Relation of unrecognized hypervolemia in chronic heart failure to clinical status, hemodynamics, and patient outcomes

doi:10.1016/j.amjcard.2004.01.070

The American Journal of Cardiology

Volume 93, Issue 10, 15 May 2004, Pages 1254-1259

https://doi.org/10.1016/j.amjcard.2004.01.070 Get rights and content

Abstract

Clinically unrecognized intravascular volume overload may contribute to worsening symptoms and disease progression in patients with chronic heart failure (CHF). The present study was undertaken to prospectively compare measured blood volume status (determined by radiolabeled albumin technique) with clinical and hemodynamic characteristics and patient outcomes in 43 nonedematous ambulatory patients with CHF. Blood volume analysis demonstrated that 2 subjects (5%) were hypovolemic (mean deviation from normal values −20 ± 6%), 13 subjects (30%) were normovolemic (mean deviation from normal values −1 ± 1%), and 28 subjects (65%) were hypervolemic (mean deviation from normal values +30 ± 3%). Physical findings of congestion were infrequent and not associated with blood volume status. Increased blood volume was associated with increased pulmonary capillary wedge pressure (p = 0.01) and greatly increased risk of death or urgent cardiac transplantation during a median follow-up of 719 days (1-year event rate 39% vs 0%, p <0.01 by log-rank test). Systolic blood pressure was significantly lower in hypervolemic patients than in those with normovolemia or hypovolemia (107 ± 2 vs 119 ± 2 mm Hg, p = 0.008), and hypotension was independently associated with increased risk of hypervolemia in multivariate analysis (odds ratio 2.64 for a 10-mm Hg decrease in systolic blood pressure, 95% confidence interval 1.13 to 6.19, p = 0.025). These findings demonstrate that clinically unrecognized hypervolemia is frequently present in nonedematous patients with CHF and is associated with increased cardiac filling pressures and worse patient outcomes.

Section snippets

Study group

Forty-three consecutive nonedematous ambulatory patients with CHF were studied. Subjects between 21 and 80 years of age with CHF for >3 months' duration, with stable New York Heart Association class II to IV symptoms for >2 months, and left ventricular ejection fraction ≤35% were eligible for the study. Criteria for exclusion were acute decompensated heart failure, severe renal dysfunction (serum creatine >2.5 mg/dl or history of nephrotic syndrome), severe hepatic dysfunction (serum liver

Blood volume analysis

Blood volume analysis demonstrated that 2 subjects (5%) were hypovolemic (mean deviation from normal blood volume values −20 ± 6%), 13 subjects (30%) were normovolemic (mean deviation from normal blood volume values −1 ± 1%), and 28 subjects (65%) were hypervolemic (mean deviation from normal blood volume values +30 ± 3%). The increased blood volume was largely attributable to an expanded plasma volume component (Figure 1). Patients with hypervolemia had significantly lower ejection fraction

Discussion

The present findings demonstrate that blood volume, as determined by the radiolabeled albumin technique, is frequently increased in nonedematous patients with CHF and is associated with increased cardiac filling pressures and worse patient outcomes. Physical examination did not accurately predict hypervolemia in these subjects.

This report had a larger study population and more comprehensive clinical characterization than previous studies on blood volume analysis in CHF and is the first to

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Citation Excerpt :
The findings of this study in a large cohort of HF patients indicate that both the extent and composition of intravascular volume expansion affect clinical outcomes and, importantly, volume profiles and their impact vary with the progression of HF. A previously reported outpatient study has shown increased risk for adverse outcomes in the setting of an expanded BV11 and preliminary data from our group in after-hospital chronic HF patients suggests that an expanded BV is associated with a reduced risk of HF re-hospitalization or death.12 In the current analysis, intravascular volume profiles were predictive of risk for HF admission, HF readmission, or death, however, clinical outcomes were divergent between inpatients and outpatients relative to their volume profiles.
Heart failure (HF) commonly progresses over time and identifying differences in volume profiles may help stratify risk and guide therapy. The aim of this study was to assess the pathophysiologic and prognostic roles of volume profiles for HF progression in stable ambulatory and hospitalized patients. HF patients who had undergone quantitative intravascular volume analysis (185 outpatients and 139 inpatients) were retrospectively assessed for the combined end point of HF-related hospital admissions (outpatients), HF-readmissions (inpatients), and overall all-cause mortality. After multivariate Cox regression analysis, greater total blood volume expansion was associated with higher risk of HF-admission in previously stable outpatients (HR: 1.023, CI 1.005 to 1.043; p = 0.013) while in more advanced HF (inpatients) total blood volume expansion was associated with lower risk for HF-readmission and mortality (HR: 0.982, CI 0.967 to 0.997; p = 0.017). Secondary analysis suggests that subclinical plasma volume expansion was a driving factor for the detrimental association in outpatients (HR: 1.018, CI 0.997 to 1.036; p = 0.054), while an increase in red blood cell mass was central to the beneficial association in advanced HF (HR: 0.979, CI 0.968 to 0.991; p <0.001). In conclusion, understanding differences in plasma volume and red blood cell mass profiles can provide insight into the pathophysiology and progression of HF.

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Relation of unrecognized hypervolemia in chronic heart failure to clinical status, hemodynamics, and patient outcomes

Abstract

Section snippets

Study group

Blood volume analysis

Discussion

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