Congestion Matters! How to Assess It: Old and New Methods
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Marat Fudim, MD Duke University
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Congestion Matters! How to Assess It: Old and New Methods
- 1. Congestion Matters! How to Assess It: Old and New Methods @FudimMarat Marat Fudim, MD, MHS Associate Professor Division of Cardiology, Duke University
- 2. Disclosures Research Support: – NIH, Doris Duke, Reprieve, Sardocor Consultant/Ownership Interest: – Abbott, Alio Health, Alleviant, Artha, Audicor, AxonTherapies, Bodyguide, Bodyport, Boston Scientific, Broadview, Cadence, Cardioflow, Coridea, CVRx, Daxor, Deerfield Catalyst, Edwards LifeSciences, Echosens, EKO, Feldschuh Foundation, Fire1, FutureCardia, Galvani, Gradient, Hatteras, HemodynamiQ, Impulse Dynamics, Intershunt, Medtronic, Merck, NIMedical, NovoNordisk, NucleusRx, NXT Biomedical, Orchestra, Pharmacosmos, PreHealth, Presidio, Procyreon, ReCor, SCPharma, Shifamed, Splendo, Summacor, SyMap, Verily, Vironix, Viscardia, Zoll.
- 3. How Do We Typically Assess Congestion? Narang. JCF 2020, de la Espriella, Fudim, Rev Esp Cardiol 2023
- 4. Chaudhry et al. Circulation. 2007 Zile et al. Circulation. 2008 Challenging the Paradigm Chronic hemodynamic monitoring has demonstrated increased pulmonary pressure without weight gain does not equal weight gain 50% of patients had increase in pressure but no change in weight Increasing pulmonary pressure… PA Pressure
- 5. Decongestion is NOT all about diuresis
- 6. Pressure does NOT equal Volume Yaranov, Fudim et al. JCF 2022 Vasoconstriction/Volume Redistribution 10 20 30 40 -40 -20 0 20 40 60 PAD vs TBV PAD in mmHg TBV deviation% Volume Overload Normal pressure – High volume: Diurese Normal pressure – Normal Volume: Goal High pressure – High volume: Diurese High pressure – Low/Normal volume: Vasodilate R2=0.002 Pulmonary Arterial Diastolic Pressure vs Total Blood Volume
- 7. Admission Blood Volume Analysis Euvolemia Zone Volume Overload Volume Down
- 8. Volume Distribution - Stressed Blood Volume Argaiz, Twitter 2020 Jean Claude Van Damme, Blood Spor Venoconstriction via Sympathetic tone increase
- 9. iCPET 9 Fudim, Patel et al. JACC HF 2020 Borlaug BA et al. Circ Heart Fail, 2010
- 11. Position Matters Rao VN, Fudim M, et al. Circ HF 2022 Supine iCPET Upright iCPET
- 12. What Can We Monitor?
- 13. 13 Implantables / ICDs PULMONARY ARTERY PRESSURE SENSOR PATIENT ELECTRONICS SYSTEM MERLIN.NET™ PCN
- 14. ZOLL - HFMS Heart Failure Monitoring System (HFMS) Detects ECG and heart rate through 2 electrodes, and respiration rate, activity, and posture through a tri-axial accelerometer. A measure of lung fluid, is estimated using low-power electromagnetic pulses in the RF wavelength range between 0.5-2.5 GHz.
- 15. Sesinel: End-to-End Solution for Heart Failure Management 1 5 • 3-5 Minutes Per Application • Data Uploaded to Cloud • Daily spot checks in the patient’s Home • Highly sensitive & predictive measures (6 raw measurements, 12 derived metrics) • Optional 24-hr Monitoring • Level-1 Triaging • Monitoring and triaging of data • Reducing information overload (Highly specific escalations to the correct setting) • Symptomology when needed • Medical Staff Engaged Only as Needed • Certified Integration w/Patient EHR • Works w/existing care pathways/protocols • Patient Data Automatically Updated • Customizable Settings: based on patient specific requirements
- 16. Bodyport Scale Body weight Multi-frequency Peripheral impedance Phase angle Pulse rate Pulse rate variability Cardiac output Left ventricular ejection time Pulse transit time Signal collection & feature extraction Biomarker calculation DeVore, Fudim et al. 2024 THT
- 17. 17 SIGNALS VITALS SENSORS Respiration Rate Heart Rate Peak VO2 Cardiac Output LV Filling Pressures Blood Pressure Oxygen Saturation Electrical Rhythm Electrocardiography E C G Photoplethysmography P P G Seismocardiography S C G Optical Pulse Wave Mechanical Vibrations A Noninvasive Alternative for Filling Pressure Assessment
- 18. Take Home Messages Congestion is a complex concept Patients often leave the hospital congested Congestion ≠ volume overload Pressure and volume are hard to assess Landscape of congestion assessment is changing 18
Editor's Notes
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- A visual representation of how volume shifts occur is shown here. Through vasoconstriction we can shift UBV towards the SBV. This shift alone can explain the increase in cardiac filling pressures and does not require external fluid gain.
- Physiologic phenotyping through noninvasive and invasive exercise testing may assist in discriminating HFpEF subgroups and potentially distinct clinical profiles Sanjiv Shah has proposed the following paradigm in order to distinguish HFpEF subgroups: Resting PCWP < 15; Exercise them -- > if PCWP <25 and PCWP/CO <2, then HFpEF is ruled out Peak exercise ≥ 25 or PCWP / CO >2, then exercise HFpEF due to increased LA pressures under stress Resting PCWP ≥ 15, then look for findings of volume overload If not volume overloaded, look for pulmonary vascular disease and right heart failure Once you identify broad groups of HFpEF, then do subphenotyping by quantitative imaging, cardiac biopsy, liquid biopsy, exercise phenotyping, machine learning (Shah Circ 2020)