A new tool to measure hydration status in acute heart failure – Is bioelectrical impedance vector analysis (BIVA) making its way to the wards?

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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "126" "paginaFinal" => "127" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Pimenta, P. Bettencourt" "autores" => array:2 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "Pimenta" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:4 [ "nombre" => "P." "apellidos" => "Bettencourt" "email" => array:1 [ 0 => "paulobettencourt40@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Medicina Interna, Centro Hospitalar São João, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Faculdade de Medicina UP, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Una nueva herramienta para medir el estado de hidratación en la insuficiencia cardiaca aguda. ¿Se encamina el análisis del vector de bioimpedancia hacia la cabecera del paciente?" ] ] "textoCompleto" => "Heart failure (HF), the end-stage of most cardiovascular diseases, is a major health care burden with an important individual and socio-economic impact. Hospitalization for acute heart failure (AHF) is a clear inflection point in the natural history of the disease as it is independently associated with worse outcomes. Patients discharged after decompensation of HF have high rates of early adverse events, with ∼25% being readmitted in the following month, and 24% dying at 1 year, in contrast to a rate of 5.9% in chronic stable HF patients.<a class="elsevierStyleCrossRef" href="#bib0065">1</a>Addressing congestion has been one of the major challenges that physicians caring for HF patients face in everyday clinical practice. Congestion is by far the most frequent clinical presentation of AHF and results in the majority of the symptoms and signs of that syndrome, also contributing to renal dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0070">2,3</a> Nevertheless, a substantial proportion of patients are discharged inadequately decongested.<a class="elsevierStyleCrossRefs" href="#bib0070">2,3</a> While congestion improves during hospitalization in response to therapy, its presence at discharge is associated with an increased risk of new hospital admissions and mortality.<a class="elsevierStyleCrossRefs" href="#bib0075">3,4</a> In chronic HF patients, subclinical congestion is also commonly observed and has important prognostic implications.<a class="elsevierStyleCrossRef" href="#bib0085">5</a> On the other hand, overdiuresis leading to intravascular volume depletion could compromise organ perfusion and result in low cardiac output manifestations, to which HF patients are particularly susceptible. Although signs of congestion and low cardiac output are both associated with worse outcomes in AHF,<a class="elsevierStyleCrossRef" href="#bib0065">1</a> persistent high filling pressures seem to be prognostically more important than cardiac index.<a class="elsevierStyleCrossRef" href="#bib0090">6</a> Therefore, managing hypervolemia is a demanding task for clinicians, whose success has important individual and health-care consequences.In spite of being a primary focus in HF treatment, the assessment of volemic status has largely relied on the same tools for a long time. Physicians have used clinical history, physical examination and chest X-ray, as well as invasive monitoring in specific situations, as core armamentarium to establish volume status, make therapeutic decisions and assess clinical response. This panorama changed somewhat when natriuretic peptides were introduced in routine clinical practice. Brain natriuretic peptide (BNP) and its N-terminal fragment (NT-proBNP) correlate with clinical, functional and haemodynamic markers of increased cardiac filling pressures and hypervolemia, and have a unanimously accepted role in AHF work-up and as prognostic markers.<a class="elsevierStyleCrossRef" href="#bib0095">7</a> Echocardiography and ultrasonographic evaluation of inferior vena cava diameter and collapsibility, and of the presence of lung comets have also proved to be helpful tools, but are less available in the wards. Another step forward may be hydration status evaluation using impedance analysis.Bioimpedance analysis measures the effective “resistance” to an electrical current flow through the body by applying a small alternating current. Different methods have been developed, including whole-body, segmental or thoracic, using external or implanted intra-thoracic devices. The information gathered has been used to assess haemodynamic parameters (impedance cardiography) and fluid status, particularly in the setting of congestive states such as heart and renal failure. Bioelectrical impedance vector analysis (BIVA) uses whole-body impedance to establish a patient's hydration status, having as reference values those obtained in a healthy population. It is a quick, reproducible, easy and non-invasive technique that can be performed at the patients’ bedside, provided that they can be supine and electrodes can be adequately positioned. Some studies have addressed BIVA in AHF management and prognostic stratification, but its role, while conceptually appealing, still demands clarification.<a class="elsevierStyleCrossRef" href="#bib0100">8</a>Trejo-Velasco et al.<a class="elsevierStyleCrossRef" href="#bib0105">9</a> used BIVA to stratify a hospital cohort of AHF patients according to hydration status after standard clinical management, aiming to validate a previous observation reporting its utility in prognosis assessment.<a class="elsevierStyleCrossRef" href="#bib0110">10</a> They found that less than half (47.6%) of the patients had a normal hydration status previously to discharge, according to BIVA parameters, while somewhat unexpectedly, there were more patients, especially women, in the dehydrated group (29.6%) than in the hyperhydrated group (22.8%). An abnormal hydration pre-discharge status was associated with more than double the risk of readmission for HF or all-cause death during the mean follow-up of 11 months.This study reflects both the challenge of attaining euvolemia in AHF patients and the importance of this demanding task. What remains to be answered is if using BIVA to guide decongestion would result in different outcomes, as the authors suggest. BIVA hydration assessment has been previously used in combination with BNP to “tailor” the therapy of AHF patients whose BNP levels did not promptly decrease in response to standard management.<a class="elsevierStyleCrossRef" href="#bib0115">11</a> Even so, body hydration was not significantly different in early-, late- and non-responders, while BNP levels were higher and outcomes poorer in the latter group. This could be because BNP is essentially a marker of increased filling pressures, that is, a marker of intravascular congestion, while BIVA measures total body water, either extra and intracellular, but gives no information on intravascular status and cardiac filling pressures, as it is unable to distinguish plasma volume from tissue oedema. BNP not only correlates with central volemia measured by impedance, but also with markers of cardiac and renal disease severity and other variables such as haemoglobin and albumin.<a class="elsevierStyleCrossRef" href="#bib0120">12</a> The two methods may sometimes convey different and conflicting information. Therefore, integrating those variables and clinical evaluation at an individual patient level may not be an easy task and this complexity may explain the conflicting results of BNP-guided therapy trials. On the other hand, the two methods could have additive and independent values in risk stratification of HF patients. While the association of BNP levels with clinical meaningful outcomes such as hospitalizations and death is robust, the role of hydration status as measured by BIVA as a prognostic marker is beginning to be explored.This report by Trejo-Velasco et al.<a class="elsevierStyleCrossRef" href="#bib0105">9</a> adds relevant information on that matter, contributing to a build up of evidence that could, in the near future, lead to the introduction of this simple technology into everyday clinical practice. However, further studies on its independent prognostic role apart from natriuretic peptides are needed." 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