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Volume Overload and Quantitated Plasma Volume: How Effective Is Intravenous Diuretic Therapy in Patients Hospitalized for Decompensated Chronic Heart Failure?
S42 Journal of Cardiac Failure Vol. 19 No. 8S August 2013 Likewise, MLWHF scores were similar for pts with HFrEF and HFpEF (54.5 vs 51.5, p50.17). Across multiple domains of the KCCQ, there were no significant differences between subjects with HFrEF and HFpEF(Table). Conclusion: HFpEF pts constitute a minority of pts admitted for HF to a VA hospital, and they appear to have significantly impaired QoL. Indeed at the time of first post-hospitalization clinic evaluation, QoL is equally impaired among pts with HFrEF or HFpEF. Strategies to improve both clinical outcomes and QoL in HFpEF are desperately needed. Table. Quality of Life in HFrEF and HFpEF at First Outpatient Clinic Visit HFrEF
121 Volume Overload and Quantitated Plasma Volume: How Effective Is Intravenous Diuretic Therapy in Patients Hospitalized for Decompensated Chronic Heart Failure? Wayne L. Miller; Mayo Clinic, Rochester, MN
HFpEF
Mean Mean Number of Score Number of Score Mean P Subjects (std dev) Subjects (std dev) Difference Value MLWHF KCCQ Overall Summary Clinical Summary Social Limitation Quality of Life Self Efficacy Total Symptom Score Symptom Burden Symptom Frequency Symptom Stability Physical Limitation
with ADHF. These findings may explain the novel relationship between exercise capacity and BMD in ADHF patients.
452
54.5 (25.5)
206
51.5 (26.9)
2.99
.17
484 484 457 480 475 482
48.1 51.2 41.6 47.4 75.8 54.8
(24.4) (24.5) (30.8) (27.1) (24.5) (27.1)
222 222 204 220 219 221
47.4 48.6 42.0 49.2 77.3 51.4
(25.8) (25.6) (32.5) (27.8) (23.6) (28.6)
0.68 2.64 -0.43 -1.83 -1.52 3.42
.74 .19 .87 .41 .44 .13
482 480
57.2 (27.1) 52.3 (29)
220 218
54.6 (28.3) 48.1 (30.8)
2.53 4.17
.26 .084
479 471
56.5 (27.6) 47.2 (26.7)
218 215
52.4 (27.4) 45.3 (27.8)
4.06 1.97
.072 .38
120 Osteoporosis Is Prevalent and Exercise Capacity Independently Predicts Bone Mineral Density in Male Patients with Acute Decompensated Heart Failure Jong-Chan Youn1, Yumie Rhee2, Jaewon Oh1, Seok-Min Kang1; 1Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; 2Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea Background: Heart failure is associated with increased risk of osteoporosis. However, the prevalence and predictors of osteoporosis in patients with acute decompensated heart failure (ADHF) are not well investigated. Methods: Fifty male patients with ADHF (60 6 16 years, mean ejection fraction 28.0 6 11.5%) were prospectively and consecutively enrolled. Quantitative CT scans for bone mineral density (BMD) as well as biochemical, echocardiographic and cardiopulmonary exercise tests were evaluated. Results: Sixteen patients (32%) had osteopenia (volumetric lumbar BMD of 80-120 mg/cm3) and six patients (12%) had osteoporosis (BMD ! 80 mg/cm3). C-telopeptide of type I collagen (0.564 6 0.323 ng/mL) was within normal range, however osteocalcin (18.7 6 23.2 ng/mL) and 25-hydroxyvitamin D (13.8 6 7.0 ng/mL) were low, while parathyroid hormone (65.3 6 41.0 pg/mL) was increased. Lumbar BMD was lower in ischemic patients than non-ischemic patients (107.9 mg/cm3 vs. 144.7 mg/cm3, p50.007). Multivariate regression analysis revealed peak VO2 which is a well known prognostic marker in ADHF, independently predicts BMD when controlled for age, BMI, etiology of heart failure (b50.487, p50.022). Conclusion: Osteoporosis is more prevalent in ischemic patients and exercise capacity independently predicts bone mineral density in patients
Background: The assessment and management of fluid volume overload has been a recurrent and perplexing issue in the management of patients hospitalized and often re-hospitalized with decompensated heart failure (DHF). The objective of this study was to quantitate plasma volume (PV) status in patients with DHF, and to determine the effectiveness of standard in-hospital diuresis management in reducing volume overload, and if the quantitation of PV could serve as a tool to guide more effective in-hospital diuretic therapy to achieve practice guideline-recommended euvolemia. Methods: PV was measured in patients with a history of chronic HF admitted to hospital for management of clinically determined volume overload. Intravascular volume was determined by a validated radiolabeled-albumin dilutional technique (Volumex, Daxor Corp., NY, NY) at hospital admission and at hospital discharge. Normal PV is defined pre hoc as measured volumes within 68% of the expected normal value; mild volume expansion is #20% of predicted normal value. Volume status reported as absolute value and percentage of the normal value for the individual patient. The coefficient of variation of the analytic technique is !3.5%. Changes in quantitated volume status pre-post diuretic therapy were compared to clinical parameters of volume assessment [body weight change; net fluid input and urine output (I/Os)]. Results: Twenty-seven patients were evaluated (7369 yrs, sCr 1.760.8 mg/dL, LVEF 40618%, LOS (length of stay) 6.362.1 days). All patients except 3 received intravenous loop diuretic therapy (furosemide) at 10-20 mg/hr for average of 562 days. The remaining 3 patients received oral furosemide equivalent of 80-160 mg per day. Admission to discharge PV and clinical parameters are shown below. Conclusions: Quantitated PV demonstrates that patients with DHF are significantly intravascularly volume expanded and that usual clinically-guided diuretic therapy only marginally impacts volume status at discharge despite large reductions in body weight and high net negative I/Os. Mobilization of interstitial volume intravascularly likely accounts for this disparity and suggests that DHF patients require longer periods of, or more effective diuretic therapy, to achieve euvolemia. Longer LOS may, however, be compensated by lower rates of 30-day re-hospitalization. Admission Measured PV Normal Expected PV (Euvolemia) PV Expansion Change in Body Weight Net I/Os
4.7 6 1.1 Liters 3.2 6 0.4 Liters þ46 6 30%
Discharge 4.3 6 1.0 Liters þ32 6 22% (p50.214) 7.0 6 4.6 kg 7.4 6 6.5 Liters
122 A Multidisciplinary Approach at the Primary Care Level Improves Heart Failure Care Kathleen Tong1, Sharon Myers2, Patricia Poole3, Jennifer Nguyen3, Erin Griffin4, Bridget Levich2; 1UC Davis, Sacramento, CA; 2UC Davis, Sacramento, CA; 3UC Davis, Sacramento, CA; 4UC Davis, Sacramento, CA Introduction: Heart failure (HF) is a complex, chronic disease characterized by high mortality and morbidity affecting more than 5 million Americans. Specialized HF clinics with multidisciplinary staff have been associated with favorable outcomes. The number of HF patients will likely exceed the capacity of these specialty clinics. Sustainable and effective programs will be needed to support a growing HF population in the primary care setting. Hypothesis: A dedicated HF pharmacist and nurse team based in a primary care clinic can improve access to care, reduce hospital use, and empower patients to participate in self-care management. Methods: Patients from a practice of ten PCPs were voluntarily enrolled in a pilot study for HF case management based on referral from hospital discharge or their PCP from January 1 to October 31, 2012. Patients O18yrs with a diagnosis of HFpEF and HFrEF were included. The minimum intervention included early contact from the pilot team, in person patient assessment, medication reconciliation, HF education, and the development of patient driven self-care goals. Additional encounters with the patient were provided in person and telephonically as needed. The nurse and pharmacist used an institution approved care protocol. Patient demographic and clinical data were recorded and compared to their own historical outcomes prior to enrollment and to a matched cohort from different practice sites within our system as a control group. The advanced HF cardiologist also hosted three educational forums on HF for the pilot site PCPs during the pilot. Results: Forty-six patients were enrolled in the program. The average time to first contact with a clinic after discharge for the intervention group was lower than the control group (2.6 d vs. 5.1 d). There was a 35% reduction in the total number of all cause admissions in the pilot patients compared to themselves in the same time period in the previous year. Of the self-care goals identified by patients, 83%
121 Volume Overload and Quantitated Plasma Volume: How Effective Is Intravenous Diuretic Therapy in Patients Hospitalized for Decompensated Chronic Heart Failure? Wayne L. Miller; Mayo Clinic, Rochester, MN
HFpEF
Mean Mean Number of Score Number of Score Mean P Subjects (std dev) Subjects (std dev) Difference Value MLWHF KCCQ Overall Summary Clinical Summary Social Limitation Quality of Life Self Efficacy Total Symptom Score Symptom Burden Symptom Frequency Symptom Stability Physical Limitation
with ADHF. These findings may explain the novel relationship between exercise capacity and BMD in ADHF patients.
452
54.5 (25.5)
206
51.5 (26.9)
2.99
.17
484 484 457 480 475 482
48.1 51.2 41.6 47.4 75.8 54.8
(24.4) (24.5) (30.8) (27.1) (24.5) (27.1)
222 222 204 220 219 221
47.4 48.6 42.0 49.2 77.3 51.4
(25.8) (25.6) (32.5) (27.8) (23.6) (28.6)
0.68 2.64 -0.43 -1.83 -1.52 3.42
.74 .19 .87 .41 .44 .13
482 480
57.2 (27.1) 52.3 (29)
220 218
54.6 (28.3) 48.1 (30.8)
2.53 4.17
.26 .084
479 471
56.5 (27.6) 47.2 (26.7)
218 215
52.4 (27.4) 45.3 (27.8)
4.06 1.97
.072 .38
120 Osteoporosis Is Prevalent and Exercise Capacity Independently Predicts Bone Mineral Density in Male Patients with Acute Decompensated Heart Failure Jong-Chan Youn1, Yumie Rhee2, Jaewon Oh1, Seok-Min Kang1; 1Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; 2Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea Background: Heart failure is associated with increased risk of osteoporosis. However, the prevalence and predictors of osteoporosis in patients with acute decompensated heart failure (ADHF) are not well investigated. Methods: Fifty male patients with ADHF (60 6 16 years, mean ejection fraction 28.0 6 11.5%) were prospectively and consecutively enrolled. Quantitative CT scans for bone mineral density (BMD) as well as biochemical, echocardiographic and cardiopulmonary exercise tests were evaluated. Results: Sixteen patients (32%) had osteopenia (volumetric lumbar BMD of 80-120 mg/cm3) and six patients (12%) had osteoporosis (BMD ! 80 mg/cm3). C-telopeptide of type I collagen (0.564 6 0.323 ng/mL) was within normal range, however osteocalcin (18.7 6 23.2 ng/mL) and 25-hydroxyvitamin D (13.8 6 7.0 ng/mL) were low, while parathyroid hormone (65.3 6 41.0 pg/mL) was increased. Lumbar BMD was lower in ischemic patients than non-ischemic patients (107.9 mg/cm3 vs. 144.7 mg/cm3, p50.007). Multivariate regression analysis revealed peak VO2 which is a well known prognostic marker in ADHF, independently predicts BMD when controlled for age, BMI, etiology of heart failure (b50.487, p50.022). Conclusion: Osteoporosis is more prevalent in ischemic patients and exercise capacity independently predicts bone mineral density in patients
Background: The assessment and management of fluid volume overload has been a recurrent and perplexing issue in the management of patients hospitalized and often re-hospitalized with decompensated heart failure (DHF). The objective of this study was to quantitate plasma volume (PV) status in patients with DHF, and to determine the effectiveness of standard in-hospital diuresis management in reducing volume overload, and if the quantitation of PV could serve as a tool to guide more effective in-hospital diuretic therapy to achieve practice guideline-recommended euvolemia. Methods: PV was measured in patients with a history of chronic HF admitted to hospital for management of clinically determined volume overload. Intravascular volume was determined by a validated radiolabeled-albumin dilutional technique (Volumex, Daxor Corp., NY, NY) at hospital admission and at hospital discharge. Normal PV is defined pre hoc as measured volumes within 68% of the expected normal value; mild volume expansion is #20% of predicted normal value. Volume status reported as absolute value and percentage of the normal value for the individual patient. The coefficient of variation of the analytic technique is !3.5%. Changes in quantitated volume status pre-post diuretic therapy were compared to clinical parameters of volume assessment [body weight change; net fluid input and urine output (I/Os)]. Results: Twenty-seven patients were evaluated (7369 yrs, sCr 1.760.8 mg/dL, LVEF 40618%, LOS (length of stay) 6.362.1 days). All patients except 3 received intravenous loop diuretic therapy (furosemide) at 10-20 mg/hr for average of 562 days. The remaining 3 patients received oral furosemide equivalent of 80-160 mg per day. Admission to discharge PV and clinical parameters are shown below. Conclusions: Quantitated PV demonstrates that patients with DHF are significantly intravascularly volume expanded and that usual clinically-guided diuretic therapy only marginally impacts volume status at discharge despite large reductions in body weight and high net negative I/Os. Mobilization of interstitial volume intravascularly likely accounts for this disparity and suggests that DHF patients require longer periods of, or more effective diuretic therapy, to achieve euvolemia. Longer LOS may, however, be compensated by lower rates of 30-day re-hospitalization. Admission Measured PV Normal Expected PV (Euvolemia) PV Expansion Change in Body Weight Net I/Os
4.7 6 1.1 Liters 3.2 6 0.4 Liters þ46 6 30%
Discharge 4.3 6 1.0 Liters þ32 6 22% (p50.214) 7.0 6 4.6 kg 7.4 6 6.5 Liters
122 A Multidisciplinary Approach at the Primary Care Level Improves Heart Failure Care Kathleen Tong1, Sharon Myers2, Patricia Poole3, Jennifer Nguyen3, Erin Griffin4, Bridget Levich2; 1UC Davis, Sacramento, CA; 2UC Davis, Sacramento, CA; 3UC Davis, Sacramento, CA; 4UC Davis, Sacramento, CA Introduction: Heart failure (HF) is a complex, chronic disease characterized by high mortality and morbidity affecting more than 5 million Americans. Specialized HF clinics with multidisciplinary staff have been associated with favorable outcomes. The number of HF patients will likely exceed the capacity of these specialty clinics. Sustainable and effective programs will be needed to support a growing HF population in the primary care setting. Hypothesis: A dedicated HF pharmacist and nurse team based in a primary care clinic can improve access to care, reduce hospital use, and empower patients to participate in self-care management. Methods: Patients from a practice of ten PCPs were voluntarily enrolled in a pilot study for HF case management based on referral from hospital discharge or their PCP from January 1 to October 31, 2012. Patients O18yrs with a diagnosis of HFpEF and HFrEF were included. The minimum intervention included early contact from the pilot team, in person patient assessment, medication reconciliation, HF education, and the development of patient driven self-care goals. Additional encounters with the patient were provided in person and telephonically as needed. The nurse and pharmacist used an institution approved care protocol. Patient demographic and clinical data were recorded and compared to their own historical outcomes prior to enrollment and to a matched cohort from different practice sites within our system as a control group. The advanced HF cardiologist also hosted three educational forums on HF for the pilot site PCPs during the pilot. Results: Forty-six patients were enrolled in the program. The average time to first contact with a clinic after discharge for the intervention group was lower than the control group (2.6 d vs. 5.1 d). There was a 35% reduction in the total number of all cause admissions in the pilot patients compared to themselves in the same time period in the previous year. Of the self-care goals identified by patients, 83%