Editorial
Quantifying the congestion
Dimensionando la congestión
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Rubio-Gracia, I. Giménez-López, C. Josa-Laorden, M.M. Sánchez-Marteles, V. Garcés-Horna, F. Ruiz-Laiglesia, P. Sampériz Legarre, E. Bueno Juana, B. Amores-Arriaga, J.I. Pérez-Calvo" "autores" => array:10 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Rubio-Gracia" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Giménez-López" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Josa-Laorden" ] 3 => array:2 [ "nombre" => "M.M." "apellidos" => "Sánchez-Marteles" ] 4 => array:2 [ "nombre" => "V." "apellidos" => "Garcés-Horna" ] 5 => array:2 [ "nombre" => "F." "apellidos" => "Ruiz-Laiglesia" ] 6 => array:2 [ "nombre" => "P." "apellidos" => "Sampériz Legarre" ] 7 => array:2 [ "nombre" => "E." "apellidos" => "Bueno Juana" ] 8 => array:2 [ "nombre" => "B." "apellidos" => "Amores-Arriaga" ] 9 => array:2 [ "nombre" => "J.I." "apellidos" => "Pérez-Calvo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256520300266" "doi" => "10.1016/j.rce.2019.10.014" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256520300266?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887421000229?idApp=WRCEE" "url" => "/22548874/0000022100000004/v2_202104080754/S2254887421000229/v2_202104080754/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Quantifying the congestion" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "228" "paginaFinal" => "229" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Casado, J. Górriz" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Casado" "email" => array:1 [ 0 => "casadocerrada@telefonica.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Górriz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad Funcional Multidisciplinar de Insuficiencia Cardiaca, Servicio de Medicina Interna, Hospital Universitario de Getafe, Getafe, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad Funcional Multidisciplinar de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario de Getafe, Getafe, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dimensionando la congestión" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the scope of heart failure (HF), congestion is defined as the presence of signs and symptoms secondary to the extracellular accumulation of fluid as a consequence of the increase in intracardiac filling pressures. The European Society of Cardiology has highlighted the importance of not interpreting the terms “congestion” and “volume overload” as synonyms, given that the redistribution of volume, mainly starting at the splanchnic vessels, can condition a certain degree of congestion without the presence of fluid overload.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This mechanism would justify why not all patients with acute HF have weight gain.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In our daily routine, a combination of clinical, radiologic (chest x-ray), and biochemical (natriuretic peptides) parameters are what is most frequently used to evaluate congestion in patients with HF. However, all of these measurements show varying degrees of sensitivity and specificity which, on most occasions, are very far from ideal.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> For this reason, new techniques for evaluating congestion are slowly but steadily gaining traction. Ultrasound allows us to estimate right (vena cava collapsibility) and left (Doppler tissue study; e wave deceleration time <130 ms, e/e’ ratio > 12, among others) intrachamber pressures. In addition, B lines on a lung ultrasound have recently been gaining supporters at breakneck speed among clinicians who want greater reliability in the evaluation of congestion. These B lines are able to detect congestion even where traditional methods are not, in what has come to be called residual or subclinical congestion.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> New biomarkers are gradually being added to the arsenal. They include, for example, soluble CD146, cancer antigen 125, and adrenomedullin, although there are still uncertainties surrounding their use and the multiple derivatives of their applicability in habitual clinical practice have yet to be fully defined.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the study presented by Rubio et al. and published in this issue of Revista Clínica Española,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> the prognostic utility of a series of tools for evaluating systemic congestion upon admission is retrospectively analyzed in 203 patients with acute decompensated heart failure. Based on its outcomes, it can be deduced that both NT-proBNP and relative plasma volume are the most useful markers for evaluating the prognosis of overall mortality due to decompensation at one year from hospitalization. It is not clear why the remaining tools evaluated (urea/creatinine ratio, lung ultrasound, and cancer antigen 125) did not provide prognostic information. Each and every one of those markers has previously demonstrated prognostic utility in patients with HF in different scenarios.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6,7</span></a> The fact that the majority of patients assessed had preserved ejection fraction may partly justify these outcomes, given that previous studies have been conducted nearly entirely on patients with HF and reduced ejection fraction.</p><p id="par0020" class="elsevierStylePara elsevierViewall">At present, the importance of congestion in terms of prognosis is undeniable. Indeed, achieving normal blood volume by the time of hospital discharge is a priority, as the presence of congestion upon discharge is a powerful predictor of readmissions and events during follow-up.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Thus, the issue is: What is the most reliable tool for evaluating congestion? And, more importantly: Out of all of these possible tools, which most closely brings together prognosis and congestion? To date, there is no gold standard in this regard.</p><p id="par0025" class="elsevierStylePara elsevierViewall">As occurs in other scenarios, we resort to certain biomarkers in search of an objective solution to the problem and to date, natriuretic peptides are the most prominent, but they are far from ideal. Although there are no studies demonstrating that decongestive therapy guided by natriuretic peptides improves prognosis, there is evidence which shows that a reduction in their levels in HF follow-up is linked to fewer events.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Natriuretic peptides again come out on top in the scenario described by Rubio et al. However, it should be kept in mind that in reality, these are surrogate biomarkers of congestion, given that what generates synthesis of natriuretic peptide precursors is the increase in telediastolic pressure in the ventricular wall. It is therefore likely that in HF, what is really multidimensional is NT-proBNP itself, given that out of all the available tools, it has the highest probability of being related to prognosis in congestive patients with HF. In fact, what would truly have been alarming would have been if this marker were not related to prognosis in the patients evaluated.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Despite the more than demonstrated utility of natriuretic peptides, it is notable that access to these measurements is still not universal. A January 2015 survey conducted by the Spanish Society of Cardiology of 107 public hospitals encompassing a catchment population of more than 31 million residents, the emergency determination of natriuretic peptides was available in 65% of emergency departments (what would correspond to only 66% of the population covered by these departments).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">There is still much to be learned and clarified in regard to congestion. One such example is evidence of the involvement of immune and inflammatory factors in its physiopathology. The existence of a strong link between congestion and inflammation, with the endothelium as the nexus of this link, now appears to be proven.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The endothelium, an organ with a surface similar to a tennis court, intervenes in a fundamental manner in numerous processes such as inflammation, coagulation, oxygenation, and tissue flow.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study by Rubio et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> reflects the importance of a multidimensional approach to evaluating congestion, opening a path forward that remains to be taken. Some of the current markers may fall along the wayside, but others will undoubtedly last. Congestion—so classic and yet so current—has become a true diagnostic and treatment challenge in modern medicine.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Casado J, Górriz J. Dimensionando la congestión. Rev Clin Esp. 2021;221:228–229.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). 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