; low-gradient [LG] AS, n = 1,383) from the CURRENT AS registry-2 were included. Cardiac damage was categorized into 4 groups (stage 0, stage 1, stage 2, and stage 3/4). RESULTS:The cumulative incidence of the primary outcome (all-cause death or heart failure hospitalization) increased with advancing cardiac damage stages in both HG and LG AS. Adjusted HRs for stages 1, 2, and 3/4 vs stage 0 were significantly higher in both HG and LG cohorts (HG AS: HR: 2.47; 95% CI: 1.23-4.96 [stage 1]; HR: 3.39; 95% CI: 1.72-6.67 [stage 2]; HR: 4.01; 95% CI: 1.95-8.25 [stage 3/4]; LG AS: HR: 1.72; 95% CI: 1.04-2.84 [stage 1]; HR: 2.28; 95% CI: 1.44-3.61 [stage 2]; HR: 2.95; 95% CI: 1.79-4.88 [stage 3/4]). The higher risk of the primary outcome with more advanced cardiac damage was consistent regardless of the presence of symptoms and the initial treatment strategies in both HG and LG AS. CONCLUSIONS:Cardiac damage staging is a useful tool for prognostic stratification in patients with severe AS, independent of gradient patterns, symptoms, and initial treatment strategies.

The term “classical low-flow low-gradient (LG) aortic stenosis (AS)” is widely used, with the conventional assumption that reduced left ventricular ejection fraction (LVEF) implies low flow (stroke volume index [SVi] < 35 ml/m2). This study included 285 patients with LG AS and LVEF < 50

AIMS The association between serum cholinesterase and prognosis in acute heart failure (AHF) remains to be elucidated. We investigated the serum cholinesterase level at discharge from hospitalization for AHF and its association with clinical outcomes in patients with AHF. METHODS AND RESULTS Among 4056 patients enrolled in the Kyoto Congestive Heart Failure multicentre registry, we analysed 2228 patients with available serum cholinesterase data. The study population was classified into three groups according to serum cholinesterase level at discharge: low tertile (<180 U/L, N = 733), middle tertile (≥180 U/L and <240 U/L, N = 746), and high tertile (≥240 U/L, N = 749). Patients in the low tertile had higher tricuspid pressure gradient, greater inferior vena cava diameter, and higher brain natriuretic peptide (BNP) levels than those in the high tertile. The cumulative 1-year incidence of the primary outcome measure (a composite endpoint of all-cause death and hospitalization for HF) was higher in the low and middle tertiles than in the high tertile [46.5% (low tertile) and 31.4% (middle tertile) vs. 22.1% (high tertile), P < 0.0001]. After adjustment for 26 variables, the excess risk of the low tertile relative to the high tertile for the primary outcome measure remained significant (hazard ratio 1.37, 95% confidence interval 1.10-1.70, P = 0.006). Restricted cubic spline models below the median of cholinesterase demonstrated incrementally higher hazards at low cholinesterase levels. CONCLUSIONS Low serum cholinesterase levels are associated with congestive findings on echocardiography, higher BNP, and higher risks for a composite of all-cause death and HF hospitalization in patients with AHF.

ABSTRACT Background Reducing anxiety about motor vehicle driving in patients receiving implantable cardioverter defibrillators and cardiac resynchronization therapy with defibrillators is important not only for improving quality of life but also for preventing vehicle collisions owing to driver distraction. This study aimed to clarify the driving‐related anxiety of patients with these defibrillators and the factors that predict such anxiety. Methods We conducted a cross‐sectional survey using a self‐administered questionnaire of patients who had been driving a vehicle after device implantation at a general hospital between August 2018 and November 2019. Results The mean age was 60.8 ± 12.6 years. The reasons for implantation were primary prevention in 47 patients and secondary prevention in 30 patients. A total of 16 patients experienced anxiety about driving and 61 did not. Significantly more younger patients (mean age of 50.4 vs. 63.6 years, p < 0.001) and those with implantable cardioverter defibrillators had anxiety (100% vs. 73.8%, p = 0.02). Multivariable analysis indicated that age was the only independent factor that predicted driving‐related anxiety (odds ratio, 0.937; 95% confidence interval, 0.883–0.993). Conclusions Identifying and addressing driving‐related anxiety in patients (particularly young patients) with defibrillators is important in preventing motor vehicle collisions and improving quality of life.

AbstractAimsAtrial fibrillation (AF) and heart failure (HF) with preserved ejection fraction (HFpEF) are interlinked and frequently coexisting conditions. To date, patients with AF and HFpEF have limited evidence guiding their management. This study aimed to investigate the predictors of adverse outcomes among patients with AF and HFpEF.MethodsThe Fushimi AF Registry is a community‐based prospective survey of AF patients in Fushimi‐ku, Kyoto, Japan. From the registry, we explored predictors for a composite of cardiac death or HF hospitalization among AF patients with HFpEF (defined as having a prior HF hospitalization or New York Heart Association class ≥2 in association with heart disease and left ventricular ejection fraction ≥50%). Besides, we investigated whether the scoring using the predictors identified by the Fushimi AF Registry could stratify the outcomes in patients with AF and HFpEF registered in another independent Kyoto Congestive Heart Failure Registry.ResultsOf 755 patients with AF and HFpEF [mean age: 77.5 ± 9.9 years; female: 391 (52%); paroxysmal AF: 258 (34%); and mean CHA2DS2‐VASc score: 4.5 ± 1.5], cardiac death or HF hospitalization occurred in 246 patients (33%) during the median follow‐up period of 4.4 years in the Fushimi AF Registry. Using multivariate Cox regression analysis, age ≥75 years [hazard ratio (HR): 1.72, 95% confidence interval (CI): 1.26–2.36] and non‐cardiovascular comorbidities such as anaemia (HR: 1.83, 95% CI: 1.37–2.46), chronic kidney disease (HR: 1.69, 95% CI: 1.27–2.26), diabetes mellitus (HR: 1.55, 95% CI: 1.15–2.09) and chronic obstructive pulmonary disease (HR: 1.87, 95% CI: 1.08–3.22) were independent predictors of adverse outcomes. Meanwhile, cardiovascular comorbidities including coronary artery disease, valvular heart disease or cardiomyopathy were not significantly associated with adverse outcomes. These results were also the case when analysed for patients with AF and HFpEF who registered in the Kyoto Congestive Heart Failure registry (N = 878). The score assigning 1 point for each five predictors (age, anaemia, chronic kidney disease, diabetes mellitus and chronic obstructive pulmonary disease; ranging 0–5 points) stratified the incidence of adverse outcomes among patients with AF and HFpEF registered in the Kyoto Congestive Heart Failure Registry as well as among those in the Fushimi AF Registry (both log‐rank; P < 0.001).ConclusionsNon‐cardiovascular comorbidities such as anaemia, diabetes mellitus and kidney or pulmonary disease in addition to advanced age were independent predictors of adverse outcomes in patients with AF and HFpEF. Our study suggests the importance of focusing on these non‐cardiovascular comorbidities for individualized risk stratification and optimal management in patients with AF and HFpEF.

There was a scarcity of data evaluating variations in treatment approaches and clinical outcomes for severe aortic stenosis (AS) between medical centers with and without availability of transcatheter aortic valve implantation (TAVI). Current study population was 2993 patients with severe AS enrolled in the CURRENT AS Registry-2 (2581 patients from 10 TAVI centers; 412 patients from 10 non-TAVI centers). TAVI centers more frequently opted for the initial aortic valve replacement (AVR) strategy compared to non-TAVI centers (60

BACKGROUND:Most patients hospitalized for heart failure (HF) present with signs of congestion. Prognostic significance of clinical congestion may vary depending on left ventricular ejection fraction (LVEF). This study aims to investigate the prognostic impact of congestion across different LVEF categories. METHODS AND RESULTS:Composite congestion scores (CCSs; 0-9) derived from the severity of edema, jugular venous pressure, and orthopnea, were analyzed on admission and at discharge in 3787 patients hospitalized for HF (LVEF ≥ 40%: n = 2347, LVEF < 40%: n = 1440). The median admission CCS was 4 in both LVEF strata (P = .64). Adjusted hazard ratios (HRs; 95% confidence interval [CI]) of the moderate (CCS 4-6) and severe congestion [7-9] groups relative to the mild congestion [0-3] group on admission for a composite of all-cause death or HF rehospitalization were 1.20 (1.04-1.39, P = .01) and 1.54 (1.27-1.86, P < .001) in the LVEF ≥ 40% stratum, and 1.20 (1.01-1.44, P = .04) and 0.82 (0.61-1.07, P = .14) in the LVEF < 40% stratum, respectively (Pinteraction< .001). A total of 16% of the patients with LVEF ≥40% and 14% with LVEF <40% had residual congestion (CCS ≥ 1) at discharge, which was associated with a respective adjusted HR of 1.40 (1.18-1.65, P < .001) and 1.25 (0.98-1.58, P = .07) for postdischarge death or HF rehospitalization (Pinteraction = 0.63). CONCLUSION:The severity of clinical congestion on admission was associated with adverse clinical outcomes in patients with LVEF ≥ 40%, but not in those with LVEF < 40%. These findings warrant further studies to better understand the detailed profile of congestion across the LVEF spectrum.