B-Type Natriuretic Peptide and Non-Invasive Haemodynamics and Hydration Status Assessments in the Management of Patients with Acute Heart Failure in the Emergency Department

Abstract

Introduction: An impairment of cardiac haemodynamics and fluid retention may occur in patients with acute heart failure (AHF) because of left ventricular (LV) dysfunction due to volume and or pressure overload. The measurement of B-type natriuretic peptide (BNP) represents the 'gold standard' of biomarker assessment for evaluating LV adaptations to AHF. More recently, Nexfin and bioelectric impedance vector analysis (BIVA) techniques have been proposed for non-invasively assessing haemodynamic and hydration status, respectively. These techniques are rapidly and easily executable and, most importantly, may be repeated over time. Aim: To validate the applicability of Nexfin and BIVA techniques, in association with BNP dosage, and changes of these parameters after treatment during hospitalization in patients with AHF referring to the emergency department (ED). Methods: We enrolled 44 patients (20 female, mean age 77 -7.7 years), referring to ED for AHF. During hospitalization (mean -SD: 4.12 -1.45 days), all patients underwent BNP measurements at admission, 24 hours, 72 hours and at discharge. At the same time intervals, Nexfin and BIVA were also performed. According to international guidelines, all patients were treated with optimal pharmacological therapy, independently of other parameters examined during hospitalization. Results: Compared with baseline (747.61 -658.54 pg mL), we observed a statistically significant reduction of BNP levels at 72 hours (357.64 -193.81 pg mL; p < 0.05) and at discharge times (248.57 -194.46 pg mL; p < 0.05). In addition, a significant reduction of hydration status, evaluated through BIVA, was observed at discharge compared with hospital admission (from 79.44 -6.47% to 76.35 -5.5%; p < 0.05). This was paralleled at Nexfin evaluation by a significant increase of cardiac index (from 2.32 -0.95 to 3.9 -1.18 L min m 2 ) and clinical improvement of New York Heart Association class at discharge compared with hospital admission. Finally, we observed a statistically significant correlation between percentage variation of cardiac index and hydration status from admission to discharge (p < 0.05). Conclusions: In patients with AHF, admitted to ED, simultaneous monitoring of cardiac index and of hydration status by non-invasive methods may be useful for confirming clinical diagnosis, beyond dosages of BNP. These techniques could also be useful for intra-hospital management of AHF patients. In fact, their variations, coupled with the BNP ones, during hospitalization, may be of value in order to easily and rapidly identify clinical and haemodynamic improvements of AHF, which may be of key relevance for appropriate discharges from EDs.

Additive diagnostic and prognostic value of Bioelectrical Impedance Vector Analysis (BIVA) to brain natriuretic peptide ‘grey-zone’ in patients with acute heart failure in the emergency department

“…Moreover, HI seems to be a quantitative parameter that can be used independently of gender, differently from a BIVA nomogram. 13,26 We share similar results with Parrinello et al, 27 although our data also suggest that assessing peripheral congestion with BIVA may provide additional clinical utility, especially when BNP provides little help. It is well known that a value of BNP between 100 and 400 pg/ml is considered to be a 'grey zone' and a BNP value included in this range is difficult to interpret as diagnostic of AHF.…”

“…9,29 Because clinical and preclinical fluid retention is one of the most frequent causes of re-hospitalizations in AHF patients, a rapid and inexpensive instrument for quantifying peripheral oedema at the moment of a patient's presenting in ED could be an important prognostic tool with which the emergency physicians could immediately assess a risk stratification of these patients. 2,26,30 Previous data from our group 15 demonstrated that sequential BIVA measurements in AHF patients results in an improvement of patients' outcomes linked to optimizing diuretic treatment. In that study we also showed a correlation with events at three months in patients with mean hydration values >80% at the moment of hospital discharge.…”

The emerging role of biomarkers and bio-impedance in evaluating hydration status in patients with acute heart failure

“…The BIVA technique was developed at the University of Padua (Italy) (7) . The machine uses an alternating current fl ux of 800 μ A and an operating frequency of 50 kHz.…”

“…In this important scenario, several studies have investigated and have further confi rmed the emerging role of biomarkers, such as natriuretic peptides (NPs) (5) , assisted by bio-impedance vector analysis (BIVA) in the management of congestion due to increased TBW content in the setting of chronic heart failure (CHF) or acute heart failure (AHF) patients (6,7) .…”

“…The aim of this review is thereby to provide some insights on the currently used non-invasive methods for hydration assessment and to describe the appealing results obtained with the various bio-electrical impedance methods coupled with some laboratory parameters in AHF patients, since they represent the most common and evident example of hyperhydration status among critical diseases (7) .…”