Congestion In Chronic Heart Failure Research Articles

Usefulness of Antigen Carbohydrate 125 and N-Terminal Pro-B-Type Natriuretic Peptide for Assessing Congestion in Chronic Heart Failure: Insights from the CARDIOREN Registry

Introduction: A comprehensive assessment of congestion, including circulating biomarkers, is recommended in patients with acute heart failure. The circulating biomarkers natriuretic peptides (NPs) and carbohydrate antigen-125 (CA125) could be useful for congestion assessment in ambulatory chronic heart failure (CHF), but there is only limited information about their applicability in this context. Therefore, this study aimed to examine the association of plasma CA125 and NP levels with clinical and ultrasound congestion parameters in CHF. Methods: This is a cross-sectional substudy of the Cardioren Spanish Registry, which enrolled 1,107 patients with CHF from 13 tertiary hospitals in Spain between October 2021 and February 2022. Through ambulatory visits, we performed a comprehensive assessment of congestion-related parameters, including clinical variables (orthopnea, peripheral edema, and jugular engorgement, represented by the composite congestion score [CCS]), echocardiography variables (lung B-lines and inferior vena cava [IVC] diameter), and circulating biomarkers (CA125 and NPs). The association of the NP and CA125 levels with the clinical and echocardiographic congestion parameters was examined by multiple linear and logistic regression analyses. Results: This substudy included 802 patients for whom all the biomarker parameters were available {median age, 74 (interquartile range [IQR], 63–81) years; 65% male}. The proportion of patients with left ventricular ejection fraction ≥50% and estimated glomerular filtration rate <60 was 34% and 58%, respectively. The median CCS was 0 (IQR: 0–1), with 45% of the sample exhibiting a median CCS of ≥1. The jugular engorgement, peripheral edema, and orthopnea rates were 32%, 21%, and 21%, respectively. A total of 35% of patients who underwent ultrasound examination showed lung B-lines, and the median IVC diameter was 16 mm. The median CA125 and NTproBNP levels were 14 U/mL (IQR: 9–28) and 1,382 pg/mL (IQR: 563–3,219), respectively. Multivariate analysis showed that higher CA125 levels were independently associated with higher odds of peripheral edema (p = 0.023) and lung B-lines (p < 0.001). Further, NTproBNP was positively associated with jugular engorgement (p < 0.001), orthopnea (p = 0.034), and enlarged IVC diameter (p = 0.031). Conclusions: Clinical signs of congestion are frequent in CHF. In the ambulatory setting, NTproBNP was associated with parameters linked to intravascular congestion such as orthopnea, jugular engorgement, and IVC diameter, whereas CA125 was associated with extravascular volume overload parameters (peripheral edema and lung B-lines).

P217 SHORT–TERM EFFECTS OF DAPAGLIFLOZIN ON CARDIAC BIOMARKERS, FLUID RETENTION, RENAL AND PULMONARY FUNCTION IN HFREF PATIENTS: NOT AS GOOD AS EXPECTED

Abstract Background Sodium–glucose co–transporter–2 inhibitors (SGLT2–i) are currently a standard therapy for patients with heart failure with reduced ejection fraction (HFrEF). Still, their potential benefits on biomarkers, respiratory function parameters and fluid retention have not been extensively studied. Bioimpedance vector analysis (BIVA) has emerged as a new tool capable of assessing congestion, providing an estimate of the total body water and hydration index (HI). BIVA is more accurate than NT–proBNP in detecting peripheral congestion in chronic heart failure and can be used to evaluate the effects of the treatment. This study aims to assess the short–term effects of Dapagliflozin on spirometry, diffusing capacity of the lungs for carbon monoxide (DLCO), cardiac biomarkers, and BIVA. Methods Stable HF patients (EF &amp;lt;40%, NYHA class II or III) eligible for SGLT2–I therapy according to guidelines underwent standard spirometry, DLCO, BIVA and venous blood sampling at baseline (V0) and after 2–4 weeks of therapy (V1). Results Patients characteristics (N=32) at baseline are shown in Table 1. None of the patients interrupted the treatment and/or experienced adverse events. After 26±6 days, we observed worsening of renal function (eGFR from 73.1±28.5 mL/min/1.73m2 to 67.4±27.0 mL/min/1.73m2, p&amp;lt;0.001) and potassium levels (4.36±0.36 mEq/l vs 4.58±0.57 mEq/l, p= 0.017). There were no significant changes in NT–proBNP levels (1378 [615–2542] ng/l vs 1034 [554–2552] ng/l, p= 0.538). HI, total body water, DLCO and spirometry values did not change. On the contrary, a mild reduction in hsTnI was observed (13.88 [9.24–26.8] ng/l vs 11.58 [7.7–24.2] ng/l). Conclusions Our study did not detect short–term effects of Dapagliflozin on spirometry values, DLCO, fluid retention and NT–proBNP. As revealed in DAPA–HF trial, a mild worsening of potassium and serum creatinine levels was observed. Taken together, these results suggest that the favourable effects of Dapagliflozin could unfold over a longer period of time. A more extended follow–up and a larger population are needed to confirm these preliminary data.

Relationship and outcomes between volume status, cardiac and renal dysfunction in patients with chronic heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background Right heart and renal dysfunction occurring due to volume fluid redistribution remain a front-line issue in the development of the syndrome of congestion in chronic heart failure (HF). Quantitative total blood volume (TBV) measurements and Speckle-tracking Echo (STE) provide complementary information on the myocardial function which allows for providing a more integrated assessment of clinical status and outcomes. Purpose We hypothesize adverse outcomes in patients with heart failure (HF) who have expansion of TBV, right ventricular (RV) and renal dysfunction. Methods This is a prospective study and a total of 66 participants NYHA class III&amp;IV with chronic HF are enrolled from 2014-2022. TBV, right heart catheterization, TTE, TEE, and kidney function tests is performed. STE is calculated using TomTec software for all heart chambers. Patients is divided into 1-st group of the total participants, 2-nd group is patients adverse outcomes which are heart transplant (HT) or death, 3rd group is of alive patients. Simple, multivariable linear regression analyses is used to evaluate associations between TBV, cardiac and renal function. Statistical analyses is performed using JMP, BlueSky, and two-sided with P-values &amp;lt;0.05 considered to be statistically. Results Of 66 patients, the 1-st group has 66 patients, the 2nd group has 44 patients out of which deceased are 32 patients (48.4%), HT has 12 patients (18.1%), and the 3rd group has 22 patients (33.3%). In the 2nd group, out of the 44 patients, 35 (79.5%) patients have HFrEF, and 9 (20.4%) patients presented HFpEF. In the 3rd group out of 22 patients, 15 (68.2%) have HFrEF, and 7 (31.8%) patients have HFpEF. RV dimensions are significantly related to TBV in all groups of participants (Table 1). In the total patients, TBV is directly correlated to a moderate degree with EDSRV (r = 0.51, P &amp;lt; 0.001), ESSRV (r = 0.44, P &amp;lt; 0.001) and FAC (r = 0.40, P &amp;lt; 0.001). More significant moderate and strong relationships are observed in patients with adverse outcome between TVB and EDSRV (r = 0.54, P &amp;lt; 0.001), ESSRV (r = 0.65, P &amp;lt; 0.001) and FAC (r = 0.48, P &amp;lt; 0.001). In group 1, weak and direct association of TBV and RV GLS, FW LS, FW LSR, and RA reservoir strain. In the 2nd group, TBV directly correlated to a moderate degree with FW LS (r = 0.41, P = 0.005) and FW LSR (r = 0.43, P = 0.002). Similar relationships in the 2nd group are observed between TBV and renal function parameters (TBV and eGFR (r = 0.53, P &amp;lt; 0.001)). The direct and weak correlation obtained between TBV and BUN in both 1st and 2nd groups. In patients with adverse outcomes, TBV is directly proportional to LV Diastolic BP. Conclusion The association among intravascular volume and parameters of RV dilatation, myocardial and renal dysfunction in patients with chronic HF is associated with adverse outcomes. Understanding the impact of all these variables guide optimal and effective individualized HF management and therapy.

118 SHORT-TERM EFFECTS OF DAPAGLIFLOZIN ON CARDIAC BIOMARKERS, FLUID RETENTION, RENAL AND PULMONARY FUNCTION IN HFREF PATIENTS: NOT AS GOOD AS EXPECTED

Abstract Background Sodium-glucose co-transporter-2 inhibitors (SGLT2-i) are currently a standard therapy for patients with heart failure with reduced ejection fraction (HFrEF). Still, their potential benefits on biomarkers, respiratory function parameters and fluid retention have not been extensively studied. Bioimpedance vector analysis (BIVA) has emerged as a new tool capable of assessing congestion, providing an estimate of the total body water and hydration index (HI). BIVA is more accurate than NT-proBNP in detecting peripheral congestion in chronic heart failure and can be used to evaluate the effects of the treatment. This study aims to assess the short-term effects of Dapagliflozin on spirometry, diffusing capacity of the lungs for carbon monoxide (DLCO), cardiac biomarkers, and BIVA. Methods Stable HF patients (EF &amp;lt;40%, NYHA class II or III) eligible for SGLT2-I therapy according to guidelines underwent standard spirometry, DLCO, BIVA and venous blood sampling at baseline (V0) and after 2-4 weeks of therapy (V1). Results Patients characteristics (N=32) at baseline are shown in Table 1. None of the patients interrupted the treatment and/or experienced adverse events. After 26±6 days, we observed worsening of renal function (eGFR from 73.1±28.5 mL/min/1.73m2 to 67.4±27.0 mL/min/1.73m2, p&amp;lt;0.001) and potassium levels (4.36±0.36 mEq/l vs 4.58±0.57 mEq/l, p= 0.017). There were no significant changes in NT-proBNP levels (1378 [615-2542] ng/l vs 1034 [554-2552] ng/l, p= 0.538). HI, total body water, DLCO and spirometry values did not change. On the contrary, a mild reduction in hsTnI was observed (13.88 [9.24-26.8] ng/l vs 11.58 [7.7-24.2] ng/l). Conclusions Our study did not detect short-term effects of Dapagliflozin on spirometry values, DLCO, fluid retention and NT-proBNP. As revealed in DAPA-HF trial, a mild worsening of potassium and serum creatinine levels was observed. Taken together, these results suggest that the favourable effects of Dapagliflozin could unfold over a longer period of time. A more extended follow-up and a larger population are needed to confirm these preliminary data.

The ordinal scale of X-ray assessment of venous congestion in chronic heart failure

Aim. To develop an ordinal scale for x-ray assessment of venous congestion in chronic heart failure based on the results of the standard assessment of chest radiographs.&#x0D; Methods. The ordinal assessment on the scale consists of a numerical expression of four radiological symptoms: cardiomegaly, pleural effusion, and changes in the pulmonary pattern due to vascular and interstitial components. The presence of each of these symptoms corresponds to a score of 1 point. In the result, ordinal X-ray assessment varies from 0 to 4 points. Simultaneously objective clinical, instrumental and laboratory measures of the severity of congestive heart failure were recorded in patients.&#x0D; Results. Cardiomegaly, the presence of pleural effusion and changes in the pulmonary pattern due to vascular and interstitial components was numerically estimated according to the standard assessment of chest X-rays for the scale of radiological assessment of venous congestion. Correlation between numerical estimates of the ordinal scale and objective clinical, instrumental and laboratory measures of venous stasis in the sample of 225 patients showed the validity of the assessment. The statistically significant direct relationships between value of the ordinal scale for X-ray assessment of venous congestion with functional class and stage of chronic heart failure, the level of NT-terminal fragment of brain natriuretic peptide, the frequency of respiratory movements, the scale of clinical state, the index of the left atrium, the systolic pressure in the pulmonary artery, as well as an inverse dependence with the 6-minute walk test values were proved. Sufficient internal consistency of the ordinal scale was demonstrated (Cronbach's alpha 0.73). We also found that the scale demonstrated predictive informativeness, which was manifested by a significant increase in the mortality of patients with chronic heart failure in cases where the scale values increase to 2.&#x0D; Conclusion. The proposed ordinal scale for x-ray assessment of venous congestion has sufficient reliability (internal consistency) for practical application, as well as criteria and prognostic validity; the scale can be considered as a simple, accessible and informative addition to the standard examination of polymorbid patients with chronic heart failure, which may be useful for advanced assessment of the patient's condition and risk of death within the next year.

Effect of ferric carboxymaltose on calculated plasma volume status and clinical congestion: a FAIR-HF substudy.

AimsIron deficiency worsens symptoms, quality of life, and exercise capacity in chronic heart failure (CHF) and might do so by promoting fluid retention. We assessed whether iron repletion improved congestion in CHF and appraised the prognostic utility of calculated plasma volume status (PVS), a novel index of congestion, in the FAIR‐HF data set.Methods and resultsIn FAIR‐HF, 459 iron deficient CHF patients were randomized to intravenous ferric carboxymaltose (FCM) or saline and assessed at 4, 12, and 24 weeks. Using weight and haematocrit, we calculated PVS in 436 patients. At baseline, PVS and weight were −5.5 ± 7.7% and 76.9 ± 14.3 kg, with peripheral oedema evident in 35% of subjects. Higher PVS values correlated to other congestion surrogates such as lower serum albumin. At 4 weeks, FCM was associated with greater reductions in weight (0.02) and PVS (P < 0.0001), and a trend for improved peripheral oedema at 24 weeks (0.07). Irrespective of treatment allocation, patients with a decrease in PVS from baseline to week 24 had higher increments in 6 min walking distance (61.4 m vs. 43.5 m, 0.02) and were more likely to improve their NYHA class (33.3% vs. 15.5%, 0.001). A PVS > −4% at baseline predicted worse outcomes even after adjustment for treatment assignment (hazard ratio 1.88, 95% confidence interval 1.01–3.51, 0.046).ConclusionsIntravenous iron therapy with FCM is associated with early reductions in PVS and weight, implying that decongestion might be one mechanism via which iron repletion aids CHF patients. Calculated PVS is of prognostic utility in this cohort.

P1823Malnutrition and its association with congestion in chronic heart failure

P1823Malnutrition and its association with congestion in chronic heart failure

Influence of Thoracic Fluid Compartments on Pulmonary Congestion in Chronic Heart Failure

IntroductionPulmonary congestion is a common finding of heart failure (HF), but it remains unclear how pulmonary and heart blood volumes (Vp and Vh, respectively) and extravascular lung water (EVLW) change in stable HF and affect lung function. MethodsFourteen patients with HF (age 68 ± 11 y, LVEF 33 ± 8%) and 12 control subjects (age 65 ± 9 y) were recruited. A pulmonary function test, thoracic computerized tomographic (CT) scan, and contrast perfusion scan were performed. From the thoracic scan, a histogram of CT attenuation of lung tissue was generated and skew, kurtosis, and full-width half-max (FWHM) calculated as surrogates of EVLW. Blood volumes were calculated from the transit time of the contrast through the great vessels of the heart. ResultsPatients with HF had greater Vp and Vh (Vp 0.55 ± 0.21 L vs 0.41 ± 0.13 L; Vh 0.53 ± 0.33 L vs 0.40 ± 0.15 L) and EVLW (skew 3.2 ± 0.5 vs 3.7 ± 0.7; kurtosis 19.4 ± 6.6 vs 25.9 ± 9.4; FWHM 73 ± 13 HU vs 59 ± 9 HU). Spirometric measures were decreased in HF (percentage of predicted: forced vital capacity 86 ± 17% vs 104 ± 9%; forced expiratory volume in 1 second 83 ± 20% vs 105 ± 11%; maximal mid-expiratory flow 82 ± 42% vs 115 ± 43%). Vp was associated with decreased expiratory flows, and EVLW was associated with decreased lung volumes. ConclusionsCongestion in stable patients with HF includes expanded Vp and Vh and increased EVLW associated with reductions in lung volumes and expiratory flows.

Lung congestion in chronic heart failure: haemodynamic, clinical, and prognostic implications.

The goal of the study was to examine the prognostic impact, haemodynamic and clinical features associated with lung congestion in patients with chronic heart failure (HF). HF patients (n = 186) and HF-free controls (n = 21) underwent right heart catheterization, echocardiography, pulmonary function testing and chest radiography that was blindly scored for the presence and severity of lung oedema. Lung congestion correlated directly with pulmonary vascular resistance (PVR, P = 0.004) and inversely with pulmonary artery (PA) compliance (P < 0.001) and the diffusion limit for carbon monoxide (DLCO , P = 0.009). Compared with dry lung HF, wet lung HF patients (congestion score > median) had 25% lower PA compliance and 25-35% higher PVR, transpulmonary gradients and PA pressures (40 vs. 32 mmHg, P < 0.001) despite marginally higher PA wedge pressure (PAWP; 22 vs. 19 mmHg, P = 0.002). Wet lung HF patients displayed more right ventricular (RV) dilatation and dysfunction, more restrictive ventilation and greater reduction of DLCO . The strongest correlates of lung congestion were NT-proBNP, haemoglobin, albumin, and glomerular filtration, all surpassing PAWP. After a median of 333 days (interquartile range 80-875), 59 patients (32%) died. Lung congestion was associated with reduced survival (P < 0.0001), even after adjusting for PAWP, NT-proBNP, anaemia, CAD and renal dysfunction. Interstitial lung oedema is associated with pulmonary vascular disease, RV overload and dysfunction and increased mortality in HF. These data reinforce the importance of aggressive decongestion in HF and suggest that novel agents aimed at reducing lung water may help to deter progression of pulmonary vascular disease and biventricular HF.

Lung Ultrasound for the Evaluation of Pulmonary Congestion in Outpatients: A Comparison With Clinical Assessment, Natriuretic Peptides, and Echocardiography

The aim of this study was to define the performance of lung ultrasound (LUS) compared with clinical assessment, natriuretic peptides, and echocardiography, to evaluate decompensation in patients with systolic heart failure (HF) in an outpatient clinic. Evaluation of pulmonary congestion in chronic HF is challenging. LUS has been recently proposed as a reliable tool for the semiquantification of extravascular lung water through assessment of B-lines. This was a cohort study of patients with moderate to severe systolic HF. Receiver-operating characteristic (ROC) analyses were performed to compare LUS with a previously validated clinical congestion score (CCS), amino-terminal portion of B-type natriuretic peptide (NT-proBNP), E/e' ratio, chest x-ray, and 6-min walk test. Ninety-seven patients were enrolled. Decompensation was present in 57.7% of patients when estimated by CCS, 68% by LUS, 53.6% by NT-proBNP, and 65.3% by E/e' ≥15. The number of B-lines was correlated to NT-proBNP (r = 0.72; p < 0.0001), E/e' (r = 0.68; p < 0.0001), and CCS (r = 0.43; p < 0.0001). In ROC analyses, considering as reference for decompensation a combined method (E/e' ≥ 15 and/or NT-proBNP >1,000 pg/ml), LUS yielded a C-statistic of 0.89 (95% confidence interval: 0.82 to 0.96), providing the best accuracy with a cutoff ≥ 15 B-lines (sensitivity 85%, specificity 83%). A systematic approach using CCS, E/e', NT-proBNP, chest x-ray, and 6-min walk test in different combinations as reference for decompensation also corroborated this cutoff and found a similar accuracy for LUS. In an HF outpatient clinic, B-lines were significantly correlated with more established parameters of decompensation. A B-line ≥15 cutoff could be considered for a quick and reliable assessment of decompensation in outpatients with HF.

CALCULATED PLASMA VOLUME STATUS RELATES TO EXERCISE CAPACITY IN CHRONIC HEART FAILURE

Plasma volume (PV) expansion drives systemic congestion in chronic heart failure (CHF) and is a plausible substrate for exercise limitation. Because no simply means of quantifying PV in CHF exists, we derived an index of relative PV status (PVS) and tested its relation to exercise performance in CHF