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Ambulatory assessment of volume status in patients with Heart Failure

Taiyeb M Khumri MDAssistant Professor of MedicineUniversity of Missouri at Kansas City

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“No financial relationships to disclose.”

Disclosures:Prognostic significance of congestion

Sensitivity and specificity of clinical findings of heart failure

Biomarkers for assessment of volume status

Newer, device based methods of volume assessment

Objectives

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What do we know about these patients that get hospitalized for HF?

ADHERE OPTIMIZE HF

Prior HF (%) 75 87

New onset HF (%) 25 13

Cardiogenic shock (%) 2 <1

LVEF <40% (%) 59 52

The majority of patients admitted with ADHF are known to the medical system

The main reason for hospitalization is congestion

Congestion

Hemodynamic congestion –• Contributes to progression of HF by

activating neurohormones, causing subendocardial ischaemia and remodeling of the LV

• Contributes to the cardio-renal syndrome

Clinical congestionCauses symptoms

European Journal of Heart Failure (2010) 12, 423–433

Clinical congestion is just the tip of the iceberg

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Prognostic significance of congestion

In patients with HF, elevated JVP is independently

associated with adverse outcomes, including

progression of heart failure.N Engl J Med 2001; 345:574-81Am Heart J 2000;140:840-7

The ability to maintain freedom from congestion

identifies a population with good survival despite previous

class IV symptoms.

Prognostic significance of congestion

J Card Fail. 2016 Mar; 22(3): 182–189.

Elevated PCWP, rather than severely reduced CI is of prognostic significance

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Prognostic significance of congestion

European Heart Journal (2013) 34, 835–843

Clinical congestion at discharge is associated with an increased risk of 30-day and overall all cause mortality and

heart failure hospitalization

Question

Right heart catheterization is considered to gold standard for assessment of intracardiac filling pressures.

The best way for assessment of congestion isA. Clinical examination and weightB. Right heart catheterizationC. EchocardiogramD. BNP

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No improvement in survival or hospitalization Increased in hospital complications

Limitations of right heart catheterization

JAMA. 2005;294(13):1625-1633 J Heart Lung Transplant 2015;34:438–447

A significant proportion of patients are reclassified within a week of RHC and have

increased filling pressures

Limitations of right heart catheterization

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Clinical assessment

JACC: Heart Failure Jul 2018, 6 (7) 543-551

The least sensitive physical finding for assessment of clinical congestion is

A. EdemaB. RalesC. JVPD. S3

Rales and pulmonary edema are found infrequently in patient with chronic heart failure due to exaggerated lymphatic drainage

Question

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A combination of rales,edema, and elevated meanjugular venous pressurehas a 100% specificity forPCWP ≥ 22 mmHg

JAMA. 1989 Feb 10;261(6):884-8.J Am Coll Cardiol 1993;22 :968 –974.

Circ Heart Fail 2008;1:170–177.

Clinical finding Sensitivity SpecificityDyspnea on exertion 66 52

Orthopnea ≥ 2 pillows 86 25

Edema 46 73

Rales ≥ 1/3 15 89

Resting JVD 70 79HJR 83 27

S3 73 42

Chest X ray

Pulm edema 60 73

Pleural effusion 43 79

Clinical assessment How to Estimate JVP

Estimate vertical height to sternal angle of Louis, then add 5

• A well-lit room

• Position the patient at an angle such thatthe meniscus of blood in the right jugularvein is brought into vision (usually an angleof 30 degrees to 45 degrees from thehorizontal)

4

4 + 5 = 9 cmRAP (mm Hg) = ¾ x

JVD (cm)

JAMA. 275(8):630-634, February 28, 1996

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Bendopnea

• The patient bends forward while sitting in a chair and touching one’s feet with one's hands. The patient should not hold his or her breath. Then at 10-s intervals, the patient is asked of they are experiencing difficulty breathing.

• Bendopnea was considered present if dyspnea occurred within 30 s of bending

J Am Coll Cardiol HF 2014;2:24–31

Bendopnea was present in 28% subjects and median time to symptom onset was 8 seconds.

Benefit of Intensive weight and symptom monitoring

Monitoring of weight and symptoms do not reduce readmission or death

N Engl J Med 2010;363:2301-2309

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The biologically active form of natriuretic peptide isA. BNPB. NTproBNP

BNP

Question

• Natriuretic peptides (NPs) are released from the heart in response to pressure and volume overload.

• 3 major NPs, atrial natriuretic peptide (ANP), B-type natriuretic peptide (BNP), and C-type NP

• BNP has minimal storage in granules; rather, it is synthesized and secreted in bursts

• BNP and NTproBNP levels are reasonably correlated, and either can be used

Natriuretic peptides

J Am Coll Cardiol 2007;50:2357–68

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Prognostic significance of Natriuretic peptides

J Am Coll Cardiol 2008;52:997—1003.Am Heart J 2006;152:828—34.

Eur Heart J 2008;29:1011—8.

• For BNP, a concentration of ∼125 pg/mL represents the inflection point for risk, while it is 1000 pg/mL for NT-proBNP.

• A biological variability of 25% for NT-proBNP and 40% for BNP is more to be expected

• Largest prognostic value relative to changes in NT-proBNP concentration is observed 2 weeks after a therapy change

Natriuretic peptide guided HF treatment

In high-risk patients with HFrEF, a strategy of NT-proBNP-guided therapy was not more effective than a usual care strategy in improving outcomes

JAMA. 2017;318(8):713-720

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The Gheorghiade congestion score

European Journal of Heart Failure (2010) 12, 423–433

Implantable devices of assessment of volume status

• Implantable rhythm devices

• Implantable hemodynamic monitors (IHM)

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Physiological Variable Clinical Relevance

First heart sound Associated with ventricular contraction status

Third heart sound Associated with early diastolic filling

Thoracic impedance Associated with fluid accumulation and pulmonary edema

Respiration rate Rapid shallow breathing patterns associated with shortness of breath

Ratio of respiration rate to tidal volume

Heart rate Indicator of cardiac status

Activity Global patient status and fatigue

Parameter CriterionFluid Index ≥60 ohm/daysAT/AF Duration ≥6 hours & not persistent AT/AFV. rate during AT/AF

AT/AF ≥24 hrs & V. ≥ 90 bpm

Patient Activity Avg. <1 hr over 1 weekNight Heart Rate ≥85 bpm for 7 consecutive daysHRV <60 ms for 7 consecutive daysCRT % Pacing < 90% for 5 of 7 daysShock(s) 1 or more shocks

OR Fluid Index ≥100 ohm/day

JACC 2010;55(17):1803-1810

JACC HF 2017;5:216–25

While data from rhythm devices can risk stratify

patients, there is no data to use them in guiding

treatment

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Time course of decompensation

Intra-cardiac filling pressure increase predates symptoms of HF byA. Occurs at the same timeB. 24 hoursC. 7 daysD. 15-30 days

J Am Coll Cardiol 2003;41:565–71

Intracardiac pressures can rise upto 2 weeks prior to HF decompensation

Question CardioMEMS

Lancet 2011; 377: 658–66

Use of IHM reduce rates of hospital admission for heart

failure in NYHA class III patients

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Lancet 2016; 387: 453–61Circ Heart Fail. 2014;7:935-944

Use of IHM

Has sustained reduction in HF hospitalization in NYHA III patients

Allows more uptitration of HF therapies

Has benefits in both HFrEG and HFpEF

CardioMEMS Summary• Congestion has significant prognostic implications and clinical congestion is only a tip of the

iceberg

• Clinical assessment of congestion has significant limitations and may be inadequate to reduce HF hospitalizations.

• Assessment of natriuretics peptides has diagnostic and prognostic significance but cannot be used to guide therapy

• There are a large variety of implantable cardiac devices which can be used to assess intravascular volume status

• IHM guided therapy reduced HF hospitalization in NYHA III HF patients with both HFpEF and HFrEF

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Thank You