Subclinical Volume Overload Across the Spectrum of Heart Failure: Lessons From Total Blood Volume Measurements

Abstract

Consensus heart failure (HF) management guidelines recommend routine assessment of volume status at clinical encounters with heart failure patients, but standard clinical approaches for detection of intravascular volume overload in patients with chronic heart failure are known to have poor diagnostic accuracy. 1 Androne A.S. Hryniewicz K. Hudaihed A. Mancini D. Lamanca J. Katz S.D. Relation of unrecognized hypervolemia in chronic heart failure to clinical status, hemodynamics, and patient outcomes. Am J Cardiol. 2004; 93: 1254-1259 Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar , 2 Yancy C.W. Jessup M. Bozkurt B. Butler J. Casey Jr, D.E. Drazner M.H. et al. 2013ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013; 62: e147-e239 Crossref PubMed Scopus (4706) Google Scholar Direct measurement of intravascular volume with radionuclide methods has consistently demonstrated a wide range of heterogeneity of total blood volume (TBV) in patients with advanced heart failure, and high prevalence of increased intravascular volume in the absence of edema or other signs of congestion. 1 Androne A.S. Hryniewicz K. Hudaihed A. Mancini D. Lamanca J. Katz S.D. Relation of unrecognized hypervolemia in chronic heart failure to clinical status, hemodynamics, and patient outcomes. Am J Cardiol. 2004; 93: 1254-1259 Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar , 3 Bonfils P.K. Damgaard M. Taskiran M. Goetze J.P. Norsk P. Gadsboll N. Impact of diuretic treatment and sodium intake on plasma volume in patients with compensated systolic heart failure. Eur J Heart Fail. 2010; 12: 995-1001 Crossref PubMed Scopus (37) Google Scholar , 4 Miller W.L. Mullan B.P. Understanding the heterogeneity in volume overload and fluid distribution in decompensated heart failure is key to optimal volume management: role for blood volume quantitation. JACC Heart Fail. 2014; (in press) Crossref Scopus (100) Google Scholar , 5 Miller W.L. Mullan B.P. Volume overload profiles in patients with preserved and reduced ejection fraction chronic heart failure: are there differences? A pilot study. JACC Heart Fail. 2016; 4: 453-459 Crossref PubMed Scopus (53) Google Scholar In this issue of the Journal of Cardiac Failure, Miller et al. extend these previous findings, and demonstrate the presence of marked heterogeneity in TBV distribution in a prospective cohort study of 46 subjects with stable NYHA Class I and II heart failure with reduced ejection fraction (HFrEF). 6 Miller W.L. Albers D.P. Gansen D.N. Mullan B.P. Intravascular volume profiles in patients with class I and II systolic heart failure: heterogeneity and volume overload are common even in mild heart failure. J Card Fail. 2017; Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The presented data confirm a high prevalence of intravascular volume overload despite absence of clinical signs of congestion, and in a subset of 28 patients with repeated measurements after one year, demonstrate that heterogeneity of TBV and high prevalence of intravascular volume overload persists over time. Variability in both plasma volume (PV) and red blood cell mass (RBCM) contributed to the observed heterogeneity in TBV in this cohort.