Assessment and Management of Volume Overload and Congestion in Chronic Heart Failure: Can Measuring Blood Volume Provide New Insights?

Methods for the Assessment of Volume Overload and Congestion in Heart Failure

Acute decompensated heart failure entails a dysregulation of renal and cardiac function, with fluid volume excess or congestion being a key component. We provide an overview of methods for its assessment in clinical practice. Evaluation of congestion can be achieved using different methods including plasma biomarkers, measurement of blood volume from the volume of distribution of [131I]-human serum albumin, sonographic modalities, implantable devices, invasive measurements of volume status including right heart catheterization, and impedance methods. Integration into clinical practice of accessible, cost-effective, and evidence-based modalities for volume assessment will be pivotal in the management of acute decompensated heart failure.

Blood Volume Analysis and Cardiorenal Syndrome: From Bench to Bedside

BACKGROUND

This review delves into the intricate landscape of cardiorenal syndrome (CRS) and highlights the pivotal role of blood volume analysis (BVA) in improving patient care and outcomes.

SUMMARY

BVA offers a direct and highly accurate quantification of intravascular volume, red blood cell volume, and plasma volume, complete with patient-specific norms. This diagnostic tool enhances the precision of diuretic and red cell therapies, significantly elevating the effectiveness of conventional care.

KEY MESSAGES

Our objectives encompass a comprehensive understanding of how BVA informs the evaluation and treatment of CRS, including its subtypes, pathophysiology, and clinical significance. We delve into BVA principles, techniques, and measurements, elucidating its diagnostic potential and advantages compared to commonly used surrogate measures. We dissect the clinical relevance of BVA in various CRS scenarios, emphasizing its unique contributions to each subtype. By assessing the tangible impact of BVA on patient outcomes through meticulous analysis of relevant clinical studies, we unveil its potential to enhance health outcomes and optimize resource utilization. Acknowledging the challenges and limitations associated with BVA's clinical implementation, we underscore the importance of multidisciplinary collaboration among cardiologists, nephrologists, and other clinicians. Finally, we identify research gaps and propose future directions for BVA and CRS, contributing to ongoing advancements in this field and patients affected by this complicated clinical syndrome.

Deviations From the Ideal Plasma Volume and Isolated Tricuspid Valve Surgery—Paving the Way for New Risk Stratification Parameters

Background

Congestion and plasma volume expansion are important features of heart failure, whose prognostic significance has been investigated in a range of surgical and non-surgical settings. The aim of this study was to evaluate the value of the estimated plasma volume status (ePVS) in patients undergoing isolated tricuspid valve surgery.

Methods

This study included patients who underwent isolated tricuspid valve surgery at the Vienna General Hospital (Austria) between July 2008 and November 2018. The PVS cut-off was calculated using ROC analysis and Youden's Index.

Results

Eighty eight patients (median age: 58 [IQR: 35-70] years; 44.3% male; 75.6% NYHA III/IV; median EuroSCORE II 2.65 [IQR: 1.70-5.10]; 33.0% endocarditis-related regurgitation; 60.2% isolated repair; 39.8% isolated replacement) were included in this study. Patients who died within 1 year following surgery had significantly higher baseline ePVS values than survivors (median ePVS 5.29 [IQR: −1.55-13.55] vs. −3.68 [IQR: −10.92-4.22]; p = 0.005). During a median actuarial follow-up of 3.02 (IQR: 0.36-6.80) years, patients with a preoperative ePVS ≥ −4.17 had a significantly increased mortality (log-rank p = 0.006).

Conclusions

ePVS is an easily obtainable risk parameter for patients undergoing isolated tricuspid valve surgery capable of predicting mid- and long-term outcomes after isolated tricuspid valve surgery.

In-Hospital Weight Loss and Outcomes in Patients With Heart Failure

BACKGROUND

Acute decompensation of heart failure (HF) is often marked by fluid retention, and weight loss is a marker of successful diuresis. We examined the relationship between in-hospital weight loss and post-discharge outcomes in patients with HF.

METHODS

We conducted a propensity score-matched study of 8830 patients hospitalized for decompensated HF in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, in which 4415 patients in the weight-loss group and 4415 patients in the no-weight-loss group were balanced on 75 baseline characteristics. We defined weight loss as an admission-to-discharge weight loss of 1-30 kilograms, and we defined no weight loss as a weight gain or loss of < 1 kilogram. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with weight loss were estimated.

RESULTS

Patients had a mean age of 78 years, 57% were women, and 11% were African American. The median weight loss in the weight-loss group was 3.6 (interquartile range, 2.0-6.0) kilograms. HRs and 95% CIs for 30-day all-cause mortality, all-cause readmission and HF readmission associated with weight loss were 0.75 (0.63-0.90), 0.90 (0.83-0.99) and 0.83 (0.72-0.96), respectively. Respective 60-day HRs (95% CIs) were 0.80 (0.70-0.92), 0.91 (0.85-0.98) and 0.88 (0.79-0.98). These associations were attenuated and lost significance during 6 months of follow-up.

CONCLUSIONS

Among older patients hospitalized for decompensated HF, in-hospital weight loss was associated with a lower risk of mortality and hospital readmission. These findings suggest that in-hospital weight loss, a marker of successful diuresis and decongestion, is also a marker of improved clinical outcomes.

The venous contribution to cardiovascular performance: From systemic veins to left ventricular function: A review

The venous system contains ≈ 70 % of the total blood volume and is responsible in heart failure for key symptoms of congestion. It is active: it can increase or relax its tone with physiologic or pharmacologic stimuli. It is heterogeneous, behaves as a two-compartment model, compliant (splanchnic veins) and noncompliant (nonsplanchnic veins). It is dynamic in health and disease: in heart failure the vascular capacitance (storage space) is decreased and can result in volume redistribution from the abdominal compartment to the thoracic compartment (heart and lungs), which increases pulmonary pressures and precipitates pulmonary congestion. A noninvasive assessment of venous function, at rest and dynamically during stress, is warranted. The systemic haemodynamic congestion is assessed with inferior vena cava diameter and collapsibility. The pulmonary congestion is assessed with B-lines and pleural effusion. The contribution of left ventricular filling is assessed with end-diastolic volume, integrated with left ventricular function.

Influence of electrolyte balance on the prognosis of long-term cardiovascular events after acute coronary syndrome

Aim. To assess the effect of electrolyte changes on the prognosis of long-term cardiovascular events after acute coronary syndrome (ACS).

Material and methods. The study included 105 patients with ACS who underwent coronary angiography (CA) with coronary stenting. At the study inclusion (before CA with coronary stenting), we collected data on traditional risk factors, analyzed levels of urinary sodium and potassium, kaliuresis and natriuresis. Free water clearance (FWC) and electrolyte free water clearance (EFWC), as well as fluid balance using bioelectrical impedance analysis were determined. Study endpoints (fatal and nonfatal cardiovascular events) were determined 6,2±0,2 months after CA with coronary stenting.

Results. It was found that a decrease in urinary sodium (χ2=5,64, p=0,02, Constanta B0 =-0,62, Estimate =-16,5) and natriuresis (χ2=4,1, р=0,044, Constanta B0 =-1,38, Estimate =-5,2) increase the death risk. Urinary sodium of 0,2 mol/L and natriuresis of 0,5 mol are threshold levels of increased risk of death. Urinary potassium decrease was associated with an increase in death risk (threshold level — 0,5 mol/L, χ2=4,99, р=0,025, Constanta B0 =-0,63, Estimate =-70,4) and acute myocardial infarction (threshold level — 0,06 mol/L, χ2=3,93, р=0,04, Constanta B0 =-0,99, Estimate =-58,0) in the long-term period. Increase in EFWC increased the likelihood of long-term transient ischemic attack after ACS (χ2=4,61, р=0,03, Constanta B0 =-2,95, Estimate =-1,0). There were no significant relationships in the matter of FWC (p>0,05). However, with a decrease in intracellular fluid volume compared to normal values and a decrease in FWC or an increase in EFWC, the likelihood of longterm composite endpoints after ACS increases.

Conclusion. As a result of the study, risk markers for long-term fatal and non-fatal cardiovascular events after ACS were established: decrease in urinary sodium <0,2 mol/l and potassium <0,5 mol/l; decrease in FWC and increase in EFWC with or without cellular dehydration. The established markers can complement the current cardiovascular risk score methods in patients with ACS.

Blood Pressure, Congestion and Heart Failure with Preserved Ejection Fraction Among Patients with and Without Type 2 Diabetes Mellitus. A Cluster Analysis Approach from the Observational Registry DICUMAP

INTRODUCTION

The association of patients with heart failure (HF) and preserved ejection fraction (HFpEF) and with type 2 diabetes mellitus (T2DM) is strong and related additionally to blood pressure (BP).

AIMS

To analyze distinctive clinical profiles among patients with HFpEF both with and without T2DM.

METHODS

The study was based on a Spanish National Registry (multicenter and prospective) of patients with HF (DICUMAP), that enrolled outpatients with HF who underwent an ambulatory BP monitoring (ABPM) and then were followed-up for 1 year. We categorized patients according to the presence/absence of T2DM then building different clusters based on K-medoids algorithm.

RESULTS

103 patients were included. T2DM was present in 44.7%. The patients with T2DM were grouped into two clusters and those without T2DM into three. All patients with T2DM had kidney disease and anemia. Among them, cluster 2 had higher systolic blood pressure and pulse pressure (PP) with a bad outcome (p = 0.03) regarding HF mortality and readmissions, influenced by eGFR (HR 0.93, 95% CI 0.97-0.87, p = 0.04), and hemoglobin (HR 0.65, 95% CI 0.71-0.63, p = 0.03). Among those without T2DM, cluster 3 had a pathological ABPM pattern with the highest PP, cluster 4 was slightly similar to cluster 2, and cluster 5 expressed a more benign pattern without differences on both, HF mortality and readmissions.

CONCLUSIONS

Patients with HFpEF and T2DM expressed two different profiles depending on neurohormonal activation and arterial stiffness with prognostic implications. Patients without T2DM showed three profiles depending on ABPM pattern, kidney disease and PP without prognostic repercussion.

Effects of the sodium-glucose co-transporter-2 inhibitor dapagliflozin on estimated plasma volume in patients with type 2 diabetes

AIMS

To compare the effects of the sodium-glucose co-transporter-2 (SGLT2) inhibitor dapagliflozin on estimated (ePV) and measured plasma volume (mPV) and to characterize the effects of dapagliflozin on ePV in a broad population of patients with type 2 diabetes.

MATERIALS AND METHODS

The Strauss formula was used to calculate changes in ePV. Change in plasma volume measured with ¹²⁵ I-human serum albumin (mPV) was compared with change in ePV in 10 patients with type 2 diabetes randomized to dapagliflozin 10 mg/d or placebo. Subsequently, changes in ePV were measured in a pooled database of 13 phase 2b/3 placebo-controlled clinical trials involving 4533 patients with type 2 diabetes who were randomized to dapagliflozin 10 mg daily or matched placebo.

RESULTS

The median change in ePV was similar to the median change in mPV (-9.4% and -9.0%) during dapagliflozin treatment. In the pooled analysis of clinical trials, dapagliflozin decreased ePV by 9.6% (95% confidence interval 9.0 to 10.2) compared to placebo after 24 weeks. This effect was consistent in various patient subgroups, including subgroups with or without diuretic use or established cardiovascular disease.

CONCLUSIONS

ePV may be used as a proxy to assess changes in plasma volume during dapagliflozin treatment. Dapagliflozin consistently decreased ePV compared to placebo in a broad population of patients with type 2 diabetes.

Gestational hypertensive disorders show unique patterns of circulatory deterioration with ongoing pregnancy

A combined assessment of heart, arteries, veins, and body fluid content throughout pregnancy has not yet been reported. We hypothesized that a gradual aggravation of circulatory dysfunction exists from the latent to the clinical phase of gestational hypertensive disease (GHD), and that pathways are unique for preeclampsia with early onset < 34 wk (EPE) and late onset ≥ 34 wk (LPE), and gestational hypertension (GH). Women with singleton pregnancy and no known diseases were invited for a prospective, observational study and had standardized sphygmomanometric blood pressure measurement, bioimpedance body water spectrum analysis, impedance cardiography for cardiac and arterial assessment, and combined Doppler-ECG of hepatic and renal interlobar veins and uterine arteries. Outcome was categorized as uncomplicated (UP, n = 1,700), EPE ( n = 87), LPE ( n = 218), or GH ( n = 188). A linear mixed model for repeated measurements, corrected for age, parity, and body mass index, was employed in SAS 9.4 to analyze trimestral changes within and between groups. From the first to the third trimester, body water increased in all groups, and an increasing number of abnormal parameters relative to UP occurred in all GHD. First-trimester blood pressure and peripheral resistance were higher in GHD than UP, together with increased uterine flow resistance and extracellular water in EPE, and with lower heart rate and aorta flow velocity in LPE. An overall gestational rise of body water volumes coexists with a gradual worsening of cardiovascular dysfunction in GHD, of which pathophysiological pathways are unique for EPE, LPE, and GH, respectively.