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Bioimpedance Vector Analysis in the Diagnosis of Acute Decompensated Heart Failure in the Emergency Department
The 16th Annual Scientific Meeting
337 Outpatient Ultrafiltration for Acute Decompensated Heart Failure: Single Center Experience Sitaramesh Emani1, Jennifer Host1, Gina Mentzer1, Donald Kikta2, Todd Yamokoski1, Garrie Haas1; 1Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Internal Medicine, University Hospitals, Cleveland, OH Background: Ultrafiltration (UF) has been shown to be an effective option in the treatment of acute decompensated heart failure (ADHF). To date, the majority of published data have focused on the use of UF in the inpatient setting. Little information exists on the application of this treatment modality in the outpatient setting. Herein we report our preliminary experience with the use of UF for mild AHDF cases in an effort to avoid inpatient admissions. Methods: A retrospective chart analysis of patient who underwent UF in the outpatient setting between 2009-2011. Patients were initially identified as outpatient UF candidates after evaluation by the Heart Failure team at our institution. Patients with clinical findings suggestive of ADHF without hemodynamic compromise or acute cardiogenic shock were considered to be eligible. Additionally, proximity to our center with reliable transportation options for multiple days of treatment, if necessary, was considered. Data recorded included the length of therapy, fluid volume removed, change in weight, catheter type used, and adverse events. Freedom from an ED visit or inpatient admission within 2 weeks was also recorded. UF received within a short span (consecutive days or within 5 days) was considered to be a single episode. Results: Twenty-one episodes of outpatient UF occurred in the specified time frame. Average length of therapy was 2.29 days (range 1-3), with UF occurring on average 7.92 hrs/ d resulting in an average fluid removal of 2 liters/d. Total average weight loss was 8.4 kg (3.2% weight loss). Freedom from an unplanned acute presentation at 2 weeks was 75%. Eight of 21 UF episodes were delivered using a commercially available duallumen UF catheter (central line); the rest were through peripheral IV access. No adverse events were noted. Serum creatinine values pre- and post-UF were 1.4860.52 and 1.5060.52, respectively (p NS). Conclusions: Outpatient UF is a reasonable option for mild ADHF. Effective volume removal can be achieved safely without exposure to increased doses of loop diuretics, which may translate to improved HF outcomes. Outpatient UF may also reduce inpatient admissions in an otherwise high-risk population.
HFSA
S103
criteria. Results: 34 of the 97 patients enrolled had adjudicated ADHF. Unlike serum BNP, BIVA-derived hydration had no significant correlation with renal function. Patients with adjudicated ADHF had a significantly higher mean BIVA-derived hydration compared to those without ADHF (77.9% vs. 73.6%, p50.038). An optimum BIVA-derived hydration of 78% was determined by the receiver operating characteristic curve (p50.002). BIVA-derived hydration rates than 78% yielded an area under the curve (AUC) of 0.688 (95% CI: 0.5740.809) for adjudicated ADHF. BNP alone produced an AUC of 0.84 (95% CI: 0.749-0.930) and the combination of BIVA-derived hydration with BNP yielded an AUC of 0.892 (95% CI: 0.815-0.970). Conclusions: BIVA-derived hydration rate adds to the diagnostic accuracy of BNP in the diagnosis of ADHF in undifferentiated dyspneic patients in the ED and does not correlate with renal function.
338 Who are at Risk of Diastolic Heart Failure in Response to Volume Load? Seong Woo Han, Hong Seog Seo, Chang Gyu Park, Jin Oh Na, Eung Ju Kim, Dong Joo Oh; Cardiovascular Medicine, Korea University Guro Hospital, Seoul, Republic of Korea Background: The clinical profile of diastolic heart failure (DHF) has been only characterized by retrospective observational studies. Objectives: We aimed to characterize the subjects prone to DHF in response to volume load. Methods: Patients undergoing chronic hemodialysis (HD) were consecutively enrolled. Of total 71, sixty one eligible patients who have left ventricular (LV) ejection fraction $50% were investigated. The echocardiographic parameters before and after HD and body composition before HD using noninvasive bioimpedance analysis were measured. Results: Although none of the subjects had symptom or sign of heart failure after HD, 18 (30%) patients were diagnosed as DHF at the time of pre-HD (DHF group). The last 3-month averaged interdialytic weight gain, which was regarded as the volume loaded, was nearly same between control and DHF group (2.460.7 kg vs. 2.360.7 kg, p50.248). DHF patients were older (66.1610.9 years vs. 52.2613.4 years, p!0.001) and more often women (77.8% vs. 44.2%, p50.024). The prevalence of hypertension was over 90% in both groups, but its duration was longer in DHF group. Body fat percentage and the ratio of extracellular (ECF) to intracellular fluid (ICF) were significantly higher and hematocrit level was lower in DHF group. Before and after HD, DHF group showed significantly higher systolic and pulse pressure, LV mass index and E/E’ but lower E/A. Conclusions: For the same volume loaded, the subjects prone to DHF were older and more often women and had longer duration of hypertension, higher body fat percentage, ECF/ICF, LV mass index and worse LV diastolic function.
339 Bioimpedance Vector Analysis in the Diagnosis of Acute Decompensated Heart Failure in the Emergency Department Devin W. Kehl1,2, Rajiv Choudhary2, Bryan Dieffenbach1, Paul Clopton2, Pam R. Taub1,2, Alan S. Maisel1,2; 1University of California at San Diego, CA; 2Veterans Affairs San Diego Healthcare System, San Diego, CA Objective: To determine the diagnostic utility of Bioimpedance Vector Analysis (BIVA) and its additive value to serum B-type natriuretic peptide (BNP) among dyspneic patients in the emergency department (ED). Background: BIVA represents a novel and noninvasive means to assess volume status among inpatients with acute decompensated heart failure (ADHF). Whether it can be used to diagnose ADHF in undifferentiated dyspneic patients in the ED is less clear. Methods: BIVA was performed to measure total body hydration percentage on 97 consecutive adult patients presenting to the ED with a chief complaint of dyspnea. Adjudication of ADHF was done retrospectively using Framingham
340 Beta-Blocker Dose Reduction in Acute Decompensated Heart Failure Requiring Milrinone Treatment Brent C. Lampert, Jeffrey J. Teuteberg, Michael Mathier, Ravi Ramani, Marc Simon, Hunter Champion, Jessica Pisarcik, Dennis McNamara; Heart and Vascular Institute, University of Pittsburgh, PA Introduction: Benefits of beta-blocker therapy in chronic heart failure are well established. Yet, there is limited evidence on how to adjust beta-blockers when a patient with acute decompensated heart failure (ADHF) requires treatment with milrinone. Clinical practice varies from continuing the full dose to discontinuing them entirely. Hypothesis: Beta-blocker dose reduction in patients with ADHF requiring milrinone will have no effect on diuresis and other clinical outcomes. Methods: We prospectively enrolled 37 patients on stable beta-blocker therapy who presented with ADHF requiring milrinone treatment. Decision to initiate milrinone and adjust beta-blocker dose were at the discretion of the primary physician managing the patient. Patients who received # 50% (low betablocker group) of their baseline beta-blocker dose were compared to those who received 50% of their baseline dose (high beta-blocker group). Results: There were 18 patients in the low beta-blocker group and 19 patients in the high betablocker group. Mean dose was 30% of baseline admission dose in the low betablocker group and 94% of baseline in the high beta-blocker group (p!0.0001). There were no differences between groups for baseline heart rate (81 vs 76 bpm, p 5 0.36), mean arterial pressure (79 vs 81 mmHg, p50.42), mean pulmonary artery pressure (42 vs 45 mmHg, p50.31), wedge pressure (27 vs 26 mmHg, p50.64), pulmonary artery saturation (45 vs 46%, p50.64) and cardiac index (1.90 vs 1.87 l/min/m2, p50.78). Diuresis over 72 hours did not differ (3.53 vs 3.80 l, p50.32). Heart rate at 72 hours was significantly higher in the low beta blocker group (89 vs 79 bpm, p50.03) but mean arterial pressure did not differ (76 vs 78 mmHg, p50.48). At 72 hours serum sodium (136 vs. 136 mMol/L, p50.90), BUN (27 vs 32 mg/dL, p50.25), and creatinine (1.4 vs. 1.6 mg/dL, p50.26) did not differ. Length of inotrope use (7.7 vs. 8.5 days, p50.75) and hospital length of stay (13.1 vs. 14.9 days, p50.95) were similar. There was no difference in the number of patients discharged on a beta-blockers (12 vs 17, p50.22), but the high beta-blocker group was discharged on a higher percentage of their admission dose (60 vs 93%, p50.02). Conclusions: Patients with ADHF requiring milrinone who are continued on a higher dose of beta-blockers had no difference in diuresis at 72 hours and other clinical outcomes compared to patients in whom the dose is reduced.
337 Outpatient Ultrafiltration for Acute Decompensated Heart Failure: Single Center Experience Sitaramesh Emani1, Jennifer Host1, Gina Mentzer1, Donald Kikta2, Todd Yamokoski1, Garrie Haas1; 1Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Internal Medicine, University Hospitals, Cleveland, OH Background: Ultrafiltration (UF) has been shown to be an effective option in the treatment of acute decompensated heart failure (ADHF). To date, the majority of published data have focused on the use of UF in the inpatient setting. Little information exists on the application of this treatment modality in the outpatient setting. Herein we report our preliminary experience with the use of UF for mild AHDF cases in an effort to avoid inpatient admissions. Methods: A retrospective chart analysis of patient who underwent UF in the outpatient setting between 2009-2011. Patients were initially identified as outpatient UF candidates after evaluation by the Heart Failure team at our institution. Patients with clinical findings suggestive of ADHF without hemodynamic compromise or acute cardiogenic shock were considered to be eligible. Additionally, proximity to our center with reliable transportation options for multiple days of treatment, if necessary, was considered. Data recorded included the length of therapy, fluid volume removed, change in weight, catheter type used, and adverse events. Freedom from an ED visit or inpatient admission within 2 weeks was also recorded. UF received within a short span (consecutive days or within 5 days) was considered to be a single episode. Results: Twenty-one episodes of outpatient UF occurred in the specified time frame. Average length of therapy was 2.29 days (range 1-3), with UF occurring on average 7.92 hrs/ d resulting in an average fluid removal of 2 liters/d. Total average weight loss was 8.4 kg (3.2% weight loss). Freedom from an unplanned acute presentation at 2 weeks was 75%. Eight of 21 UF episodes were delivered using a commercially available duallumen UF catheter (central line); the rest were through peripheral IV access. No adverse events were noted. Serum creatinine values pre- and post-UF were 1.4860.52 and 1.5060.52, respectively (p NS). Conclusions: Outpatient UF is a reasonable option for mild ADHF. Effective volume removal can be achieved safely without exposure to increased doses of loop diuretics, which may translate to improved HF outcomes. Outpatient UF may also reduce inpatient admissions in an otherwise high-risk population.
HFSA
S103
criteria. Results: 34 of the 97 patients enrolled had adjudicated ADHF. Unlike serum BNP, BIVA-derived hydration had no significant correlation with renal function. Patients with adjudicated ADHF had a significantly higher mean BIVA-derived hydration compared to those without ADHF (77.9% vs. 73.6%, p50.038). An optimum BIVA-derived hydration of 78% was determined by the receiver operating characteristic curve (p50.002). BIVA-derived hydration rates than 78% yielded an area under the curve (AUC) of 0.688 (95% CI: 0.5740.809) for adjudicated ADHF. BNP alone produced an AUC of 0.84 (95% CI: 0.749-0.930) and the combination of BIVA-derived hydration with BNP yielded an AUC of 0.892 (95% CI: 0.815-0.970). Conclusions: BIVA-derived hydration rate adds to the diagnostic accuracy of BNP in the diagnosis of ADHF in undifferentiated dyspneic patients in the ED and does not correlate with renal function.
338 Who are at Risk of Diastolic Heart Failure in Response to Volume Load? Seong Woo Han, Hong Seog Seo, Chang Gyu Park, Jin Oh Na, Eung Ju Kim, Dong Joo Oh; Cardiovascular Medicine, Korea University Guro Hospital, Seoul, Republic of Korea Background: The clinical profile of diastolic heart failure (DHF) has been only characterized by retrospective observational studies. Objectives: We aimed to characterize the subjects prone to DHF in response to volume load. Methods: Patients undergoing chronic hemodialysis (HD) were consecutively enrolled. Of total 71, sixty one eligible patients who have left ventricular (LV) ejection fraction $50% were investigated. The echocardiographic parameters before and after HD and body composition before HD using noninvasive bioimpedance analysis were measured. Results: Although none of the subjects had symptom or sign of heart failure after HD, 18 (30%) patients were diagnosed as DHF at the time of pre-HD (DHF group). The last 3-month averaged interdialytic weight gain, which was regarded as the volume loaded, was nearly same between control and DHF group (2.460.7 kg vs. 2.360.7 kg, p50.248). DHF patients were older (66.1610.9 years vs. 52.2613.4 years, p!0.001) and more often women (77.8% vs. 44.2%, p50.024). The prevalence of hypertension was over 90% in both groups, but its duration was longer in DHF group. Body fat percentage and the ratio of extracellular (ECF) to intracellular fluid (ICF) were significantly higher and hematocrit level was lower in DHF group. Before and after HD, DHF group showed significantly higher systolic and pulse pressure, LV mass index and E/E’ but lower E/A. Conclusions: For the same volume loaded, the subjects prone to DHF were older and more often women and had longer duration of hypertension, higher body fat percentage, ECF/ICF, LV mass index and worse LV diastolic function.
339 Bioimpedance Vector Analysis in the Diagnosis of Acute Decompensated Heart Failure in the Emergency Department Devin W. Kehl1,2, Rajiv Choudhary2, Bryan Dieffenbach1, Paul Clopton2, Pam R. Taub1,2, Alan S. Maisel1,2; 1University of California at San Diego, CA; 2Veterans Affairs San Diego Healthcare System, San Diego, CA Objective: To determine the diagnostic utility of Bioimpedance Vector Analysis (BIVA) and its additive value to serum B-type natriuretic peptide (BNP) among dyspneic patients in the emergency department (ED). Background: BIVA represents a novel and noninvasive means to assess volume status among inpatients with acute decompensated heart failure (ADHF). Whether it can be used to diagnose ADHF in undifferentiated dyspneic patients in the ED is less clear. Methods: BIVA was performed to measure total body hydration percentage on 97 consecutive adult patients presenting to the ED with a chief complaint of dyspnea. Adjudication of ADHF was done retrospectively using Framingham
340 Beta-Blocker Dose Reduction in Acute Decompensated Heart Failure Requiring Milrinone Treatment Brent C. Lampert, Jeffrey J. Teuteberg, Michael Mathier, Ravi Ramani, Marc Simon, Hunter Champion, Jessica Pisarcik, Dennis McNamara; Heart and Vascular Institute, University of Pittsburgh, PA Introduction: Benefits of beta-blocker therapy in chronic heart failure are well established. Yet, there is limited evidence on how to adjust beta-blockers when a patient with acute decompensated heart failure (ADHF) requires treatment with milrinone. Clinical practice varies from continuing the full dose to discontinuing them entirely. Hypothesis: Beta-blocker dose reduction in patients with ADHF requiring milrinone will have no effect on diuresis and other clinical outcomes. Methods: We prospectively enrolled 37 patients on stable beta-blocker therapy who presented with ADHF requiring milrinone treatment. Decision to initiate milrinone and adjust beta-blocker dose were at the discretion of the primary physician managing the patient. Patients who received # 50% (low betablocker group) of their baseline beta-blocker dose were compared to those who received 50% of their baseline dose (high beta-blocker group). Results: There were 18 patients in the low beta-blocker group and 19 patients in the high betablocker group. Mean dose was 30% of baseline admission dose in the low betablocker group and 94% of baseline in the high beta-blocker group (p!0.0001). There were no differences between groups for baseline heart rate (81 vs 76 bpm, p 5 0.36), mean arterial pressure (79 vs 81 mmHg, p50.42), mean pulmonary artery pressure (42 vs 45 mmHg, p50.31), wedge pressure (27 vs 26 mmHg, p50.64), pulmonary artery saturation (45 vs 46%, p50.64) and cardiac index (1.90 vs 1.87 l/min/m2, p50.78). Diuresis over 72 hours did not differ (3.53 vs 3.80 l, p50.32). Heart rate at 72 hours was significantly higher in the low beta blocker group (89 vs 79 bpm, p50.03) but mean arterial pressure did not differ (76 vs 78 mmHg, p50.48). At 72 hours serum sodium (136 vs. 136 mMol/L, p50.90), BUN (27 vs 32 mg/dL, p50.25), and creatinine (1.4 vs. 1.6 mg/dL, p50.26) did not differ. Length of inotrope use (7.7 vs. 8.5 days, p50.75) and hospital length of stay (13.1 vs. 14.9 days, p50.95) were similar. There was no difference in the number of patients discharged on a beta-blockers (12 vs 17, p50.22), but the high beta-blocker group was discharged on a higher percentage of their admission dose (60 vs 93%, p50.02). Conclusions: Patients with ADHF requiring milrinone who are continued on a higher dose of beta-blockers had no difference in diuresis at 72 hours and other clinical outcomes compared to patients in whom the dose is reduced.