Risk stratification after acute heart failure based on dual measures of heart fibrosis and fluid overload

Usefulness of combining galectin-3 and BIVA assessments in predicting short- and long-term events in patients admitted for acute heart failure”
B De Berardinis, L Magrini, G Zampini, B Zancla, G Salerno, P Cardelli, E Di Stasio, HK Gaggin, A Belcher, BA Parry, JT Nagurney, JL Januzzi Jr and S Di Somma
BioMed Res Int. 2014; 2014: 983098. doi: 10.1155/2014/983098

In patients with acute heart failure, high serum levels of galectin-3 (a b-galactoside-binding lectin expressed by macrophages and associated with heart fibrosis) are predictive of the need for rehospitalization and the risk of death. The risk of death in these patients is also associated with congestion, which can be measured using bioimpedance vector analysis (BIVA). Researchers in Italy and the United States tested whether the combined use of these two prognostic biomarkers had added value.

This prospective study enrolled 205 patients who presented to hospital emergency departments with acute heart failure. At admission, patients underwent clinical evaluation, blood sampling for galectin-3 determination, and bioimpedance analysis. Follow-up over 18 months considered both rehospitalization and death.

Galectin-3 levels at admission were significantly higher in patients who subsequently died during the 18-month follow-up than in those who survived. Values of reactance normalized to height (Xc/H) were also significantly higher among those who subsequently died, but there was no difference between groups for values of resistance (Rz/H) or phase angle. Statistical analysis suggested that the combination of galectin-3 and BIVA phase angle had better prognostic value than either parameter alone.

The authors concluded that “early assessment of galectin-3 and BIVA seems to be useful in identifying patients at high risk for death and rehospitalization at short and long term. Combining the biomarker and the device could be of great utility since they monitor the severity of two pathophysiological different mechanisms: heart fibrosis and fluid overload.”

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Abnormal hydration status of patients with acute heart failure predicts the risk of rehospitalization and death in the following year

Bioelectrical impedance vector analysis and clinical outcomes in patients with acute heart failure”
J Nunez, B Mascarell, H Stubbe, S Ventura, C Bonanad, V Bodí, E Nunez, G Minana, L Facila, AO Bayés-Genis, FJ Chorro and J Sanchis
J Cardiovasc Med (Hagerstown). 2016 Apr; 17(4):283-90. doi: 10.2459/JCM.0000000000000208

Acute heart failure (AHF) is associated with congestion (fluid overload), which may present as pulmonary edema, leg swelling, and ascites. Because congestion is a negative prognostic marker, the accurate assessment of these patients’ hydration status is important for guiding treatment decisions. Researchers in Spain used bioimpedance vector analysis (BIVA) to assess hydration status in AHF patients and evaluated its ability to predict rehospitalization and mortality.

A total of 369 patients with new AHF or decompensated chronic heart failure underwent BIVA in supine position before discharge from hospital. A CardioEFG device (Akern), operating at 50 kHz, was used, and patients were classified into three categories, namely dehydration (<72.7%), normohydration (72.7–74.3%) and hyperhydration (>74.3%).

At discharge, 62 patients were found to be dehydrated, 166 had normal hydration, and 141 had hyperhydration. At a median follow-up of one year, 80 patients had died and 93 required readmission for heart failure. Mortality rates were lowest among normohydrated patients (15.1%), intermediate among dehydrated patients (19.4%) and highest in the hyperhydrated group (30.5%). The readmission rate was also highest among hyperhydrated cases (29.1% vs. 19.4% and 24.1% in dehydrated and normohydrated cases, respectively). In multivariable analyses, BIVA hydration status was significantly associated with mortality and readmission rates.

The authors concluded that their study “may encourage the use of this technique not only for monitoring hydration status during AHF hospitalization (and, perhaps, tailoring diuretic therapy) but also for discharge risk stratification.” They also noted that, because BIVA can detect dehydration, it may be used to identify “patients in which fluid overload was not the main pathophysiological mechanism causing decompensations [and who may have received] excessive/inappropriate decongestive treatments.”


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BIVA before contrast medium administration can identify patients at risk of contrast-induced nephropathy

Pre-procedural bioimpedance vectorial analysis of fluid status and prediction of contrast-induced acute kidney injury”
M Maioli, A Toso, M Leoncini, N Musilli, F Bellandi, MH Rosner, PA McCullough and C Ronco 
J Am Coll Cardiol. 2014 Apr 15; 63(14): 1387-94. doi: 10.1016/j.jacc.2014.01.025

Contrast-induced nephropathy (CIN) is a form of acute kidney injury attributed to the use of iodinated contrast media for diagnostic and therapeutic procedures. The risk of CIN is high in patients with renal insufficiency or cardiovascular pathologies and in those undergoing invasive coronary angiography. Prophylactic hydration with intravenous saline, prior to the administration of contrast medium, is recommended to help prevent CIN in high-risk patients (although recent evidence disputes this recommendation). Researchers in Italy tested whether the hydration status, measured by bioimpedance vector analysis (BIVA), could predict which patients would experience CIN, and they published their findings in the Journal of the American College of Cardiology.

The single-center study enrolled 900 patients with stable coronary artery disease (CAD) who were scheduled for coronary angiography using iodixanol contrast medium. Patients received saline hydration for 12 h before and after the procedure. Serum creatinine was measured before the procedure and on consecutive days afterwards to diagnose CIN. Bioimpedance measurements were taken immediately before the administration of contrast medium, using a tetrapolar impedance plethysmograph (EFG electrofluidgraph, Akern). Values of resistance (R), reactance (Xc), and impedance (Z) were normalized to height (H).

Overall, CIN occurred in 54 patients (6.0%). Patients who experienced CIN had significantly higher R/H and Z/H ratios, indicating lower hydration status. No difference between groups was seen in the Xc/H ratio or phase angle. Statistical analysis showed that lower fluid status (higher R/H ratio) was a significant and independent predictor of CIN in patients with stable CAD. The authors conclude that “point-of-care BIVA is a user-friendly, rapid, simple tool for assessing peri-procedural fluid levels in patients with CAD undergoing contrast medium administration. It allows identification of patients at high risk for developing [CIN].”


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