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CLINICAL CARDIOLOGY
Jakarta, 28 April 2012
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Hospitalizations for HF Are Increasing
0
100,000
200,000
300,000
400,000
500,000
600,000
'79
'81
'83
'85
'87
'89
'91
'93
'95
'97
Discharges
Women
Men
CDC/NCHS. AHA Heart Stroke and Statistical Update, 2001.
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Mortality Rates After First Hospitalization for HF
Jong et al.Arch Intern Med. 2002;162:1689-1694.
Age- and Sex-Stratified Case-Fatality Rates 30 Days and 1 YearAfter First Hospitalization for HF
Men Women
Mortality, % Mortality, %
Age Group, y No. of Patients 30-Day 1-Year No. of Patients 30-Day 1-Year
20-49
50-64
65-74
75
All Ages
655
3048
5923
9310
18,936
4.6
5.5
8.6
15.6
11.4
15.0
20.5
28.8
43.1
34.0
375
1892
4412
13,087
19,766
4.3
5.4
6.8
14.7
11.8
10.9
19.5
23.0
37.9
32.3
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Most Admitted Patients Are Volume Overloaded
Any dyspnea89%
Pulmonary congestion (CXR)74%
Rales67%
Dyspnea at rest34%
Peripheral edema65%
ADHERE Registry. 3rdQtr 2003 National Benchmark Report.
At HospitalizationADHERE1
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Over 90% of All Hospitalizations for Acutely
Decompensated Heart Failure (ADHF) Are Due to
Fluid Overload1
The Majority of These Patients Have Failed
Treatment With Oral Diuretics2
1. Aronson.ACC. 2000.
2. Adams et al.Am Heart J.2005;149:209-216.
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Fluid overload in normal heart
- Kidney responsible
for 20% of cardiac
output
- Good heart-kidney
relationship
- Integrity of arterial
circulation
HEART FAILURE :Heart-Kidney
Disintegration
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Fluid overload in heart failure
Arterial Underfilling Hypothesis
Angiotensin IIVasopressin
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Cardiorenal syndrome type 1
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HemodynamicCongestion
Clinicalcongestion
VS
Hemodynamic congestion may occur
earlier than clinical congestion Even when clinical congestion is
relieved, patients may still have
hemodynamic congestion
- LV filling
- intravascular
pressure
- Classic signs
- Symptoms
Diuretics
Challenges in Assessment of Fluid Overload
ACE-I/ARB
Aldosterone
antagonist
Beta blocker
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Fluid overload = worse prognosis
Lucas et al : assessed patients 4 to 6 weeks after hospital
discharge for 5 signs of hypervolemia: orthopnea, peripheral edema,
weight gain, need to increase baseline diuretic dose, and jugular
venous distension.
Patients with any 3 of the 5 signs 6 weeks after discharge had a 3-
fold increase in mortality at 2 years after the index hospitalization.
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...even in non heart failure patients
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Ronco, a renowned
nephrologist :5B approach for fluid overload
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Unfortunately....
Classic symptoms & signs has low sensitivity for the
presence of volume overload
Meaning : they can also present frequently without
actual volume overload
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What can we do ?
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Identify the underlying problems...
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What about BNPs?
Myocardial stretch is not analogue of fluid overload
Increase of BNP can happen in other setting
BNP rise may be slower than change in blood volume
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We need multiple modalities...
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...and consider multiple
compartments
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The Vascular Pedicle
The vascular pedicle is
bordered on the right by
venous structures (right
brachiocephalic vein above
and superior vena cava) and
on the left by an arterial
structure (the left subclavianartery origin).
VPW is the distance between
parallel lines drawn from the
point at which the superiorvena cava intersects the right
main bronchus an a line
drawn at the takeoff of the
left subclavian artery from
the aorta
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Salahuddin et al, Indian J Crit Care Med October-December 2007 Vol 11 Issue 4
VPW correlated closely
with positive fluid
balance, r = + 0.88, P
0.000. ROC demonstrated
that VPW of 86.5 mm
had a 100% sensitivity
and an 80% specificity(AUC 0.823) for
predicting fluid overload
1200 ml
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Echocardiography : measure
intravascular volume with caval index
Caval index(%) = (IVC expiratory diameterIVCinspiratory diameter)/ IVC expiratory diameter 100
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Beyond echocardiography : Lung Ultrasound
B lines correlates with extravascular lung water evaluatio
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BioImpedance Vector Analysis : whole
body fluid volume assessment
ESC id li 2008 I iti l
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ESC guideline 2008 : Initial
treatment of acute HF
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Yes
Stevenson LW. Eur J Heart Fail.1999;1:251
NoWarm & Dry
PCWP normal
CI normal(compensated)
Cold & Wet
PCWP elevatedCI decreased
Cold & Dry
PCWP low/normalCI decreased
Congestion at Rest
Low
Perfusion
at Rest
No
Yes
Warm & WetPCWP elevated
CI normal
Congestion vs. Low perfusion
4 Possible Hemodynamic Profiles of HF
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Narrow fluid tolerance in HF
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Indication of diuretics in HF
Loop diuretics is the first line therapy...
Diuretic Strategy in ADHF
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Diuretic Strategy in ADHF
THE DOSE study : 300 patients, double blind randomized study
High dose : 2,5 x previous oral dose
Low dose : equivalent to previous oral dose
HIGH DOSEvs LOW DOSE ?
BOLUS vs CONTINUOUS ?
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No significant differences in patients global assessment of
symptoms or in the change in renal function when diuretic therapy
was administered by bolus as compared with continuous infusion
or at a high dose as compared with a low dose
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PROBLEM #1 : Diuretic Resistance
Can be described as a clinical state in which the
diuretic response is diminished or lost before the
therapeutic goal of relief from edema has been
reached
1
Affects 20%30% of patients with HF2
1. Kramer et al. Nephrol Dial Transplant. 1999;14(suppl 4):39-42.
2. Ellison. Cardiology. 2001;96:132-143.
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Diuretic Resistance: Two Types
Braking phenomenon
A decrease in response to a diuretic after the first dose has been
administered
Long-term tolerance
Tubular hypertrophy to compensate for salt loss
Brater. N Engl J Med. 1998;339:387.
C f Di ti R i t i HF1 3
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Causes of Diuretic Resistance in HF1-3
Decreased renal function and distal Na+ delivery
Variability in diuretic absorption (bioavailability)
Neurohormonal activation (RAAS/SNS) Drugs/dietincreased sodium intake
Noncompliance with medications
Infrequent dosing
1. Neuberg et al.Am Heart J. 2002;144:31-38.
2. Brater. N Engl J Med. 1998;339:387-395.
3. Wilcox. J Am Soc Nephrol. 2002;13:798-805.
Overcoming Diuretic Resistence in HF
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Restrict daily fluid intake (1.01.5 L)
Moderate restriction of daily salt intake (2 g)
Avoid NSAIDs
Institute and uptitrate ACE inhibitors and/or angiotensin receptorblocker
Give short-acting loop diuretic orally in several divided(and increasing) doses, bolus, or continuous intravenousadministration
Use sequential nephron blockade via combination loop diuretic andthiazide diuretic
Add small doses of spironolactone (12.525 mg)
Consider short-term acetazolamide in selected patients
Overcoming Diuretic Resistence in HF
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Bayliss et al. Br Heart J.1987;57:17
Before
(n=12)
PlasmaReninActivity
(ng/mL/h)
50
10
2.5
0.5
PlasmaAldosterone
(pmol/L)
Mean, 95%
ConfidenceInterval
1000
600
200
100 P =.0007P =.0002After
Diuretic
(n=11)
Diuretics Activate Neurohormonal Systems in HF?
Before
(n=12)
After
Diuretic
(n=11)
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PROBLEM #2 : Hyponatremia
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When to treat ?
Serum sodium < 120 meq/L or
symptomatic
How to treat ?
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Tolvaptan in Heart Failure : quite
promising
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PROBLEM #3 : Oliguria and or increasing
Serum Creatinine Level
S l i Ul fil i i HF
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Solution : Ultrafiltration in HF
European and North American practice guidelines state
that UF is reasonable for patients with refractory congestion
not responding to medical therapy and assign to this
recommendation a class IIa, level of evidence: B.
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Ultrafiltration Initiation ?
- Neither practice guidelines nor clinical trial data provide guidance as
to which clinical variables should trigger initiation of extracorporeal
therapies
- The expert consensus suggests that a congestion grade higher than
12 together with low urine output (1,000 mL/24 h) should trigger the
use of extracorporeal fluid removal.
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Possible Contraindications to Ultrafiltration inPatients With HF
Inadequate venous access
Hypotension
Hypercoagulable states
Stage V chronic kidney disease; requirementfor hemodialysis
Patients responsive to diuretics
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Comparison to Continuous Venovenous
Hemofiltration
Aquapheresis CVVH
Patient Fluid overload Renal
Prescriber Any who have received training
(cardiologist, hospitalist,nephrologist, surgeon, etc)
Nephrologist
Treatment venue Inpatient/Outpatient ICU
Blood withdrawal rates 1040 mL/min 100300 mL/min
Extracorporeal volumes 33 mL 100300 mL
Venous access Peripheral or central CentralReported adverse events
since June 2002
Aquadex 6 (0.12% MDR
event per patient, 5000
patients) 0 device malfunctions
Prisma 812
(patient numbers not available)
NxStage 230 (23% MDR event
per patient, 1000 patients)
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TAKE HOME MESSAGE
1. Fluid overload is predictor of worse
prognosis in HF
2. Assessment is not always easy so
we must use multiple modalities3. Diuretics is firstline therapy, but
watch out for :- Diuretic resistance
- Hyponatremia
- Oliguria/worsening renal function
4. Consider ultrafiltration in the future
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