What is the mortality rate of pulmonary congestion?

Mortality Rate of Pulmonary Congestion in Heart Failure

Pulmonary congestion in acute heart failure carries a mortality rate of 5-15% during hospitalization, with an additional 10-15% dying within 6-12 weeks post-discharge, and patients with significant residual congestion (≥3 signs) face 2-year survival rates as low as 41%. 1

In-Hospital and Short-Term Mortality

• Acute hospitalization mortality ranges from 5-15% or higher in patients admitted with acute heart failure and pulmonary congestion 1
• An additional 10-15% of patients who survive to discharge will die within the subsequent 6-12 weeks 1
• Patients presenting with clinical congestion (dyspnea, edema, and jugular venous distension) experience a 2-3 fold increase in 60-day mortality compared to those without these features 1, 2

Long-Term Mortality Based on Residual Congestion

The presence and severity of residual congestion at discharge is the critical determinant of long-term outcomes:

• Patients with 0 residual congestion signs: 87% 2-year survival 1
• Patients with 1-2 residual congestion signs: 67% 2-year survival 1
• Patients with ≥3 residual congestion signs: 41% 2-year survival 1

This represents a progressive mortality gradient directly tied to inadequate decongestion before discharge.

Contemporary Data on Residual Congestion

More recent studies confirm these findings with additional granularity:

• At 7 days of hospitalization or discharge, 28.7% of patients still have significant residual congestion, which independently increases risk of heart failure readmission by 88% at 60 days and all-cause mortality by 54% at 180 days 3
• Each 3-point increase in congestion severity score is associated with a 6% increase in mortality risk, 9% increase in heart failure rehospitalization, and 2% increase in all-cause rehospitalization at 1 year 4
• Lung congestion detected on chest radiography is independently associated with reduced survival even after adjusting for pulmonary artery wedge pressure, NT-proBNP, anemia, coronary artery disease, and renal dysfunction 5

Pathophysiologic Mechanisms Driving Mortality

The high mortality stems from multiple interconnected mechanisms:

• Hemodynamic congestion precedes clinical congestion by days to weeks, representing the "tip of the iceberg" of underlying hemodynamic derangements 1, 2
• Sustained elevation of left ventricular diastolic pressure activates neurohormonal pathways and causes subendocardial ischemia, leading to myocardial necrosis/apoptosis and secondary mitral regurgitation 2
• Elevated right atrial pressure contributes to cardiorenal syndrome by reducing the renal perfusion gradient, perpetuating a vicious cycle of fluid retention 2
• Pulmonary congestion correlates with increased pulmonary vascular resistance (25% higher) and reduced pulmonary artery compliance (25% lower), driving right ventricular dysfunction and biventricular failure 5

Clinical Pitfalls

A critical caveat is that many patients are discharged with persistent signs of congestion and without adequate weight loss, particularly problematic in healthcare systems with shorter hospital stays 1. Physical examination signs of congestion have low sensitivity (58%) for detecting elevated pulmonary capillary wedge pressure ≥22 mmHg, meaning clinicians may underestimate residual congestion 1, 2.