Unrecognized Volume Overload in Congestive Heart Failure

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US Cardiology 2004;2004:1(1):141-144

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A recent study reported the clinical characteristics and outcomes of 43 non-edematous ambulatory patients with congestive heart failure, in whom clinical volume status was categorized by a direct measurement of blood volume by a radioisotope technique.1 Despite on-going treatment with high doses of loop diuretics and few physical signs of congestion, 65% of the subjects in this cohort were found to have large increases in blood volume. Those patients that were classified as hypervolemic (>8% above the predicted normal blood volume) had a mortality rate of 39% within one year, and a 55% mortality rate within two years versus a 0% mortality rate for those patients who were classified as normovolemic or hypovolemic.

Since more than 4.5 million Americans have been diagnosed with heart failure, and nearly 550,000 new cases are diagnosed annually,2 it is important to consider the potential contribution of direct blood volume measurement in enhancing diagnosis, treatment, and prognostic assessment of heart failure patients.

Heart failure is a clinical syndrome rather than a specific disease state. Progressive changes in left ventricular structure and peripheral arteriolar structure and function that occur in response to various sources of myocellular stress and/or injury reduce cardiac output reserve and aerobic capacity. Renal hypoperfusion secondary to reduced cardiac output is commonly associated with sodium and water retention (increased plasma volume) and consequent congestive signs and symptoms. Co-morbid conditions, such as hypertension, renal disease, diabetes, and coronary artery disease (CAD) also contribute to progression of disease and heterogeneity in clinical presentations.

Blood Volume Measurement Technique

Although derangements in blood volume are integral in the pathophysiology of heart failure, until recently direct measurement of blood volume has not been feasible for routine clinical practice. Radioisotopic blood volume measurement is considered the gold standard for assessment of blood volume.3 However, until recently, radioisotopic measurement of blood volume has been difficult and time-consuming, requiring as much as four to six hours to complete. As a result, clinical blood volume status has been routinely estimated using a combination of findings from clinical history, physical examination, and proxy tests such as the hematocrit, hemoglobin, plasma brain natriuretic peptide levels, and azotemia.

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References
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