1
|
Patel S, Green A, Ashokumar S, Hoke A, Rachoin JS. Objective Methods of Assessing Fluid Status to Optimize Volume Management in Kidney Disease and Hypertension: The Importance of Ultrasound. J Clin Med 2023; 12:6368. [PMID: 37835014 PMCID: PMC10573183 DOI: 10.3390/jcm12196368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/21/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
Fluid overload, a prevalent complication in patients with renal disease and hypertension, significantly impacts patient morbidity and mortality. The daily clinical challenges that clinicians face include how to identify fluid overload early enough in the course of the disease to prevent adverse outcomes and to guide and potentially reduce the intensity of the diuresis. Traditional methods for evaluating fluid status, such as pitting edema, pulmonary crackles, or chest radiography primarily assess extracellular fluid and do not accurately reflect intravascular volume status or venous congestion. This review explores the rationale, mechanism, and evidence behind more recent methods used to assess volume status, namely, lung ultrasound, inferior vena cava (IVC) ultrasound, venous excess ultrasound score, and basic and advanced cardiac echocardiographic techniques. These methods offer a more accurate and objective assessment of fluid status, providing real-time, non-invasive measures of intravascular volume and venous congestion. The methods we discuss are primarily used in inpatient settings, but, given the increased pervasiveness of ultrasound technology, some could soon expand to the outpatient setting.
Collapse
Affiliation(s)
- Sharad Patel
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Adam Green
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Sandhya Ashokumar
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
| | - Andrew Hoke
- Department of Medicine, Cooper University Health Care, Camden, NJ 08103, USA;
| | - Jean-Sebastien Rachoin
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| |
Collapse
|
2
|
Cooper L, DeVore A, Cowger J, Pinney S, Baran D, DeWald TA, Burt T, Pietzsch JB, Walton A, Aaronson K, Shah P. Patients hospitalized with acute heart failure, worsening renal function, and persistent congestion are at high risk for adverse outcomes despite current medical therapy. Clin Cardiol 2023; 46:1163-1172. [PMID: 37464579 PMCID: PMC10577559 DOI: 10.1002/clc.24080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Approximately 1/3 of patients with acute decompensated heart failure (ADHF) are discharged with persistent congestion. Worsening renal function (WRF) occurs in approximately 50% of patients hospitalized for ADHF and the combination of WRF and persistent congestion are associated with higher risk of mortality and HF readmissions. METHODS We designed a multicenter, prospective registry to describe current treatments and outcomes for patients hospitalized with ADHF complicated by WRF (defined as a creatinine increase ≥0.3 mg/dL) and persistent congestion at 96 h. Study participants were followed during the hospitalization and through 90-day post-discharge. Hospitalization costs were analyzed in an economic substudy. RESULTS We enrolled 237 patients hospitalized with ADHF, who also had WRF and persistent congestion. Among these, the average age was 66 ± 13 years and 61% had a left ventricular ejection fraction (LVEF) ≤ 40%. Mean baseline creatinine was 1.7 ± 0.7 mg/dL. Patients with persistent congestion had a high burden of clinical events during the index hospitalization (7.6% intensive care unit transfer, 2.1% intubation, 1.7% left ventricular assist device implantation, and 0.8% dialysis). At 90-day follow-up, 33% of patients were readmitted for ADHF or died. Outcomes and costs were similar between patients with reduced and preserved LVEF. CONCLUSIONS Many patients admitted with ADHF have WRF and persistent congestion despite diuresis and are at high risk for adverse events during hospitalization and early follow-up. Novel treatment strategies are urgently needed for this high-risk population.
Collapse
Affiliation(s)
- Lauren Cooper
- Department of CardiologyNorth Shore University HospitalManhassetNew YorkUSA
- Inova Heart & Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Adam DeVore
- Department of MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Jennifer Cowger
- Division of Cardiovascular MedicineHenry Ford HospitalsDetroitMichiganUSA
| | - Sean Pinney
- Heart & Vascular CenterUniversity of Chicago MedicineChicagoIllinoisUSA
| | | | - Tracy A. DeWald
- Department of MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
| | | | | | | | - Keith Aaronson
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Palak Shah
- Inova Heart & Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| |
Collapse
|
3
|
Liu Z, Zhu Y, Zhang L, Wu M, Huang H, Peng K, Zhao W, Chen S, Peng X, Li N, Zhang H, Zhou Y, Chen Y, Xiao S, Yi L, Fan J, Zeng J. Impact of signs and symptoms on the prognosis of patients with HFmrEF. BMC Cardiovasc Disord 2023; 23:420. [PMID: 37620764 PMCID: PMC10464266 DOI: 10.1186/s12872-023-03436-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Worsening of heart failure (HF) symptoms is the leading cause of medical contact and hospitalization of patients with mildly reduced ejection fraction (HFmrEF). The prognostic value of signs and symptoms for patients with HFmrEF is currently unclear. This study investigated the prognostic impact of signs and symptoms in HFmrEF patients. METHODS A Cox proportional risk regression model analyzed the relationship between the number of signs/symptoms and outcomes in 1691 hospitalized HFmrEF patients. Ten significant signs and symptoms were included. Patients were divided into three groups (A: ≤2, B: 3-5, C: ≥6 signs/symptoms). Stratified analysis on male and female patients was performed. The primary endpoint was all-cause mortality, and the secondary outcome was a composite of cardiovascular death and heart failure readmission (CV events) post-discharge. RESULTS After a median follow-up of 33 months, all-cause mortality occurred in 457 patients and CV events occurred in 977 patients. Incidence of all-cause mortality was 20.7%, 32.3%* and 49.4%*† in group A, B and C of male patients, (*P < 0.05 vs. A, †P < 0.05 vs. B) and 18.8%, 33.6% and 55.8%* in group A, B and C of female patients. Incidence of CV events was 64.8%, 70.1%* and 87.5%* in group A, B and C of male patients, 61.9%, 75.3%, and 86.1%* in group A, B and C of female patients. Multivariate Cox regression showed older age, renal insufficiency, higher number of signs and symptoms (≥ 3, hazard ratio [HR] 1.317, 95% confidence interval [CI] 1.070-1.621, P = 0.009; ≥6, HR 1.982, 95% CI 1.402-2.801, P < 0.001), myocardial infarction, stroke, faster heart rate on admission, and diabetes were independently associated with all-cause mortality(all P < 0.05). Similarly, higher number of signs and symptoms (≥ 3, HR 1.271, 95% CI 1.119-1.443, P < 0.001; ≥6, HR 1.955, 95% CI 1.524-2.508, P < 0.001), older age, renal insufficiency, atrial fibrillation, and diabetes were independently associated with cardiovascular events (all P < 0.05). CONCLUSIONS Higher number of symptoms and signs is associated with increased risk of all-cause mortality and CV events in HFmrEF patients. Our results highlight the prognostic importance of careful inquiry on HF symptoms and related physical examination in HFmrEF patients.
Collapse
Affiliation(s)
- Zhican Liu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Yunlong Zhu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China.
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China.
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
| | - Lingling Zhang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Mingxin Wu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Haobo Huang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Ke Peng
- Department of Scientific Research, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Wenjiao Zhao
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Sihao Chen
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Xin Peng
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Na Li
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Hui Zhang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Yuying Zhou
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Yongliang Chen
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Sha Xiao
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Liqing Yi
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Jie Fan
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Jianping Zeng
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China.
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China.
| |
Collapse
|
4
|
Kadosh BS, Berg DD, Bohula EA, Park JG, Baird-Zars VM, Alviar C, Alzate J, Barnett CF, Barsness GW, Burke J, Chaudhry SP, Daniels LB, DeFilippis A, Delicce A, Fordyce CB, Ghafghazi S, Gidwani U, Goldfarb M, Katz JN, Keeley EC, Kenigsberg B, Kontos MC, Lawler PR, Leibner E, Menon V, Metkus TS, Miller PE, O'Brien CG, Papolos AI, Prasad R, Shah KS, Sinha SS, Snell RJ, So D, Solomon MA, Ternus BW, Teuteberg JJ, Toole J, van Diepen S, Morrow DA, Roswell RO. Pulmonary Artery Catheter Use and Mortality in the Cardiac Intensive Care Unit. JACC. HEART FAILURE 2023; 11:903-914. [PMID: 37318422 PMCID: PMC10527413 DOI: 10.1016/j.jchf.2023.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND The appropriate use of pulmonary artery catheters (PACs) in critically ill cardiac patients remains debated. OBJECTIVES The authors aimed to characterize the current use of PACs in cardiac intensive care units (CICUs) with attention to patient-level and institutional factors influencing their application and explore the association with in-hospital mortality. METHODS The Critical Care Cardiology Trials Network is a multicenter network of CICUs in North America. Between 2017 and 2021, participating centers contributed annual 2-month snapshots of consecutive CICU admissions. Admission diagnoses, clinical and demographic data, use of PACs, and in-hospital mortality were captured. RESULTS Among 13,618 admissions at 34 sites, 3,827 were diagnosed with shock, with 2,583 of cardiogenic etiology. The use of mechanical circulatory support and heart failure were the patient-level factors most strongly associated with a greater likelihood of the use of a PAC (OR: 5.99 [95% CI: 5.15-6.98]; P < 0.001 and OR: 3.33 [95% CI: 2.91-3.81]; P < 0.001, respectively). The proportion of shock admissions with a PAC varied significantly by study center ranging from 8% to 73%. In analyses adjusted for factors associated with their placement, PAC use was associated with lower mortality in all shock patients admitted to a CICU (OR: 0.79 [95% CI: 0.66-0.96]; P = 0.017). CONCLUSIONS There is wide variation in the use of PACs that is not fully explained by patient level-factors and appears driven in part by institutional tendency. PAC use was associated with higher survival in cardiac patients with shock presenting to CICUs. Randomized trials are needed to guide the appropriate use of PACs in cardiac critical care.
Collapse
Affiliation(s)
- Bernard S Kadosh
- Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York University Langone Health, New York, New York, USA; Lenox Hospital, Northwell Health, New York, New York, USA.
| | - David D Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Alviar
- Department of Medicine at New York University Grossman School of Medicine, Bellevue Hospital, New York, New York, USA
| | - James Alzate
- Lenox Hospital, Northwell Health, New York, New York, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - James Burke
- Lehigh Valley Heart Institute, Allentown, Pennsylvania, USA
| | | | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | | | | | - Christopher B Fordyce
- University of British Columbia, University of British Columbia Centre for Cardiovascular Innovation, Cardiovascular Health Program, University of British Columbia Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
| | - Shahab Ghafghazi
- Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Umesh Gidwani
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ellen C Keeley
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Benjamin Kenigsberg
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Evan Leibner
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Thomas S Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rajnish Prasad
- Wellstar Cardiovascular Medicine, Marietta, Georgia, USA
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | | | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, USA
| | - Bradley W Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University Medical Center, Palo Alto, California, USA
| | - Joseph Toole
- Lenox Hospital, Northwell Health, New York, New York, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | |
Collapse
|
5
|
Miller WL. Measurement of Blood Volume in Patients with Heart Failure: Clinical Relevance, Surrogates, Historical Background and Contemporary Methodology. Heart Int 2023; 17:36-43. [PMID: 37456346 PMCID: PMC10339432 DOI: 10.17925/hi.2023.17.1.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/22/2023] [Indexed: 07/18/2023] Open
Abstract
The development of clinical congestion resulting from volume overload, either by renal fluid retention or redistribution of blood volume from venous reservoirs, is a recurrent scenario in patients with chronic heart failure (HF). As a result, the treatment of congestion, most commonly by initiating aggressive diuretic therapy, is a front-line issue in the management of patients with HF. However, the association of clinical congestion and volume overload with physical signs and symptoms, as well as other surrogates of volume assessment, has limitations in accuracy and, therefore, reliability to direct appropriate interventions. The ability to quantitate intravascular volume and identify the variability in volume profiles among patients with HF can uniquely inform individualized volume management and aid in risk stratification. This tool is provided by contemporary nuclear medicine-based BVA-100 methodology, which uses the well-established indicator-dilution principle and is a requested topic for discussion in this review.
Collapse
Affiliation(s)
- Wayne L Miller
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
6
|
Turk M, Robertson T, Koratala A. Point-of-care ultrasound in diagnosis and management of congestive nephropathy. World J Crit Care Med 2023; 12:53-62. [PMID: 37034023 PMCID: PMC10075049 DOI: 10.5492/wjccm.v12.i2.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/08/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Congestive nephropathy is kidney dysfunction caused by the impact of elevated venous pressures on renal hemodynamics. As a part of cardiorenal syndrome, the diagnosis is usually made based on history and physical examination, with findings such as jugular venous distension, a third heart sound, and vital signs as supporting findings. More recently, however, these once though objective measures have come under scrutiny for their accuracy. At the same time, bedside ultrasound has increased in popularity and is routinely being used by clinicians to take some of the guess work out of making the diagnosis of volume overload and venous congestion. In this mini-review, we will discuss some of the traditional methods used to measure venous congestion, describe the role of point-of-care ultrasound and how it can ameliorate a clinician’s evaluation, and offer a description of venous excess ultrasound score, a relatively novel scoring technique used to objectively quantify congestion. While there is a paucity of published large scale clinical trials evaluating the potential benefit of ultrasonography in venous congestion compared to gold standard invasive measurements, more study is underway to solidify the role of this objective measure in daily clinical practice.
Collapse
Affiliation(s)
- Michael Turk
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA 15222, United States
| | - Thomas Robertson
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA 15222, United States
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| |
Collapse
|
7
|
Prognostic implications of post-discharge hemodynamic congestion assessed by peripheral venous pressure among patients discharged from acute heart failure. Int J Cardiol 2023; 374:58-64. [PMID: 36610550 DOI: 10.1016/j.ijcard.2022.12.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/20/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Congestion is a major cause of hospitalization for heart failure (HF). Peripheral venous pressure (PVP) strongly correlates with right atrial pressure. We recently reported that high PVP at discharge portends a poor prognosis in patients hospitalized for HF. In the same population, we aimed to analyze changes in PVP after discharge and to evaluate prognostic implications of post-discharge PVP. METHODS PVP was measured at the forearm vein of 163 patients in the 1-month post-discharge follow-up visit. The primary outcome was a composite of cardiovascular death or re-hospitalization for HF after the 1-month follow-up visit up to 1 year after discharge. RESULTS Post-discharge PVP correlated with jugular venous pressure, the inferior vena cava diameter, and brain-type natriuretic peptide levels. The cumulative incidence of the primary outcome event was significantly higher in patients with PVP above the median (6 mmHg) than in those with median PVP or lower (39.8% versus 16.9%, Log-rank P = 0.04). Age- and sex-adjusted risk of PVP per 1 mmHg for the primary outcome measure was significant (hazard ratio: 1.12 [95% confidence interval 1.03-1.21]). 35% of patients who had PVP ≤6 mmHg at discharge had PVP >6 mmHg at the 1-month follow-up. PVP significantly decreased from discharge to 1-month follow-up in patients without the primary outcome event (from 6 [4-10] to 6 [4-8] mmHg, P=0.01), but remained high in those with the primary outcome event (from 8 [5-11] to 7 [5-10.5] mmHg, P = 0.9). CONCLUSIONS PVP measurements during the early post-discharge period may be useful to identify high risk patients. TRIAL REGISTRATION NUMBER UMIN000034279.
Collapse
|
8
|
Pulmonary Artery Systolic Pressure and Cava Vein Status in Acute Heart Failure with Preserved Ejection Fraction: Clinical and Prognostic Implications. Diagnostics (Basel) 2023; 13:diagnostics13040692. [PMID: 36832179 PMCID: PMC9955829 DOI: 10.3390/diagnostics13040692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Peak tricuspid regurgitation (TR) velocity and inferior cava vein (ICV) distention are two recognized features of increased pulmonary artery pressure (PASP) and right atrial pressure, respectively. Both parameters are related to pulmonary and systemic congestion and adverse outcomes. However, few data exist about the assessment of PASP and ICV in acute patients affected by heart failure with preserved ejection fraction (HFpEF). Thus, we investigated the relationship existing among clinical and echocardiographic features of congestion, and we analyzed the prognostic impact of PASP and ICV in acute HFpEF patients. METHODS AND RESULTS We analyzed clinical congestion PASP and ICV value in consecutive patients admitted in our ward by echocardiographic examination using peak Doppler velocity tricuspid regurgitation and ICV diameter and collapse for the assessment of PASP and ICV dimension, respectively. A total of 173 HFpEF patients were included in the analysis. The median age was 81 and median left ventricular ejection fraction (LVEF) was 55% [50-57]. Mean values of PASP was 45 mmHg [35-55] and mean ICV was 22 [20-24] mm. Patients with adverse events during follow-up showed significantly higher values of PASP (50 [35-55] vs. 40 [35-48] mmHg, (p = 0.005) and increased values of ICV (24 [22-25] vs. 22 [20-23] mm, p < 0.001). Multivariable analysis showed prognostic power of ICV dilatation (HR 3.22 [1.58-6.55], p = 0.001) and clinical congestion score ≥ 2 (HR 2.35 [1.12-4.93], p = 0.023), but PASP increase did not reach statistical significance (p = 0.874). The combination of PASP > 40 mmHg and ICV > 21 mm was capable of identifying patients with increased events (45% vs. 20%). CONCLUSIONS ICV dilatation provides additional prognostic information with respect to PASP in patients with acute HFpEF. A combined model adding PASP and ICV assessment to clinical evaluation is a useful tool for predicting HF related events.
Collapse
|
9
|
Haag S, Jobs A, Stiermaier T, Fichera CF, Paitazoglou C, Eitel I, Desch S, Thiele H. Lack of correlation between different congestion markers in acute decompensated heart failure. Clin Res Cardiol 2023; 112:75-86. [PMID: 35648271 PMCID: PMC9849150 DOI: 10.1007/s00392-022-02036-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 05/03/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hospitalizations for acute decompensated heart failure (ADHF) are commonly associated with congestion-related signs and symptoms. Objective and quantitative markers of congestion have been identified, but there is limited knowledge regarding the correlation between these markers. METHODS Patients hospitalized for ADHF irrespective of left ventricular ejection fraction were included in a prospective registry. Assessment of congestion markers (e.g., NT-proBNP, maximum inferior vena cava diameter, dyspnea using visual analogue scale, and a clinical congestion score) was performed systematically on admission and at discharge. Telephone interviews were performed to assess clinical events, i.e., all-cause death or readmission for cardiovascular cause, after discharge. Missing values were handled by multiple imputation. RESULTS In total, 130 patients were prospectively enrolled. Median length of hospitalization was 9 days (interquartile range 6 to 16). All congestion markers declined from admission to discharge (p < 0.001). No correlation between the congestion markers could be identified, neither on admission nor at discharge. The composite endpoint of all-cause death or readmission for cardiovascular cause occurred in 46.2% of patients. Only NT-proBNP at discharge was predictive for this outcome (hazard ratio 1.48, 95% confidence interval 1.15 to 1.90, p = 0.002). CONCLUSION No correlation between quantitative congestion markers was observed. Only NT-proBNP at discharge was significantly associated with the composite endpoint of all-cause death or readmission for cardiovascular cause. Findings indicate that the studied congestion markers reflect different aspects of congestion.
Collapse
Affiliation(s)
- Svenja Haag
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Medical Clinic II, University Hospital Schleswig-Holstein, Lübeck, Germany ,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Alexander Jobs
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Medical Clinic II, University Hospital Schleswig-Holstein, Lübeck, Germany ,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany ,Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany ,Leipzig Heart Institute, Leipzig, Germany
| | - Thomas Stiermaier
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Medical Clinic II, University Hospital Schleswig-Holstein, Lübeck, Germany ,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Carlo-Federico Fichera
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Medical Clinic II, University Hospital Schleswig-Holstein, Lübeck, Germany ,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Christina Paitazoglou
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Medical Clinic II, University Hospital Schleswig-Holstein, Lübeck, Germany ,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Ingo Eitel
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Medical Clinic II, University Hospital Schleswig-Holstein, Lübeck, Germany ,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Steffen Desch
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Medical Clinic II, University Hospital Schleswig-Holstein, Lübeck, Germany ,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany ,Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany ,Leipzig Heart Institute, Leipzig, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany ,Leipzig Heart Institute, Leipzig, Germany
| |
Collapse
|
10
|
Aronson D, Nitzan Y, Petcherski S, Bravo E, Habib M, Burkhoff D, Abraham WT. Enhancing Sweat Rate Using a Novel Device for the Treatment of Congestion in Heart Failure. Circ Heart Fail 2023; 16:e009787. [PMID: 36321445 DOI: 10.1161/circheartfailure.122.009787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Current treatment of fluid retention in heart failure relies primarily on diuretics. However, adequate decongestion is not achieved in many patients. We aimed to study the feasibility and short-term performance of a novel approach to remove fluids and sodium directly from the interstitial compartment by enhancing sweat rate. METHODS We used a device designed to enhance fluid and salt loss via the eccrine sweat glands. Skin temperature in the lower body was increased from 35 °C to 38 °C, where the slope of the relationship between temperature and sweat production is linear. The sweat evaporates instantaneously, thus avoiding the awareness of perspiration. The primary efficacy endpoint was the ability to increase skin temperature to the desired range. A secondary efficacy endpoint was a clinically meaningful hourly sweat output, defined as ≥150 mL/h. The primary safety endpoint was any procedure-related adverse events. RESULTS We studied 6 normal subjects and 18 patients with congestion. Participants underwent 3 treatment sessions of up to 4 hours. Skin temperature increased to a median of 37.5 °C (interquartile range, 37.1-37.9 °C) with the median core temperature increasing by 0.2 °C (interquartile range, 0.1-0.3 °C). The median hourly weight loss during treatment was 215 g/h (interquartile range, 165-285; range, 100-344 g/h). In 80% of treatment procedures, the average sweat rate was ≥150 mL/h. There were no significant changes in hemodynamic variables or renal function and no procedure-related adverse events. CONCLUSIONS Enhancing sweat rate was safe and resulted in a clinically meaningful fluid removal and weight loss. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04578353.
Collapse
Affiliation(s)
- Doron Aronson
- Department of Cardiology, Rambam Medical Center, and B. Rappaport Faculty of Medicine, Technion Medical School, Haifa, Israel (D.A., S.P., E.B., M.H.)
| | | | - Sirouch Petcherski
- Department of Cardiology, Rambam Medical Center, and B. Rappaport Faculty of Medicine, Technion Medical School, Haifa, Israel (D.A., S.P., E.B., M.H.)
| | - Evgeny Bravo
- Department of Cardiology, Rambam Medical Center, and B. Rappaport Faculty of Medicine, Technion Medical School, Haifa, Israel (D.A., S.P., E.B., M.H.)
| | - Manhal Habib
- Department of Cardiology, Rambam Medical Center, and B. Rappaport Faculty of Medicine, Technion Medical School, Haifa, Israel (D.A., S.P., E.B., M.H.)
| | - Daniel Burkhoff
- Cardiovascular Research Foundation and Columbia University, New York, NY (D.B.)
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus (W.T.A.)
| |
Collapse
|
11
|
Miller WL, Fudim M, Mullan BP. Blood volume and chronic kidney disease in heart failure - Can volume expansion help balance the Cardio-Renal Axis for better clinical outcomes? Physiol Rep 2022; 10:e15526. [PMID: 36461656 PMCID: PMC9718939 DOI: 10.14814/phy2.15526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/07/2022] [Accepted: 11/13/2022] [Indexed: 06/17/2023] Open
Abstract
Intravascular volume is largely regulated by the kidneys but how differences in intravascular volume profiles interact with chronic kidney disease (CKD) to influence outcomes in chronic heart failure (HF) has not been explored. Our hypothesis was that a greater degree of volume expansion (VE) would moderate the impact of CKD on HF-related clinical outcomes. Quantitative blood volume (BV) data were available in 137 patients at the time of hospital discharge using a nuclear medicine radiolabeled albumin indicator-dilution technique. The study patients were stratified by the cohort median glomerular filtration rate (GFR, 44 ml/min/1.73 m2 ). An a priori cut-point of ≥+25% above normal BV was then used to further stratify the two GFR subgroups and prospectively analyzed for 1-year HF-related mortality or 1st re-hospitalization. Persistent BV expansions ≥+25% were present in 51% of the cohort. In the subgroup with GFR above the median (N = 68) greater or lesser BV expansion from +25% did not differentiate outcomes. However, in the subgroup with GFR below the median (N = 69), BV expansion-stratified risk (log-rank p = 0.022) with <+25% VE associated with poorer outcomes, while VE ≥ + 25% was associated with lower risk and comparable to GFR above the median. In patients with chronic HF, significant intravascular VE and CKD are common co-existing conditions. The presence of larger VE, however, appears to be a factor mitigating the impact of declining renal function on clinical outcomes, and as an element of volume pathophysiology warrants further study.
Collapse
Affiliation(s)
- Wayne L. Miller
- Department of Cardiovascular MedicineMayo ClinicRochesterMinnesotaUSA
| | - Marat Fudim
- Division of CardiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Brian P. Mullan
- Division of Diagnostic Radiology and Nuclear MedicineMayo ClinicRochesterMinnesotaUSA
| |
Collapse
|
12
|
Buchnev AS, Itkin GP, Drobyshev AA, Kuleshov AP, Esipova OY, Syrbu AI. Mechanized lymphatic drainage in acute decompensated heart failure. A study on a hydrodynamic test bench. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2022. [DOI: 10.15825/1995-1191-2022-4-54-59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective: to investigate the effectiveness of a new mechanized lymphatic drainage method in acute decompensated heart failure (ADHF) modeling through local reduction in venous pressure in the site of lymphatic drainage from the thoracic duct.Materials and methods. Main components of the device are a catheter with built-in inlet and outlet mechanical valves designed for insertion into the left brachiocephalic vein through the left internal jugular vein. It comes with an extracorporeal drive system made as a valveless pulsator pump with a 10 ml shock discharge and a controller ensuring preset frequency and pressure/rarefaction duty cycle. The operating principle of the device is based on local reduction of venous pressure in the site of lymphatic drainage from the thoracic duct (in the junction of the left internal jugular and subclavian veins).Results. When modeling hydrodynamics under ADHF conditions on a hydrodynamic test bench, the upper venous flow through the left brachiocephalic vein was 0.4 l/min, the pressure in the site of lymphatic drainage from the thoracic duct, was decreased from 20–25 mmHg to 0–5 mmHg due to operation of the mechanized drainage device with suction/injection phase duration ratio 0.2/0.8 and pulsator pump operating frequency from 30 to 60 beats/min.
Collapse
Affiliation(s)
- A. S. Buchnev
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - G. P. Itkin
- Shumakov National Medical Research Center of Transplantology and Artificial Organs; Moscow Institute of Physics and Technology
| | - A. A. Drobyshev
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - A. P. Kuleshov
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - O. Yu. Esipova
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - A. I. Syrbu
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| |
Collapse
|
13
|
Palazzuoli A, Ruocco G, Valente S, Stefanini A, Carluccio E, Ambrosio G. Non-invasive assessment of acute heart failure by Stevenson classification: Does echocardiographic examination recognize different phenotypes? Front Cardiovasc Med 2022; 9:911578. [PMID: 36237905 PMCID: PMC9551647 DOI: 10.3389/fcvm.2022.911578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/31/2022] [Indexed: 12/05/2022] Open
Abstract
Background Acute heart failure (AHF) presentation is universally classified in relation to the presence or absence of congestion and the peripheral perfusion condition according to the Stevenson diagram. We sought to evaluate a relationship existing between clinical assessment and echocardiographic evaluation in patients with AHF. Materials and methods This is a retrospective blinded multicenter analysis assessing both clinical and echocardiographic analyses during the early hospital admission for AHF. Patients were categorized into four groups according to the Stevenson presentation: group A (warm and dry), group B (cold and dry), group C (warm and wet), and group D (cold and wet). Echocardiographic evaluation was executed within 12 h from the first clinical evaluation. The following parameters were measured: left ventricular (LV) volumes, LV ejection fraction (LVEF); pattern Doppler by E/e1 ratio, pulmonary artery systolic pressure (PASP), tricuspid annular plane systolic excursion (TAPSE), and inferior cave vein diameter (ICV). Results We studied 208 patients, 10 in group A, 16 in group B, 153 in group C, and 29 in group D. Median age of our sample was 81 [69–86] years and the patients enrolled were mainly men (66.8%). Patients in groups C and A showed significant higher levels of systolic arterial pressures with respect to groups B and D (respectively, 130 [115–145] mmHg vs. 122 [119–130] mmHg vs. 92 [90–100] mmHg vs. 95 [90–100] mmHg, p < 0.001). Patients in groups A and C (warm) demonstrated significant higher values of LVEF with respect to patients in groups B and D (43 [34–49] vs. 42 [30–49] vs. 27 [15–31] vs. 30 [22–42]%, p < 0.001). Whereas group B experienced significant lower TAPSE values compared with other group (14 [12–17] mm vs. A: 17 [16–21] mm vs. C: 18 [14–20] mm vs. D: 16 [12–17] mm; p = 0.02). Finally, echocardiographic congestion score including PASP ≥ 40 mmHg, ICV ≥ 21, mm and E/e’ > 14 did not differ among groups. Follow-up analysis showed an increased mortality rate in D group (HR 8.2 p < 0.04). Conclusion The early Stevenson classification remains a simple and universally recognized approach for the detection of congestion and perfusion status. The combined clinical and echocardiographic assessment may be useful to better define the patients’ profile.
Collapse
Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic Department, Le Scotte Hospital, University of Siena, Siena, Italy
- *Correspondence: Alberto Palazzuoli,
| | - Gaetano Ruocco
- Cardiology Unit, Riuniti of Valdichiana Hospitals, USL-SUD-EST Toscana, Montepulciano, Italy
| | - Serafina Valente
- Cardiology Unit, Cardio Thoracic Department, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Andrea Stefanini
- Cardiovascular Diseases Unit, Cardio Thoracic Department, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Erberto Carluccio
- Division of Cardiology and Center for Clinical and Translational Research – CERICLET, University of Perugia, Perugia, Italy
| | - Giuseppe Ambrosio
- Division of Cardiology and Center for Clinical and Translational Research – CERICLET, University of Perugia, Perugia, Italy
| |
Collapse
|
14
|
Miller WL. Fluid Volume Homeostasis in Heart Failure: A Tale of 2 Circulations. J Am Heart Assoc 2022; 11:e026668. [PMID: 36073644 DOI: 10.1161/jaha.122.026668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fluid volume homeostasis in health and heart failure (HF) requires a complex interaction of 2 systems, the intravascular and interstitial-lymphatic circulations. With the development of HF both the intravascular and interstitial compartments undergo variable degrees of volume remodeling which can include significant expansion. This reflects the impact of multiple pathophysiologic mechanisms on both fluid compartments which initially play a compensatory role to stabilize intravascular circulatory integrity but with progression in HF can evolve to produce the various manifestations of volume overload and clinical HF congestion. The intent of this review is to help enhance recognition of the pathophysiologic and clinical importance of the interlinked roles of these 2 circulatory systems in volume regulation and chronic HF. It would also be hoped that a better understanding of the interacting functions of the intravascular and interstitial-lymphatic fluid compartments can potentially aid development of novel management strategies particularly addressing the generally undertargeted interstitial-lymphatic system and help bring such approaches forward through a more integrated view of these 2 circulatory systems.
Collapse
Affiliation(s)
- Wayne L Miller
- Division of Circulatory Failure, Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| |
Collapse
|
15
|
Paniagua D, Levine GN, Cornwell LD, Jimenez E, Kar B, Jneid H, Denktas AE, Ma TS. Decongestion Models and Metrics in Acute Heart Failure: ESCAPE Data in the Age of the Implantable Cardiac Pressure Monitor. Tex Heart Inst J 2022; 49:485300. [PMID: 36001949 DOI: 10.14503/thij-21-7587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The United States Food and Drug Administration restricts the use of implantable cardiac pressure monitors to patients with New York Heart Association (NYHA) class III heart failure (HF). We investigated whether single-pressure monitoring could predict survival in HF patients as part of a model constructed using data from the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial. We validated survival models in 204 patients, using all-cause 180-day mortality. Two levels of model complexity were tested: 1) a simplified 1-pressure model based on pulmonary artery mean pressure ([PAM]1P) (information obtainable from an implanted intracardiac monitor alone), and 2) a pair of 5-variable risk score models based on right atrial pressure (RAP) + pulmonary capillary wedge pressure (PCWP) ([RAP+PCWP]5V) and on RAP + PAM ([RAP+PAM]5V). The more complex models used 5 dichotomous variables: a congestion index above a certain threshold value, baseline systolic blood pressure of <100 mmHg, baseline blood urea nitrogen level of ≥ 34 mg/dL, need for cardiopulmonary resuscitation or mechanical ventilation, and posttreatment NYHA class IV status. The congestion index was defined as posttreatment RAP+PCWP or posttreatment RAP+PAM, with congestion thresholds of 34 and 42 mmHg, respectively (median pulmonary catheter indwelling time, 1.9 d). The 5-variable models predicted survival with areas under the curve of 0.868 for the (RAP+PCWP)5V model and 0.827 for the (RAP+PAM)5V model, whereas the 1-pressure model predicted survival with an area under the curve of 0.718. We conclude that decongestion as determined by hemodynamic assessment predicts survival in HF patients and that it may be the final pathway for treatment benefit despite improvements in pharmacologic intervention since the ESCAPE trial.
Collapse
Affiliation(s)
- David Paniagua
- Section of Cardiology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Department of Adult Cardiology, Texas Heart Institute, Houston, Texas
| | - Glenn N Levine
- Section of Cardiology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Lorraine D Cornwell
- Section of Thoracic Surgery, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Ernesto Jimenez
- Section of Thoracic Surgery, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Biswajit Kar
- Section of Cardiology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,The University of Texas Health Science Center at Houston, Houston, Texas
| | - Hani Jneid
- Section of Cardiology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Ali E Denktas
- Section of Cardiology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Tony S Ma
- Section of Cardiology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| |
Collapse
|
16
|
McCallum W, Tighiouart H, Testani JM, Griffin M, Konstam MA, Udelson JE, Sarnak MJ. Rates of In-Hospital Decongestion and Association with Mortality and Cardiovascular Outcomes Among Patients Admitted for Acute Heart Failure. Am J Med 2022; 135:e337-e352. [PMID: 35472391 PMCID: PMC10767835 DOI: 10.1016/j.amjmed.2022.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Decongestion is an important goal in the management of acute heart failure. Whether the rate of decongestion is associated with mortality and cardiovascular outcomes is unknown. METHODS Using data from 4133 patients from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial, we used multivariable Cox regression models to evaluate the association between rates of in-hospital change in assessments of volume overload, including b-type natriuretic peptide (BNP), N-terminal pro b-type natriuretic peptide (NT-proBNP), as well as change in hemoconcentration, with risk of all-cause mortality and a composite outcome of cardiovascular mortality or heart failure hospitalization. RESULTS More rapid rates of in-hospital decongestion were associated with decreased risk of mortality and the composite outcome over a median 10-month follow-up. In reference to the quartile of slowest decline, the quartile with the fastest BNP and NT-proBNP decline had lower hazards of mortality (hazard rate [HR] = 0.43 [0.31, 0.59] and HR = 0.27 [0.19, 0.40], respectively) and composite outcome (HR = 0.49 [0.39, 0.60] and HR = 0.54 [0.42, 0.71], respectively). In reference to the quartile of slowest increase, the quartile with the fastest hematocrit increase had lower hazards of mortality (HR = 0.77 [0.62, 0.95]) and composite outcome (HR = 0.75 [0.64, 0.88]). Results were also consistent when models were repeated using propensity-score matching. CONCLUSIONS Faster rates of decongestion are associated with reduced risk of mortality and a composite of cardiovascular mortality and heart failure hospitalization. It remains unknown whether more rapid decongestion provides cardiovascular benefit or whether it serves as a proxy for less treatment resistant heart failure.
Collapse
Affiliation(s)
- Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, Mass.
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Mass; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Mass
| | - Jeffrey M Testani
- Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
| | - Matthew Griffin
- Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
| | - Marvin A Konstam
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Mass
| | - James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Mass
| | - Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Mass
| |
Collapse
|
17
|
Aronson D. The interstitial compartment as a therapeutic target in heart failure. Front Cardiovasc Med 2022; 9:933384. [PMID: 36061549 PMCID: PMC9428749 DOI: 10.3389/fcvm.2022.933384] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/15/2022] [Indexed: 12/23/2022] Open
Abstract
Congestion is the single most important contributor to heart failure (HF) decompensation. Most of the excess volume in patients with HF resides in the interstitial compartment. Inadequate decongestion implies persistent interstitial congestion and is associated with worse outcomes. Therefore, effective interstitial decongestion represents an unmet need to improve quality of life and reduce clinical events. The key processes that underlie incomplete interstitial decongestion are often ignored. In this review, we provide a summary of the pathophysiology of the interstitial compartment in HF and the factors governing the movement of fluids between the interstitial and vascular compartments. Disruption of the extracellular matrix compaction occurs with edema, such that the interstitium becomes highly compliant, and large changes in volume marginally increase interstitial pressure and allow progressive capillary filtration into the interstitium. Augmentation of lymph flow is required to prevent interstitial edema, and the lymphatic system can increase fluid removal by at least 10-fold. In HF, lymphatic remodeling can become insufficient or maladaptive such that the capacity of the lymphatic system to remove fluid from the interstitium is exceeded. Increased central venous pressure at the site of the thoracic duct outlet also impairs lymphatic drainage. Owing to the kinetics of extracellular fluid, microvascular absorption tends to be transient (as determined by the revised Starling equation). Therefore, effective interstitial decongestion with adequate transcapillary plasma refill requires a substantial reduction in plasma volume and capillary pressure that are prolonged and sustained, which is not always achieved in clinical practice. The critical importance of the interstitium in the congestive state underscores the need to directly decongest the interstitial compartment without relying on the lowering of intracapillary pressure with diuretics. This unmet need may be addressed by novel device therapies in the near future.
Collapse
|
18
|
Gil-Martínez P, Curbelo J, Roy-Vallejo E, Mesado-Martínez D, Ciudad-Sañudo M, Suárez-Fernández C. Assessment of clinical and hemodynamic congestion as predictors of mortality in elderly outpatients with heart failure. Rev Clin Esp 2022; 222:377-384. [PMID: 35537991 DOI: 10.1016/j.rceng.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 12/27/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This work aims to evaluate whether a clinical examination and measurement of N-terminal pro-brain natriuretic peptide can predict poor prognosis in outpatients with heart failure. PATIENTS AND METHODS We carried out a retrospective study from 2010 to 2018 in 238 patients diagnosed with heart failure. At baseline, we evaluated the presence of pulmonary rales and bilateral leg edema (clinical congestion) together with N-terminal pro-brain natriuretic peptide ≥ 1500 pg/mL (hemodynamic congestion). Patients were classified into 4 groups depending on their congestion pattern: no congestion (G1) (n = 50); clinical congestion (G2) (n = 43); hemodynamic congestion (G3) (n = 73); and clinical and hemodynamic congestion (G4) (n = 72). The primary outcome was all-cause mortality at one year of follow-up. RESULTS A total of 238 patients were included. The mean age was 82 years, 61.8% were women, and 20.7% had reduced left ventricular ejection fraction. Thirty patients died in the first year of follow-up (12.6%). After controlling for confounding variables (sex, recent discharge for heart failure, estimated glomerular filtration rate, and left ventricular ejection fraction), the independent risk of death in each group compared to G1 as the reference group was: G2: HR 4.121 (95%CI 1.131-15.019); G3: HR 2.511 (95%CI 1.007-6.263); and G4: HR 7.418 (95%CI 1.630-33.763). CONCLUSION Congestion in outpatients with heart failure correlates with prognosis. Patients with both clinical and hemodynamic congestion had the highest risk of all-cause death at one year.
Collapse
Affiliation(s)
- P Gil-Martínez
- Servicio de Medicina Interna, Hospital Universitario de la Princesa. Fundación Investigación Biosanitaria del Hospital de la Princesa, Madrid, Spain; Grupo de trabajo de Insuficiencia Cardíaca de la Sociedad Española de Medicina Interna, Madrid, Spain.
| | - J Curbelo
- Servicio de Medicina Interna, Hospital Universitario de la Princesa. Fundación Investigación Biosanitaria del Hospital de la Princesa, Madrid, Spain; Grupo de trabajo de Insuficiencia Cardíaca de la Sociedad Española de Medicina Interna, Madrid, Spain
| | - E Roy-Vallejo
- Servicio de Medicina Interna, Hospital Universitario de la Princesa. Fundación Investigación Biosanitaria del Hospital de la Princesa, Madrid, Spain; Grupo de trabajo de Insuficiencia Cardíaca de la Sociedad Española de Medicina Interna, Madrid, Spain
| | - D Mesado-Martínez
- Grupo de trabajo de Insuficiencia Cardíaca de la Sociedad Española de Medicina Interna, Madrid, Spain; Servicio de Medicina Interna, Hospital Universitario General de Villalba, Villalba, Madrid, Spain
| | - M Ciudad-Sañudo
- Servicio de Medicina Interna, Hospital Universitario de la Princesa. Fundación Investigación Biosanitaria del Hospital de la Princesa, Madrid, Spain
| | - C Suárez-Fernández
- Servicio de Medicina Interna, Hospital Universitario de la Princesa. Fundación Investigación Biosanitaria del Hospital de la Princesa, Madrid, Spain
| |
Collapse
|
19
|
Evaluación del grado de congestión clínica y hemodinámica como predictores de mortalidad en pacientes ambulatorios con insuficiencia cardíaca de edad avanzada. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
20
|
|
21
|
Mazimba S, Mwansa H, Breathett K, Strickling JE, Shah K, McNamara C, Mehta N, Kwon Y, Lamp J, Feng L, Tallaj J, Pamboukian S, Mubanga M, Matharoo J, Lim S, Salerno M, Mwansa V, Bilchick KC. Systemic arterial pulsatility index (SAPi) predicts adverse outcomes in advanced heart failure patients. Heart Vessels 2022; 37:1719-1727. [PMID: 35534640 DOI: 10.1007/s00380-022-02070-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/31/2022] [Indexed: 11/30/2022]
Abstract
Ventriculo-arterial (VA) coupling has been shown to have physiologic importance in heart failure (HF). We hypothesized that the systemic arterial pulsatility index (SAPi), a measure that integrates pulse pressure and a proxy for left ventricular end-diastolic pressure, would be associated with adverse outcomes in advanced HF. We evaluated the SAPi ([systemic systolic blood pressure-systemic diastolic blood pressure]/pulmonary artery wedge pressure) obtained from the final hemodynamic measurement in patients randomized to therapy guided by a pulmonary arterial catheter (PAC) and with complete data in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. Cox proportional hazards regression was performed for the outcomes of (a) death, transplant, left ventricular assist device (DTxLVAD) or hospitalization, (DTxLVADHF) and (b) DTxLVAD. Among 142 patients (mean age 56.8 ± 13.3 years, 30.3% female), the median SAPi was 2.57 (IQR 1.63-3.45). Increasing SAPi was associated with significant reductions in DTxLVAD (HR 0.60 per unit increase in SAPi, 95% CI 0.44-0.84) and DTxLVADHF (HR 0.81 per unit increase, 95% CI 0.70-0.95). Patients with a SAPi ≤ 2.57 had a marked increase in both outcomes, including more than twice the risk of DTxLVAD (HR 2.19, 95% CI 1.11-4.30) over 6 months. Among advanced heart failure patients with invasive hemodynamic monitoring in the ESCAPE trial, SAPi was strongly associated with adverse clinical outcomes. These findings support further investigation of the SAPi to guide treatment and prognosis in HF undergoing invasive hemodynamic monitoring.
Collapse
Affiliation(s)
- Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA.
| | - Hunter Mwansa
- Division of Internal Medicine, University of Illinois College of Medicine, Peoria, IL, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Indiana University, Indianapolis, IN, USA
| | - Jarred E Strickling
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA
| | - Kajal Shah
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA
| | - Coleen McNamara
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA
| | - Nishaki Mehta
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA
| | - Younghoon Kwon
- Division of Cardiovascular Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Josephine Lamp
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA
| | - Lu Feng
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA
| | - Jose Tallaj
- Division of Cardiovascular Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Salpy Pamboukian
- Division of Cardiovascular Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mwenya Mubanga
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Solna, Stockholm, Sweden
| | - Jashanjeet Matharoo
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA
| | - Scott Lim
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA
| | - Michael Salerno
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA
| | - Victor Mwansa
- Division of Cardiology, Heartland Regional Medical Group, Marion, IL, USA
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, University of Virginia Health System, 1215 Lee St., PO Box 800158, Charlottesville, VA, 22908-0158, USA
| |
Collapse
|
22
|
Ricci JE, Aguilhon S, Occean BV, Soullier C, Solecki K, Robert C, Huet F, Cornillet L, Schmutz L, Chevallier T, Akodad M, Leclercq F, Cayla G, Lattuca B, Roubille F. Impact of Daily Bedside Echocardiographic Assessment on Readmissions in Acute Heart Failure: A Randomized Clinical Trial. J Clin Med 2022; 11:jcm11072047. [PMID: 35407655 PMCID: PMC8999405 DOI: 10.3390/jcm11072047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/20/2022] [Accepted: 03/31/2022] [Indexed: 12/04/2022] Open
Abstract
Acute heart failure (AHF) management is challenging, with high morbidity and readmission rates. There is little evidence of the benefit of HF monitoring during hospitalization. The aim of the study was to assess whether daily bedside echocardiographic monitoring (JetEcho) improved outcomes in AHF. In this prospective, open, two parallel-arm study (clinicaltrials.gov: NCT02892227), participants from two university hospitals were randomized to either standard of care (SC) or daily treatment adjustment including diuretics guided by JetEcho evaluating left ventricular filling pressure and volemia. The primary outcome was 30-day readmission rate. Key secondary outcomes were six-month cumulative incidence death, worsening HF during hospitalization and increasing of myocardial and renal biomarkers. From 250 included patients, 115 were finally analyzed in JetEcho group and 112 in SC group. Twenty-two (19%) patients were readmitted within 30 days in JetEcho group and 17 (15%) in SC group (relative risk [RR] 1.26; 95% confidence interval [CI], 0.70−2.24; p = 0.4). Worsening HF occurred in 17 (14%) patients in the JetEcho group and 24 (20%) in the SC group (RR 0.7; 95% [CI] 0.39 to 1.2; p = 0.2). No significant difference was found between the two groups concerning natriuretic peptides and renal function (p > 0.05 for all). The cumulative incidence rate of death from any cause at six months from discharge was 8.7% in the JetEcho group and 11.6% in the SC group (HR 0.63, 95% [CI] 0.3−1.4, p = 0.3). In AHF patients, a systematic daily bedside echocardiographic monitoring did not reduce 30-day readmission rate for HF and short-term clinical outcomes.
Collapse
Affiliation(s)
- Jean-Etienne Ricci
- Department of Cardiology, CHU Nîmes, University of Montpellier, CEDEX 9, 30029 Nîmes, France; (S.A.); (C.S.); (C.R.); (L.C.); (L.S.); (G.C.); (B.L.)
- IMAGINE UR UM 103, Department Cardiology, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France
- Correspondence: ; Tel.: +33-466-683-116; Fax: +33-466-683-611
| | - Sylvain Aguilhon
- Department of Cardiology, CHU Nîmes, University of Montpellier, CEDEX 9, 30029 Nîmes, France; (S.A.); (C.S.); (C.R.); (L.C.); (L.S.); (G.C.); (B.L.)
- Department of Cardiology, Montpellier University Hospital, CEDEX 5, 34295 Montpellier, France; (K.S.); (F.H.); (M.A.); (F.L.); (F.R.)
| | - Bob-Valéry Occean
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, University of Montpellier, CEDEX 9, 30029 Nîmes, France; (B.-V.O.); (T.C.)
| | - Camille Soullier
- Department of Cardiology, CHU Nîmes, University of Montpellier, CEDEX 9, 30029 Nîmes, France; (S.A.); (C.S.); (C.R.); (L.C.); (L.S.); (G.C.); (B.L.)
- IMAGINE UR UM 103, Department Cardiology, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France
| | - Kamila Solecki
- Department of Cardiology, Montpellier University Hospital, CEDEX 5, 34295 Montpellier, France; (K.S.); (F.H.); (M.A.); (F.L.); (F.R.)
| | - Christelle Robert
- Department of Cardiology, CHU Nîmes, University of Montpellier, CEDEX 9, 30029 Nîmes, France; (S.A.); (C.S.); (C.R.); (L.C.); (L.S.); (G.C.); (B.L.)
| | - Fabien Huet
- Department of Cardiology, Montpellier University Hospital, CEDEX 5, 34295 Montpellier, France; (K.S.); (F.H.); (M.A.); (F.L.); (F.R.)
| | - Luc Cornillet
- Department of Cardiology, CHU Nîmes, University of Montpellier, CEDEX 9, 30029 Nîmes, France; (S.A.); (C.S.); (C.R.); (L.C.); (L.S.); (G.C.); (B.L.)
| | - Laurent Schmutz
- Department of Cardiology, CHU Nîmes, University of Montpellier, CEDEX 9, 30029 Nîmes, France; (S.A.); (C.S.); (C.R.); (L.C.); (L.S.); (G.C.); (B.L.)
| | - Thierry Chevallier
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, University of Montpellier, CEDEX 9, 30029 Nîmes, France; (B.-V.O.); (T.C.)
| | - Mariama Akodad
- Department of Cardiology, Montpellier University Hospital, CEDEX 5, 34295 Montpellier, France; (K.S.); (F.H.); (M.A.); (F.L.); (F.R.)
| | - Florence Leclercq
- Department of Cardiology, Montpellier University Hospital, CEDEX 5, 34295 Montpellier, France; (K.S.); (F.H.); (M.A.); (F.L.); (F.R.)
| | - Guillaume Cayla
- Department of Cardiology, CHU Nîmes, University of Montpellier, CEDEX 9, 30029 Nîmes, France; (S.A.); (C.S.); (C.R.); (L.C.); (L.S.); (G.C.); (B.L.)
| | - Benoît Lattuca
- Department of Cardiology, CHU Nîmes, University of Montpellier, CEDEX 9, 30029 Nîmes, France; (S.A.); (C.S.); (C.R.); (L.C.); (L.S.); (G.C.); (B.L.)
- IMAGINE UR UM 103, Department Cardiology, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France
| | - François Roubille
- Department of Cardiology, Montpellier University Hospital, CEDEX 5, 34295 Montpellier, France; (K.S.); (F.H.); (M.A.); (F.L.); (F.R.)
- Physiologie et Médecine Expérimentale du Cœur et des Muscles, INSERM U1046, CNRS UMR 9214, University of Montpellier, CEDEX 5, 34295 Montpellier, France
| |
Collapse
|
23
|
Reduction of Hospitalization and Mortality by Echocardiography-Guided Treatment in Advanced Heart Failure. J Cardiovasc Dev Dis 2022; 9:jcdd9030074. [PMID: 35323622 PMCID: PMC8953534 DOI: 10.3390/jcdd9030074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/19/2022] [Accepted: 03/01/2022] [Indexed: 02/01/2023] Open
Abstract
In advanced heart failure (AHF) clinical evaluation fails to detect subclinical HF deterioration in outpatient settings. The aim of the study was to determine whether the strategy of intensive outpatient echocardiographic monitoring, followed by treatment modification, reduces mortality and re-hospitalizations at 12 months. Methods: 214 patients with ejection fraction < 30% and >1 hospitalization during the last year underwent clinical evaluation and echocardiography at discharge and were divided into intensive (IMG; N = 143) or standard monitoring group (SMG; N = 71). In IMG, volemic status and left ventricular filling pressure were assessed 14, 30, 90, 180 and 365 days after discharge. HF treatment, particularly diuretic therapy, was temporarily intensified when HF deterioration signs and E/e’ > 15 were detected. In SMG, standard outpatient monitoring without obligatory echocardiography at outpatient visits was performed. Results: We observed lower hospitalization (absolute risk reduction [ARR]-0.343, CI-95%: 0.287−0.434, p < 0.05; number needed to treat [NNT]-2.91) and mortality (ARR-0.159, CI 95%: 0.127−0.224, p < 0.05; NNT-6.29) in IMG at 12 months. One-year survival was 88.8% in IMG and 71.8% in SMG (p < 0.05). Conclusion: In AHF, outpatient monitoring of volemic status and intracardiac filling pressures to individualize treatment may potentially reduce hospitalizations and mortality at 12 months follow-up. Echocardiography-guided outpatient therapy is feasible and clinically beneficial, providing evidence for the larger application of this approach.
Collapse
|
24
|
Scicchitano P, Paolillo C, De Palo M, Potenza A, Abruzzese S, Basile M, Cannito A, Tangorra M, Guida P, Caldarola P, Ciccone MM, Massari F. Sex Differences in the Evaluation of Congestion Markers in Patients with Acute Heart Failure. J Cardiovasc Dev Dis 2022; 9:jcdd9030067. [PMID: 35323615 PMCID: PMC8956089 DOI: 10.3390/jcdd9030067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
The impact of sex on the assessment of congestion in acute heart failure (AHF) is still a matter of debate. The objective of this analysis was to evaluate sex differences in the evaluation of congestion at admission in patients hospitalized for AHF. We consecutively enrolled 494 AHF patients (252 female). Clinical congestion assessment, B-type natriuretic peptide levels analysis, blood urea nitrogen to creatinine ratio (BUN/Cr), plasma volume status estimate (by means of Duarte or Kaplam-Hakim PVS), and hydration status evaluation through bioimpedance analysis were performed. There was no difference in medications between men and women. Women were older (79 ± 9 yrs vs. 77 ± 10 yrs, p = 0.005), and had higher left ventricular ejection fraction (45 ± 11% vs. 38 ± 11%, p < 0.001), and lower creatinine clearance (42 ± 25 mL/min vs. 47 ± 26 mL/min, p = 0.04). The prevalence of peripheral oedema, orthopnoea, and jugular venous distention were not significantly different between women and men. BUN/Cr (27 ± 9 vs. 23 ± 13, p = 0.04) and plasma volume were higher in women than men (Duarte PVS: 6.0 ± 1.5 dL/g vs. 5.1 ± 1.5 dL/g, p < 0.001; Kaplam−Hakim PVS: 7.9 ± 13% vs. −7.3 ± 12%, p < 0.001). At multivariate logistic regression analysis, female sex was independently associated with BUN/Cr and PVS. Female sex was independently associated with subclinical biomarkers of congestion such as BUN/Cr and PVS in patients with AHF. A sex-guided approach to the correct evaluation of patients with AHF might become the cornerstone for the correct management of these patients.
Collapse
Affiliation(s)
- Pietro Scicchitano
- Cardiology Section, Hospital “F. Perinei”, 70022 Bari, Italy; (A.P.); (S.A.); (M.B.); (A.C.); (M.T.); (F.M.)
- Correspondence: ; Tel.: +39-0803108286
| | | | - Micaela De Palo
- Cardiac Surgery Unit, Azienda Ospedaliero-Universitaria Policlinico Bari, 70124 Bari, Italy;
| | - Angela Potenza
- Cardiology Section, Hospital “F. Perinei”, 70022 Bari, Italy; (A.P.); (S.A.); (M.B.); (A.C.); (M.T.); (F.M.)
| | - Silvia Abruzzese
- Cardiology Section, Hospital “F. Perinei”, 70022 Bari, Italy; (A.P.); (S.A.); (M.B.); (A.C.); (M.T.); (F.M.)
| | - Marco Basile
- Cardiology Section, Hospital “F. Perinei”, 70022 Bari, Italy; (A.P.); (S.A.); (M.B.); (A.C.); (M.T.); (F.M.)
| | - Antonia Cannito
- Cardiology Section, Hospital “F. Perinei”, 70022 Bari, Italy; (A.P.); (S.A.); (M.B.); (A.C.); (M.T.); (F.M.)
| | - Maria Tangorra
- Cardiology Section, Hospital “F. Perinei”, 70022 Bari, Italy; (A.P.); (S.A.); (M.B.); (A.C.); (M.T.); (F.M.)
| | - Piero Guida
- Cardiology Section, Hospital “Miulli”, Acquaviva delle Fonti, 70021 Bari, Italy;
| | | | - Marco Matteo Ciccone
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy;
| | - Francesco Massari
- Cardiology Section, Hospital “F. Perinei”, 70022 Bari, Italy; (A.P.); (S.A.); (M.B.); (A.C.); (M.T.); (F.M.)
| |
Collapse
|
25
|
Abstract
The introduction of multiple new pharmacological agents over the past three decades in the field of heart failure with reduced ejection fraction (HFrEF) has led to reduced rates of mortality and hospitalizations, and consequently the prevalence of HFrEF has increased, and up to 10% of patients progress to more advanced stages, characterized by high rates of mortality, hospitalizations, and poor quality of life. Advanced HFrEF patients often show persistent or progressive signs of severe HF symptoms corresponding to New York Heart Association class III or IV despite being on optimal medical, surgical, and device therapies. However, a subpopulation of patients with advanced HF, those with the most advanced stages of disease, were often insufficiently represented in the major trials demonstrating efficacy and tolerability of the drugs used in HFrEF due to exclusion criteria such as low BP and kidney dysfunction. Consequently, the results of many landmark trials cannot necessarily be transferred to patients with the most advanced stages of HFrEF. Thus, the efficacy and tolerability of guideline-directed medical therapies in patients with the most advanced stages of HFrEF often remain unsettled, and this knowledge is of crucial importance in the planning and timing of consideration for referral for advanced therapies. This review discusses the evidence regarding the use of contemporary drugs in the advanced HFrEF population, covering components such as guideline HFrEF drugs, diuretics, inotropes, and the use of HFrEF drugs in LVAD recipients, and provides suggestions on how to manage guideline-directed therapy in this patient group.
Collapse
|
26
|
Nohria A, Drazner MH. Should weight loss be targeted during an acute heart failure admission? J Card Fail 2022; 28:1125-1127. [PMID: 35114385 DOI: 10.1016/j.cardfail.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Anju Nohria
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA.
| | - Mark H Drazner
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
27
|
Abdin A, Anker SD, Butler J, Coats AJS, Kindermann I, Lainscak M, Lund LH, Metra M, Mullens W, Rosano G, Slawik J, Wintrich J, Böhm M. 'Time is prognosis' in heart failure: time-to-treatment initiation as a modifiable risk factor. ESC Heart Fail 2021; 8:4444-4453. [PMID: 34655282 PMCID: PMC8712849 DOI: 10.1002/ehf2.13646] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 08/30/2021] [Accepted: 09/19/2021] [Indexed: 01/14/2023] Open
Abstract
In heart failure (HF), acute decompensation can occur quickly and unexpectedly because of worsening of chronic HF or to new-onset HF diagnosed for the first time ('de novo'). Patients presenting with acute HF (AHF) have a poor prognosis comparable with those with acute myocardial infarction, and any delay of treatment initiation is associated with worse outcomes. Recent HF guidelines and recommendations have highlighted the importance of a timely diagnosis and immediate treatment for patients presenting with AHF to decrease disease progression and improve prognosis. However, based on the available data, there is still uncertainty regarding the optimal 'time-to-treatment' effect in AHF. Furthermore, the immediate post-worsening HF period plays an important role in clinical outcomes in HF patients after hospitalization and is known as the 'vulnerable phase' characterized by high risk of readmission and early death. Early and intensive treatment for HF patients in the 'vulnerable phase' might be associated with lower rates of early readmission and mortality. Additionally, in the chronic stable HF outpatient, treatments are often delayed or not initiated when symptoms are stable, ignoring the risk for adverse outcomes such as sudden death. Consequently, there is a dire need to better identify HF patients during hospitalization and after discharge and treating them adequately to improve their prognosis. HF is an urgent clinical scenario along all its stages and disease conditions. Therefore, time plays a significant role throughout the entire patient's journey. Therapy should be optimized as soon as possible, because this is beneficial regardless of severity or duration of HF. Time lavished before treatment initiation is recognized as important modifiable risk factor in HF.
Collapse
Affiliation(s)
- Amr Abdin
- Klinik für Innere Medizin III‐Kardiologie, Angiologie und Internistische IntensivmedizinUniversitätsklinikum des SaarlandesKirrberger Strasse 100Homburg66421Germany
| | - Stefan D. Anker
- Department of Cardiology & Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK), partner site BerlinCharité—Universitätsmedizin Berlin (Campus CVK)BerlinGermany
| | - Javed Butler
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | | | - Ingrid Kindermann
- Klinik für Innere Medizin III‐Kardiologie, Angiologie und Internistische IntensivmedizinUniversitätsklinikum des SaarlandesKirrberger Strasse 100Homburg66421Germany
| | - Mitja Lainscak
- Division of CardiologyGeneral Hospital Murska SobotaMurska SobotaSlovenia
- Faculty of MedicineUniversity of LjubljanaLjubljanaSlovenia
- Faculty of Natural Sciences and MathematicsUniversity of MariborMariborSlovenia
| | - Lars H. Lund
- Division of Cardiology, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Marco Metra
- Department of CardiologyUniversity and Civil Hospitals of BresciaBresciaItaly
| | - Wilfried Mullens
- Department of CardiologyZiekenhuis Oost‐Limburg (ZOL)GenkBelgium
| | - Giuseppe Rosano
- Department of Medical SciencesIRCCS San Raffaele PisanaRomeItaly
| | - Jonathan Slawik
- Klinik für Innere Medizin III‐Kardiologie, Angiologie und Internistische IntensivmedizinUniversitätsklinikum des SaarlandesKirrberger Strasse 100Homburg66421Germany
| | - Jan Wintrich
- Klinik für Innere Medizin III‐Kardiologie, Angiologie und Internistische IntensivmedizinUniversitätsklinikum des SaarlandesKirrberger Strasse 100Homburg66421Germany
| | - Michael Böhm
- Klinik für Innere Medizin III‐Kardiologie, Angiologie und Internistische IntensivmedizinUniversitätsklinikum des SaarlandesKirrberger Strasse 100Homburg66421Germany
| |
Collapse
|
28
|
Vecchi AL, Muccioli S, Marazzato J, Mancinelli A, Iacovoni A, De Ponti R. Prognostic Role of Subclinical Congestion in Heart Failure Outpatients: Focus on Right Ventricular Dysfunction. J Clin Med 2021; 10:jcm10225423. [PMID: 34830705 PMCID: PMC8625381 DOI: 10.3390/jcm10225423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/01/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND subclinical pulmonary and peripheral congestion is an emerging concept in heart failure, correlated with a worse prognosis. Very few studies have evaluated its prognostic impact in an outpatient setting and its relationship with right-ventricular dysfunction. The study aims to investigate subclinical congestion in chronic heart failure outpatients, exploring the close relationship between the right heart-pulmonary unit and peripheral congestion. MATERIALS AND METHODS in this observational study, 104 chronic HF outpatients were enrolled. The degree of congestion and signs of elevated filling pressures of the right ventricle were evaluated by physical examination and a transthoracic ultrasound to define multiparametric right ventricular dysfunction, estimate the right atrial pressure and the pulmonary artery systolic pressure. Outcome data were obtained by scheduled visits and phone calls. RESULTS ultrasound signs of congestion were found in 26% of patients and, among this cohort, half of them presented as subclinical, affecting their prognosis, revealing a linear correlation between right ventricular/arterial coupling, the right-chambers size and ultrasound congestion. Right ventricular dysfunction, TAPSE/PAPS ratio, clinical and ultrasound signs of congestion have been confirmed to be useful predictors of outcome. CONCLUSIONS subclinical congestion is widespread in the heart failure outpatient population, significantly affecting prognosis, especially when right ventricular dysfunction also occurs, suggesting a strict correlation between the heart-pulmonary unit and volume overload.
Collapse
Affiliation(s)
- Andrea Lorenzo Vecchi
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (R.D.P.)
- Correspondence:
| | - Silvia Muccioli
- Department of Cardiology, Mauriziano Umberto I Hospital, 10128 Torino, Italy;
| | - Jacopo Marazzato
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (R.D.P.)
| | - Antonella Mancinelli
- Department of Cardiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (A.M.); (A.I.)
| | - Attilio Iacovoni
- Department of Cardiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (A.M.); (A.I.)
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (R.D.P.)
| |
Collapse
|
29
|
Harrison NE, Ehrman R, Favot M, Gowland L, Lenning J, Abidov A, Henry S, Gupta S, Welch R, Levy P. Right ventricular dysfunction in acute heart failure from emergency department to discharge: Predictors and clinical implications. Am J Emerg Med 2021; 52:25-33. [PMID: 34861517 DOI: 10.1016/j.ajem.2021.11.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Among acute heart failure (AHF) inpatients, right ventricular dysfunction (RVD) predicts clinical outcomes independent of left ventricular (LV) dysfunction. Prior studies have not accounted for congestion severity, show conflicting findings on echocardiography (echo) timing, and excluded emergency department (ED) patients. We describe for the first time the epidemiology, predictors, and outcomes of RVD in AHF starting with earliest ED treatment. METHODS Point-of-care echo and 10-point lung ultrasound (LUS) were obtained in 84 prospectively enrolled AHF patients at two EDs, ≤1 h after first intravenous diuresis, vasodilator, and/or positive pressure ventilation (PPV). Echo and LUS were repeated at 24, 72, and 168 h, unless discharged sooner (n = 197 exams). RVD was defined as <17 mm tricuspid annulus plane systolic excursion (TAPSE), our primary measure. To identify correlates of RVD, a multivariable linear mixed model (LMM) of TAPSE through time was fit. Possible predictors were specified a priori and/or with p ≤ 0.1 difference between patients with/without RVD. Data were standardized and centered to facilitate comparison of relative strength of association between predictors of TAPSE. Survival curves for a 30-day death or AHF readmission primary outcome were assessed for RVD, LUS severity, and LVEF. A multivariable generalized linear mixed model (GLMM) for the outcome was used to adjust RVD for LVEF and LUS. RESULTS 46% (n = 39) of patients at ED arrival showed RVD by TAPSE (median 18 mm, interquartile range 13-23). 18 variables with p ≤ 0.1 unadjusted difference with/without RVD, and 12 a priori predictors of RVD were included in the multivariable LMM model of TAPSE through time (R2 = 0.76). Missed antihypertensive medication (within 7 days), ED PPV, chronic obstructive pulmonary disease history, LVEF, LUS congestion severity, and right ventricular systolic pressure (RVSP) were the strongest multivariable predictors of RVD, respectively, and the only to reach statistical significance (p < 0.05). 30-day death or AHF readmission was associated with RVD at ED arrival (hazard ratio {HR} 3.31 {95%CI: 1.28-8.53}, p = 0.009), ED to discharge decrease in LUS (HR 0.11 {0.01-0.85}, p < 0.0001 for top quartile Δ), but not LVEF (quartile 2 vs. 1 HR 0.78 {0.22-2.68}, 3 vs. 1 HR 0.55 {0.16-1.92}, 4 vs. 1 HR 0.32 {0.09-1.22}, p = 0.30). The area under the receiver operating curve on GLMM for the primary outcome by TAPSE (p = 0.0012), ΔLUS (p = 0.0005), and LVEF (p = 0.8347) was 0.807. CONCLUSION In this observational study, RVD was common in AHF, and predicted by congestion on LUS, LVEF, RVSP, and comorbidities from ED arrival through discharge. 30-day death or AHF-rehospitalization was associated with RVD at ED arrival and ΔLUS severity, but not LVEF.
Collapse
Affiliation(s)
- Nicholas E Harrison
- Indiana University School of Medicine, Department of Emergency Medicine, USA; Wayne State University School of Medicine, Department of Emergency Medicine, USA.
| | - Robert Ehrman
- Wayne State University School of Medicine, Department of Emergency Medicine, USA
| | - Mark Favot
- Wayne State University School of Medicine, Department of Emergency Medicine, USA
| | - Laura Gowland
- Wayne State University School of Medicine, Department of Emergency Medicine, USA
| | - Jacob Lenning
- Wayne State University School of Medicine, Department of Emergency Medicine, USA
| | - Aiden Abidov
- Wayne State University School of Medicine, Department of Medicine Section of Cardiology, John D. Dingell VA Medical Center, Section of Cardiology, USA
| | - Sarah Henry
- Wayne State University School of Medicine, USA
| | - Sushane Gupta
- Wayne State University School of Medicine, Department of Emergency Medicine, USA
| | - Robert Welch
- Wayne State University School of Medicine, Department of Emergency Medicine, USA
| | - Phillip Levy
- Wayne State University School of Medicine, Department of Emergency Medicine, USA
| |
Collapse
|
30
|
Prognosis of acute heart failure based on clinical data of congestion. Rev Clin Esp 2021; 222:321-331. [PMID: 34756646 DOI: 10.1016/j.rceng.2021.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES This work aims to assess whether symptoms/signs of congestion in patients with acute heart failure (AHF) evaluated in hospital emergency departments (HED) allows for predicting short-term progress. PATIENTS AND METHODS The study group comprised consecutive patients diagnosed with AHF in 45 HED from EAHFE Registry. We collected clinical variables of systemic congestion (edema in the lower extremities, jugular vein distention, hepatomegaly) and pulmonary congestion (dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, and pulmonary crackles) and analysed their individual and group association with all-cause 30-day of mortality crudely and adjusted for differences between groups. RESULTS We analysed 18,120 patients (median = 83 years, interquartile range [IQR] = 76-88; women = 55.7%). Of them, 44.6% had > 3 congestive symptoms/signs. Individually, the 30-day adjusted risk of death increased 14% for jugular vein distention (hazard ratio [HR] = 1.14, 95% confidence interval [95%CI] = 1.01-1.28) and 96% for dyspnea on exertion (HR = 1.96, 95% CI = 1.55-2.49). Assessed jointly, the risk progressively increased with the number of symptoms/signs present; compared to patients without symptoms/signs of congestion, the risk increased by 109%, 123 %, and 156% in patients with 1-2, 3-5, and 6-7 symptoms/signs, respectively. These associations did not show interaction with the final disposition of the patient after their emergency care (discharge/hospitalization) with the exception of edema in the lower extremities, which had a better prognosis in discharged patients (HR = 0.66, 95% CI = 0.49-0.89) than hospitalised patients (HR = 1.01, 95% CI = 0.65-1.57; interaction p < 0.001). CONCLUSION The presence of a greater number of congestive symptoms/signs was associated with greater all-cause 30-day mortality. Individually, jugular vein distention and dyspnea on exertion were associated with higher short-term mortality.
Collapse
|
31
|
Nelsson A, Kanski M, Engblom H, Ugander M, Carlsson M, Arheden H. Pulmonary blood volume measured by cardiovascular magnetic resonance: influence of pulmonary transit time methods and left atrial volume. J Cardiovasc Magn Reson 2021; 23:123. [PMID: 34706735 PMCID: PMC8554972 DOI: 10.1186/s12968-021-00809-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increased pulmonary blood volume (PBV) is a measure of congestion and is associated with an increased risk of cardiovascular events. PBV can be quantified using cardiovascular magnetic resonance (CMR) imaging as the product of cardiac output and pulmonary transit time (PTT), the latter measured from the contrast time-intensity curves in the right and left side of the heart from first-pass perfusion (FPP). Several methods of estimating PTT exist, including pulmonary transit beats (PTB), peak-to-peak, and center of gravity (CoG). The aim of this study was to determine the accuracy and precision for these methods of quantifying the PBV, taking the left atrium volume (LAV) into consideration. METHODS Fifty-eight participants (64 ± 11 years, 24 women) underwent 1.5 T CMR. PTT was quantified from (1) a basal left ventricular short-axis image (FPP), and (2) the reference method with a separate contrast administration using an image intersecting the pulmonary artery (PA) and the LA (CoG(PA-LA)). RESULTS Compared to the reference, PBV for (a) PTB(FPP) was 14 ± 17% larger, (b) peak-peak(FPP) was 17 ± 16% larger, and (c) CoG(FPP) was 18 ± 10% larger. Subtraction of the LAV (available for n = 50) decreased overall differences to - 1 ± 19%, 2 ± 18%, and 3 ± 12% for PTB(FPP), peak-peak(FPP), and CoG(FPP), respectively. Lowest interobserver variability was seen for CoG(FPP) (- 2 ± 7%). CONCLUSIONS CoG(PA-LA) and FPP methods measured the same PBV only when adjusting for the LAV, since FPP inherently quantifies a volume consisting of PBV + LAV. CoG(FPP) had the best precision and lowest interobserver variability among the FPP methods of measuring PBV.
Collapse
Affiliation(s)
- Anders Nelsson
- Clinical Physiology, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Mikael Kanski
- Clinical Physiology, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Henrik Engblom
- Clinical Physiology, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
- Kolling Institute, Royal North Shore Hospital, and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Marcus Carlsson
- Clinical Physiology, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Håkan Arheden
- Clinical Physiology, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
32
|
Kataoka H. Chloride in Heart Failure Syndrome: Its Pathophysiologic Role and Therapeutic Implication. Cardiol Ther 2021; 10:407-428. [PMID: 34398440 PMCID: PMC8555043 DOI: 10.1007/s40119-021-00238-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 12/18/2022] Open
Abstract
Until recently, most studies of heart failure (HF) focused on body fluid dynamics through control of the sodium and water balance in the body. Chloride has remained largely ignored in the medical literature, and in clinical practice, chloride is generally considered as an afterthought to the better-known electrolytes of sodium and potassium. In recent years, however, the important role of chloride in the distribution of body fluid has emerged in the field of HF pathophysiology. Investigation of HF pathophysiology according to the dynamics of serum chloride is rational considering that chloride is an established key electrolyte for tubulo-glomerular feedback in the kidney and a possible regulatory electrolyte for body fluid distribution. The present review provides a historical overview of HF pathophysiology, followed by descriptions of the recent attention to the electrolyte chloride in the cardiovascular field, the known role of chloride in the human body, and recent new findings regarding the role of chloride leading to the proposed ‘chloride theory’ hypothesis in HF pathophysiology. Next, vascular and organ congestion in HF is discussed, and finally, a new classification and potential therapeutic strategy are proposed according to the ‘chloride theory’.
Collapse
|
33
|
Taniguchi C, Seto N, Shimizu Y. Outpatient nursing support for self-monitoring in patients with chronic heart failure. PLoS One 2021; 16:e0254019. [PMID: 34214121 PMCID: PMC8253386 DOI: 10.1371/journal.pone.0254019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 06/17/2021] [Indexed: 11/19/2022] Open
Abstract
Background Early symptoms of worsening heart failure are difficult for patients to detect and manage, contributing to the high readmission rate for worsening heart failure. Thus, it is important to promote self-monitoring and to support patients in recognizing and interpreting their symptoms. This study aimed to explore the ways in which specialized nurses in the outpatient setting provide support for self-monitoring in patients with chronic heart failure in Japan. Methods This exploratory study adopted a qualitative study design. The participants were a convenience sample of five nurses certified in chronic heart failure nursing and one advanced practice nurse certified in chronic care nursing, all with experience in outpatient nursing in Japan. Data were collected from June 2017 to October 2017 through semi-structured one-on-one interviews and were analyzed using an established qualitative inductive method. Results The analysis identified seven themes describing the nursing support provided by the study participants. Among these were three themes describing different forms of direct support for self-monitoring: “Encourage patients to reflect on their own,” “Support touching the body and developing body awareness,” and “Support sharing the task.” Two themes described practice perspectives: “Support self-monitoring that is not overly sensitive” and “Support connection with the patient’s life.” Two final themes described contextual factors in the outpatient care setting: “Struggling with constraints and powerlessness” and “Building a support system in the outpatient setting.” Conclusions The findings provide a practice for nurses promoting self-monitoring in patients with chronic heart failure in the outpatient setting. The study findings inform and provide goals for the support of self-monitoring in patients with heart failure and also, suggest the need to establish a strong support system for outpatient care in Japan.
Collapse
Affiliation(s)
- Chinatsu Taniguchi
- Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- * E-mail:
| | - Natsuko Seto
- Faculty of Nursing, Graduate School of Nursing, Kansai Medical University, Hirakata, Osaka, Japan
| | - Yasuko Shimizu
- Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| |
Collapse
|
34
|
Burden of Heart Failure Signs and Symptoms, Prognosis, and Response to Therapy: The PARAGON-HF Trial. JACC-HEART FAILURE 2021; 9:386-397. [PMID: 33714741 DOI: 10.1016/j.jchf.2021.01.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/13/2021] [Accepted: 01/13/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study investigated the prognostic importance of heart failure (HF) signs and symptoms in patients with heart failure and preserved ejection fraction (HFpEF), and the effect of sacubitril/valsartan on HF signs and symptoms. BACKGROUND In patients with HFpEF, worsening of HF symptoms, as a marker of cardiac decompensation, is frequently the reason for hospitalization. In this heterogenous disease entity, the prognostic value of HF signs and symptoms with regard to cardiovascular (CV) outcomes is poorly defined. METHODS The authors examined the association between baseline HF signs and symptoms (rest dyspnea, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, fatigue, edema, jugular venous distension, rales, and third heart sound) as well as burden of these HF signs and symptoms (classified as ≤2 and ≥3 HF signs and symptoms) and the primary composite of total HF hospitalizations and CV death, its components, and all-cause death in 4,725 patients enrolled in PARAGON-HF (Prospective Comparison of ARNI With ARB Global Outcomes in HFpEF) with available signs and symptoms at randomization. Response to sacubitril/valsartan on the basis of the presence of signs and symptoms was evaluated. Effects of sacubitril/valsartan on signs and symptoms over time were assessed using binary repeated-measures logistic regression. RESULTS Patients with high (≥3) burden of HF signs and symptoms (n = 1,772 [38%]) were more commonly women, had slightly lower left ventricular ejection fractions, higher body mass index, and more advanced New York Heart Association functional class compared with patients with low (≤2) burden (n = 2,953 [62%]) (p < 0.001 for all). Levels of N-terminal pro-B-type natriuretic peptide did not differ significantly between groups (p = 0.14). Greater burden of signs and symptoms was associated with higher risk for total HF hospitalizations and CV death (rate ratio [RR]: 1.50; 95% confidence interval [CI]: 1.30 to 1.74) and all-cause death (RR: 1.41; 95% CI: 1.21 to 1.65). Among individual signs and symptoms, orthopnea (RR: 1.29; 95% CI: 1.04 to 1.61) and rales (RR: 1.52; 95% CI: 1.10 to 2.10) were most predictive of the primary endpoint. Treatment response to sacubitril/valsartan was not significantly modified by burden of HF signs and symptoms (p for interaction = 0.08), though patients with orthopnea appeared to derive greater benefit from sacubitril/valsartan (RR: 0.67; 95% CI: 0.49 to 0.90) than those without orthopnea (RR: 0.97; 95% CI: 0.82 to 1.14; p for interaction = 0.04). Compared with valsartan, sacubitril/valsartan did not significantly decrease overall burden of HF signs and symptoms over time (odds ratio: 0.84; 95% CI: 0.67 to 1.07) but did reduce exertional dyspnea (odds ratio: 0.76; 95% CI: 0.63 to 0.93). CONCLUSIONS High burden of HF signs and symptoms, particularly the presence of orthopnea and rales, portends a higher risk for adverse CV events in patients with HF with preserved ejection fraction. Sacubitril/valsartan did not significantly decrease the burden of HF signs and symptoms over time but did reduce exertional dyspnea relative to valsartan. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
Collapse
|
35
|
Rossello X, Bueno H, Gil V, Jacob J, Martín-Sánchez FJ, Llorens P, Herrero Puente P, Alquézar-Arbé A, Espinosa B, Raposeiras-Roubín S, Müller CE, Mebazaa A, Maggioni AP, Pocock S, Chioncel O, Miró Ò. Synergistic Impact of Systolic Blood Pressure and Perfusion Status on Mortality in Acute Heart Failure. Circ Heart Fail 2021; 14:e007347. [PMID: 33677977 DOI: 10.1161/circheartfailure.120.007347] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Physical examination remains the cornerstone in the assessment of acute heart failure. There is a lack of adequately powered studies assessing the combined impact of both systolic blood pressure (SBP) and hypoperfusion on short-term mortality. METHODS Patients with acute heart failure from 41 Spanish emergency departments were recruited consecutively in 3 time periods between 2011 and 2016. Logistic regression models were used to assess the association of 30-day mortality with SBP (<90, 90-109, 110-129, and ≥130 mm Hg) and with manifestations of hypoperfusion (cold skin, cutaneous pallor, delayed capillary refill, livedo reticularis, and mental confusion) at admission. RESULTS Among 10 979 patients, 1143 died within the first 30 days (10.2%). There was an inverse association between 30-day mortality and initial SBP (35.4%, 18.9%, 12.4%, and 7.5% for SBP<90, SBP 90-109, SBP 110-129, and SBP≥130 mm Hg, respectively; P<0.001) and a positive association with hypoperfusion (8.0%, 14.8%, and 27.6% for those with none, 1, ≥2 signs/symptoms of hypoperfusion, respectively; P<0.001). After adjustment for 11 risk factors, the prognostic impact of hypoperfusion on 30-day mortality varied across SBP categories: SBP≥130 mm Hg (odds ratio [OR]=1.03 [95% CI, 0.77-1.36] and OR=1.18 [95% CI, 0.86-1.62] for 1 and ≥2 compared with 0 manifestations of hypoperfusion), SBP 110 to 129 mm Hg (OR=1.23 [95% CI, 0.86-1.77] and OR=2.18 [95% CI, 1.44-3.31], respectively), SBP 90 to 109 mm Hg (OR=1.29 [95% CI, 0.79-2.10] and OR=2.24 [95% CI, 1.36-3.66], respectively), and SBP<90 mm Hg (OR=1.34 [95% CI, 0.45-4.01] and OR=3.22 [95% CI, 1.30-7.97], respectively); P-for-interaction =0.043. CONCLUSIONS Hypoperfusion confers an incremental risk of 30-day all-cause mortality not only in patients with low SBP but also in normotensive patients. On admission, physical examination plays a major role in determining prognosis in patients with acute heart failure.
Collapse
Affiliation(s)
- Xavier Rossello
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma (X.R.).,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (X.R., H.B. S.R.-R.)
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (X.R., H.B. S.R.-R.).,Instituto de Investigación i+12, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain (H.B.).,Facultad de Medicina (H.B.), Universidad Complutense de Madrid, Spain
| | - Víctor Gil
- Emergency Department, Hospital Clínic, Barcelona (V.G., O.M.).,Emergencies: Processes and Pathologies Research Group, IDIBAPS, University of Barcelona (V.G., O.M.)
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Catalonia (J.J.)
| | - Francisco Javier Martín-Sánchez
- Emergency Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC) (F.J.M.-S.), Universidad Complutense de Madrid, Spain
| | - Pere Llorens
- Emergency Department, Home Hospitalization and Short Stay Unit, Hospital General de Alicante (P.L., B.E.)
| | - Pablo Herrero Puente
- Emergency Department, Hospital Universitario Central de Asturias, Oviedo (P.H.P.)
| | - Aitor Alquézar-Arbé
- Emergency Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia (A.A.-A.)
| | - Begoña Espinosa
- Emergency Department, Home Hospitalization and Short Stay Unit, Hospital General de Alicante (P.L., B.E.)
| | - Sergio Raposeiras-Roubín
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (X.R., H.B. S.R.-R.).,Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain (S.R.-R.)
| | - Christian E Müller
- Cardiovascular Research Institute Basel (CRIB) and Cardiology Department, University Hospital Basel, University of Basel, Switzerland (C.E.M.).,The GREAT (Global Research in Acute Cardiovascular Conditions Team) Network (C.E.M., A.M., O.M.)
| | - Alexandre Mebazaa
- The GREAT (Global Research in Acute Cardiovascular Conditions Team) Network (C.E.M., A.M., O.M.).,InsermU942 - MASCOT, Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospital, Université Paris Diderot, France (A.M.)
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy (A.P.M.)
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (S.P.)
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania (O.C.).,University of Medicine Carol Davila, Bucharest, Romania (O.C.)
| | - Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona (V.G., O.M.).,The GREAT (Global Research in Acute Cardiovascular Conditions Team) Network (C.E.M., A.M., O.M.)
| | | |
Collapse
|
36
|
Diuresis-Related Weight Loss Reflects Interstitial Compartment Decongestion with Minimal Impact on Intravascular Volume Expansion or Outcomes in Post-Acute Heart Failure: Metrics of Decongestion and Volume Status. J Card Fail 2021; 27:445-452. [PMID: 33347996 DOI: 10.1016/j.cardfail.2020.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/20/2020] [Accepted: 12/08/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Findings from heart failure (HF) studies linking diuresis-related weight loss to clinical decongestion and outcomes are mixed. Differential responses of interstitial and intravascular volume compartments to diuretic therapy and heterogeneity in volume profiles may confound the clinical interpretation of weight loss in patients with HF. METHODS AND RESULTS Data were prospectively collected in hospitalized patients requiring diuresis. Plasma volume (PV) was measured using I-131-labelled albumin indicator-dilution methodology. The cohort was stratified by tertiles of weight loss and analyzed for interstitial fluid loss relative to changes in PV and HF-related morality or first rehospitalization. Among 92 patients, the admission PV was expanded +42% (4.7 ± 1.2 L) above normal with significant variability (14% normal PV, 18% mild-moderate expansion, and 68% with large PV expansion [>+25% above normal]). With diuresis there were proportional decreases in interstitial volume (-6.5 ± 4.4%) and PV (-7.5 ± 11%); however, absolute decreases in the PV (-254 mL, interquartile range -11 to -583 mL) were less than 10% of interstitial volume loss (-5040 mL, interquartile range -2800 to -7989 mL); greater interstitial fluid loss did not translate into better outcomes (log-rank P = .430). CONCLUSIONS Diuresis-related decreases in weight reflect fluid loss from the interstitial compartment with only minor changes in the PV and without an impact on outcomes. Further, the degree of PV expansion at hospital admission does not drive the magnitude of the diuresis response, even with a wide spectrum of body weights; interstitial fluid overload is preferentially targeted and PV relatively preserved. Therefore, greater interstitial fluid loss reflects clinical decongestion, but not better outcomes, and a limited association with intravascular volume profiles potentially confounding weight loss as a prognostic metric in HF.
Collapse
|
37
|
Kataoka H. Proposal for New Classification and Practical Use of Diuretics According to Their Effects on the Serum Chloride Concentration: Rationale Based on the "Chloride Theory". Cardiol Ther 2020; 9:227-244. [PMID: 32378135 PMCID: PMC7584720 DOI: 10.1007/s40119-020-00172-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Indexed: 02/06/2023] Open
Abstract
Currently, diuretic therapy for heart failure (HF) pathophysiology is primarily focused on the sodium and water balance. Over the last several years, however, chloride (Cl) has been recognized to have an important role in HF pathophysiology, as both a prognostic marker and a possible central factor regulating the body fluid status. I recently proposed a unifying hypothesis for HF pathophysiology, called the "chloride theory", during HF worsening and recovery, as follows. Chloride is the key electrolyte for regulating both reabsorption of tubular electrolytes and water in the kidney through the renin-angiotensin-aldosterone system and distributing body fluid in each compartment of the body. As changes between the serum Cl concentration and plasma volume are intimately associated with worsening HF and its recovery after decongestive therapy, modulation of the serum Cl concentration by careful selection and combination of various diuretics and their doses could become an attractive therapeutic option for HF. In this review, I will propose a new classification and practical use of diuretics according to their effects on the serum Cl concentration. Diuretic use according to this classification is expected to be a useful strategy for the treatment of patients with HF.
Collapse
|
38
|
Manavi T, Vazquez P, O'Grady H, Martina J, Rose M, Nielsen D, Fitzpatrick D, Forouzan O, Nagy M, Sharif F, Zafar H. A novel wireless implant for central venous pressure measurement: First animal experience. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2020; 1:130-138. [PMID: 35265885 PMCID: PMC8890339 DOI: 10.1016/j.cvdhj.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2022] Open
Abstract
Background/Objective Central venous pressure (CVP) serves as a surrogate for right atrial pressure, and thus could potentially predict a wider range of heart failure conditions. The purpose of this work is to assess CVP, through an implantable sensor incorporated with a novel anchor design, in the inferior and superior vena cava of an animal model. Methods Two animals (Dorset sheep) were implanted with sensors at 3 different locations: inferior vena cava (IVC), superior vena cava (SVC), and pulmonary artery (PA). Two sensors with distinct anchor designs considering anatomical requirements were used. A standard PA sensor (trade name Cordella) was deployed in the PA and SVC, whereas a sensor with a modified cylindrical anchor with various struts was designed to reside in the IVC. Each implant was calibrated against a Millar catheter reference sensor. The ability of the central venous sensors to detect changes in pressure was evaluated by modifying the fluid volume of the animal. Results The sensors implanted in both sheep were successful, which provided an opportunity to understand the relationship between PA and CVP via simultaneous readings. The mapping and implantation in the IVC took less than 15 minutes. Multiple readings were taken at each implant location using a hand-held reader device under various conditions. CVP recorded in the IVC (6.49 mm Hg) and SVC (6.14 mm Hg) were nearly the same. PA pressure (13-14 mm Hg) measured was higher than CVP, as expected. The SVC waveforms showed clear beats and respiration. Respiration could be seen in the IVC waveforms, but not all beats were easily distinguishable. Both SVC and IVC readings showed increases in pressure (3.7 and 2.7 mm Hg for SVC and IVC, respectively) after fluid overload was induced via extra saline administration. Conclusion In this work, the feasibility of measuring CVP noninvasively was demonstrated. The established ability of wireless PA pressure sensors to enable prevention of decompensation events weeks ahead can now be explored using central venous versions of such sensors.
Collapse
Affiliation(s)
- Tejaswini Manavi
- Cardiovascular Research & Innovation Centre, National University of Ireland Galway, Galway, Ireland.,Lambe Institute for Translational Research, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Patricia Vazquez
- Cardiovascular Research & Innovation Centre, National University of Ireland Galway, Galway, Ireland.,Lambe Institute for Translational Research, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Helen O'Grady
- Cardiovascular Research & Innovation Centre, National University of Ireland Galway, Galway, Ireland.,Lambe Institute for Translational Research, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | | | | | | | | | | | | | - Faisal Sharif
- Cardiovascular Research & Innovation Centre, National University of Ireland Galway, Galway, Ireland.,Lambe Institute for Translational Research, School of Medicine, National University of Ireland Galway, Galway, Ireland.,BioInnovate Ireland, Galway, Ireland.,Department of Cardiology, University Hospital Galway, Galway, Ireland.,CÚRAM-SFI Centre for Research in Medical Devices, Galway, Ireland
| | - Haroon Zafar
- Cardiovascular Research & Innovation Centre, National University of Ireland Galway, Galway, Ireland.,Lambe Institute for Translational Research, School of Medicine, National University of Ireland Galway, Galway, Ireland.,BioInnovate Ireland, Galway, Ireland
| |
Collapse
|
39
|
Yamamoto M, Seo Y, Iida N, Ishizu T, Yamada Y, Nakatsukasa T, Nakagawa D, Kawamatsu N, Sato K, Machino-Ohtsuka T, Aonuma K, Ohte N, Ieda M. Prognostic Impact of Changes in Intrarenal Venous Flow Pattern in Patients With Heart Failure. J Card Fail 2020; 27:20-28. [PMID: 32652246 DOI: 10.1016/j.cardfail.2020.06.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 06/08/2020] [Accepted: 06/29/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND It remains unclear whether intrarenal venous flow (IRVF) patterns in patients with heart failure (HF) could change over the clinical course, and whether the changes could have a clinical impact. Thus, this study aimed to clarify these characteristics as well as to identify the relation between changes in the IRVF pattern and renal impairment progression. METHODS AND RESULTS Patients with HF with repetitive IRVF evaluations were enrolled. Doppler waveforms of IRVF were classified into the following 3 flow patterns: continuous, biphasic discontinuous, and monophasic discontinuous. Primary end points included death from cardiovascular diseases and unplanned hospitalization for HF. Finally, 108 patients with adequate images were enrolled. The IRVF in 35 patients (32.4%) shifted to another pattern at the follow-up examinations. The median brain natriuretic peptide level in the continuous flow pattern at follow-up was significantly decreased (183 to 60 pg/mL, P < .001), whereas that of the discontinuous flow pattern at follow-up was increased (from 339 to 366 pg/mL, P = .042) and the estimated glomerular filtration rate was decreased (from 55 to 50 mL/min/1.73 m2, P = .013). A multivariable Cox proportional hazard model analysis revealed that the discontinuous pattern at follow-up (P < .001) and brain natriuretic peptide (P = .021) were significantly associated with the end points, independent of age, estimated glomerular filtration rate, and serum sodium level. CONCLUSIONS The IRVF pattern could be changed depending on the status of congestion. Persistent or worsened renal congestion, represented by discontinuous flow patterns, during the clinical courses indicated a poor prognosis accompanied by renal impairment in patients with HF.
Collapse
Affiliation(s)
- Masayoshi Yamamoto
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan;.
| | - Noriko Iida
- Clinical Laboratory, University of Tsukuba Hospital, Tsukuba, Japan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yu Yamada
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tomofumi Nakatsukasa
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Daishi Nakagawa
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoto Kawamatsu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kimi Sato
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | | | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Nobuyuki Ohte
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| |
Collapse
|
40
|
Rosenblum H, Kapur NK, Abraham WT, Udelson J, Itkin M, Uriel N, Voors AA, Burkhoff D. Conceptual Considerations for Device-Based Therapy in Acute Decompensated Heart Failure. Circ Heart Fail 2020; 13:e006731. [DOI: 10.1161/circheartfailure.119.006731] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acute decompensated heart failure remains the most common cause of hospitalization in older adults, and studies of pharmacological therapies have yielded limited progress in improving outcomes for these patients. This has prompted the development of novel device–based interventions, classified mechanistically based on the way in which they intend to improve central hemodynamics, increase renal perfusion, remove salt and water from the body, and result in clinically meaningful degrees of decongestion. In this review, we provide an overview of the pathophysiology of acute decompensated heart failure, current management strategies, and failed pharmacological therapies. We provide an in depth description of seven investigational device classes designed to target one or more of the pathophysiologic derangements in acute decompensated heart failure, denoted by the acronym DRI
2
P
2
S. Dilators decrease central pressures by increasing venous capacitance through splanchnic nerve modulation. Removers remove excess fluid through peritoneal dialysis, aquaphoresis, or hemodialysis. Inotropes directly modulate the cardiac nerve plexus to enhance ventricular contractility. Interstitial devices enhance volume removal through lymphatic duct decompression. Pushers are novel descending aorta rotary pumps that directly increase renal artery pressure. Pullers reduce central venous pressures or renal venous pressures to increase renal perfusion. Selective intrarenal artery catheters facilitate direct delivery of short acting vasodilator therapy. We also discuss challenges posed in clinical trial design for these novel device–based strategies including optimal patient selection and appropriate end points to establish efficacy.
Collapse
Affiliation(s)
- Hannah Rosenblum
- Division of Cardiology, New York Presbyterian Hospital, New York, NY (H.R., N.U.)
| | - Navin K. Kapur
- Cardiology, Tufts Medical Center, Boston, MA (N.K.K., J.U.)
| | - William T. Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH (W.T.A.)
| | - James Udelson
- Cardiology, Tufts Medical Center, Boston, MA (N.K.K., J.U.)
| | - Maxim Itkin
- Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadephia, PA (M.I.)
| | - Nir Uriel
- Division of Cardiology, New York Presbyterian Hospital, New York, NY (H.R., N.U.)
| | - Adriaan A. Voors
- Department of Cardiology, University of Groningen, Groningen, the Netherlands (A.A.V.)
| | | |
Collapse
|
41
|
Impact of Obesity on Volume Status in Patients With Ambulatory Chronic Heart Failure. J Card Fail 2019; 26:112-117. [PMID: 31568830 DOI: 10.1016/j.cardfail.2019.09.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 08/29/2019] [Accepted: 09/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fluid overload is common in heart failure (HF) and obesity; however, the relationship between the extent of intravascular volume expansion and indices such as body mass index (BMI) in obese and non-obese patients with HF has not been defined to address the issue of a HF obesity phenotype. METHODS Total blood volume (TBV) was measured clinically using a radiolabeled albumin indicator-dilution technique in patients with predominately class III ambulatory chronic HF (N=66). Obesity was defined by BMI ≥30 kg/m2. RESULTS Markedly increased intravascular volume expansion (defined by TBV expansion >+25% above normal) was highly prevalent in the obese (53%) compared to non-obese patients with HF (29%, P = .04) driven by plasma volume expansion. TBV was correlated with excess body weight and BMI (both P < .01). Also, cardiac index was higher, systemic vascular resistance lower, and left ventricular filling pressures comparable in obese compared with non-obese patients. CONCLUSIONS Quantitative assessment of intravascular volume demonstrates for the first time that severe (not mild or moderate) volume expansion is highly common in obese patients with ambulatory chronic HF. This supports an evolving concept of an obesity-specific HF phenotype. Further study is needed to understand the mechanisms controlling volume regulation and the potential compensatory or detrimental impact on outcomes in obesity and HF.
Collapse
|
42
|
Simonavičius J, Sanders van-Wijk S, Rickenbacher P, Maeder MT, Pfister O, Kaufmann BA, Pfisterer M, Čelutkienė J, Puronaitė R, Knackstedt C, van Empel V, Brunner-La Rocca HP. Prognostic Significance of Longitudinal Clinical Congestion Pattern in Chronic Heart Failure: Insights From TIME-CHF Trial. Am J Med 2019; 132:e679-e692. [PMID: 31051151 DOI: 10.1016/j.amjmed.2019.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relationship between longitudinal clinical congestion pattern and heart failure outcome is uncertain. This study was designed to assess the prevalence of congestion over time and to investigate its impact on outcome in chronic heart failure. METHODS A total of 588 patients with chronic heart failure older than 60 years of age with New York Heart Association (NYHA) functional class ≥II from the TIME-CHF study were included. The endpoints for this study were survival and hospitalization-free heart failure survival. Orthopnea, NYHA ≥III, paroxysmal nocturnal dyspnea, hepatomegaly, peripheral pitting edema, jugular venous distension, and rales were repeatedly investigated and related to outcomes. These congestion-related signs and symptoms were used to design a 7-item Clinical Congestion Index. RESULTS Sixty-one percent of patients had a Clinical Congestion Index ≥3 at baseline, which decreased to 18% at month 18. During the median [interquartile range] follow-up of 27.2 [14.3-39.8] months, 17%, 27%, and 47% of patients with baseline Clinical Congestion Index of 0, 1-2, and ≥3 at inclusion, respectively, died (P <.001). Clinical Congestion Index was identified as an independent predictor of mortality at all visits (P <.05) except month 6 and reduced hospitalization-free heart failure survival (P <.05). Successful decongestion was related to better outcome as compared to persistent congestion or partial decongestion (log-rank P <0.001). CONCLUSIONS The extent of congestion as assessed by means of clinical signs and symptoms decreased over time with intensified treatment, but it remained present or relapsed in a substantial number of patients with heart failure and was associated with poor outcome. This highlights the importance of appropriate decongestion in chronic heart failure.
Collapse
Affiliation(s)
- Justas Simonavičius
- Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | | | - Peter Rickenbacher
- Department of Cardiology, University Hospital Bruderholz, Bruderholz, Switzerland
| | - Micha T Maeder
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Otmar Pfister
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Beat A Kaufmann
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | | | - Jelena Čelutkienė
- Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Roma Puronaitė
- Department of Information Systems, Centre of Informatics and Development, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Clinic of Cardiac and Vascular diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; Institute of Data Science and Digital Technologies, Faculty of Mathematics and Informatics, Vilnius University, Vilnius, Lithuania
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Cardiology, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
43
|
Cooper LB, Lippmann SJ, DiBello JR, Gorsh B, Curtis LH, Sikirica V, Hernandez AF, Sprecher DL, Laskey WK, Saini R, Fonarow GC, Hammill BG. The Burden of Congestion in Patients Hospitalized With Acute Decompensated Heart Failure. Am J Cardiol 2019; 124:545-553. [PMID: 31208702 DOI: 10.1016/j.amjcard.2019.05.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/03/2019] [Accepted: 05/13/2019] [Indexed: 12/19/2022]
Abstract
Congestion is associated with adverse outcomes in heart failure (HF) patients. We characterized congestion in patients hospitalized for HF and examined the association between congestion severity at admission and postdischarge outcomes. Using the OPTIMIZE-HF registry linked to Medicare claims, we analyzed patients ≥65 years old hospitalized for HF from 2003 to 2004. Congestion severity was measured using a 15-point scale that scores dyspnea, orthopnea, fatigue, jugular venous pressure, rales, and edema. Patient characteristics and outcomes were described by congestion strata. Proportional hazards models were fit to examine associations between congestion and 1-year outcomes. Congestion scores for the 24,724 patients ranged from 0 to 14, with a median of 5 (Q1, Q3: 3, 7). At baseline, patients with the highest scores (≥7) had the highest rates of recent HF hospitalizations, EF ≤40%, and co-morbidities, including arrhythmias, diabetes mellitus, and renal insufficiency. Adjusting for patient characteristics, a 3-point congestion score increase was positively associated with mortality (hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.03, 1.09), all-cause rehospitalization (HR 1.02, 95% CI 1.00, 1.04), and HF rehospitalization (HR 1.09, 95% CI 1.06, 1.12), but not emergency department visits (HR 0.99, 95% CI 0.97, 1.01). In conclusion, for patients hospitalized with HF, congestion was associated with rehospitalization and mortality.
Collapse
|
44
|
Efficacy of Tolvaptan in Elderly Patients with Heart Failure and Preserved Ejection Fraction. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2019. [DOI: 10.2478/jce-2019-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background: There is no known therapy with proven efficacy for improving clinical outcomes in elderly patients with heart failure (HF) and preserved ejection fraction (HFpEF). In this study, we aimed to evaluate the efficacy of tolvaptan (TLV) in elderly HFpEF patients. Methods: This retrospective observational study involved 100 consecutive elderly HFpEF patients hospitalized at the Nagoya Heart Center, Japan. Inclusion criteria were: (1) patients aged ≥75 years; (2) first hospitalization secondary to HF; (3) received medical therapy for HF, without invasive treatment; and (4) clinical follow-up for >6 months after discharge. The primary endpoint was rehospitalization due to worsening HF, and the secondary endpoint was worsening renal function (WRF) during hospitalization and at 6 months after discharge. Sixty background-matched HFpEF patients were divided into 2 groups: with TLV therapy (TLV (+), n = 29) and without TLV therapy (TLV (–), n = 31). In the TLV (+) group, TLV therapy was continued after discharge. Clinical outcomes of these patients were evaluated. Results: Bed rest period and length of hospital stay were significantly shorter in the TLV (+) group than in the TLV (−) group. The dose of loop diuretics, mean serum creatinine levels, and incidence of WRF development were significantly lower in the TLV (+) group. Incidence of rehospitalization was also significantly lower in the TLV (+) group (log-rank test; p = 0.018). The multivariate logistic regression analysis demonstrated that TLV therapy reduces the incidence of rehospitalization in elderly patients with HFpEF. Conclusions: TLV therapy reduced the bed rest period, length of hospital stay, and rate of rehospitalization without WRF in elderly HFpEF patients, suggesting that TLV could represent an effective therapy for this group of patients.
Collapse
|
45
|
Abstract
BACKGROUND Acute decompensated heart failure (ADHF) is the most common presenting phenotype of acute heart failure (AHF). The main goal of this article was to review the contemporary management strategies in these patients and to describe how future clinical trials may address unmet clinical needs. AREAS OF UNCERTAINTY The current pathophysiologic understanding of AHF is incomplete. The guideline recommendations for the management of ADHF are based only on algorithms provided by expert consensus guided by blood pressure and/or clinical signs of congestion or hypoperfusion. The lack of adequately conducted trials to address the unmet need for evidence therapy in AHF has not yet been surpassed, and at this time, there is no evidence-based strategy for targeted decongestive therapy to improve outcomes. The precise time point for initiation of guideline-directed medical therapies (GDMTs), as respect to moment of decompensation, is also unknown. DATA SOURCES The available data informing current management of patients with ADHF are based on randomized controlled trials, observational studies, and administrative databases. THERAPEUTIC ADVANCES A major step-forward in the management of ADHF patients is recognizing congestion, either clinical or hemodynamic, as a major trigger for heart failure (HF) hospitalization and most important target for therapy. However, a strategy based exclusively on congestion is not sufficient, and at present, comprehensive assessment during hospitalization of cardiac and noncardiovascular substrate with identification of potential therapeutic targets represents "the corner-stone" of ADHF management. In the last years, substantial data have emerged to support the continuation of GDMTs during hospitalization for HF decompensation. Recently, several clinical trials raised hypothesis of "moving to the left" concept that argues for very early implementation of GDMTs as potential strategy to improve outcomes. CONCLUSIONS The management of ADHF is still based on expert consensus documents. Further research is required to identify novel therapeutic targets, to establish the precise time point to initiate GDMTs, and to identify patients at risk of recurrent hospitalization.
Collapse
|
46
|
Rubio-Gracia J, Giménez-López I, Damman K, Sánchez-Marteles M, Garcés-Horna V, Josa-Laorden C, de la Rica-Escuin M, Pérez-Calvo J. Presión intraabdominal y empeoramiento de la función renal durante las descompensaciones de la insuficiencia cardiaca. Un informe preliminar del estudio PIA. Rev Clin Esp 2019; 219:229-235. [DOI: 10.1016/j.rce.2018.09.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/13/2018] [Accepted: 09/04/2018] [Indexed: 12/20/2022]
|
47
|
Intraabdominal pressure and worsening renal function during decompensations of heart failure. A preliminary report from the PIA study. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2018.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
48
|
Chioncel O, Collins SP, Ambrosy AP, Pang PS, Antohi EL, Iliescu VA, Maggioni AP, Butler J, Mebazaa A. Improving Postdischarge Outcomes in Acute Heart Failure. Am J Ther 2019; 25:e475-e486. [PMID: 29985826 PMCID: PMC6114135 DOI: 10.1097/mjt.0000000000000791] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville,
TN, USA
| | - Andrew P Ambrosy
- Division of Cardiology, Duke University Medical Center, Durham, NC,
USA Duke Clinical Research Institute, Durham, NC, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of
Medicine, Indiana USA
| | - Elena-Laura Antohi
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Vlad Anton Iliescu
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Aldo P Maggioni
- ANMCO Research Center, Florence, Italy; EORP-European Society of
Cardiology, Sophia Antipolis, France
| | - Javed Butler
- Department of Medicine, University of Mississippi School of
Medicine, Jackson, MI, USA
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care, APHP – Saint
Louis Lariboisière University Hospitals, University Paris Diderot and INSERM
UMR-S 942, Paris, France
| |
Collapse
|
49
|
Voors AA, Kremer D, Geven C, ter Maaten JM, Struck J, Bergmann A, Pickkers P, Metra M, Mebazaa A, Düngen H, Butler J. Adrenomedullin in heart failure: pathophysiology and therapeutic application. Eur J Heart Fail 2019; 21:163-171. [PMID: 30592365 PMCID: PMC6607488 DOI: 10.1002/ejhf.1366] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/18/2018] [Accepted: 10/22/2018] [Indexed: 12/17/2022] Open
Abstract
Adrenomedullin (ADM) is a peptide hormone first discovered in 1993 in pheochromocytoma. It is synthesized by endothelial and vascular smooth muscle cells and diffuses freely between blood and interstitium. Excretion of ADM is stimulated by volume overload to maintain endothelial barrier function. Disruption of the ADM system therefore results in vascular leakage and systemic and pulmonary oedema. In addition, ADM inhibits the renin-angiotensin-aldosterone system. ADM is strongly elevated in patients with sepsis and in patients with acute heart failure. Since hallmarks of both conditions are vascular leakage and tissue oedema, we hypothesize that ADM plays a compensatory role and may exert protective properties against fluid overload and tissue congestion. Recently, a new immunoassay that specifically measures the biologically active ADM (bio-ADM) has been developed, and might become a biomarker for tissue congestion. As a consequence, measurement of bio-ADM might potentially be used to guide diuretic therapy in patients with heart failure. In addition, ADM might be used to guide treatment of (pulmonary) oedema or even become a target for therapy. Adrecizumab is a humanized, monoclonal, non-neutralizing ADM-binding antibody with a half-life of 15 days. Adrecizumab binds at the N-terminal epitope of ADM, leaving the C-terminal side intact to bind to its receptor. Due to its high molecular weight, the antibody adrecizumab cannot cross the endothelial barrier and consequently remains in the circulation. The observation that adrecizumab increases plasma concentrations of ADM indicates that ADM-binding by adrecizumab is able to drain ADM from the interstitium into the circulation. We therefore hypothesize that administration of adrecizumab improves vascular integrity, leading to improvement of tissue congestion and thereby may improve clinical outcomes in patients with acute decompensated heart failure. A phase II study with adrecizumab in patients with sepsis is ongoing and a phase II study on the effects of adrecizumab in patients with acute decompensated heart failure with elevated ADM is currently in preparation.
Collapse
Affiliation(s)
- Adriaan A. Voors
- Department of CardiologyUniversity of GroningenGroningenThe Netherlands
| | - Daan Kremer
- Department of CardiologyUniversity of GroningenGroningenThe Netherlands
| | - Christopher Geven
- Department of Intensive Care Medicine, Radboud Center for Infectious DiseasesRadboud University Medical CenterNijmegenThe Netherlands
| | | | - Joachim Struck
- Sphingotec GmbHHennigsdorfGermany
- Adrenomed AGHennigsdorfGermany
| | | | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud Center for Infectious DiseasesRadboud University Medical CenterNijmegenThe Netherlands
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthInstitute of Cardiology, University of BresciaBresciaItaly
| | - Alexandre Mebazaa
- APHP, Hôpitaux Universitaires Saint‐Louis Lariboisière; INI‐CRCTUniversity Paris DiderotParisFrance
| | - Hans‐Dirk Düngen
- Department of CardiologyCharité Universitätsmedizin, Campus Virchow‐KlinikumBerlinGermany
| | - Javed Butler
- Division of CardiologyStony Brook UniversityStony BrookNYUSA
| |
Collapse
|
50
|
Russell FM, Ehrman RR, Ferre R, Gargani L, Noble V, Rupp J, Collins SP, Hunter B, Lane KA, Levy P, Li X, O'Connor C, Pang PS. Design and rationale of the B-lines lung ultrasound guided emergency department management of acute heart failure (BLUSHED-AHF) pilot trial. Heart Lung 2018; 48:186-192. [PMID: 30448355 DOI: 10.1016/j.hrtlng.2018.10.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/20/2018] [Accepted: 10/22/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Medical treatment for acute heart failure (AHF) has not changed substantially over the last four decades. Emergency department (ED)-based evidence for treatment is limited. Outcomes remain poor, with a 25% mortality or re-admission rate within 30days post discharge. Targeting pulmonary congestion, which can be objectively assessed using lung ultrasound (LUS), may be associated with improved outcomes. METHODS BLUSHED-AHF is a multicenter, randomized, pilot trial designed to test whether a strategy of care that utilizes a LUS-driven treatment protocol outperforms usual care for reducing pulmonary congestion in the ED. We will randomize 130 ED patients with AHF across five sites to, a) a structured treatment strategy guided by LUS vs. b) a structured treatment strategy guided by usual care. LUS-guided care will continue until there are ≤15 B-lines on LUS or 6h post enrollment. The primary outcome is the proportion of patients with B-lines ≤ 15 at the conclusion of 6 h of management. Patients will continue to undergo serial LUS exams during hospitalization, to better understand the time course of pulmonary congestion. Follow up will occur through 90days, exploring days-alive-and-out-of-hospital between the two arms. The study is registered on ClinicalTrials.gov (NCT03136198). CONCLUSION If successful, this pilot study will inform future, larger trial design on LUS driven therapy aimed at guiding treatment and improving outcomes in patients with AHF.
Collapse
Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Robinson Ferre
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Vicki Noble
- Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jordan Rupp
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benton Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen A Lane
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Phillip Levy
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - Xiaochun Li
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher O'Connor
- Division of Cardiology, INOVA Heart and Vascular Institute, Falls Church, VA, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis EMS, Indianapolis, IN, USA.
| |
Collapse
|