Background: The impact of different clinical congestion phenotypes in advanced heart failure (HF) has not been fully investigated. We aimed to evaluate congestion patterns in patients with advanced heart failure HF (AdvHF). Methods: The HELP-HF registry enrolled consecutive patients with HF and at least one high-risk 'I NEED HELP' marker. Patients' characteristics and outcomes were compared across different clinically defined congestion patterns. The primary endpoint was the composite of all-cause mortality or first HF hospitalization. Results: A total of 1149 patients were included (mean age 75.1 ± 11.5 years, median left ventricular ejection fraction 35%). Among them, 332 patients (28.9%) had no sign of congestion, 327 (28.5%) had peripheral congestion, 144 (12.5%) had pulmonary congestion and 346 (30.1%) had both peripheral and pulmonary congestion. The 1-year rate of the primary endpoint progressively increased across these four groups (36.5%, 44%, 45.8% and 47.7%; P = 0.0002), as did all-cause and cardiovascular (CV) mortality (both P < 0.0001). Compared with no congestion, pulmonary congestion and combined congestion were independently associated with the primary endpoint [adjusted hazard ratio (aHR) 1.60, 95% confidence interval (CI) 1.15-2.21; and aHR 1.36, 95% CI 1.05-1.77, respectively], as well as with all-cause and CV mortality. Peripheral congestion was independently associated with an increased risk of recurrent HF hospitalizations (aHR 1.37, 95% CI 1.01-1.86), whereas pulmonary congestion and combined congestion were not. Conclusions: In our real-world multicentre registry enrolling patients with markers of AdvHF, a simple bedside congestion classification identified distinct clinical characteristics and stratified the risk of clinical events.
