Measuring Congestion in Acute Heart Failure: The “Holy Grail” Still Awaits

Murad, Khalil; Dunlap, Mark E.

doi:10.1016/j.cardfail.2016.06.424

Cited by 5 publications

(2 citation statements)

References 14 publications

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“…Hemoconcentration (i.e., an increase in hemoglobin/hematocrit in response to diuretic therapy) has been suggested as a putative metric to help guide inpatient decongestion ( 79 , 97 , 98 ). Because hemoconcentration is highly dependent upon the rate of fluid shifts ( 99 , 100 ), it can also be observed during the generation of edema due to fluid loss from the intravascular compartment ( 101 , 102 ). The lack of hemoconcentration is entirely consistent with efficient decongestion or with ineffective decongestion (both with matching refill).…”

Section: Transcapillary Plasma Refillmentioning

confidence: 99%

The interstitial compartment as a therapeutic target in heart failure

Aronson

2022

Front. Cardiovasc. Med.

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Congestion is the single most important contributor to heart failure (HF) decompensation. Most of the excess volume in patients with HF resides in the interstitial compartment. Inadequate decongestion implies persistent interstitial congestion and is associated with worse outcomes. Therefore, effective interstitial decongestion represents an unmet need to improve quality of life and reduce clinical events. The key processes that underlie incomplete interstitial decongestion are often ignored. In this review, we provide a summary of the pathophysiology of the interstitial compartment in HF and the factors governing the movement of fluids between the interstitial and vascular compartments. Disruption of the extracellular matrix compaction occurs with edema, such that the interstitium becomes highly compliant, and large changes in volume marginally increase interstitial pressure and allow progressive capillary filtration into the interstitium. Augmentation of lymph flow is required to prevent interstitial edema, and the lymphatic system can increase fluid removal by at least 10-fold. In HF, lymphatic remodeling can become insufficient or maladaptive such that the capacity of the lymphatic system to remove fluid from the interstitium is exceeded. Increased central venous pressure at the site of the thoracic duct outlet also impairs lymphatic drainage. Owing to the kinetics of extracellular fluid, microvascular absorption tends to be transient (as determined by the revised Starling equation). Therefore, effective interstitial decongestion with adequate transcapillary plasma refill requires a substantial reduction in plasma volume and capillary pressure that are prolonged and sustained, which is not always achieved in clinical practice. The critical importance of the interstitium in the congestive state underscores the need to directly decongest the interstitial compartment without relying on the lowering of intracapillary pressure with diuretics. This unmet need may be addressed by novel device therapies in the near future.

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Section: Transcapillary Plasma Refillmentioning

confidence: 99%

The interstitial compartment as a therapeutic target in heart failure

Aronson

2022

Front. Cardiovasc. Med.

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“…Incomplete diuresis with residual congestion places the patient at risk for readmission. However, the definition of decongestion is not standardized, creating uncertainty about whether a given patient has “diuresed enough.” Decongestion may be identified by changes in weight, urine output, urine sodium/creatinine ratio, inferior vena cava size, reduction in natriuretic peptide or filling pressures, increases in serum osmolality or intrathoracic impedance, hemoconcentration, clinical examination findings, and serial chest radiographs. Dyspnea relief is an accepted patient-centric target, but most patients experience improvement by 24 hours, even as the best instruments to measure dyspnea remain in question.…”

Section: Reassessing Decongestion Goals During Hf Hospitalizationsmentioning

confidence: 99%

Reconfiguring the Hospital-to-Home Transition Into an Active Treatment Period for Patients With Heart Failure

Menon

Hauptman

2017

JAMA Cardiol

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Prevention of readmissions for heart failure (HF) is a distinct challenge, as up to 25% of patients require rehospitalization within 30 days. 1 Although rates have fallen, progress has stalled. 2 Currently, readmission prevention programs focus on patient education, self-care initiatives, telephonic follow-up, medication reconciliation, and weight monitoring, 3 which are founded on behavior-modification, personnel-dependent models. However, consistent and reproducible improvements in 30-day readmission rates have not been demonstrated, and increasing the number of conventional interventions may not affect readmission rates to a degree that justifies added expenditures. 4 Conversely, while lengths of stay are demonstrably longer in Europe, readmission rates are lower. Whether this reflects lower-intensity decongestion or simply prolongation of standard therapy is not known.We advocate for reconfiguring the transition between the hospital and home by extending active treatment beyond the acute care setting. Short-term augmentation with additional oral or parenteral therapy to effect meaningful ongoing decongestion should be critically evaluated for feasibility, safety, and efficacy.

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Congestion/decongestion in heart failure: what does it mean, how do we assess it, and what are we missing?—is there utility in measuring volume?

Miller

2024

Heart Fail Rev

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Measuring Congestion in Acute Heart Failure: The “Holy Grail” Still Awaits

Cited by 5 publications

References 14 publications

The interstitial compartment as a therapeutic target in heart failure

The interstitial compartment as a therapeutic target in heart failure

Reconfiguring the Hospital-to-Home Transition Into an Active Treatment Period for Patients With Heart Failure

Congestion/decongestion in heart failure: what does it mean, how do we assess it, and what are we missing?—is there utility in measuring volume?

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