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Krzesinski P, Sobotnicki A, Gacek A, Siebert J, Walczak A, Murawski P, Gielerak G. Noninvasive Bioimpedance Methods From the Viewpoint of Remote Monitoring in Heart Failure. JMIR Mhealth Uhealth 2021; 9:e25937. [PMID: 33949964 PMCID: PMC8135018 DOI: 10.2196/25937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 02/07/2021] [Accepted: 03/31/2021] [Indexed: 12/28/2022] Open
Abstract
Heart failure (HF) is a major clinical, social, and economic problem. In view of the important role of fluid overload in the pathogenesis of HF exacerbation, early detection of fluid retention is of key importance in preventing emergency admissions for this reason. However, tools for monitoring volume status that could be widely used in the home setting are still missing. The physical properties of human tissues allow for the use of impedance-based noninvasive methods, whose different modifications are studied in patients with HF for the assessment of body hydration. The aim of this paper is to present the current state of knowledge on the possible applications of these methods for remote (home-based) monitoring of patients with HF.
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Affiliation(s)
- Pawel Krzesinski
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | | | - Adam Gacek
- Institute of Medical Technology and Equipment (ŁUKASIEWICZ-ITAM), Zabrze, Poland
| | - Janusz Siebert
- Department of Family Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Andrzej Walczak
- Software Engineering Department, Cybernetics Faculty, Military University of Technology, Warsaw, Poland
| | - Piotr Murawski
- Department of Informatics, Military Institute of Medicine, Warsaw, Poland
| | - Grzegorz Gielerak
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
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Martins C, Machado da Silva J, Guimarães D, Martins L, Vaz da Silva M. MONITORIA: The start of a new era of ambulatory heart failure monitoring? Part I - Theoretical Rationale. Rev Port Cardiol 2021; 40:329-337. [PMID: 34187634 DOI: 10.1016/j.repce.2020.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 07/28/2020] [Indexed: 10/21/2022] Open
Abstract
Heart failure (HF) is a multifactorial chronic syndrome with progressive increasing incidence causing a huge financial burden worldwide. Remote monitoring should, in theory, improve HF management, but given increasing morbidity and mortality, a question remains: are we monitoring it properly? Device-based home monitoring enables objective and continuous measurement of vital variables and non-invasive devices should be first choice for elderly patients. There is no shortage of literature on the subject, however, most studies were designed to monitor a single variable or class of variables that were not properly assembled and, to the best of our knowledge, there are no large randomized studies about their impact on HF patient management. To overcome this problem, we carefully selected the most critical possible HF decompensating factors to design MONITORIA, a non-invasive device for comprehensive HF home monitoring. MONITORIA stands for MOnitoring Non-Invasively To Overcome mortality Rates of heart Insufficiency on Ambulatory, and in this paper, which is part I of a series of three articles, we discuss the theoretical basis for its design. MONITORIA and its inherent follow-up strategy will optimize HF patient care as it is a promising device, which will essentially adapt innovation not to the disease but rather to the patients.
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Affiliation(s)
- Carla Martins
- Internal Medicine, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal.
| | | | - Diana Guimarães
- Faculty of Engineering of the University of Porto, Porto, Portugal
| | - Luís Martins
- Cardiology, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
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MONITORIA: The start of a new era of ambulatory heart failure monitoring? Part I - Theoretical Rationale. Rev Port Cardiol 2021; 40:329-337. [PMID: 33483175 DOI: 10.1016/j.repc.2020.07.013] [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: 11/28/2018] [Revised: 05/22/2020] [Accepted: 07/28/2020] [Indexed: 11/23/2022] Open
Abstract
Heart failure (HF) is a multifactorial chronic syndrome with progressive increasing incidence causing a huge financial burden worldwide. Remote monitoring should, in theory, improve HF management, but given increasing morbidity and mortality, a question remains: are we monitoring it properly? Device-based home monitoring enables objective and continuous measurement of vital variables and non-invasive devices should be first choice for elderly patients. There is no shortage of literature on the subject, however, most studies were designed to monitor a single variable or class of variables that were not properly assembled and, to the best of our knowledge, there are no large randomized studies about their impact on HF patient management. To overcome this problem, we carefully selected the most critical possible HF decompensating factors to design MONITORIA, a non-invasive device for comprehensive HF home monitoring. MONITORIA stands for MOnitoring Non-Invasively To Overcome mortality Rates of heart Insufficiency on Ambulatory, and in this paper, which is part I of a series of three articles, we discuss the theoretical basis for its design. MONITORIA and its inherent follow-up strategy will optimize HF patient care as it is a promising device, which will essentially adapt innovation not to the disease but rather to the patients.
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4
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Kleiner-Shochat M, Kapustin D, Fudim M, Ambrosy AP, Glantz J, Kazatsker M, Kleiner I, Weinstein JM, Panjrath G, Roguin A, Meisel SR. The Degree of the Predischarge Pulmonary Congestion in Patients Hospitalized for Worsening Heart Failure Predicts Readmission and Mortality. Cardiology 2020; 146:49-59. [PMID: 33113535 DOI: 10.1159/000510073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prediction of readmission and death after hospitalization for heart failure (HF) is an unmet need. AIM We evaluated the ability of clinical parameters, NT-proBNP level and noninvasive lung impedance (LI), to predict time to readmission (TTR) and time to death (TTD). METHODS AND RESULTS The present study is a post hoc analysis of the IMPEDANCE-HF extended trial comprising 290 patients with LVEF ≤45% and New York Heart Association functional class II-IV, randomized 1:1 to LI-guided or conventional therapy. Of all patients, 206 were admitted 766 times for HF during a follow-up of 57 ± 39 months. The normal LI (NLI), representing the "dry" lung status, was calculated for each patient at study entry. The current degree of pulmonary congestion (PC) compared with its dry status was represented by ΔLIR = ([measured LI/NLI] - 1) × 100%. Twenty-six parameters recorded during HF admission were used to predict TTR and TTD. To determine the parameter which mainly impacted TTR and TTD, variables were standardized, and effect size (ES) was calculated. Multivariate analysis by the Andersen-Gill model demonstrated that ΔLIRadmission (ES = 0.72), ΔLIRdischarge (ES = -3.14), group assignment (ES = 0.2), maximal troponin during HF admission (ES = 0.19), LVEF related to admission (ES = -0.22) and arterial hypertension (ES = 0.12) are independent predictors of TTR (p < 0.01, χ2 = 1,206). Analysis of ES showed that residual PC assessed by ∆LIRdischarge was the most prominent predictor of TTR. One percent improvement in predischarge PC, assessed by ∆LIRdischarge, was associated with a likelihood of TTR increase by 14% (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.13-1.15, p < 0.01) and TTD increase by 8% (HR 1.08, 95% CI 1.07-1.09, p < 0.01). CONCLUSION The degree of predischarge PC assessed by ∆LIR is the most dominant predictor of TTR and TTD.
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Affiliation(s)
- Michael Kleiner-Shochat
- Heart Institute, Hillel Yaffe Medical Center, Hadera, Israel, .,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel,
| | - Daniel Kapustin
- University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Marat Fudim
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrew P Ambrosy
- The Permanente Medical Group, San Francisco, California, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Juliya Glantz
- Heart Institute, Hillel Yaffe Medical Center, Hadera, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Mark Kazatsker
- Heart Institute, Hillel Yaffe Medical Center, Hadera, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Ilia Kleiner
- Department of Cardiology, University Medical Center, Beer Sheva, Israel
| | | | - Gurusher Panjrath
- Department of Medicine (Cardiology), George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Ariel Roguin
- Heart Institute, Hillel Yaffe Medical Center, Hadera, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Simcha R Meisel
- Heart Institute, Hillel Yaffe Medical Center, Hadera, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Hankinson SJ, Williams CH, Ton VK, Gottlieb SS, Hong CC. Should we overcome the resistance to bioelectrical impedance in heart failure? Expert Rev Med Devices 2020; 17:785-794. [PMID: 32658589 PMCID: PMC8356137 DOI: 10.1080/17434440.2020.1791701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Heart failure is associated with increased neurohormonal activation that results in changes in body composition including volume overload and the loss of skeletal muscle, body fat, and bone density. Bioelectrical impedance measures body composition based on the conduction of electrical current through body fluids. AREAS COVERED The PubMed and Scopus databases were reviewed up to the third week of June 2020. Cross-sectional studies, retrospective observational studies, prospective observational studies, and randomized controlled trials have examined numerous bioelectrical impedance monitoring strategies to guide the diagnosis, prognosis, and treatment of heart failure. These monitoring strategies include intrathoracic impedance, lung impedance, bioelectrical impedance vector analysis, leg bioelectrical impedance, and thoracic bioreactance. EXPERT COMMENTARY Based on the current evidence, more studies are needed to validate bioelectrical impedance in heart failure. Lung impedance appears to be useful for guiding heart failure treatment in patients with ST-elevation myocardial infarction and improving outcomes in outpatients with heart failure. Furthermore, bioelectrical impedance has potential as a noninvasive, quantitative heart failure variable for population-based research.
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Affiliation(s)
- Stephen J. Hankinson
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Charles H. Williams
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Van-Khue Ton
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Harvard Medical School, Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen S. Gottlieb
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Charles C. Hong
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Lycholip E, Palevičiūtė E, Aamodt IT, Hellesø R, Lie I, Strömberg A, Jaarsma T, Čelutkienė J. Non-invasive home lung impedance monitoring in early post-acute heart failure discharge: Three case reports. World J Clin Cases 2019; 7:951-960. [PMID: 31119140 PMCID: PMC6509267 DOI: 10.12998/wjcc.v7.i8.951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/15/2019] [Accepted: 02/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients discharged after hospitalization for acute heart failure (AHF) are frequently readmitted due to an incomplete decongestion, which is difficult to assess clinically. Recently, it has been shown that the use of a highly sensitive, non-invasive device measuring lung impedance (LI) reduces hospitalizations for heart failure (HF); it has also been shown that this device reduces the cardiovascular and all-cause mortality of stable HF patients when used in long-term out-patient follow-ups. The aim of these case series is to demonstrate the potential additive role of non-invasive home LI monitoring in the early post-discharge period.
CASE SUMMARY We present a case series of three patients who had performed daily LI measurements at home using the edema guard monitor (EGM) during 30 d after an episode of AHF. All patients had a history of chronic ischemic HF with a reduced ejection fraction and were hospitalized for 6–17 d. LI measurements were successfully made at home by patients with the help of their caregivers. The patients were carefully followed up by HF specialists who reacted to the values of LI measurements, blood pressure, heart rate and clinical symptoms. LI reduction was a more frequent trigger to medication adjustments compared to changes in symptoms or vital signs. Besides, LI dynamics closely tracked the use and dose of diuretics.
CONCLUSION Our case series suggests non-invasive home LI monitoring with EGM to be a reliable and potentially useful tool for the early detection of congestion or dehydration and thus for the further successful stabilization of a HF patient after a worsening episode.
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Affiliation(s)
- Edita Lycholip
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 03101, Lithuania
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Vilnius 08661, Lithuania
| | - Eglė Palevičiūtė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 03101, Lithuania
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Vilnius 08661, Lithuania
| | - Ina Thon Aamodt
- Faculty of Medicine, Institute of Health and Society, Department of Nursing Science, University of Oslo, Oslo 0318, Norway
- Center for Patient-Centered Heart and Lung Research, Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo 0420, Norway
| | - Ragnhild Hellesø
- Departamento of Nursing Science, Institute of Health and Society, University of Oslo, Oslo 0318, Norway
| | - Irene Lie
- Center for Patient-Centered Heart and Lung Research, Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo 0420, Norway
| | - Anna Strömberg
- Department of Medical and Health Sciences, Linkoping University, Linkoping 58185, Sweden
| | - Tiny Jaarsma
- Department of Social and Welfare Studies, Linkoping University, Norrkoping 58185, Sweden
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 03101, Lithuania
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Vilnius 08661, Lithuania
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7
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Kleiner Shochat M, Fudim M, Shotan A, Blondheim DS, Kazatsker M, Dahan I, Asif A, Rozenman Y, Kleiner I, Weinstein JM, Panjrath G, Sobotka PA, Meisel SR. Prediction of readmissions and mortality in patients with heart failure: lessons from the IMPEDANCE-HF extended trial. ESC Heart Fail 2018; 5:788-799. [PMID: 30094959 PMCID: PMC6165944 DOI: 10.1002/ehf2.12330] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/09/2018] [Accepted: 06/13/2018] [Indexed: 12/17/2022] Open
Abstract
Aims Readmissions for heart failure (HF) are a major burden. We aimed to assess whether the extent of improvement in pulmonary fluid content (ΔPC) during HF hospitalization evaluated by lung impedance (LI), or indirectly by other clinical and laboratory parameters, predicts readmissions. Methods and results The present study is based on pre‐defined secondary analysis of the IMPEDANCE‐HF extended trial comprising 266 HF patients at New York Heart Association Class II–IV and left ventricular ejection fraction ≤ 35% randomized to LI‐guided or conventional therapy during long‐term follow‐up. Lung impedance‐guided patients were followed for 58 ± 36 months and the control patients for 46 ± 34 months (P < 0.01) accounting for 253 and 478 HF hospitalizations, respectively (P < 0.01). Lung impedance, N‐terminal pro‐brain natriuretic peptide, weight, radiological score, New York Heart Association class, lung rales, leg oedema, or jugular venous pressure were measured at admission and discharge on each hospitalization in both groups with the difference defined as ΔPC. Average LI‐assessed ΔPC was 12.1% vs. 9.2%, and time to HF readmission was 659 vs. 306 days in the LI‐guided and control groups, respectively (P < 0.01). Lung impedance‐based ΔPC predicted 30 and 90 day HF readmission better than ΔPC assessed by the other variables (P < 0.01). The readmission rate for HF was lower if ΔPC > median compared with ΔPC ≤ median for all parameters evaluated in both study groups with the most pronounced difference predicted by LI (P < 0.01). Net reclassification improvement analysis showed that adding LI to the traditional clinical and laboratory parameters improved the predictive power significantly. Conclusions The extent of ΔPC improvement, primarily the LI based, during HF‐hospitalization, and study group allocation strongly predicted readmission and event‐free survival time.
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Affiliation(s)
- Michael Kleiner Shochat
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Marat Fudim
- Department of CardiologyDuke University Medical CenterDurhamNCUSA
| | - Avraham Shotan
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - David S. Blondheim
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Mark Kazatsker
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Iris Dahan
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Aya Asif
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Yoseph Rozenman
- Cardiovascular Institute, Sackler Faculty of MedicineWolfson Medical Center, Holon, Tel‐Aviv UniversityTel‐AvivIsrael
| | - Ilia Kleiner
- Cardiology DepartmentUniversity Medical CenterBeer‐ShevaIsrael
| | | | - Gurusher Panjrath
- Department of Medicine (Cardiology)George Washington University School of Medicine and Health SciencesWashingtonDCUSA
| | - Paul A. Sobotka
- Department of CardiologyThe Ohio State UniversityColumbusOHUSA
| | - Simcha R. Meisel
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
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8
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Webb DJ, Coll B, Heerspink HJL, Andress D, Pritchett Y, Brennan JJ, Houser M, Correa-Rotter R, Kohan D, Makino H, Perkovic V, Remuzzi G, Tobe SW, Toto R, Busch R, Pergola P, Parving HH, de Zeeuw D. Longitudinal Assessment of the Effect of Atrasentan on Thoracic Bioimpedance in Diabetic Nephropathy: A Randomized, Double-Blind, Placebo-Controlled Trial. Drugs R D 2018; 17:441-448. [PMID: 28831752 PMCID: PMC5629141 DOI: 10.1007/s40268-017-0201-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Fluid retention is a common adverse event in patients who receive endothelin (ET) receptor antagonist therapy, including the highly selective ETA receptor antagonist, atrasentan. Objective We performed longitudinal assessments of thoracic bioimpedance in patients with type 2 diabetes mellitus and nephropathy to determine whether a decrease in bioimpedance accurately reflected fluid retention during treatment with atrasentan. Study Design We conducted a randomized, double-blind, placebo-controlled study in 48 patients with type 2 diabetes mellitus and nephropathy who were receiving stable doses of renin angiotensin system inhibitors and diuretics. Methods Patients were randomized 1:1:1 to placebo, atrasentan 0.5 mg, or atrasentan 1.25 mg once daily for 8 weeks. Thoracic bioimpedance, vital signs, clinical exams, and serologies were taken at weeks 1, 2, 4, 6, and 8, with the exception of serum hemoglobin, which was not taken at week 1, and serum brain natriuretic peptide, which was only taken at baseline, week 4, and week 8. Results Alterations in bioimpedance were more often present in those who received atrasentan than in those who received placebo, though overall differences were not statistically significant. Transient declines in thoracic bioimpedance during the first 2 weeks of atrasentan exposure occurred before or during peak increases in body weight and hemodilution (decreased serum hemoglobin). Conclusions We conclude that thoracic bioimpedance did not reflect changes in weight gain or edema with atrasentan treatment in this study. However, the sample size was small, and it may be of interest to explore the use of thoracic bioimpedance in a larger population to understand its potential clinical use in monitoring fluid retention in patients with chronic kidney disease who receive ET receptor antagonists.
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Affiliation(s)
- David J Webb
- Edinburgh Hypertension Excellence Centre, Clinical Pharmacology Unit, University of Edinburgh, E3.22, QMRI, 47 Little France Crescent, Edinburgh, EH16 4TJ, Scotland, UK.
| | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | | | | | | | - Ricardo Correa-Rotter
- National Medical Science and Nutrition Institute Salvador Zubiran, Mexico City, Mexico
| | - Donald Kohan
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Hirofumi Makino
- Okayama University Graduate School of Medicine, Okayama, Japan
| | | | - Giuseppe Remuzzi
- Azienda Ospedaliera Papa Giovanni XXIII and IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | | | - Robert Toto
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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9
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Harjola VP, Parissis J, Brunner-La Rocca HP, Čelutkienė J, Chioncel O, Collins SP, De Backer D, Filippatos GS, Gayat E, Hill L, Lainscak M, Lassus J, Masip J, Mebazaa A, Miró Ò, Mortara A, Mueller C, Mullens W, Nieminen MS, Rudiger A, Ruschitzka F, Seferovic PM, Sionis A, Vieillard-Baron A, Weinstein JM, de Boer RA, Crespo-Leiro MG, Piepoli M, Riley JP. Comprehensive in-hospital monitoring in acute heart failure: applications for clinical practice and future directions for research. A statement from the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2018; 20:1081-1099. [PMID: 29710416 DOI: 10.1002/ejhf.1204] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/20/2018] [Accepted: 03/26/2018] [Indexed: 12/17/2022] Open
Abstract
This paper provides a practical clinical application of guideline recommendations relating to the inpatient monitoring of patients with acute heart failure, through the evaluation of various clinical, biomarker, imaging, invasive and non-invasive approaches. Comprehensive inpatient monitoring is crucial to the optimal management of acute heart failure patients. The European Society of Cardiology heart failure guidelines provide recommendations for the inpatient monitoring of acute heart failure, but the level of evidence underpinning most recommendations is limited. Many tools are available for the in-hospital monitoring of patients with acute heart failure, and each plays a role at various points throughout the patient's treatment course, including the emergency department, intensive care or coronary care unit, and the general ward. Clinical judgment is the preeminent factor guiding application of inpatient monitoring tools, as the various techniques have different patient population targets. When applied appropriately, these techniques enable decision making. However, there is limited evidence demonstrating that implementation of these tools improves patient outcome. Research priorities are identified to address these gaps in evidence. Future research initiatives should aim to identify the optimal in-hospital monitoring strategies that decrease morbidity and prolong survival in patients with acute heart failure.
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Affiliation(s)
- Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | | | | | - Jelena Čelutkienė
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine, Clinic of Cardiac and Vascular Diseases, Vilnius, Lithuania
| | - Ovidiu Chioncel
- University of Medicine Carol Davila/Institute of Emergency for Cardiovascular Disease, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel De Backer
- Department of Intensive Care Medicine, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Etienne Gayat
- Département d'Anesthésie- Réanimation-SMUR, Hôpitaux Universitaires Saint Louis-Lariboisière, INSERM-UMR 942, AP-, HP, Université Paris Diderot, Paris, France
| | | | - Mitja Lainscak
- Department of Internal Medicine and Department of Research and Education, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Johan Lassus
- Cardiology, Heart and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Josep Masip
- Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain.,Hospital Sanitas CIMA, Barcelona, Spain
| | - Alexandre Mebazaa
- U942 INSERM, AP-HP, Paris, France.,Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT), Nancy, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France.,AP-HP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Òscar Miró
- Emergency Department, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Andrea Mortara
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk - Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | | | - Alain Rudiger
- Cardio-surgical Intensive Care Unit, University and University Hospital Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Petar M Seferovic
- Department of Internal Medicine, Belgrade University School of Medicine and Heart Failure Center, Belgrade University Medical Center, Belgrade, Serbia
| | - Alessandro Sionis
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antoine Vieillard-Baron
- INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ, 94807 Villejuif, France, University Hospital Ambroise Paré, AP-, HP, Boulogne-Billancourt, France
| | | | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology, G. da Saliceto Hospital, Piacenza, Italy
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10
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Non-Invasive Lung IMPEDANCE-Guided Preemptive Treatment in Chronic Heart Failure Patients: A Randomized Controlled Trial (IMPEDANCE-HF Trial). J Card Fail 2016; 22:713-22. [PMID: 27058408 DOI: 10.1016/j.cardfail.2016.03.015] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/24/2016] [Accepted: 03/25/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Previous investigations have suggested that lung impedance (LI)-guided treatment reduces hospitalizations for acute heart failure (AHF). A single-blind 2-center trial was performed to evaluate this hypothesis (ClinicalTrials.gov-NCT01315223). METHODS The study population included 256 patients from 2 medical centers with chronic heart failure and left ventricular ejection fraction ≤35% in New York Heart Association class II-IV, who were admitted for AHF within 12 months before recruitment. Patients were randomized to a control group treated by clinical assessment and a monitored group whose therapy was also assisted by LI, and followed for at least 12 months. Noninvasive LI measurements were performed with a new high-sensitivity device. Patients, blinded to their assignment group, were scheduled for monthly visits in the outpatient clinics. The primary efficacy endpoint was AHF hospitalizations; the secondary endpoints were all-cause hospitalizations and mortality. RESULTS There were 67 vs 158 AHF hospitalizations during the first year (P < .001) and 211 vs 386 AHF hospitalizations (P < .001) during the entire follow-up among the monitored patients (48 ± 32 months) and control patients (39 ± 26 months, P = .01), respectively. During the follow-up, there were 42 and 59 deaths (hazard ratio 0.52, 95% confidence interval 0.35-0.78, P = .002) with 13 and 31 of them resulting from heart failure (hazard ratio 0.30, 95% confidence interval 0.15-0.58 P < .001) in the monitored and control groups, respectively. The incidence of noncardiovascular death was similar. CONCLUSION Our results seem to validate the concept that LI-guided preemptive treatment of chronic heart failure patients reduces hospitalizations for AHF as well as the incidence of heart failure, cardiovascular, and all-cause mortality.
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Charach G, Rubalsky O, Charach L, Rabinovich A, Argov O, Rogowski O, George J. Internal thoracic impedance - a useful method for expedient detection and convenient monitoring of pleural effusion. PLoS One 2015; 10:e0122576. [PMID: 25919389 PMCID: PMC4412530 DOI: 10.1371/journal.pone.0122576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/18/2015] [Indexed: 11/24/2022] Open
Abstract
Measurement of internal thoracic impedance (ITI) is sensitive and accurate in detecting acute pulmonary edema even at its preclinical stage. We evaluated the suitability of the highly sensitive and noninvasive RS-207 monitor for detecting pleural effusion and for demonstrating increased ITI during its resolution. This prospective controlled study was performed in a single department of internal medicine of a university-affiliated hospital between 2012-2013. One-hundred patients aged 25–96 years were included, of whom 50 had bilateral or right pleural effusion of any etiology (study group) and 50 had no pleural effusion (controls). ITI, the main component of which is lung impedance, was continuously measured by the RS-207 monitor. The predictive value of ITI monitoring was determined by 8 measurements taken every 8 hours. Pleural effusion was diagnosed according to well-accepted clinical and roentgenological criteria. During treatment, the ITI of the study group increased from 32.9±4.2 ohm to 42.8±3.8 ohm (p<0.0001) compared to non-significant changes in the control group (59.6±6.6 ohm, p = 0.24). Prominent changes were observed in the respiratory rate of the study group: there was a decrease from 31.2±4.0 to 19.5±2.4 ohm (35.2%) compared to no change for the controls, and a mean increase from 83.6±5.3%-92.5±1.6% (13.2%) in O2 saturation compared to 94.2±1.7% for the controls. Determination of ITI for the detection and monitoring of treatment of patients with pleural effusion enables earlier diagnosis and more effective therapy, and can prevent hospitalization and serious complications, such as respiratory distress, and the need for mechanical ventilation.
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Affiliation(s)
- Gideon Charach
- Department of Internal Medicine “C”, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- * E-mail:
| | - Olga Rubalsky
- Department of Internal Medicine “C”, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Charach
- Department of Internal Medicine “C”, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Rabinovich
- Department of Internal Medicine “C”, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Argov
- Department of Internal Medicine “C”, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Rogowski
- Department of Internal Medicine “C”, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob George
- Department of Internal Medicine “C”, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Cardiology Department Kaplan Medical Center, affiliated to Hebrew University Medical Center, Jerusalem, Israel
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Shochat M, Shotan A, Blondheim DS, Kazatsker M, Dahan I, Asif A, Shochat I, Frimerman A, Rozenman Y, Meisel SR. Derivation of baseline lung impedance in chronic heart failure patients: use for monitoring pulmonary congestion and predicting admissions for decompensation. J Clin Monit Comput 2014; 29:341-9. [PMID: 25193676 DOI: 10.1007/s10877-014-9610-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 08/27/2014] [Indexed: 12/18/2022]
Abstract
The instantaneous lung impedance (ILI) is one of the methods to assess pulmonary congestion or edema (PCE) in chronic heart failure (CHF) patients. Due to usually existing PCE in CHF patients when evaluated, baseline lung impedance (BLI) is unknown. Therefore, the relation of ILI to BLI is unknown. Our aim was to evaluate methods to calculate and appraise BLI or its derivative as reflecting the clinical status of CHF patients. ILI and New York Heart Association (NYHA) class were assessed in 222 patients (67 ± 11 years, LVEF <35 %) during 32 months of frequent outpatient clinic visits. ILI, measured in 120 asymptomatic patients at NYHA class I, with no congestion on the chest X-ray and a low-normal 6-min walk, was defined as BLI. Using measured BLI and ILI values in these patients, formulas for BLI calculation were derived based on logistic regression analysis or on the disparity between BLI and ILI values at different NYHA stages. Both models were equally reliable with <3 % difference between measured and calculated BLI (p = NS). ΔLIR = (ILI/BLI - 1) × 100 % reflected the degree of PCE, or deviation from baseline, correlated with NYHA class (r = -0.9, p < 0.001) and could serve for monitoring. Of study patients, 123 were re-hospitalized for PCE during follow up. Their ΔLIR decreased gradually from -21.7 ± 8.2 % 4 weeks pre-admission to -37.8 ± 9.3 % on admission (p < 0.001). Patients improved during hospital stay (NYHA 3.7 ± 0.5 to 2.9 ± 0.8, p < 0.0001) with ΔLIR increasing to -29.1 ± 12.0 % (p < 0.001). ΔLIR based on calculated BLI correlated with the clinical status of CHF patients and allowed the prediction of hospitalizations for PCE.
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Affiliation(s)
- Michael Shochat
- Heart Institute, Hillel Yaffe Medical Center, P.O. Box 169, 38100, Hadera, Israel,
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Quinones PA, Kirchberger I, Heier M, Kuch B, Trentinaglia I, Mielck A, Peters A, von Scheidt W, Meisinger C. Marital status shows a strong protective effect on long-term mortality among first acute myocardial infarction-survivors with diagnosed hyperlipidemia--findings from the MONICA/KORA myocardial infarction registry. BMC Public Health 2014; 14:98. [PMID: 24479754 PMCID: PMC3937149 DOI: 10.1186/1471-2458-14-98] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 01/25/2014] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Reduction of long term mortality by marital status is well established in general populations. However, effects have been shown to change over time and differ considerably by cause of death. This study examined the effects of marital status on long term mortality after the first acute myocardial infarction. METHODS Data were retrieved from the population-based MONICA (Monitoring trends and determinants on cardiovascular diseases)/KORA (Cooperative Health Research in the Region of Augsburg)-myocardial infarction registry which assesses cases from the city of Augsburg and 2 adjacent districts located in southern Bavaria, Germany. A total of 3,766 men and women aged 28 to 74 years who were alive 28 days after their first myocardial infarction were included. Hazard ratios (HR) for the effects of marital status on mortality after one to 10 years of follow-up are presented. RESULTS The study population included 2,854 (75.8%) married individuals. During a median follow-up of 5.3 years, with an inter-quartile range of 3.3 to 7.6 years, 533 (14.15%) deaths occurred. Among married and unmarried individuals 388 (13.6%) and 145 (15.9%) deaths occurred, respectively. Overall marital status showed an insignificant protective HR of 0.76 (95% confidence interval (CI) 0.47-1.22). Stratified analyses revealed strong protective effects only among men and women younger than 60 who were diagnosed with hyperlipidemia. HRs ranged from 0.27 (95% CI 0.13-0.59) for a two-year survival to 0.43 (95% CI 0.27-0.68) for a 10-year survival. Substitution of marital status with co-habitation status confirmed the strata-specific effect [HR: 0.52 (95% CI 0.31-0.86)]. CONCLUSIONS Marital status has a strong protective effect among first myocardial infarction survivors with diagnosed hyperlipidemia, which diminishes with increasing age. Treatments, recommended lifestyle changes or other attributes specific to hyperlipidema may be underlying factors, mediated by the social support of spouses. Underlying causes should be examined in further studies.
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Affiliation(s)
- Philip Andrew Quinones
- Institute of Epidemiology II, Helmholtz-Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Augsburg, Germany
| | - Inge Kirchberger
- Institute of Epidemiology II, Helmholtz-Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Augsburg, Germany
| | - Margit Heier
- Institute of Epidemiology II, Helmholtz-Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Augsburg, Germany
| | - Bernhard Kuch
- Department of Internal Medicine I, Central Hospital of Augsburg, Augsburg, Germany
- Department of Internal Medicine/Cardiology, Hospital of Nördlingen, Nördlingen, Germany
| | - Ines Trentinaglia
- Institute of Epidemiology II, Helmholtz-Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Andreas Mielck
- Institute of Health Economics and Health Care Management, Helmholtz-Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Annette Peters
- Institute of Epidemiology II, Helmholtz-Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Wolfgang von Scheidt
- Department of Internal Medicine I, Central Hospital of Augsburg, Augsburg, Germany
| | - Christa Meisinger
- Institute of Epidemiology II, Helmholtz-Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Augsburg, Germany
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Charach G, Shochat M, Rabinovich A, Ayzenberg O, George J, Charach L, Rabinovich P. Preventive treatment of alveolar pulmonary edema of cardiogenic origin. J Geriatr Cardiol 2013; 9:321-7. [PMID: 23341835 PMCID: PMC3545247 DOI: 10.3724/sp.j.1263.2012.07231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 10/09/2012] [Accepted: 11/23/2012] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of preventive treatment (PT) on alveolar pulmonary edema (APE) of cardiogenic origin using a monitor based on principles of internal thoracic impedance (ITI) measurements. METHODS We conducted blinded clinical trials on patients with ST-elevation myocardial infarction (STEMI) and monitored whether the condition would progress to APE. ITI was measured non-invasively by the Edema Guard Monitor (EGM, model RS-207) every 30 min. The measurement threshold for the diagnosis of APE was fixed at > 12% decrease in ITI from baseline as described in our methodology. The patients were divided into one group that received standard treatment after the appearance of clinical signs of APE without considering the prediction of APE by EGM devise (Group 1), and another group of asymptomatic patients in whom development of APE was predicted by using only EGM measurements (Group 2). The latter participants' PT consisted of furosemide, intravenous nitroglycerine and supplemental oxygen. RESULTS One-hundred and fifty patients with acute STEMI were enrolled into this study. Group 1 included 100 patients (53% males, age 64.1 ± 12.6 years). Treatment was started after the clinical appearance of overt signs of APE. Group 2 included 50 patients (54% males, age 65.2 ± 11.9 years) who received PT based on EGM measurements. Group 2 had significantly fewer cases of APE (n = 4, 8%) than Group 1 (n = 100, 100%) (P > 0.001). While APE was lethal in six (6%) Group 1 patients, PT resulted in prompt resolution of APE in all four (8%) Group 2 patients. CONCLUSION ITI is a useful modality for early diagnosis and PT of pulmonary edema of cardiogenic origin.
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Affiliation(s)
- Gideon Charach
- Department of Internal Medicine "C", Tel Aviv Sourasky Medical Center, 6 Weizman Street Tel Aviv 64239, Israel
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