1
|
Cosentino N, Marenzi G, Muratori M, Magrì D, Cattadori G, Agostoni P. Fluid balance in heart failure. Eur J Prev Cardiol 2023; 30:ii9-ii15. [PMID: 37819223 DOI: 10.1093/eurjpc/zwad166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 10/13/2023]
Abstract
Fluid retention is a major determinant of symptoms in patients with heart failure (HF), and it is closely associated with prognosis. Hence, congestion represents a critical therapeutic target in this clinical setting. The first therapeutic strategy in HF patients with fluid overload is optimization of diuretic intervention to maximize water and sodium excretion. When diuretic therapy fails to relieve congestion, renal replacement therapy represents the only alternative option for fluid removal, as well as a way to restore diuretic responsiveness. On this background, the pathophysiology of fluid balance in HF is complex, with heart, kidney, and lung being deeply involved in volume regulation and management. Therefore, the interplay between these organs should be appreciated and considered when fluid overload in HF patients is targeted.
Collapse
Affiliation(s)
- Nicola Cosentino
- Centro Cardiologico Monzino, I.R.C.C.S., Via Parea 4, Milan 20138, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Giancarlo Marenzi
- Centro Cardiologico Monzino, I.R.C.C.S., Via Parea 4, Milan 20138, Italy
| | - Manuela Muratori
- Centro Cardiologico Monzino, I.R.C.C.S., Via Parea 4, Milan 20138, Italy
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, 'Sapienza' Università degli Studi di Roma, Roma 00198, Italy
| | - Gaia Cattadori
- Unità Operativa Cardiologia Riabilitativa, IRCCS Multimedica, Milan 20123, Italy
| | | |
Collapse
|
2
|
Agostoni P, Salvioni E. Heart and Lungs in Heart Failure Is the Story of a Couple's Uneasy Cohabitation in a One-Bedroom Apartment. Chest 2023; 163:1348-1350. [PMID: 37295873 DOI: 10.1016/j.chest.2022.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 06/12/2023] Open
Affiliation(s)
- Piergiuseppe Agostoni
- Dipartimento di Scienze Cliniche e Medicina di Comunità, Università degli Studi di Milano, Milan, Italy; Centro Cardiologico Monzino, IRCCS, Milan, Italy.
| | | |
Collapse
|
3
|
Mapelli M, Mattavelli I, Salvioni E, Banfi C, Ghilardi S, De Martino F, Gugliandolo P, Mantegazza V, Volpato V, Basile C, Branco Pires MIF, Sassi V, Nusca B, Vignati C, Contini M, Sforza C, Biondi ML, Perrone Filardi P, Agostoni P. Impact of Sacubitril/Valsartan on surfactant binding proteins, central sleep apneas, lung function tests and heart failure biomarkers: Hemodynamic or pleiotropism? Front Cardiovasc Med 2022; 9:971108. [PMID: 36186983 PMCID: PMC9520298 DOI: 10.3389/fcvm.2022.971108] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeLittle is known about the mechanism underlying Sacubitril/Valsartan effects in patients with heart failure (HFrEF). Aim of the study is to assess hemodynamic vs. non-hemodynamic Sacubitril/Valsartan effects by analyzing several biological and functional parameters.MethodsSeventy-nine patients (86% males, age 66 ± 10 years) were enrolled. At baseline and 6 months after reaching the maximum Sacubitril/Valsartan tolerated dose, we assessed biomarkers, transthoracic echocardiography, polysomnography, spirometry, and carbon monoxide diffusing capacity of the lung (DLCO).ResultsMean follow-up was 8.7 ± 1.4 months with 83% of patients reaching Sacubitril/Valsartan maximum dose (97/103 mg b.i.d). Significant improvements were observed in cardiac performance and biomarkers: left ventricular ejection fraction increased (31 ± 5 vs. 37 ± 9 %; p < 0.001), end-diastolic and end-systolic volumes decreased; NT-proBNP decreased (1,196 [IQR 648–2891] vs. 958 [IQR 424-1,663] pg/ml; p < 0.001) in parallel with interleukin ST-2 (28.4 [IQR 19.4–36.6] vs. 20.4 [IQR 15.1–29.2] ng/ml; p < 0.001) and circulating surfactant binding proteins (proSP-B: 58.43 [IQR 40.42–84.23] vs. 50.36 [IQR 37.16–69.54] AU; p = 0.014 and SP-D: 102.17 [IQR 62.85–175.34] vs. 77.64 [IQR 53.55-144.70] AU; p < 0.001). Forced expiratory volume in 1 second and forced vital capacity improved. DLCO increased in the patients' subgroup (n = 39) with impaired baseline values (from 65.3 ± 10.8 to 70.3 ± 15.9 %predicted; p = 0.013). We also observed a significant reduction in central sleep apneas (CSA).ConclusionSacubitril/Valsartan effects share a double pathway: hemodynamic and systemic. The first is evidenced by NT-proBNP, proSP-B, lung mechanics, and CSA improvement. The latter is confirmed by an amelioration of DLCO, ST-2, SP-D as well as by reverse remodeling echocardiographic parameters.
Collapse
Affiliation(s)
- Massimo Mapelli
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Irene Mattavelli
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Elisabetta Salvioni
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Cristina Banfi
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Stefania Ghilardi
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Fabiana De Martino
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Paola Gugliandolo
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Valentina Mantegazza
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Valentina Volpato
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Christian Basile
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | | | - Valentina Sassi
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | | | - Carlo Vignati
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mauro Contini
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Chiarella Sforza
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Maria Luisa Biondi
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- *Correspondence: Piergiuseppe Agostoni ;
| |
Collapse
|
4
|
Abstract
BACKGROUND Pharmacotherapies such as loop diuretics are the cornerstone treatment for acute heart failure (AHF), but resistance and poor response can occur. Ultrafiltration (UF) is an alternative therapy to reduce congestion, however its benefits, efficacy and safety are unclear. OBJECTIVES To assess the effects of UF compared to diuretic therapy on clinical outcomes such as mortality and rehospitalisation rates. SEARCH METHODS We undertook a systematic search in June 2021 of the following databases: CENTRAL, MEDLINE, Embase, Web of Science CPCI-S and ClinicalTrials.gov. We also searched the WHO ICTRP platform in October 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared UF to diuretics in adults with AHF. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for any further information, and language interpreters to translate texts. We assessed risk of bias in included studies using Risk of Bias 2 (RoB2) tool and assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 14 trials involving 1190 people. We included people who had clinical signs of acute hypervolaemia. We excluded critically unwell people such as those with ischaemia or haemodynamic instability. Mean age ranged from 57.5 to 75 years, and the setting was a mix of single and multi-centre. Two trials researched UF as a complimentary therapy to diuretics, while the remaining trials withheld diuretic use during UF. There was high risk of bias in some studies, particularly with deviations from the intended protocols from high cross-overs as well as missing outcome data for long-term follow-up. We are uncertain about the effect of UF on all-cause mortality at 30 days or less (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.13 to 2.85; 3 studies, 286 participants; very low-certainty evidence). UF may have little to no effect on all-cause mortality at the longest available follow-up (RR 1.00, 95% CI 0.73 to 1.36; 9 studies, 987 participants; low-certainty evidence). UF may reduce all-cause rehospitalisation at 30 days or less (RR 0.76, 95% CI 0.53 to 1.09; 3 studies, 337 participants; low-certainty evidence). UF may slightly reduce all-cause rehospitalisation at longest available follow-up (RR 0.91, 95% CI 0.79 to 1.05; 6 studies, 612 participants; low-certainty evidence). UF may reduce heart failure-related rehospitalisation at 30 days or less (RR 0.62, 95% CI 0.37 to 1.04; 2 studies, 395 participants; low-certainty evidence). UF probably reduces heart failure-related rehospitalisation at longest available follow-up, with a number needed to treat for an additional beneficial effect (NNTB) of 10 (RR 0.69, 95% CI 0.53 to 0.90; 4 studies, 636 participants; moderate-certainty evidence). No studies measured need for mechanical ventilation. UF may have little or no effect on serum creatinine change at 30 days since discharge (mean difference (MD) 14%, 95% CI -12% to 40%; 1 study, 221 participants; low-certainty evidence). UF may increase the risk of new initiation of renal replacement therapy at longest available follow-up (RR 1.42, 95% CI 0.42 to 4.75; 4 studies, 332 participants; low-certainty evidence). There is an uncertain effect of UF on the risk of complications from central line insertion in hospital (RR 4.16, 95% CI 1.30 to 13.30; 6 studies, 779 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: This review summarises the latest evidence on UF in AHF. Moderate-certainty evidence shows UF probably reduces heart failure-related rehospitalisation in the long term, with an NNTB of 10. UF may reduce all-cause rehospitalisation at 30 days or less and at longest available follow-up. The effect of UF on all-cause mortality at 30 days or less is unclear, and it may have little effect on all-cause mortality in the long-term. While UF may have little or no effect on serum creatinine change at 30 days, it may increase the risk of new initiation of renal replacement therapy in the long term. The effect on complications from central line insertion is unclear. There is insufficient evidence to determine the true impact of UF on AHF. Future research should evaluate UF as an adjunct therapy, focusing on outcomes such as heart failure-related rehospitalisation, cardiac mortality and renal outcomes at medium- to long-term follow-up.
Collapse
Affiliation(s)
- Mehul Srivastava
- Institute of Health Informatics Research, University College London, London, UK
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Nicholas Harrison
- Department of Emergency Medicine, Division of Research, Indiana University School of Medicine, Indianapolis, MI-Michigan, USA
| | | | - Audrey R Tan
- Institute of Health Informatics Research, University College London, London, UK
| | - Mandy Law
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
| |
Collapse
|
5
|
Liu Y, Yuan X. Efficacy and Renal Tolerability of Ultrafiltration in Acute Decompensated Heart Failure: A Meta-analysis and Systematic Review of 19 Randomized Controlled Trials. Cardiovascular Innovations and Applications 2021. [DOI: 10.15212/cvia.2021.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Acute decompensated heart failure (ADHF) is a life-threatening and costly disease. Controversy remains regarding the efficacy and renal tolerability of ultrafiltration for treating ADHF. We therefore performed this meta-analysis to evaluate this clinical issue.Methods:
A search of PubMed, EMBASE, and the Cochrane database of controlled trials was performed from inception to March 2021 for relevant randomized controlled trials. The quality of the included trials and outcomes was evaluated with the use of the risk of bias assessment tool and the Grading of
Recommendations, Assessment, Development and Evaluation (GRADE) approach, respectively. The risk ratio and the standardized mean difference (SMD) or weighted mean difference (WMD) were computed and pooled with fixed-effects or random-effects models.Results: This meta-analysis included
19 studies involving 1281 patients. Ultrafiltration was superior to the control treatments for weight loss (WMD 1.24 kg, 95% confidence interval [CI] 0.38‐2.09 kg, P=0.004) and fluid removal (WMD 1.55 L, 95% CI 0.51‐2.59 l, P=0.003) and was associated with a significant increase
in serum creatinine level compared with the control treatments (SMD 0.15 mg/dL, 95% CI 0.00‐0.30 mg/dL, P=0.04). However, no significant effects were found for serum N-terminal prohormone of brain natriuretic peptide level, length of hospital stay, all-cause mortality, or all-cause
rehospitalization in the ultrafiltration group.Conclusions: The use of ultrafiltration in patients with ADHF is superior to the use of the control treatments for weight loss and fluid removal, but has adverse renal effects and lacks significant effects on long-term prognosis, indicating
that this approach to decongestion in ADHF patients is efficient for fluid management but less safe renally.
Collapse
Affiliation(s)
- Yajie Liu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Yuan
- Department of Nephrology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
6
|
Sinagra G, Corrà U, Contini M, Magrì D, Paolillo S, Perrone Filardi P, Sciomer S, Badagliacca R, Agostoni P. Choosing among β-blockers in heart failure patients according to β-receptors' location and functions in the cardiopulmonary system. Pharmacol Res 2020; 156:104785. [PMID: 32224252 DOI: 10.1016/j.phrs.2020.104785] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/05/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Abstract
Several large clinical trials showed a favorable effect of β-blocker treatment in patients with chronic heart failure (HF) as regards overall mortality, cardiovascular mortality, and hospitalizations. Indeed, the use of β-blockers is strongly recommended by current international guidelines, and it remains a cornerstone in the pharmacological treatment of HF. Although different types of β-blockers are currently approved for HF therapy, possible criteria to choose the best β-blocking agent according to HF patients' characteristics and to β-receptors' location and functions in the cardiopulmonary system are still lacking. In such a context, a growing body of literature shows remarkable differences between β-blocker types (β1-selective blockers versus β1-β2 blockers) with respect to alveolar-capillary gas diffusion and chemoreceptor response in HF patients, both factors able to impact on quality of life and, most likely, on prognosis. This review suggests an original algorithm for choosing among the currently available β-blocking agents based on the knowledge of cardiopulmonary pathophysiology. Particularly, starting from lung physiology and from some experimental models, it focuses on the mechanisms underlying lung mechanics, chemoreceptors, and alveolar-capillary unit impairment in HF. This paper also remarks the significant benefit deriving from the correct use of the different β-blockers in HF patients through a brief overview of the most important clinical trials.
Collapse
Affiliation(s)
- Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Ugo Corrà
- Cardiology Department, Istituti Clinici Scientifici Maugeri, Veruno Institute, Veruno, Italy
| | | | - Damiano Magrì
- Department of Clinical and Molecular Medicine, "Sapienza" Università Degli Studi Di Roma, Roma, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | | | - Susanna Sciomer
- Dipartimento Di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "Sapienza" Università Degli Studi Di Roma, Roma, Italy
| | - Roberto Badagliacca
- Dipartimento Di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "Sapienza" Università Degli Studi Di Roma, Roma, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy.
| |
Collapse
|
7
|
Agostoni P, Dumitrescu D. How to perform and report a cardiopulmonary exercise test in patients with chronic heart failure. Int J Cardiol 2019; 288:107-113. [DOI: 10.1016/j.ijcard.2019.04.053] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/04/2019] [Accepted: 04/16/2019] [Indexed: 01/01/2023]
|
8
|
Abstract
BACKGROUND Pulmonary function tests (PFTs) are routinely performed in the upright position due to measurement devices and patient comfort. This systematic review investigated the influence of body position on lung function in healthy persons and specific patient groups. METHODS A search to identify English-language papers published from 1/1998-12/2017 was conducted using MEDLINE and Google Scholar with key words: body position, lung function, lung mechanics, lung volume, position change, positioning, posture, pulmonary function testing, sitting, standing, supine, ventilation, and ventilatory change. Studies that were quasi-experimental, pre-post intervention; compared ≥2 positions, including sitting or standing; and assessed lung function in non-mechanically ventilated subjects aged ≥18 years were included. Primary outcome measures were forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC, FEV1/FVC), vital capacity (VC), functional residual capacity (FRC), maximal expiratory pressure (PEmax), maximal inspiratory pressure (PImax), peak expiratory flow (PEF), total lung capacity (TLC), residual volume (RV), and diffusing capacity of the lungs for carbon monoxide (DLCO). Standing, sitting, supine, and right- and left-side lying positions were studied. RESULTS Forty-three studies met inclusion criteria. The study populations included healthy subjects (29 studies), lung disease (nine), heart disease (four), spinal cord injury (SCI, seven), neuromuscular diseases (three), and obesity (four). In most studies involving healthy subjects or patients with lung, heart, neuromuscular disease, or obesity, FEV1, FVC, FRC, PEmax, PImax, and/or PEF values were higher in more erect positions. For subjects with tetraplegic SCI, FVC and FEV1 were higher in supine vs. sitting. In healthy subjects, DLCO was higher in the supine vs. sitting, and in sitting vs. side-lying positions. In patients with chronic heart failure, the effect of position on DLCO varied. CONCLUSIONS Body position influences the results of PFTs, but the optimal position and magnitude of the benefit varies between study populations. PFTs are routinely performed in the sitting position. We recommend the supine position should be considered in addition to sitting for PFTs in patients with SCI and neuromuscular disease. When treating patients with heart, lung, SCI, neuromuscular disease, or obesity, one should take into consideration that pulmonary physiology and function are influenced by body position.
Collapse
Affiliation(s)
- Shikma Katz
- Chronic Ventilator-Dependent Division, Herzog Medical Center, POB 3900, Jerusalem, Israel
- 0000 0004 1937 0511grid.7489.2Recanati School for Community Health Professions, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Nissim Arish
- Pulmonary Institute, Shaare Zedek Medical Center, POB 3235, Jerusalem, Israel
- 0000 0004 1937 0538grid.9619.7Hebrew University-Hadassah Faculty of Medicine, Jerusalem, Israel
| | - Ariel Rokach
- Pulmonary Institute, Shaare Zedek Medical Center, POB 3235, Jerusalem, Israel
- 0000 0004 1937 0538grid.9619.7Hebrew University-Hadassah Faculty of Medicine, Jerusalem, Israel
| | - Yacov Zaltzman
- Chronic Ventilator-Dependent Division, Herzog Medical Center, POB 3900, Jerusalem, Israel
| | - Esther-Lee Marcus
- Chronic Ventilator-Dependent Division, Herzog Medical Center, POB 3900, Jerusalem, Israel
- 0000 0004 1937 0538grid.9619.7Hebrew University-Hadassah Faculty of Medicine, Jerusalem, Israel
| |
Collapse
|
9
|
Campodonico J, Mapelli M, Spadafora E, Ghilardi S, Agostoni P, Banfi C, Sciomer S. Surfactant proteins changes after acute hemodynamic improvement in patients with advanced chronic heart failure treated with Levosimendan. Respir Physiol Neurobiol 2018; 252-253:47-51. [PMID: 29548887 DOI: 10.1016/j.resp.2018.03.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 10/17/2022]
Abstract
Alveolar-capillary membrane evaluated by carbon monoxide diffusion (DLCO) plays an important role in heart failure (HF). Surfactant Proteins (SPs) have also been suggested as a worthwhile marker. In HF, Levosimendan improves pulmonary hemodynamics and reduces lung fluids but associated SPs and DLCO changes are unknown. Sixty-five advanced HF patients underwent spirometry, cardiopulmonary exercise test (CPET) and SPs determination before and after Levosimendan. Levosimendan caused natriuretic peptide-B (BNP) reduction, peakVO2 increase and VE/VCO2 slope reduction. Spirometry improved but DLCO did not. SP-A, SP-D and immature SP-B reduced (73.7 ± 25.3 vs. 66.3 ± 22.7 ng/mL*, 247 ± 121 vs. 223 ± 110 ng/mL*, 39.4 ± 18.7 vs. 34.4 ± 17.9AU*, respectively); while mature SP-B increased (424 ± 218 vs. 461 ± 243 ng/mL, * = p < 0.001). Spirometry, BNP and CPET changes suggest hemodynamic improvement and lung fluid reduction. SP-A, SP-D and immature SP-B reduction indicates a reduction of inflammatory stress; conversely mature SP-B increase suggests alveolar cell function restoration. In conclusion, acute lung fluid reduction is associated with SPs but not DLCO changes. SPs are fast responders to alveolar-capillary membrane condition changes.
Collapse
Affiliation(s)
| | | | | | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy; Dipartimento di Scienze Cliniche e di Comunità, Sezione Cardiovascolare, Università di Milano, Italy.
| | | | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesioloigiche e Geriatriche, "Sapienza", Rome University, Rome, Italy
| |
Collapse
|
10
|
Abstract
In patients with severe congestive heart failure (CHF), removal of edema by hemofiltration is associated with significant clinical and hemodynamic improvement, correction of hyponatremia, restoration of urine output and diuretic responsiveness, and with a striking fall in neurohormonal activation. Through these effects, hemofiltration is able to interrupt the progression of CHF toward refractoriness, and to revert the clinical condition of CHF patients to a lower functional class. Fluid refilling from the overhydrated interstitium is the major compensatory mechanism in the prevention of hypovolemia during hemofiltration. Hemofiltration can also be beneficial in patients who have only moderate cardiac insufficiency (NYHA classes II and III) and in whom over-hydration is restricted to the pulmonary district significantly contributing to limiting patients functional capacity. In this setting, hemofiltration, differently from diuretics, is able to remove the increased lung water content and to improve clinical condition, exercise capacity and lung function.
Collapse
Affiliation(s)
- G Marenzi
- Centro Cardiologico Monzino, IRCCS, Institute of Cardiology, University of Milan, Milan, Italy.
| | | |
Collapse
|
11
|
Abstract
Most patients presenting with acute heart failure (AHF) show signs and symptoms of fluid overload, which are closely associated with short-term and long-term outcomes. Ultrafiltration is an extremely appealing strategy for patients with AHF and concomitant overt fluid overload not fully responsive to diuretic therapy. However, although there are several theoretical beneficial effects associated with ultrafiltration, published reports have shown controversial findings. Differences in selection of the study population and in ultrafiltration indications and protocols, and high variability in the pharmacologic therapy used for the control group could explain some of these conflicting results. Here, we aimed to provide an overview on the current medical evidence supporting the use of ultrafiltration in AHF, with a special focus on the identification of potential candidates who may benefit the most from this therapeutic option.
Collapse
Affiliation(s)
- Valentina Milazzo
- Intensive Cardiac Care Unit, Centro Cardiologico Monzino, I.R.C.C.S., Milan, Italy
| | - Nicola Cosentino
- Intensive Cardiac Care Unit, Centro Cardiologico Monzino, I.R.C.C.S., Milan, Italy
| | - Giancarlo Marenzi
- Intensive Cardiac Care Unit, Centro Cardiologico Monzino, I.R.C.C.S., Milan, Italy
| |
Collapse
|
12
|
Costanzo MR, Ronco C, Abraham WT, Agostoni P, Barasch J, Fonarow GC, Gottlieb SS, Jaski BE, Kazory A, Levin AP, Levin HR, Marenzi G, Mullens W, Negoianu D, Redfield MM, Tang WHW, Testani JM, Voors AA. Extracorporeal Ultrafiltration for Fluid Overload in Heart Failure: Current Status and Prospects for Further Research. J Am Coll Cardiol 2017; 69:2428-45. [PMID: 28494980 DOI: 10.1016/j.jacc.2017.03.528] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 03/07/2017] [Indexed: 01/18/2023]
Abstract
More than 1 million heart failure hospitalizations occur annually, and congestion is the predominant cause. Rehospitalizations for recurrent congestion portend poor outcomes independently of age and renal function. Persistent congestion trumps serum creatinine increases in predicting adverse heart failure outcomes. No decongestive pharmacological therapy has reduced these harmful consequences. Simplified ultrafiltration devices permit fluid removal in lower-acuity hospital settings, but with conflicting results regarding safety and efficacy. Ultrafiltration performed at fixed rates after onset of therapy-induced increased serum creatinine was not superior to standard care and resulted in more complications. In contrast, compared with diuretic agents, some data suggest that adjustment of ultrafiltration rates to patients’ vital signs and renal function may be associated with more effective decongestion and fewer heart failure events. Essential aspects of ultrafiltration remain poorly defined. Further research is urgently needed, given the burden of congestion and data suggesting sustained benefits of early and adjustable ultrafiltration.
Collapse
|
13
|
Mittal MK, Katta N, Alpert MA. Role of isolated ultrafiltration in the management of chronic refractory and acute decompensated heart failure. Hemodial Int 2016; 20 Suppl 1:S30-S39. [PMID: 27669547 DOI: 10.1111/hdi.12464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Chronic congestive heart failure (CHF) and acute decompensated heart failure (ADHF) refractory to medical therapy represent therapeutic challenges. In such patients, attempts to reduce pulmonary and systemic congestion frequently produce deterioration of renal function. In studies of patients with chronic severe CHF refractory to medical therapy (including loop diuretics), isolated ultrafiltration was frequently able to relieve congestive symptoms by precise removal of extracellular water and sodium, and in some cases was able to restore responsiveness to loop diuretics. Randomized controlled trials comparing isolated ultrafiltration and medical therapy (mainly loop diuretics) in patients with ADHF failed to demonstrate the superiority of isolated ultrafiltration over diuretic therapy with respect to renal function and mortality. Isolated ultrafiltration reduced length of hospital stay in several studies. At this time, there is insufficient evidence to support the use of isolated ultrafiltration as initial therapy of ADHF.
Collapse
Affiliation(s)
- Mayank K Mittal
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Natraj Katta
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Martin A Alpert
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA.
| |
Collapse
|
14
|
Taron-Brocard C, Looten V, Fahlgren B, Charpentier E, Guillevin L, Barna A. [Congestive heart failure: Treatment with ultrafiltration]. Ann Cardiol Angeiol (Paris) 2016; 65:240-244. [PMID: 27344095 DOI: 10.1016/j.ancard.2016.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 04/29/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION The prevalence rate of congestive heart failure is approximately 2% in high-income countries. The aim of this study was to assess the overall benefit of ultrafiltration therapy in patients with acute or persistent congestive heart failure. METHODS We conducted a health technology assessment following the EUnetHTA guidelines, with systematic literature review from bibliographic medical databases, independent experts and manufacturer interviews. RESULTS Thirteen clinical trials and five meta-analyses were examined. In the most recent one, 608 patients were included, of which 304 received ultrafiltration therapy and 304 received intravenous loop diuretics. Ultrafiltration therapy seems to be more beneficial regarding the fluid removal and the body weight reduction, (mean difference respectively 1.44kg, IC95% [0.29; 2.59], P-value=0.01 and 1.28L [0.43; 2.12], P-value=0.003). No difference has been showed in overall mortality, renal function, hospital readmission or safety. Medico-economic studies are incomplete and contradictory. CONCLUSION Ultrafiltration therapy seems to be effective, most likely for patients ineligible or resistant to intravenous diuretics. But most topics remain uncertain, mainly impact on overall mortality, safety and cost-effectiveness. Given these knowledge-gaps, the generalization of ultrafiltration therapy should be examined cautiously, and conditional upon a large-scale systematic evaluation.
Collapse
Affiliation(s)
- C Taron-Brocard
- Comité d'évaluation et de diffusion des innovations technologiques (CEDIT), AP-HP, 3, avenue Victoria, 75004 Paris, France.
| | - V Looten
- Comité d'évaluation et de diffusion des innovations technologiques (CEDIT), AP-HP, 3, avenue Victoria, 75004 Paris, France
| | - B Fahlgren
- Comité d'évaluation et de diffusion des innovations technologiques (CEDIT), AP-HP, 3, avenue Victoria, 75004 Paris, France
| | - E Charpentier
- Comité d'évaluation et de diffusion des innovations technologiques (CEDIT), AP-HP, 3, avenue Victoria, 75004 Paris, France
| | - L Guillevin
- Comité d'évaluation et de diffusion des innovations technologiques (CEDIT), AP-HP, 3, avenue Victoria, 75004 Paris, France
| | - A Barna
- Comité d'évaluation et de diffusion des innovations technologiques (CEDIT), AP-HP, 3, avenue Victoria, 75004 Paris, France
| |
Collapse
|
15
|
Dubé BP, Agostoni P, Laveneziana P. Exertional dyspnoea in chronic heart failure: the role of the lung and respiratory mechanical factors. Eur Respir Rev 2016; 25:317-32. [DOI: 10.1183/16000617.0048-2016] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 06/13/2016] [Indexed: 11/05/2022] Open
Abstract
Exertional dyspnoea is among the dominant symptoms in patients with chronic heart failure and progresses relentlessly as the disease advances, leading to reduced ability to function and engage in activities of daily living. Effective management of this disabling symptom awaits a better understanding of its underlying physiology.Cardiovascular factors are believed to play a major role in dyspnoea in heart failure patients. However, despite pharmacological interventions, such as vasodilators or inotropes that improve central haemodynamics, patients with heart failure still complain of exertional dyspnoea. Clearly, dyspnoea is not determined by cardiac factors alone, but likely depends on complex, integrated cardio-pulmonary interactions.A growing body of evidence suggests that excessively increased ventilatory demand and abnormal “restrictive” constraints on tidal volume expansion with development of critical mechanical limitation of ventilation, contribute to exertional dyspnoea in heart failure. This article will offer new insights into the pathophysiological mechanisms of exertional dyspnoea in patients with chronic heart failure by exploring the potential role of the various constituents of the physiological response to exercise and particularly the role of abnormal ventilatory and respiratory mechanics responses to exercise in the perception of dyspnoea in patients with heart failure.
Collapse
|
16
|
Abstract
Heart failure remains a major public health concern because of its high prevalence, morbidity, mortality, and financial burden. The poor clinical outcomes associated with acute decompensated heart failure, suboptimal efficacy and safety profile of conventional treatment regimens, and unsatisfactory experiences with the newer classes of pharmacologic therapy underlie the interest in the use of extracorporeal isolated ultrafiltration in this setting. In this article, selected mechanistic aspects of ultrafiltration therapy are briefly reviewed followed by a critical overview of the largest trials in this field. I will discuss the clinical relevance of renal dysfunction and decongestion as two commonly used end points of safety and efficacy in the ultrafiltration trials, with emphasis on the emerging pertinent notions that could challenge our conventional thinking. Finally, a number of practical recommendations (e.g., customization of ultrafiltration rates) are provided for ultrafiltration therapy in the setting of acute decompensated heart failure. Because of a paucity of evidence, universally accepted consensus guidelines cannot yet be generated. As such, when considering ultrafiltration therapy for acute decompensated heart failure, the likely benefits should be carefully balanced against the potential risks for an individual patient. A conceivable implication of the ultrafiltration trials is that collaborative heart failure programs benefiting from nephrology expertise and resources could improve the outcomes and reduce the cost.
Collapse
Affiliation(s)
- Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida
| |
Collapse
|
17
|
|
18
|
|
19
|
Plácido R, Mebazaa A. Update: Acute Heart Failure (VII): Nonpharmacological Management of Acute Heart Failure. ACTA ACUST UNITED AC 2015; 68:794-802. [PMID: 26169327 DOI: 10.1016/j.rec.2015.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 05/11/2015] [Indexed: 11/22/2022]
Abstract
Acute heart failure is a major and growing public health problem worldwide with high morbidity, mortality, and cost. Despite recent advances in pharmacological management, the prognosis of patients with acute decompensated heart failure remains poor. Consequently, nonpharmacological approaches are being developed and increasingly used. Such techniques may include several modalities of ventilation, ultrafiltration, mechanical circulatory support, myocardial revascularization, and surgical treatment, among others. This document reviews the nonpharmacological approach in acute heart failure, indications, and prognostic implications.
Collapse
|
20
|
Marenzi G, Morpurgo M, Agostoni P. Continuous ultrafiltration in acute decompensated heart failure: current issues and future directions. Am J Cardiovasc Drugs 2015; 15:103-12. [PMID: 25650293 DOI: 10.1007/s40256-015-0107-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Most patients hospitalized for acutely decompensated heart failure (ADHF) present with symptoms and signs of volume overload, which are also associated with high rates of death and re-hospitalization. Several studies have investigated the possible use of extracorporeal ultrafiltration in the management of ADHF, evaluating potential clinical benefits in terms of hospitalization and survival rates versus those of conventional diuretic therapy. Though ultrafiltration remains an extremely appealing therapeutic option for patients with AHDF, some of the most recent studies have reported conflicting results. Differences in the selection of study population, heterogeneity of the indications for the use of ultrafiltration, disparity in the ultrafiltration protocols, and high variability in the pharmacologic therapies used for the control group could explain some of these contradictory findings. The purpose of the present review is to provide an overview and an update on the mechanisms and clinical effects of ultrafiltration and on currently available evidence supporting its use in ADHF.
Collapse
|
21
|
Brunot V, Daubin D, Besnard N, Gilles V, Jonquet O, Klouche K. Ultrafiltration veinoveineuse isolée dans la prise en charge de l’insuffisance cardiaque congestive et du syndrome cardiorénal. Réanimation 2014. [DOI: 10.1007/s13546-014-0918-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
22
|
Canaud B, Bowry SK, Tetta C, Gatti E. The Case for Treating Refractory Congestive Heart Failure with Ultrafiltration. Blood Purif 2014; 37 Suppl 2:51-60. [DOI: 10.1159/000361063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
23
|
Marana I, Marenzi G, Kazory A. Extracorporeal ultrafiltration for heart failure: focus on organ cross talk and clinical trials. Nephrol Ther 2014; 10:203-9. [PMID: 24997009 DOI: 10.1016/j.nephro.2014.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 01/21/2014] [Accepted: 02/12/2014] [Indexed: 12/15/2022]
Abstract
Despite major advances in pharmacological therapy and cardiac devices, heart failure patients continue to be frequently (re-)hospitalized with signs and symptoms of fluid overload. Diuretics improve the symptoms of fluid overload, but their effectiveness is reduced by a number of factors including excess salt intake, underlying chronic kidney disease, renal adaptation to their actions and neurohormonal activation. Ultrafiltration (UF) is a mechanical method of fluid removal with several potential advantages over diuretic-based conventional therapies: several recent studies have demonstrated favorable clinical response to UF therapy. Such studies have shown that removal of large amounts of isotonic fluid, in addition to relieving symptoms of congestion, can improve exercise capacity, reduce cardiac filling pressures, restore diuretic responsiveness, and portend a favorable effect on cardio-pulmonary, cardiorenal interactions, and neurohormonal hyperactivation. However, despite these proposed benefits, so far, no clinical study has yet been carried out to explore the impact of UF therapy on hard clinical endpoints such as long-term mortality. In this article, we review a number of mechanistic aspects of UF therapy, with particular emphasis on cardio-pulmonary and cardiorenal interactions, and revisit the results of more recent clinical trials in order to highlight the characteristics that can help identify patients who are more likely to benefit from this therapeutic modality.
Collapse
Affiliation(s)
- Ivana Marana
- Centro Cardiologico Monzino, IRCCS, university of Milan, Milan, Italy
| | - Giancarlo Marenzi
- Centro Cardiologico Monzino, IRCCS, university of Milan, Milan, Italy
| | - Amir Kazory
- Division of nephrology, hypertension, and renal transplantation, university of Florida, 1600 SW Archer road, 32610-0224 Gainesville, Florida, USA.
| |
Collapse
|
24
|
Kwong JS, Yu CM. Ultrafiltration for acute decompensated heart failure: A systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 2014; 172:395-402. [DOI: 10.1016/j.ijcard.2014.01.069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 01/13/2014] [Accepted: 01/18/2014] [Indexed: 12/22/2022]
|
25
|
Marenzi G, Muratori M, Cosentino ER, Rinaldi ER, Donghi V, Milazzo V, Ferramosca E, Borghi C, Santoro A, Agostoni P. Continuous Ultrafiltration for Congestive Heart Failure: The CUORE Trial. J Card Fail 2014; 20:9-17. [DOI: 10.1016/j.cardfail.2013.11.004] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/31/2013] [Accepted: 11/12/2013] [Indexed: 12/01/2022]
|
26
|
Costanzo MR, Jessup M. Treatment of congestion in heart failure with diuretics and extracorporeal therapies: effects on symptoms, renal function, and prognosis. Heart Fail Rev 2013; 17:313-24. [PMID: 21559880 DOI: 10.1007/s10741-011-9248-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In the United States and Europe, approximately 90% of heart failure hospitalizations are due to symptoms and signs of sodium and fluid excess. Congestion is associated with heart failure progression. Venous congestion, rather than a reduced cardiac output, may be the primary hemodynamic factor driving worsening renal function in patients with acutely decompensated heart failure. According to data from large national registries, approximately 40% of hospitalized heart failure patients are discharged with unresolved congestion, which may contribute to unacceptably high re-hospitalization rates. Diuretics reduce the symptoms and signs of fluid overload, but their effectiveness can be reduced by excess salt intake, underlying chronic kidney disease, renal adaptation to their action, and neurohormonal activation. In addition, the production of hypotonic urine limits the ability of loop diuretics to reduce total body sodium. Ultrafiltration is the mechanical removal of fluid from the vasculature. Hydrostatic pressure is applied to blood across a semipermeable membrane to separate isotonic plasma water from blood. Because solutes in blood freely cross the semipermeable membrane, fluid can be removed without causing significant changes in the serum concentration of electrolytes and other solutes. Relatively small, mostly single-center clinical studies of ultrafiltration have shown that removal of isotonic fluid may relieve symptoms of congestion and restore diuretic responsiveness in patients with diuretic resistance. These studies have also shown a favorable effect on neurohormonal activation. When compared with intravenous diuretics, ultrafiltration similarly changed dyspnea scores but reduced re-hospitalizations (28 of 87 patients (32%) versus 16 of 89 patients (18%), P < 0.037) in a randomized controlled trial of patients with decompensated heart failure. Future larger controlled clinical trials should evaluate further the effect of ultrafiltration on patients' outcomes, including survival.
Collapse
Affiliation(s)
- Maria Rosa Costanzo
- Midwest Heart Foundation, Edward Heart Hospital, 4th Floor, 801 South Washington Street, P.O. Box 3226, Naperville, IL 60566, USA.
| | | |
Collapse
|
27
|
Felker GM, Mentz RJ. Diuretics and ultrafiltration in acute decompensated heart failure. J Am Coll Cardiol 2012; 59:2145-53. [PMID: 22676934 DOI: 10.1016/j.jacc.2011.10.910] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 10/11/2011] [Accepted: 10/17/2011] [Indexed: 01/11/2023]
Abstract
Congestion and volume overload are the hallmarks of acute decompensated heart failure (ADHF), and loop diuretics have historically been the cornerstone of treatment. The demonstrated efficacy of loop diuretics in managing congestion is balanced by the recognized limitations of diuretic resistance, neurohormonal activation, and worsening renal function. However, the recently published DOSE (Diuretic Optimization Strategies Evaluation) trial suggests that previous concerns about the safety of high-dose diuretics may not be valid. There has been a growing interest in alternative strategies to manage volume retention in ADHF with improved efficacy and safety profiles. Peripheral venovenous ultrafiltration (UF) represents a potentially promising approach to volume management in ADHF. Small studies suggest that UF may allow for more effective fluid removal compared with diuretics, with improved quality of life and reduced rehospitalization rates. However, further investigation is needed to completely define the role of UF in patients with ADHF. This review summarizes available data on the use of both diuretics and UF in ADHF patients and identifies challenges and unresolved questions for each approach.
Collapse
Affiliation(s)
- G Michael Felker
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
| | | |
Collapse
|
28
|
Sands SA, Edwards BA, Kee K, Turton A, Skuza EM, Roebuck T, O'Driscoll DM, Hamilton GS, Naughton MT, Berger PJ. Loop Gain As a Means to Predict a Positive Airway Pressure Suppression of Cheyne-Stokes Respiration in Patients with Heart Failure. Am J Respir Crit Care Med 2011; 184:1067-75. [DOI: 10.1164/rccm.201103-0577oc] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
29
|
Fiaccadori E, Regolisti G, Maggiore U, Parenti E, Cremaschi E, Detrenis S, Caiazza A, Cabassi A. Ultrafiltration in heart failure. Am Heart J 2011; 161:439-49. [PMID: 21392597 DOI: 10.1016/j.ahj.2010.09.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 09/23/2010] [Indexed: 01/04/2023]
Abstract
Fluid overload is a key pathophysiologic mechanism underlying both the acute decompensation episodes of heart failure and the progression of the syndrome. Moreover, it represents the most important factor responsible for the high readmission rates observed in these patients and is often associated with renal function worsening, which by itself increases mortality risk. In this clinical context, ultrafiltration (UF) has been proposed as an alternative to diuretics to obtain a quicker relief of pulmonary/systemic congestion. This review illustrates technical issues, mechanisms, efficacy, safety, costs, and indications of UF in heart failure. The available evidence does not support the widespread use of UF as a substitute for diuretic therapy. Owing to its operative characteristics, UF cannot be expected to directly influence serum electrolyte levels, azotemia, and acid-base balance, or to remove high-molecular-weight substances (eg, cytokines) in clinically relevant amounts. Ultrafiltration should be used neither as a quicker way to achieve a sort of mechanical diuresis nor as a remedy for an inadequately prescribed and administered diuretic therapy. Instead, it should be reserved to selected patients with advanced heart failure and true diuretic resistance, as part of a more complex strategy aiming at an adequate control of fluid retention.
Collapse
Affiliation(s)
- Enrico Fiaccadori
- Dipartimento di Clinica Medica, Nefrologia e Scienze della Prevenzione, Universita' degli Studi di Parma, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Abstract
AIMS Heart failure (HF) patients breathe with a rapid shallow pattern during exercise. This study examined the relationship between cardiac size and tachypnoeic breathing in HF patients during exercise. METHODS AND RESULTS Thirty-seven HF patients [age = 55 ± 13 years, ejection fraction (EF) = 27 ± 10%, New York Heart Association (NYHA) class = 2.3 ± 1.2] and 42 controls (CTL) (age = 56 ± 14 years, EF = 63 ± 8%) were recruited. Participants underwent maximal exercise testing, pulmonary function testing, and chest radiography for calculation of total thoracic cavity volume (TTCV), diaphragm, heart, and lung volumes. Heart failure patients were divided into two groups: Group A = cardiac volume < median (n = 18) and Group B = cardiac volume ≥ median of the HF patients (n = 19). There was no difference between groups for TTCV (CTL = 8203 ± 1489 vs. Group A = 8694 ± 1249 vs. Group B = 8195 ± 1823 cm(3)). Cardiac volume was different between groups for both absolute (CTL = 630 ± 181 vs. Group A = 894 ± 186 vs. Group B = 1401 ± 382 cm(3), P< 0.001 for all comparisons) and %TTCV (CTL = 8 ± 2 vs. Group A = 10 ± 1 vs. Group A = 18 ± 5%, P< 0.001 for all comparisons). Similarly, total lung volume as a %TTCV was significantly different among the groups (CTL = 70 ± 4 vs. Group A = 65 ± 5 vs. Group A = 58 ± 7%, P< 0.01 for all comparisons). In HF patients, there was a trend (P = 0.10) towards an independent association between cardiac size and tidal volume (V(T)) at 75% of VO(2) peak whereas this relationship was statistically significant at VO(2) peak (P = 0.02) as patients with larger cardiac size had reduced V(T). CONCLUSION This study demonstrates the close relationship between cardiac size and breathing pattern during exercise in HF patients. These results suggest cardiac size may pose a significant constraint on the lungs during exercise and may contribute to tachypnoeic breathing.
Collapse
Affiliation(s)
- Thomas P Olson
- Division of Cardiovascular Diseases, Department of Internal Medicine, Joseph 4-221, Mayo Clinic and Foundation, Rochester, MN 55905, USA.
| | | |
Collapse
|
31
|
Bart BA. Treatment of congestion in congestive heart failure: ultrafiltration is the only rational initial treatment of volume overload in decompensated heart failure. Circ Heart Fail 2009; 2:499-504. [PMID: 19808381 DOI: 10.1161/circheartfailure.109.863381] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Bradley A Bart
- Division of Cardiology, Hennepin County Medical Center, and the University of Minnesota, Minneapolis, Minn, USA.
| |
Collapse
|
32
|
Abstract
Relief of congestive symptoms is a primary goal in treating heart failure. Ultrafiltration is a tool that can be used to safely remove sodium and water from whole blood at a controlled rate. Ultrafiltration decreases symptoms, relieves congestion, and improves hemodynamics, neurohormonal balance, and exercise capacity. This article describes the importance of congestion as a therapeutic target in heart failure and outlines the development of ultrafiltration as a treatment to address this important physiologic state.
Collapse
Affiliation(s)
- Marit Thorsgard
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA
| | | |
Collapse
|
33
|
Laveneziana P, O'Donnell DE, Ofir D, Agostoni P, Padeletti L, Ricciardi G, Palange P, Duranti R, Scano G. Effect of biventricular pacing on ventilatory and perceptual responses to exercise in patients with stable chronic heart failure. J Appl Physiol (1985) 2009; 106:1574-83. [DOI: 10.1152/japplphysiol.90744.2008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Despite the growing evidence supporting the use of biventricular cardiac resynchronization therapy (CRT) in patients with chronic heart failure (CHF), the mechanisms whereby acute hemodynamic improvements lead to improved exertional dyspnea are not precisely known. We hypothesized that improved cardiac function and ventilation-perfusion relations following CRT would reduce ventilatory demand, thereby improving dynamic operating lung volumes and enhancing tidal volume expansion during exercise. This, in turn, would be expected to reduce perceived exertional dyspnea and contribute to improved exercise performance. In a randomized, double-blind, crossover study, we compared cardiovascular, metabolic, ventilatory responses (breathing pattern, operating lung volumes, pulmonary gas exchange) and exertional symptoms in seven stable CHF patients who undertook incremental cardiopulmonary cycle exercise test with CRT switched to the “on” (CRTon) or “off” (CRToff) modality. Following CRTon, peak oxygen uptake was significantly increased by 15%, and dyspnea ratings were lower for a given work rate (at work rate of 40 W, dyspnea = 1 ± 0.4 vs. 2.5 ± 0.9 Borg units, P < 0.05) and ventilation (at ventilation of 31 l/min, dyspnea = 2 ± 0.7 vs. 3.3 ± 1.1 Borg units, P < 0.05). CRTon was associated with improvements in ventilatory threshold, oxygen pulse, and oxygen uptake/work rate relationships (10.2 ± 1 vs. 7.9 ± 1.3 ml·min−1·W−1, P < 0.05). CRTon reduced the ventilatory requirement during exercise as well as the steepness of ventilation-CO2 production slope (35 ± 4 vs. 45 ± 7, P < 0.05). Changes in end-expiratory lung volume during exercise were less with CRTon than with CRToff (0.12 vs. 0.37 liter, P < 0.05), and breathing pattern was correspondingly slower and deeper. Biventricular pacing improved all noninvasive indexes of cardiac function and oxygen delivery during exercise. The decreased ventilatory demand, improved dynamic operating lung volumes, and the increased ability to expand tidal volume during exercise are potential factors in the reduction of exertional dyspnea.
Collapse
|
34
|
|
35
|
Warburton DER, Taylor A, Bredin SSD, Esch BTA, Scott JM, Haykowsky MJ. Central haemodynamics and peripheral muscle function during exercise in patients with chronic heart failure. Appl Physiol Nutr Metab 2007; 32:318-31. [PMID: 17486176 DOI: 10.1139/h06-085] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this narrative review of the current literature, we examine the central and peripheral mechanisms responsible for the exercise intolerance of chronic heart failure and highlight briefly the benefits of exercise training in the treatment of this debilitating disorder. Specifically, we identify the common finding of reduced cardiac output reserve during exercise conditions leading to decreased exercise tolerance. We also reveal that the stroke volume response to exercise varies depending on the individual patient, the presence of mitral regurgitation, and the aetiology of heart failure. Chronic heart failure patients with left ventricular systolic dysfunction appear able to use the Frank-Starling mechanism to compensate (in part) for their decreased contractile reserve. Patients with left ventricular diastolic dysfunction have normal contractile function; however, they are unable to make use of the Frank-Starling mechanism during exercise conditions. We also reveal that pericardial constraint may limit diastolic filling and exercise capacity in patients with chronic heart failure. It appears that interventions that reduce pericardial constraint and mitral regurgitation enhance diastolic filling and increase exercise tolerance. A series of peripheral muscle changes also occur, including changes in muscle mass, cellular structure, energy metabolism, and blood flow. Each of these factors is associated with decreased exercise capacity and the symptoms of chronic heart failure. Exercise training has been shown to improve both central haemodynamics and peripheral muscle function leading to improvements in exercise capacity, functional status, and overall quality of life in patients with chronic heart failure.
Collapse
Affiliation(s)
- Darren E R Warburton
- Cardiovascular Physiology and Rehabilitation Laboratory, 6108 Thunderbird Blvd., University of British Columbia, Vancouver, BC V6T 1Z3, Canada.
| | | | | | | | | | | |
Collapse
|
36
|
Williams L, Frenneaux M. Diastolic ventricular interaction: from physiology to clinical practice. ACTA ACUST UNITED AC 2006; 3:368-76. [PMID: 16810172 DOI: 10.1038/ncpcardio0584] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Accepted: 03/30/2006] [Indexed: 11/08/2022]
Abstract
The ventricles share a common septum and, therefore, the filling of one influences the compliance of the other. This phenomenon is known as direct diastolic ventricular interaction. The interaction is noticeably increased when the force exerted by the surrounding pericardium is raised, which is termed pericardial constraint. In healthy individuals, pericardial constraint is minor in the resting state. When right ventricular volume-to-pressure ratio acutely increases, however, such as during exercise, massive pulmonary embolism, or right ventricular infarction, notable diastolic ventricular interaction occurs. In this setting, the measured left ventricular intracavitary diastolic pressure overestimates the true left ventricular filling pressure, because the effect of external forces must be subtracted. Although growth of the pericardium can be a feature of chronic cardiac enlargement, here we review the evidence of the importance of diastolic ventricular interaction in certain acute and chronic disease processes, including heart failure.
Collapse
Affiliation(s)
- Lynne Williams
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK.
| | | |
Collapse
|
37
|
Abstract
In heart failure lung dysfunction is frequent and is greater the greater the heart failure severity. It can be evaluated in terms of lung mechanics and gas diffusion. Indeed heart-lung interaction is related to heart dimensions and lung fluid content; furthermore heart-lung interaction is influenced by the body position. Lung diffusion is also altered in patients with chronic heart failure, and a low gas diffusion is associated with a reduced performance. During exercise, heart-lung interaction becomes more evident. Heart failure patients show an abnormal hyperventilation due to a progressively increased respiratory rate, and a lower tidal volume; hyperventilation is due to different causes including enhanced responses from chemo- and metabolo-receptors, increased CO(2) production and increased dead space ventilation. Several drugs affect the ventilatory pattern in heart failure patients: ACE-inhibitors and anti-aldosteronic drugs improve lung diffusion and ventilatory efficiency during exercise; beta-blockers reduce exercise-induced hyperventilation. Furthermore, ultrafiltration improves lung mechanics, both at rest and during exercise, through body fluid content reduction.
Collapse
Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Istituto di Cardiologia, Università di Milano, via Parea 4, 20138 Milan, Italy.
| | | | | | | |
Collapse
|
38
|
Palermo P, Cattadori G, Bussotti M, Apostolo A, Contini M, Agostoni P. Lateral Decubitus Position Generates Discomfort and Worsens Lung Function in Chronic Heart Failure. Chest 2005; 128:1511-6. [PMID: 16162751 DOI: 10.1378/chest.128.3.1511] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Lateral decubitus position is poorly tolerated by heart failure patients. STUDY OBJECTIVES To evaluated pulmonary function and lung diffusion in heart failure patients in the following five body positions: sitting, prone, supine, and left and right decubitus. SETTING Heart failure unit of a university hospital. SUBJECTS We studied 14 chronic heart failure patients in New York Heart Association class III and 14 healthy volunteers. MEASUREMENTS AND RESULTS After 15 min of a selected position, subjects were evaluated by a discomfort scale, ear oximetry, and pulmonary function, which included FEV1, FVC, vital capacity (VC), alveolar volume, and diffusing capacity of the lung for carbon monoxide (D(LCO)) with subcomponent membrane resistance (DM) and capillary volume. In healthy subjects, we observed a reduction of D(LCO) and capillary volume in both lateral decubiti. Some discomfort was documented in both lateral decubiti when selected positions were compared with the sitting position. In the sitting position, pulmonary function suggested slight restriction ([mean +/- SD] FVC, 89.8 +/- 22.3% predicted; FEV1, 84.7 +/- 16.9% predicted, VC, 88.6 +/- 21.5% predicted; and FEV1/VC, 74 +/- 7) with low D(LCO) (73 +/- 19% predicted). Compared with sitting, lung mechanics were unchanged in prone and supine positions; FEV1, FVC, and FEV1/VC were lower when patients were lying on their side, with unchanged alveolar volume and VC. D(LCO) was similar when comparing sitting, prone, and supine positions, and it was lower in lateral decubitus because of the lower capillary volume (vs sitting) and DM (vs prone and supine). Body position-related FVC and D(LCO) reduction were greatest in the largest hearts (deltaFVC and deltaD(LCO) vs left ventricle diastolic volume R = 0.524, p < 0.05 and R = 0.630, p < 0.02, respectively; deltaFVC and deltaD(LCO) vs cardiothoracic index R = 0.539, p < 0.05 and R = 0.685, p < 0.01, respectively). CONCLUSIONS In heart failure, lateral decubitus airway obstruction and lung diffusion impairment become greater as heart dimensions increase.
Collapse
Affiliation(s)
- Pietro Palermo
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Institute of Cardiology, University of Milan, 20138 Milan, Italy
| | | | | | | | | | | |
Collapse
|
39
|
Abstract
Fluid overload is a common presentation for decompensated heart failure, yet management strategies are poorly defined because of relatively few randomized clinical trials that delineate an optimal strategy. Patients refractory to diuretic therapy may be considered for treatment with inotropes or vasodilators, and others may be considered for venovenous ultrafiltration. The rationale for use of each therapy is reviewed.
Collapse
Affiliation(s)
- Jonathan D Sackner-Bernstein
- Clinical Scholars Program, Division of Cardiology, 1st Floor Cohen, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA.
| |
Collapse
|
40
|
Nieminen MS, Böhm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, Hasin Y, López-Sendón J, Mebazaa A, Metra M, Rhodes A, Swedberg K. Guías de Práctica Clínica sobre el diagnóstico y tratamiento de la insuficiencia cardíaca aguda. Versión resumida. Rev Esp Cardiol 2005; 58:389-429. [PMID: 15847736 DOI: 10.1157/13073896] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Markku S Nieminen
- Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland. markku.nieminen.hus.fi
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Marenzi G, Bartorelli AL, Lauri G, Assanelli E, Grazi M, Campodonico J, Marana I. Continuous veno-venous hemofiltration for the treatment of contrast-induced acute renal failure after percutaneous coronary interventions. Catheter Cardiovasc Interv 2003; 58:59-64. [PMID: 12508197 DOI: 10.1002/ccd.10373] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Acute renal failure (ARF) requiring hemodialysis after percutaneous coronary interventions (PCI) is a serious complication with poor prognosis. Hemodialysis-induced hypotension may have deleterious cardiovascular effects, especially in high-risk patients. Ultrafiltrate removal and simultaneous fluid replacement with a solution similar to plasma for high-volume controlled hydration can be obtained with hemodynamic stability by continuous veno-venous hemofiltration (CVVH). We prospectively assessed the safety and effectiveness of percutaneous CVVH (Y-shaped double-lumen catheter, circuit originating from and terminating in the femoral vein) in 33 consecutive patients (23 men and 10 women; mean age, 69 +/- 9 years) who, after PCI, developed oligo-anuric ARF, associated in 20 of them with congestive heart failure. All patients received a concomitant infusion of furosemide (500-1000 mg/day) and dopamine (2 microg/kg/min). During CVVH, the average fluid volume replacement and body fluid net reduction were 1000 +/- 247 and 75 +/- 48 ml/hr, respectively. Treatment with CVVH continued for 4.7 +/- 2.7 days and corrected fluid overload in all cases. No patient experienced systemic hypotension or hypovolemia. Diuresis recovered in 32 (97%) patients, who showed a parallel improvement of renal function parameters. One patient required chronic dialysis. In-hospital and 1-year mortality was 9.1% and 27.3%, respectively. In conclusion, our data indicate that CVVH is a safe and effective therapy of radiocontrast-induced ARF following PCI. It temporarily replaces renal function without deleterious cardiovascular effects, allowing the kidney to recover from the nephrotoxic injury. However, despite promising early results, large randomized trials are required to define the role of CVVH in ARF after PCI.
Collapse
Affiliation(s)
- GianCarlo Marenzi
- Centro Cardiologico Monzino, IRCCS, Institute of Cardiology, University of Milan, Milan, Italy.
| | | | | | | | | | | | | |
Collapse
|
42
|
Marenzi G, Lauri G, Grazi M, Assanelli E, Campodonico J, Agostoni P. Circulatory response to fluid overload removal by extracorporeal ultrafiltration in refractory congestive heart failure. J Am Coll Cardiol 2001; 38:963-8. [PMID: 11583865 DOI: 10.1016/s0735-1097(01)01479-6] [Citation(s) in RCA: 151] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The goal of this study was to investigate the hemodynamic and circulatory adjustments to extracorporeal ultrafiltration (UF) in refractory congestive heart failure (rCHF). BACKGROUND In rCHF, UF allows clinical improvement and restores diuretic efficacy. However, in the course of a UF session, patients are exposed to rapid variations of body fluid composition so that, as fluid is withdrawn from the intravascular compartment, hypotension or even shock could occur. METHODS In 24 patients with rCHF undergoing UF, we measured, after every liter of plasma water removed, hemodynamics, blood gas analysis (in both systemic and pulmonary arteries), plasma volume changes (PV) and plasma refilling rate (PRR). The PV and PRR were calculated by considering hematocrit and ultrafiltrate volume. RESULTS In all patients, UF was performed safely, without side effects or hemodynamic instability (ultrafiltrate = 4,880 +/- 896 ml). Mean right atrial, pulmonary artery and wedge pressures progressively reduced during the procedure. Cardiac output increased at the end of the procedure and, to a greater extent, 24 h later, in relation to the increase of stroke volume. Heart rate and systemic vascular resistance did not increase, and other peripheral biochemical parameters did not worsen during UF. Intravascular volume remained stable throughout the entire duration of the procedure, indicating that a proportional volume of fluid was refilled from the congested parenchyma. CONCLUSIONS In patients with rCHF, subtraction of plasma water by UF is associated with hemodynamic improvement. Fluid refilling from the overhydrated interstitium is the major compensatory mechanism for intravascular fluid removal, and hypotension does not occur when plasma refilling rate is adequate to prevent hypovolemia.
Collapse
Affiliation(s)
- G Marenzi
- Centro Cardiologico Monzino, I.R.C.C.S., Institute of Cardiology, University of Milan, Milan, Italy.
| | | | | | | | | | | |
Collapse
|
43
|
Abstract
Because the ventricles share a common septum, the filling of one may influence the compliance of the other, a phenomenon known as direct diastolic ventricular interaction (DVI). This interaction is markedly enhanced when the force exerted by the surrounding pericardium is raised (pericardial constraint). In health, in the resting state, we operate near the top of the flat component of a J-shaped pericardial stress-strain relation. Therefore, pericardial constraint (and hence DVI) is only minor. When right ventricular volume/pressure acutely increases, such as during exercise, massive pulmonary embolism, or right ventricular infarction, pericardial constraint increases and significant DVI develops. In this setting, the measured left ventricular intracavitary diastolic pressure markedly overestimates the true left ventricular filling pressure, because the external forces must be subtracted. Although the pericardium can grow during chronic cardiac enlargement, we present evidence that in certain chronic disease processes, including heart failure, DVI may also be important.
Collapse
Affiliation(s)
- J A Morris-Thurgood
- Department of Cardiology, Wales Heart Research Institute, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN, United Kingdom
| | | |
Collapse
|
44
|
Abstract
BACKGROUND Our hypothesis is that an enlarged heart may compete for space with the lungs, causing a restrictive pattern that is often seen in patients with chronic heart failure. METHODS Eighty patients with stable congestive heart failure in New York Heart Association classes II and III participated in the study. We measured cardiothoracic index (chest radiography), FEV1, vital capacity, alveolar volume, lung diffusion capacity for carbon monoxide (DLCO), and its 2 subcomponents alveolar-capillary membrane diffusion (DM), and pulmonary capillary blood volume. RESULTS Reliable measurements were obtained in 72 of 80 participants enrolled. Cardiothoracic index averaged 57% +/- 7%. FEV1, vital capacity, alveolar volume, DLCO, and DM were inversely related to the cardiothoracic index (r = -0.514, -0.557, -0.522, -0.475, and -0.480, respectively). However, the relations of DLCO and DM with the cardiothoracic index were lost when DLCO and DM were adjusted for alveolar volume. A significant correlation (P < .01) was found between alveolar volume and vital capacity, FEV1, and DLCO (r = 0.799, 0.705, and 0.614, respectively). At multivariate analysis, cardiothoracic index, FEV1, and pulmonary capillary blood volume were independent predictors of DLCO, whereas alveolar volume, FEV1, and left ventricular ejection fraction were independent predictors of DM. CONCLUSIONS Cardiac enlargement in chronic heart failure appears to be involved in causing restrictive lung pattern and a reduced alveolar volume that disturbs carbon monoxide diffusion.
Collapse
Affiliation(s)
- P Agostoni
- Centro Cardiologico, Fondazione Monzino, IRCCS, Istituto di Cardiologia dell' Universita degli Studi, Milan, Italy.
| | | | | | | | | | | |
Collapse
|
45
|
Agostoni PG, Guazzi M, Bussotti M, Grazi M, Palermo P, Marenzi G. Lack of improvement of lung diffusing capacity following fluid withdrawal by ultrafiltration in chronic heart failure. J Am Coll Cardiol 2000; 36:1600-4. [PMID: 11079664 DOI: 10.1016/s0735-1097(00)00929-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES We sought to investigate the possibility that lung diffusing capacity reduction observed in chronic heart failure is reversible in the short term. BACKGROUND Mechanical properties of the lung usually ameliorate with antifailure treatment including drugs, ultrafiltration and heart transplantation, whereas lung diffusion rarely improves. METHODS We studied the mechanical properties of the lung (pulmonary function tests with determination of alveolar volume, extravascular lung fluids and lung tissue), lung diffusion for carbon monoxide (DLco), including membrane diffusing capacity (Dm), pulmonary capillary blood volume (Vc) and pulmonary hemodynamics, in 28 patients with stable chronic heart failure, before a single session of extracorporeal ultrafiltration (3,973 +/- 2200 ml) and four days thereafter. Lung mechanics and diffusion were also evaluated in 18 normal subjects. RESULTS Vital capacity, forced expiratory volume (1 s) and maximal voluntary ventilation were lower in patients when compared with normal subjects, and increased after ultrafiltration from 2.1 +/- 0.7 to 2.5 +/- 0.7(1)*, 1.7 +/- 0.5 to 2.0 +/- 0.6(1)* and 67 +/- 25 to 79 +/- 26 (1/min)*, respectively (* p < 0.02 vs. pre-ultrafiltration). Post-ultrafiltration alveolar volume was augmented, while lung tissue, body weight (approximately 6 kg), chest X-ray extravascular lung water score and pulmonary vascular pressure were reduced. Heart dimensions (echocardiography) remained unchanged. DLco, Dm and Vc were 29.0 +/- 5.0 ml/min/mm Hg, 47.0 +/- 11.0 ml/min/mm Hg, 102 +/- 20 ml in normal subjects and 17.1 +/- 4.0#, 24.1 +/- 6.5#, 113 +/- 38 and 17.0 +/- 5.0#, 24.8 +/- 7.9#, 100 +/- 39 in patients before and after ultrafiltration, respectively (# = p < 0.01 vs. controls). CONCLUSIONS In chronic heart failure, ultrafiltration improves volumes and mechanical properties of the lung by reducing lung fluids. Diffusion is unaffected by ultrafiltration, suggesting that, in chronic heart failure, the alveolar-capillary membrane abnormalities are fluid-independent.
Collapse
Affiliation(s)
- P G Agostoni
- Istituto di Cardiologia dell' Università degli Studi, Centro Cardiologico IRCCS, Centro di Studio per le Ricerche Cardiovascolari del CNR, Milan, Italy.
| | | | | | | | | | | |
Collapse
|
46
|
Abstract
Although reduced exercise capacity is the main complaint of patients with congestive heart failure (CHF), the best method to measure it remains controversial. Peak VO2, obtained using maximal exercise testing, is the most accurate measure of maximal functional capacity. It is related to peak exercise cardiac output and is one of the most important independent variables for the prognostic assessment of patients with CHF. It has, however, a low sensitivity for measurement of changes induced by therapy and is poorly related to everyday physical activity, patient symptoms, and quality of life. The anerobic threshold may also be regarded as a parameter of maximal functional capacity. Its value is mainly indirect, because it shows that the patient is performing a maximal effort limited by the cardiovascular system. The VO2 kinetics at the start and at the end of exercise are probably more related to patient symptoms, but it is unresolved which protocols and parameters might best be used to study this aspect of exercise performance. Duration of a submaximal exercise at a constant work rate and the distance walked during a 6-min walking test are gaining wide popularity as parameters of submaximal performance. However, when these exams are carried out up to exhaustion in patients with severe functional limitation, they may involve attainment of the anerobic threshold and therefore their clinical meaning may be similar to the one of a maximal exercise test. Moreover, tests based on the assessment of submaximal exercise capacity have been useful for assessment of therapy in single-center trials but have been often inadequate in multicenter trials.
Collapse
Affiliation(s)
- M Metra
- Department of Cardiology, University of Brescia, Italy
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Metra M, Nodari S, Raccagni D, Garbellini M, Boldi E, Bontempi L, Gaiti M, Cas LD. Maximal and Submaximal Exercise Testing in Heart Failure: . J Cardiovasc Pharmacol 1998; 32:S36-45. [DOI: 10.1097/00005344-199806321-00007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|