Patient-reported HF Symptoms Not Associated With Objective Markers of Pulmonary Congestion

Older female patient filling out questionnaire on clipboard, seated across from doctor

Patient-reported symptoms are gaining importance in clinical practice, especially with the move toward telemedicine.

Elke Platz, MD, MS, of the Cardiovascular Division at Brigham and Women’s Hospital and associate professor at Harvard Medical School, Drs. Matthew Lee and Ross Campbell of the University of Glasgow, and colleagues wondered whether the Kansas City Cardiomyopathy Questionnaire (KCCQ), a self-reported health status questionnaire for patients with heart failure (HF), could be useful to monitor worsening pulmonary congestion remotely. However, the study showed no significant associations between KCCQ total symptom score and objective pulmonary congestion markers, as reported in the European Journal of Heart Failure.


The researchers conducted a secondary analysis of a prospective, observational, two-site study of lung ultrasound in adults hospitalized with acute HF that was published in JACC Heart Failure. Patients with acute HF were enrolled if they required intravenous diuretics, regardless of ejection fraction.

At baseline, the patients completed:

  • The KCCQ
  • A lung ultrasound at the time of echocardiography
  • A chest X-ray, physical examination, and laboratory tests

A subset of patients also used a numeric rating scale from 0 to 10 to report dyspnea at rest (at the time of assessment) and on exertion (over the past two weeks).

322 patients who completed the KCCQ and underwent ultrasound were included in the current analysis, of whom 175 also completed the numeric rating scale. 60% were male, the mean age was 72, and 86% were white.


The median KCCQ total symptom score (TSS) was 33 out of 100, reflecting a substantial symptom burden. Patients in the lowest quartile had a higher prevalence of peripheral edema at presentation (92% vs. 61% in the highest quartile; P for trend <0.001). Lower KCCQ-TSS was also associated with worse dyspnea, as reported on the numeric rating scale (P for trend <0.001).

However, KCCQ-TSS was not significantly associated with the extent of pulmonary or markers of hemodynamic congestion on acute objective assessments, including:

  • Lung ultrasound (number of B-lines)
  • Findings on chest X-ray or lung auscultation
  • Echocardiography (average E/e′ measurement)
  • N-terminal pro-B-type natriuretic peptide levels

The results were similar when the cohort was restricted to patients without a prior heart failure (HF) diagnosis or those without prior HF hospitalization.

Likewise, on the numeric rating scale, there was no significant association between tertiles of dyspnea scores and measures of pulmonary congestion on lung ultrasound, chest X-ray, or physical examination.

Guidance for Clinicians

These findings suggest the KCCQ-TSS reflects subjective dyspnea burden but not necessarily the degree of pulmonary congestion. Despite the importance of patients’ symptoms in HF management, patient reports of their HF symptoms and health-related quality of life should not be used in isolation for monitoring worse pulmonary congestion.

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