Blood Volume Analysis Coupled with Ultrafiltration in the Management of Congestive Heart Failure - Guided Therapy to Achieve Euvolemia

Abstract

Abnormal regulation of intravascular volume plays a key role in the pathophysiology of heart failure. Expert consensus guidelines recommend treating volume-overloaded heart failure patients with lifestyle modifications and diuretics to return them to a euvolemic (normovolemic) state. The diagnosis of volume overload can be imprecise, as previous studies have shown that signs of congestion detected by physical examination and chest radiography are inaccurate markers of fluid excess. The most direct and accurate method available for determination of intravascular volume status is radioisotopic measurement using the indicator dilution method. This technique can be applied to clinical decision-making in heart failure patients and may be used to more precisely guide fluid removal by ultrafiltration such that patients are restored to euvolemia with minimal risk.

Acknowledgement
The author wishes to thank Sandy Gilbert, PhD, for her editorial assistance with this manuscript.

Pages

Volume Overload in Heart Failure

The burden of heart failure (HF) remains formidable in the US, with nearly one million annual hospital admissions and frequent outpatient visits to a variety of care providers.1 While HF outcomes have improved modestly over the past several decades, many patients still struggle to maintain a satisfactory quality of life.2 Implantable cardioverter– defibrillators have reduced the risk for sudden cardiac death. Thus, more patients experience progressive ventricular dysfunction and are at higher risk for episodes of fluid retention. In fact, fluid retention is the primary presenting symptom in roughly 90% of the one million annual hospitalizations for HF.3
Diuretics are the most commonly prescribed medical therapy for hospitalized HF patients.3 Diuretics are prescribed out of necessity, although they are associated with worse outcomes in both inpatient and outpatient settings.4 It is a major challenge to determine when an HF patient has achieved euvolemia (normovolemia) and to adjust diuretic therapy appropriately. Recently published guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA), the Heart Failure Society of America (HFSA), and the European Society of Cardiology (ESC) recommend regular volume assessment of HF patients coupled with therapy aimed at achieving euvolemia.1,5,6
Salt and water retention in HF is due, in part, to neurohormonal activation of the renin–angiotensin–aldosterone system (RAAS) and increased vasopressin levels. Suboptimal patient adherence to and compliance with medical therapy and dietary restrictions also contribute to volume overload.7 Almost 25% of discharged HF patients are re-hospitalized within 30 days, many for recurrent volume overload.8 Inadequate correction of hypervolemia at the initial admission may account for some of this elevated risk, while poor patient compliance and suboptimal co-ordination of care at discharge likely explain the remaining residual risk.9–12
What is lacking in the routine care of the HF patient is a more systematic approach to guide fluid management therapy by helping clinicians to determine when patients have achieved normovolemia. This article will highlight this unmet need and explore the use of quantitative blood volume analysis (BVA) as a tool to guide management of volume overload in HF patients.

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