Higher Systemic Vascular Resistance Index Research Articles

Acromegaly: The Relationship between Hemodynamic Profiles Assessed via Impedance Cardiography and Left Ventricular Systolic Function Assessed via Echocardiography.

Background/Objectives: Acromegaly-induced prolonged exposure to growth hormone and insulin-like growth factor 1 may have significant cardiovascular effects. The purpose of this study was to assess the relationship between hemodynamic parameters measured via impedance cardiography (ICG) and parameters of systolic left ventricular function measured via echocardiography in patients with acromegaly. Methods: The observational cohort study included 33 patients with newly diagnosed acromegaly, with a mean age of 47 years and without significant comorbidities. Correlation analysis (Spearman's rank correlation coefficient R) was performed on parameters obtained by ICG and left ventricular systolic function parameters obtained by echocardiography. ICG assessment included indices of (1) cardiac function as a pump: stroke volume index (SI), cardiac index (CI), Heather index (HI), velocity index (VI), and acceleration index (ACI); (2) afterload: systemic vascular resistance index (SVRI) and total arterial compliance index (TACI); and (3) thoracic fluid content (TFC). Echocardiographic examinations evaluated left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). Results: A lower LVEF was associated with a lower SI (R = 0.38; p = 0.03) and a higher SVRI (R = -0.35; p = 0.046), whereas lower GLS was associated with lower SI (R = 0.43; p = 0.02), CI (R = 0.62; p < 0.001), VI (R = 0.59; p < 0.001), ACI (R = 0.38; p = 0.048), HI (R = 0.59; p < 0.001), and TACI (R = 0.50; p = 0.006) and a higher SVRI (R = -0.59; p < 0.001). No significant correlation was observed between either LVEF or GLS and TFC. Conclusions: In patients with acromegaly, poorer echocardiographic parameters of left ventricular systolic function are associated with impaired function of the heart as a pump and higher afterload as assessed via ICG.

Childhood family environment and systemic haemodynamics in adulthood: the Cardiovascular Risk in Young Finns Study.

Childhood family environment is associated with adulthood health behaviours and cardiovascular health, but limited data are available concerning the relationship between childhood family environment and adulthood haemodynamic determinants of blood pressure. We evaluated how childhood family environment predicts adulthood systemic haemodynamics. The sample came from the Cardiovascular Risk in Young Finns Study (n=1554-1620). Childhood family environment (1980) was assessed with four cumulative risk scores: socioeconomic family risk, risky emotional family atmosphere, stressful life events, and parents' risky health behaviours. Haemodynamic outcomes in 2007 (participants being 30-45 year-olds) included stroke volume index, systemic vascular resistance index, cardiac output index and heart rate. Analyses were adjusted for childhood (1980) cardiovascular risk factors (high-density lipoprotein and low-density lipoprotein cholesterol, triglycerides, insulin, body mass index and systolic blood pressure); and adulthood (2007) health behaviours (alcohol consumption, smoking, physical activity); and finally for adulthood cardiovascular risk factors. When adjusted for age and sex, high socioeconomic family risk predicted lower stroke volume index (P=0.001), higher heart rate (P=0.001) and higher systemic vascular resistance index (P=0.030). These associations remained after controlling for childhood cardiovascular covariates or adulthood health behaviours (P⩽0.02 for all) but diluted after controlling for adulthood cardiovascular risk factors. The other childhood cumulative risk scores (stressful life events, risky emotional atmosphere, or parents' risky health behaviour) did not predict adulthood haemodynamic outcomes. High childhood socioeconomic family risk predicted adulthood haemodynamic outcomes independently of childhood cardiovascular risk factors and adulthood health behaviours, while other childhood psychosocial adversities were not associated with cardiovascular function in adulthood.

Sex differences in acute hemodynamic response in comatose survivors of OHCA

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Fonden Background In critically ill patients with cardiogenic shock, neurohormonal activation is higher in females compared with males. Whether this is the case in patients resuscitated from out of hospital cardiac arrest (OHCA) is not known and whether sex-based differences relate to achieving mean-arterial-pressure (MAP)-target has not previously been described. Methods This was an investigator-initiated, randomized, controlled study of targeted MAP (63 vs 77 mmHg) and PaO2 (9-10 vs 13-14 kPa) interventions in 789 comatose OHCA (of presumed cardiac origin) patients. Patients underwent serial hemodynamic assessments with pulmonary artery catheter at time of insertion, 6 h, 12 h, 24 h, 36 h and 48 h. Among parameters recorded were heart rate (HR), cardiac output (CO) and central venous pressure (CVP), from which cardiac index (CI) and systemic vascular resistance index (SVRI) were derived. Patient characteristics included sex for stratification, age, time to return of spontaneous circulation (ROSC) and initial electrocardiographic (ECG) rhythm. Results Hemodynamic parameters from 729 patients were analysed, of which 138 (19%) were female and 591 (81%) were male. Both groups had a median age of 64 years, with median time-to-ROSC of 19 minutes in females versus 18 minutes in males. In females versus in males, SVRI and HR were higher (fig.1,2). There were no differences among sexes with regards to CI, MAP, or dose of noradrenaline. At 12 hours, median SVRI in females was 755 dyn·s/cm5·m2 (inter-quartile ratio, IQR 569-931) versus 554 dyn·s/cm5·m2 (IQR 441-684) in males (P&amp;lt;0.0001). At the same point in time, median HR was 71 beats/minute (bpm) in females (IQR 59-82) versus 62 bpm (IQR 54-74) in males (P&amp;lt;0.0001). Lastly, 12-hour median CI was 1.82 L/min/m2 (IQR 1.54-2.40) in females versus 1.95 L/min/m2 (IQR 1.63-2.43) in males (P=0.1303). Conclusions Female comatose OHCA patients had higher SVRI and HR during the first 48 hours of ICU admission, without difference in MAP or vasopressor requirement. Sex specific physiological mechanisms may be involved in maintaining vascular resistance.

Accuracy of Cardiac Output Measured by Fourth-Generation FloTrac and LiDCOrapid, and Their Characteristics Regarding Systemic Vascular Resistance in Patients Undergoing Cardiac Surgery

The clinical use of less-invasive devices that calculate the cardiac output from arterial pressure waveform is increasing. The authors aimed to evaluate the accuracy and characteristics of the systemic vascular resistance index (SVRI) of the cardiac index measured by 2 less-invasive devices, fourth-generation FloTrac (CIFT) and LiDCOrapid (CILR), compared with the intermittent thermodilution technique, using a pulmonary artery catheter (CITD). This was a prospective observational study. This study was conducted at a single university hospital. Twenty-nine adult patients undergoing elective cardiac surgery. Elective cardiac surgery was used as an intervention. Hemodynamic parameters, CIFT, CILR, and CITD, were measured after the induction of general anesthesia, at the start of cardiopulmonary bypass, after completion of weaning from cardiopulmonary bypass, 30 minutes after weaning, and at sternal closure (135 measurements in total). The CIFT and CILR had moderate correlations with CITD (r=0.62 and 0.58, respectively). Compared with CITD, CIFT, and CILR had a bias of -0.73 and -0.61 L/min/m2, limit of agreement of -2.14-to-0.68 L/min/m2 and -2.42-to-1.20 L/min/m2, and percentage error of 39.9% and 51.2%, respectively. Subgroup analysis for evaluating SVRI characteristics showed that the percentage errors of CIFT and CILR were 33.9% and 54.5% in low SVRI (<1,200 dyne×s/cm5/m), 37.6% and 47.9% in moderate SVRI (1,200-1,800 dyne×s/cm5/m), 49.3% and 50.6% in high SVRI (>1,800 dyne·s/cm5/m2), respectively. The accuracy of CIFT or CILR was not clinically acceptable for cardiac surgery. Fourth-generation FloTrac was unreliable in high SVRI. LiDCOrapid was inaccurate across a broad range of SVRI, and minimally affected by SVRI.

PS-BPC05-7: HEMODYNAMIC MANAGEMENT OF RESISTANT HYPERTENSION

Background: Hypertension is the most prevalent chronic disease worldwide and is related to a high probability of cardiac disease, kidney disease and cerebrovascular events. Blood pressure measurement was used in the last decades to diagnose and guide antihypertensive therapy; however blood pressure is the result of the interaction of more complex hemodynamic parameters previously reserved for experimental studies or critical care patients management using invasive methods. Since 1996 few studies have proposed the use of hemodynamic parameters to classify and guide hypertension therapy with good results. Purpose: The present study's purpose was to measure hemodynamic parameters in patients with non-controlled resistant hypertension and use it to guide pharmacologic treatment to archive control blood pressure values according to the European Society of Cardiology guidelines. Methods: A total of 84 patients between 32 and 95 years old diagnosed with non-controlled primary resistant hypertension were recruited and after previous therapy washout hemodynamic parameters were measured using noninvasive Methods: preload by central venous pressure (CVP) using inferior vena cava diameter, cardiac index and systemic vascular resistance using Lyljestrand &amp; Zander modified formula. Patients were classified into 3 basic groups depending on which parameter was above normal value: hyperdynamic (HD) for high cardiac index &gt; 3.5 L/min/m2, fluid overload (FO) for CVP &gt; 8cmH2O and high systemic vascular resistance index (HSVRi) &gt; 2500 dynes/sec/m2/cm5, also 3 combined groups were a patient had 2 simultaneous hemodynamic alterations (HD+FO, HD+HSVRi and FO+HSRVi), according to this classification pharmacotherapy was guided indicating Bisoprolol in HD group, Amlodipine to HSVR patients and Hydrochlorothiazide to FO patients, in combined groups, combined therapy was given. Patients were observed for 6 months period taking as primary endpoint blood pressure control, acute cardiovascular events and hypotension. Results: A significant reduction of hemodynamic parameters and blood pressure was observed in the first month of treatment obtaining a 100% hemodynamic and blood pressure goals in all patients in the third month of therapy without hypotension or acute cardiovascular event during this period, the HD+FO group reach goals at the 6th month of treatment without reported complications. Conclusions: In this preliminary study we observed that hemodynamic guided high blood pressure control may be a valuable tool for a better understanding, classification and treatment in patients with resistant hypertension; however larger outcome studies confirm this hypothesis.

Hemodynamic differences between women and men with elevated blood pressure in China: A non-invasive assessment of 45,082 adults using impedance cardiography.

Whether there are sex differences in hemodynamic profiles among people with elevated blood pressure is not well understood and could guide personalization of treatment. We described the clinical and hemodynamic characteristics of adults with elevated blood pressure in China using impedance cardiography. We included 45,082 individuals with elevated blood pressure (defined as systolic blood pressure of ≥130 mmHg or a diastolic blood pressure of ≥80 mmHg), of which 35.2% were women. Overall, women had a higher mean systolic blood pressure than men (139.0 [±15.7] mmHg vs 136.8 [±13.8] mmHg, P<0.001), but a lower mean diastolic blood pressure (82.6 [±9.0] mmHg vs 85.6 [±8.9] mmHg, P<0.001). After adjusting for age, region, and body mass index, women <50 years old had lower systemic vascular resistance index (beta-coefficient [β] -31.7; 95% CI: -51.2, -12.2) and higher cardiac index (β 0.07; 95% CI: 0.04, 0.09) than men of their same age group, whereas among those ≥50 years old women had higher systemic vascular resistance index (β 120.4; 95% CI: 102.4, 138.5) but lower cardiac index (β -0.15; 95% CI: -0.16, -0.13). Results were consistent with a propensity score matching sensitivity analysis, although the magnitude of the SVRI difference was lower and non-significant. However, there was substantial overlap between women and men in the distribution plots of these variables, with overlapping areas ranging from 78% to 88%. Our findings indicate that there are sex differences in hypertension phenotype, but that sex alone is insufficient to infer an individual's profile.

Cushing's Disease: Assessment of Early Cardiovascular Hemodynamic Dysfunction With Impedance Cardiography.

BackgroundCushing’s disease is a rare condition associated with a high cardiovascular risk and hypercortisolemia-related hemodynamic dysfunction, the extent of which can be assessed with a noninvasive method, called impedance cardiography. The standard methods for hemodynamic assessment, such as echocardiography or ambulatory blood pressure monitoring may be insufficient to fully evaluate patients with Cushing’s disease; therefore, impedance cardiography is being currently considered a new modality for assessing early hemodynamic dysfunction in this patient population. The use of impedance cardiography for diagnosis and treatment of Cushing’s disease may serve as personalized noninvasive hemodynamic status assessment and provide a better insight into the pathophysiology of Cushing’s disease. The purpose of this study was to assess the hemodynamic profile of Cushing’s disease patients and compare it with that in the control group.Material and MethodsThis observational prospective clinical study aimed to compare 54 patients with Cushing’s disease (mean age 41 years; with 64.8% of this population affected with arterial hypertension) and a matched 54-person control group (mean age 45 years; with 74.1% of this population affected with arterial hypertension). The hemodynamic parameters assessed with impedance cardiography included the stroke index (SI), cardiac index (CI), systemic vascular resistance index (SVRI), velocity index (VI), (ACI), Heather index (HI), and thoracic fluid content (TFC).ResultsThe Cushing’s disease group was characterized by a higher diastolic blood pressure and a younger age than the control group (82.9 vs. 79.1 mmHg, p=0.045; and 41.1 vs. 44.9 years, p=0.035, respectively). Impedance cardiography parameters in the Cushing’s disease group showed: lower values of SI (42.1 vs. 52.8 ml/m2; p ≤ 0.0001), CI (2.99 vs. 3.64 l/min/m2; p ≤ 0,0001), VI (42.9 vs. 52.1 1/1000/s; p=0.001), ACI (68.7 vs. 80.5 1/100/s2; p=0,037), HI (13.1 vs. 15.2 Ohm/s2; p=0.033), and TFC (25.5 vs. 27.7 1/kOhm; p=0.006) and a higher SVRI (2,515 vs. 1,893 dyn*s*cm-5*m2; p ≤ 0.0001) than those in the control group.ConclusionsCushing’s disease is associated with significantly greater vasoconstriction and left ventricular systolic dysfunction. An individual assessment with impedance cardiography may be useful in Cushing’s disease patients in order to identify subclinical cardiovascular complications of chronic hypercortisolemia as potential therapeutic targets.

Degree of Portal and Systemic Hemodynamic Alterations Predict Recurrent AKI and Chronic Kidney Disease in Patients With Cirrhosis.

The relevance of hemodynamic derangements on the incidence of recurrent acute kidney injury (AKI) and chronic kidney disease (CKD) in patients with cirrhosis is largely unknown. Consecutive patients with cirrhosis with a complete record of baseline hemodynamics were followed for identifying risk factors for the development of recurrent AKI and CKD by using negative binomial regression and competing risk analysis, respectively. Consecutive patients with cirrhosis (n = 2013, age 50.1 ± 11.8 years, 80% male, Child A:B:C percentage 13.7:52.9:33.4, and mean Child‐Turcotte‐Pugh score 8.6 ± 1.8) were enrolled, 893 (44.3%) of whom received beta‐blockers, with 44.2% responders. Prior AKI was noted in 12.4% at enrollment. At a median follow‐up of 379 (interquartile range: 68‐869) days, AKI developed at a rate of 0.37 episodes per person‐year, and 26% patients developed CKD. A lower mean number of AKI episodes (0.05 ± 0.25 vs. 0.42 ± 0.868; P < 0.001), CKD (subdistribution hazard ratio 0.74 [0.54‐1.02]), and mortality (hazard ratio 0.21 [0.06‐0.73]) were observed in beta‐blocker responders. Albuminuria was an independent risk factor for recurrent AKI, CKD, and mortality (P < 0.05). Lower systemic vascular resistance index predicted hemodynamic response (odds ratio 2.04 [1.29‐3.22]), cumulative AKI episodes (ratio of means 0.10 [0.08‐0.14]), and development of CKD (subdistribution hazard ratio 0.70 [0.58‐0.83]). Higher hepatic venous pressure gradient (≥17 mm Hg) predicted AKI episodes (ratio of means 1.76 [1.32‐2.35]) but not CKD. Conclusion: High portal pressure and severe vasodilatation predispose patients with cirrhosis to repeated AKI episodes and development of CKD. Response to beta‐blockers and therapies targeting the vasodilatory state could prevent frequent AKI and the risk of CKD development. Albuminuria could serve as an early marker of renal dysfunction in patients with cirrhosis.

The impact of obesity on haemodynamic profiles of pregnant women beyond 34weeks' gestation.

We aimed to compare the haemodynamic profiles of obese and non-obese pregnant women, alongside describing the haemodynamic changes that occur in hypertensive disorders of pregnancies with an Appropriate for Gestational Age Fetus (HDP-AGA) beyond 34weeks' gestation. In this prospective case-control study, maternal haemodynamic assessment was carried out by a trained operator using an UltraSonic Cardiac Output Monitor during a routine clinical assessment after 34weeks of gestation. Indexed and non-indexed parameters were evaluated. Maternal hemodynamic parameters. Obese and non-obese women did not differ for non-indexed parameters (Cardiac Output, Stroke Volume, Systemic Vascular Resistance). Using indexed parameters, corrected for Body Surface Area, obese women presented significantly lower Cardiac Index z-score (-0.23±0.5 vs 0.26±1.2; p=0.004), Stroke Volume Index z-score (-0.27±0.8 vs 0.31±1.0; p<0.0001) and significantly higher Systemic Vascular Resistance Index (0.16±0.8 vs -0.36±0.7; p<0.0001). In obese women, HDP-AGA (n=19) had significantly higher Systemic Vascular Resistance Index z-score (1.26±1.7 vs 0.16±0.8; P=0.009) and significantly lower Stroke Volume Index (-0.68±0.8 vs -0.27±0.8; 0.049). Using indexed parameters, differences in haemodynamic profiles between obese and non obese women can be highlighted. Obese women seem to present a cardiac maladapation to the pregnancy (reduced cardiac index and stroke volume and increased vascular resistance) that could explain the increased risk of complications in this subgroup.

Accuracy and Trending Ability of Cardiac Index Measured by the CNAP System in Patients Undergoing Abdominal Aortic Aneurysm Surgery

The CNAP system is a noninvasive monitor that provides a continuous arterial pressure waveform using an inflatable finger cuff. The authors hypothesized that dramatic changes in systemic vascular resistance index during abdominal aortic aneurysm (AAA) surgery might affect the accuracy of noninvasive pulse contour monitors. The aim of this study was to evaluate the accuracy and trending ability of cardiac index derived by the CNAP system (CICN) in patients undergoing AAA surgery. Prospective clinical study. Cardiac surgery operating room in a single cardiovascular center. Twenty patients who underwent elective AAA surgery. CICN and cardiac index measured using 3-dimensional images (CI3D) were determined simultaneously at 8 points during the surgery. At aortic clamping and unclamping, the authors tested the trending ability of CICN using 4-quadrant plot analysis and polar plot analysis. The authors found a wide limit of agreement between CICN and CI3D (percentage error: 85.0%). The cubic splines, which show the relationship between systemic vascular resistance index and percentage CI discrepancy [(CICN-CI3D)/CI3D], were sloped positively. Four-quadrant plot analysis showed poor trending ability for CICN at both aortic clamping and unclamping (concordance rate: 29.4% and 57.9%, respectively). In the polar plot analysis, the concordance rates at aortic clamping and unclamping were 15.0% and 35.0%, respectively. CICN is not interchangeable with CI3D in patients undergoing AAA surgery. The trending ability for CICN at aortic clamping and unclamping was below the acceptable limit. These inaccuracies might be secondary to the high systemic vascular resistance index during AAA surgery.

P4558Hemodynamic management of resistant hypertension

Abstract Background Hypertension is the most prevalent chronic disease worldwide and is is related with high probability of cardiac disease, kidney disease and cerebrovascular events. Blood pressure measurement was used in the last decades to diagnose and guide antihypertensive therapy; however blood pressure is the result of interaction of more complex hemodynamic parameters previously reserved to experimental studies or critical care patients management using invasive methods. Since 1996 few studies has proposed the use of hemodynamic parameters to classify and guide hypertension therapy with good results. Purpose The present study purpose was to measure hemodynamic parameters in patients with non-controlled resistant hypertension and use it to guide pharmacologic treatment in order to archive control blood pressure values according to the European Society of Cardiology guidelines. Methods A total of 84 patients between 32 and 95 years old diagnosed with non-controlled primary resistant hypertension were recruited and after previous therapy washout hemodynamic parameters were measured using noninvasive methods: preload by central venous pressure (CVP) using inferior vena cava diameter, cardiac index and systemic vascular resistance using Lyljestrand &amp; Zander modified formula. Patients were classified in 3 basic groups depending on which parameter was above normal value: hyperdynamic (HD) for high cardiac index &gt;3.5 L/min/m2, fluid overload (FO) for CVP &gt;8cmH2O and high systemic vascular resistance index (HSVRi) &gt;2500 dynes/sec/m2/cm–5, also 3 combined groups were a patient had 2 simultaneous hemodynamic alterations (HD+FO, HD+HSVRi and FO+HSRVi), according to this classification pharmacotherapy was guided indicating Bisoprolol in HD group, Amlodipine to HSVR patients and Hydrochlorothiazide to FO patients, in combined groups, combined therapy was given. Patients were observed for 6 months period taking as primary endpoint blood pressure control, acute cardiovascular events and hypotension. Results A significant reduction of hemodynamic parameters and blood pressure was observed since the first month of treatment obtaining a 100% hemodynamic and blood pressure goals in all patients at the third month of therapy without hypotension or acute cardiovascular event during this period, the HD+FO group reach goals at the 6th month of treatment without reported complications. Conclusions In this preliminary studied we observed that hemodynamic guided high blood pressure control may be a useful tool to a better understanding, classifications and treatment in patients with resistant hypertension; however a larger outcome studies to confirm this hypothesis.

Hemodynamic Phenotypes of Hypertension Based on Cardiac Output and Systemic Vascular Resistance

Blood pressure is a physiologic measure that reflects cardiac output and systemic vascular resistance. Classification by these components could be useful in characterizing subtypes of hypertension, which may have a role in selecting treatment strategies. However, hemodynamic phenotypes of a large, stable, outpatient population with hypertension remain unknown. We included 34,238 people with systolic blood pressure of ≥130 mm Hg, who underwent impedance cardiography at 51 sites of iKang Health Checkup Centers throughout China between 2012 and 2018. Hemodynamic parameters measured included stroke volume, stroke volume index, heart rate, cardiac output, cardiac index, systemic vascular resistance, and systemic vascular resistance index. We characterized these by systolic blood pressure categories and assessed patient characteristics associated with the ratio of cardiac index to systemic vascular resistance index. Among the study cohort (n = 33,414; mean age 52 ± 13 years; 36.6% female), 49%, 40%, and 11% had systolic blood pressure130-139, 140-159, and ≥160 mm Hg, respectively. Among patients with systolic blood pressure 140-159 mm Hg, 9353 (70%) had high systemic vascular resistance index but normal/low cardiac index, 1949 (15%) had high cardiac index but low/normal systemic vascular resistance index, and 2053 (15%) had low/normal cardiac index and systemic vascular resistance index. Using multivariable analysis, we found that cardiac index to systemic vascular resistance index ratio was negatively associated with age and body mass index (all P <0.05; R-square 0.16, 0.12, and 0.09 for systolic blood pressure 130-139, 140-159 and ≥160 mm Hg, respectively). Different hemodynamic blood pressure phenotypes were identified across all hypertensive blood pressure categories. Although individual characteristics were associated with the cardiac index to systemic vascular resistance index ratio, they only weakly explained the variation.

Prediction of heparin induced hypotension during cardiothoracic surgery: A retrospective observational study

Background: High-dose heparin occasionally causes severe hypotension during cardiothoracic surgery. Being able to predict the severity of the decrease in blood pressure prior to administration of heparin would improve hemodynamic and anesthetic management. The aim of this study was to investigate the predictors of heparininduced hypotension and the effects of high-dose heparin on various hemodynamic and physiologic parameters.Methodology: The records of adult patients who underwent elective cardiothoracic surgery at University of Yamanashi Hospital between January 2016 and December 2017 were retrospectively reviewed. Single and multiple linear regression analyses were conducted to identify the predictors of heparin-induced hypotension. Results: High baseline systemic vascular resistance index (SVRI) and non-use of preoperative antihypertensive medication were significant predictors of heparininduced hypotension with a following regression equation: Percent change in mean arterial pressure = 17.273 + 0.00457 × (baseline SVRI) - 14.043 × (antihypertensive medication), where antihypertensive medication is coded as 0 = no antihypertensive drug and 1 = one or more antihypertensive drug(s), F = 7.80, the multiple correlation coefficient is 0.68645, and R adjusted for degrees of freedom is 0.41078.Conclusion: The baseline SVRI and non-use of preoperative antihypertensive medication are significant predictors of the severity of heparin-induced hypotension.Abbreviations: MAP - Mean arterial blood pressure; CVP - central venous pressure; PAP - pulmonary arterial pressure; SVRI - systemic vascular resistance index; BMI: body mass index; ASA-PS: American Society of Anesthesiologists physical status classification; DM: diabetes mellitus; eGFR: estimated glomerular filtration rate; LVEF: left ventricular ejection fraction; EDVI: end-diastolic volume index; CI: cardiac index; SvO2: mixed venous oxygen saturation; LVEF: left ventricular ejection fraction; HR: heart rate. Preregistration: The study was approved by the institutional review board of University of Yamanashi (study H30036, registered May 28, 2018).Citation: Kotoda M, Ishiyama T, Nakajima H, Matsukawa T. Prediction of heparin induced hypotension during cardiothoracic surgery: A retrospective observational study. Anaesth pain &amp; intensiv care 2019;23(2):145-150

Wave reflections and systemic vascular resistance are stronger determinants of pulse pressure amplification than aortic stiffness in drug-naïve hypertensives

ABSTRACTBackground: Aortic-to-brachial pulse pressure (PP) amplification is a novel biomarker that prognosticates the cardiovascular risk above and beyond central aortic and brachial blood pressure. This phenomenon is modulated by left ventricular contractility and chronotrophy, large-artery stiffness and reflecting properties of microcirculation. However, the relative importance of these parameters as hemodynamic determinant of PP amplification remains elusive.Methods: A total of 88 consecutive drug-naïve hypertensives underwent a non-invasive assessment of central and peripheral hemodynamics via impedance cardiography and pulse wave analysis. Participants were classified into tertiles according to the magnitude of PP amplification. Hemodynamic determinants of low PP amplification were explored in univariate and multivariate regression analysis.Results: Compared with the high tertile, patients within the low PP amplification tertile were older and more commonly female and had lower height, weight and heart rate. Augmentation index (AIx) and systemic vascular resistance index (SVRI) were higher among patients within the low PP amplification tertile, whereas aortic pulse wave velocity (PWV) did not differ among groups. In multivariate analysis, higher AIx (OR: 1.27; 95% CI: 1.09–1.48) and higher SVRI were independently associated with higher odds for low PP amplification, whereas higher heart rate was the only parameter related to lower odds for low PP amplification (OR: 0.84; 95% CI: 0.71–0.99).Conclusion: This study shows that among newly-diagnosed drug-naïve hypertensives, elevated wave reflections and systemic vascular resistance are stronger determinants of PP amplification than aortic stiffness.

Assessment of Myocardial Function in Kenyan Children With Severe, Acute Malnutrition

Mortality among African children hospitalized with severe malnutrition remains high, with sudden, unexpected deaths leading to speculation about potential cardiac causes. Malnutrition is considered high risk for cardiac failure, but evidence is limited. To investigate the role of cardiovascular dysfunction in African children with severe, acute malnutrition (SAM). A prospective, matched case-control study, the Cardiac Physiology in Malnutrition (CAPMAL) study, of 88 children with SAM (exposed) vs 22 severity-matched patients without SAM (unexposed) was conducted between March 7, 2011, and February 20, 2012; data analysis was performed from October 1, 2012, to March 1, 2016. Echocardiographic and electrocardiographic (ECG) recordings (including 7-day Holter monitoring) at admission, day 7, and day 28. Findings in children with (cases) and without (controls) SAM and in marasmus and kwashiorkor phenotypes were compared. Eighty-eight children (52 with marasmus and 36 with kwashiorkor) of the 418 admitted with SAM and 22 severity-matched controls were studied. A total of 63 children (57%) were boys; median age at admission was 19 months (range, 12-39 months). On admission, abnormalities more common in cases vs controls included severe hypokalemia (potassium <2.5 mEq/L) (18 of 81 [22%] vs 0%), hypoalbuminemia (albumin level <3.4 g/dL) (66 of 88 [75%] vs 4 of 22 [18%]), and hypothyroidism (free thyroxine level <0.70 ng/dL or thyrotropin level >4.2 mU/L) (18 of 74 [24%] vs 1 of 21 [5%]) and were associated with typical electrocardiographic changes (T-wave inversion: odds ratio, 7.3; 95% CI, 1.9-28.0; P = .001), which corrected as potassium levels improved. Fourteen children with SAM (16%) but no controls died. Myocardial mass was lower in cases on admission but not by day 7. Results of the Tei Index, a measure of global cardiac function, were within the reference range and similar in cases (median, 0.37; interquartile range [IQR], 0.26-0.45) and controls (median, 0.36; IQR, 0.28-0.42). Echocardiography detected no evidence of cardiac failure among children with SAM, including those receiving intravenous fluids to correct hypovolemia. Cardiac dysfunction was generally associated with comorbidity and typical of hypovolemia, with low cardiac index (median, 4.9 L/min/m2; IQR, 3.9-6.1 L/min/m2), high systemic vascular resistance index (median, 1333 dyne seconds/cm5/m2; IQR, 1133-1752 dyne seconds/cm5/m2), and with few differences between the marasmus and kwashiorkor manifestations of malnutrition. Seven-day continuous ECG Holter monitoring during the high-risk initial refeeding period demonstrated self-limiting significant ventricular arrhythmias in 33 of 55 cases (60%) and 6 of 18 controls (33%) (P = .049); none were temporally related to adverse events, including fatalities. There is little evidence that African children with SAM are at greater risk of cardiac dysfunction or clinically significant arrhythmias than those without SAM or that marasmus and kwashiorkor differed in cardiovascular profile. These findings should prompt a review of current guidelines.

Initial Hemodynamic Profiles of Children with Dengue Shock Syndrome in Referral Settings

Background: Fluid therapy for dengue shock syndrome (DSS) requires a dynamic approach that involves monitoring of the pathophysiological processes as well as the preload, contractility, and afterload assessment during the course dengue infection. Hemodynamically unstable DSS patients received in referral setting often complicated by fluid overload and secondary infection. Objective: This study aims to provide hemodynamic profiles and fluid responsiveness of pediatric patients admitted to the PICU with DSS. Methods: Hemodynamic profiles, laboratories, and demographic data were collected from patients aged 1 month to 18 years old with DSS who were admitted to the Pediatric Intensive Care Unit (PICU) at Dr. Sardjito General Hospital, Yogyakarta, Indonesia from January to December 2016. Hemodynamic profiles were assessed in clinically shock and not clinically shock group at PICU admission using the non-invasive Ultrasonic Cardiac Output Monitor (USCOM). Fluid responsiveness in clinically shock group was evaluated after fluid challenge with 10 ml/kgBW crystalloid or colloid. Results: Eighty six subjects were included in this study. Sixty six subjects were admitted to PICU with clinically shock condition. This group received less intravenous fluid than hemodynamically stable group (6.9 vs 7.52 ml/kgBW/hour respectively), had higher mean hematocrit level (42.09% vs 40.32% respectively), had higher hematocrit level during PICU stay (43.37% vs 42.06% respectively), significantly higher percentage to receive inotropes agent (62,1% vs 5%, p 0,000) and longer duration of inotropes usage (23,5 vs 0 hours, p 0.72). From the clinically shock patients admitted to PICU, only 19,69% were fluid responsive. Other subjects in this group with fluid non responsive state, 90,38% had low inotropic index and high systemic vascular resistance index. Among 8 patients in clinically shock group who died during PICU stay, 6 of them had low cardiac Index, fluid non responsive condition, low inotropic index and high systemic vascular resistance index. Conclusion: Only a small percentage of DSS patients with clinically shock admitted to the PICU were fluid responsive. Majority of DSS cases in children had low inotropy index and high systemic vascular resistance index.

Impact of stroke volume on prognostic outcome in patients with atrial fibrillation and concomitant heart failure with preserved ejection fraction

BackgroundAtrial fibrillation (AF) can lead to a decrease in stroke volume (SV) despite a preserved left ventricular ejection fraction (LVEF). However, no previous studies have evaluated the prognostic importance of the decreased SV in patients with AF and concomitant heart failure with preserved ejection fraction (HFpEF). MethodsWe retrospectively studied the cases of 1520 consecutive patients who had undergone right heart catheterization. HFpEF (New York Heart Association functional class ≥II and LVEF ≥50%) was observed in 574 patients. We selected 47 patients with persistent AF with a heart rate of 40–110bpm and HFpEF without other underlying heart diseases. ResultsAmong a total of 47 patients, 16 (34%) had normal SV [SV index (SVI) >35ml/m2 and 31 (66%) patients had low SV (SVI≤35ml/m2)]. During the follow-up period of 1115±305 days, 14 patients (30%) met the composite endpoint defined as cardiac death and admission due to worsening heart failure. Cox proportional hazard ratio analysis showed that SVI was a predictor of the endpoint, independently of the cardiac index and other parameters. Kaplan–Meyer analysis showed that low SVI was significantly associated with a poor prognosis, with an event-free rate of 58% at the mean follow-up period of 991 days (log-rank p=0.02). In the multiple regression analysis, a high systemic vascular resistance index and a high heart rate were independent determinants of low SVI. ConclusionsOur findings suggest that low SV had a significant impact on prognosis in patients with AF despite the preserved LVEF. The SVI depended on the heart rate and SVRI.

Complex assessment of patients with decompensated heart failure: The clinical value of impedance cardiography and N-terminal pro-brain natriuretic peptide

BackgroundAcute decompensated heart failure (ADHF) is a serious clinical problem and a condition requiring immediate diagnostics, supporting the therapeutic decision adequate to the specific ADHF mechanism. N-terminal pro-brain natriuretic peptide (NT-proBNP) is an established biochemical marker of heart failure, strongly related to hemodynamic status. Impedance cardiography (ICG) provides non-invasive hemodynamic assessment that can be performed immediately at the bedside and revealed to be useful diagnostic tool in some clinical settings in cardiology. ObjectivesThe aim of this study was to evaluate the usefulness of ICG in the admission diagnostics and monitoring the effects of treatment in patients hospitalized due to ADHF, with special emphasis on its relation to NT-proBNP. MethodsThis study enrolled 102 patients, aged over 18 years, hospitalized due to ADHF. The subjects underwent detailed clinical assessment, including ICG and NT-proBNP at admission and at discharge day. ResultsAmong all analyzed ICG parameters thoracic fluid content (TFC), a marker of chest overload, was the most significantly correlated with NT-proBNP level (R = 0.46; p = 0.000001). In comparison with patients with low thoracic fluid content (TFC ≤ 35/kΩ), those with higher TFC values (>35/kΩ) exhibited a greater severity of symptoms (NYHA functional class); higher NT-proBNP levels; lower left ventricular ejection fraction (LVEF), stroke index (SI), and cardiac index (CI); as well as significantly higher systemic vascular resistance index (SVRI). These TFC-based subgroups showed no significant differences in terms of heart rate (HR), systolic blood pressure (SBP), or diastolic blood pressure (DBP). ConclusionsThe evaluation of hemodynamic parameters, especially TFC, seems to be a worthwhile addition to standard diagnostics, both at the stage of hospital admission and while monitoring the effects of treatment. Impedance cardiography is a useful method in evaluating individual hemodynamic profiles in patients with ADHF.

Strong correlation between doppler snuffbox resistive index and systemic vascular resistance in septic patients

PurposeTo compare systemic vascular resistance index (SVRI) as measured by invasive transpulmonary indicator dilution (TPID) and non-invasive Doppler-derived resistive index in septic patients. MethodsWe measured the snuffbox resistive index (SBRI) in both hands of septic patients who received hemodynamic monitoring by TPID prospectively. ResultsThirty-six patients with septic shock were enrolled (median acute physiology and chronic health evaluation II score: 23; median age: 64 years). Four SBRI values were measured in each patient, for a total of 96 patient days and 951 ultrasound measurements. The correlation coefficients between SVRI and the four SBRI values were all higher than 0.87 (p < .001). A higher SVRI was associated with sharp waveforms and reversed diastolic flow. A resistive index (RI) of 0.97 was the lower limit of normal SVRI (1700 dyn*s*cm−5*m2), and an RI of 1.1 was the upper limit of normal SVRI (2400 dyn*s*cm−5*m2). ConclusionsUsing ultrasound to measure RI is a noninvasive, inexpensive, reliable method to evaluate peripheral vascular resistance in septic patients, and it is highly correlated with SVRI. In addition, SBRI can be used to evaluate peripheral circulatory disturbances in septic patients.

Abstract PD-016: MYOCARDIAL DEPRESSION IN PEDIATRIC DENGUE HEMORRHAGIC FEVER: A PROSPECTIVE OBSERVATIONAL STUDY

Aims & Objectives: In addition to plasma leakage, myocardial depression is thought to contribute in the pathogenesis of Dengue Hemorrhagic Fever (DHF), but its role remains unclear. We aim to compare hemodynamic parameters and myocardial inotropy among 4 grades of DHF. Methods Children (1 month – 18 years old) with DHF admitted to the emergency room (ER) or pediatric intensive care unit (PICU) were recruited between January 2016 and March 2017. Diagnosis of DHF (grade I to IV) was based on World Health Organization (WHO) criteria (2012). We excluded patient who had received fluid resuscitation or inotropes, or had congenital heart disease. Stroke volume index (SVI), Smith-Madigan Inotropy Index (SMII), Cardiac Index (CI), and Systemic Vascular Resistance Index (SVRI) was measured at first admission. Trans-jugular measurement using Ultrasonic Cardiac Output Monitor (USCOM 1A®) was performed by pediatric intensivist or trained-chief resident. Results Two hundred eight out of 230 patients were included. The SVI, CI, and SVRI were comparable among all groups (p=0.40; p=0.75; and p=0.88, respectively). However, most of grade III and IV patients had low SVI (82%), low CI (52%), and high SVRI (63%). The SMII was significantly lower in grade IV (0.96 [0.4–2.2] W/m2) than grade I (1.20 [0.7–1.8] W/m2; p<0.001), grade II (1.10 [0.9–1.8] W/m2; p=0.03), and grade III (1.10 [0.4–2.5] W/m2; p=0.005). Conclusions The most DHF grade III and IV patients were low-output and high-resistance. Myocardial depression was contributed to this condition, especially in DHF grade IV.