Treatment of subclinical fluid retention in patients with symptomatic heart failure: effect on exercise performance.
BACKGROUND
Patients with heart failure frequently have elevated intracardiac diastolic pressures but no clinical evidence of excess fluid retention. We speculated that such pressure elevations may indicate subclinical fluid retention and that removal of this fluid could improve exercise intolerance.


METHODS
To test this hypothesis, we studied 10 patients with right atrial pressure > or = 8 mm Hg but without rales, edema, or apparent jugular venous distension. Right-sided heart catheterization was performed, after which patients underwent maximal treadmill cardiopulmonary testing. Patients were then hospitalized and underwent maximal diuresis, after which exercise was repeated.


RESULTS
Before diuresis, right atrial pressure averaged 16 +/- 5 mm Hg (+/-standard deviation), pulmonary capillary wedge pressure 30 +/- 6 mm Hg, and peak exercise Vo2 11.2 +/- 2.3 ml/min/ kg. Patients underwent diuresis of 4.5 +/- 2.2 kg over 4 +/- 2 days to a resting right atrial pressure of 6 +/- 4 and wedge pressure of 19 +/- 7 mm Hg. After diuresis, all patients reported overall symptomatic improvement. Maximal exercise duration increased significantly from 9.2 +/- 4.2 to 12.5 +/- 4.7 minutes. At matched peak workloads, significant improvements were also seen in minute ventilation (45 +/- 12 to 35 +/- 9 L/min), lactate levels (42 +/- 16 to 29 +/- 9 mg/dl), and Borg dyspnea scores (15 +/- 3 to 12 +/- 4) (all p < 0.05).


CONCLUSIONS
Invasive hemodynamic monitoring allows the identification of excess fluid retention in patients with heart failure when there are no clinical signs of fluid overload. Removal of this subclinical excess fluid improves exercise performance and exertional dyspnea.
Chomsky
D B
DB
Cardiology Division, Vanderbilt University Medical Center, Nashville, Tenn. 37232-6300, USA.
Lang
C C
CC
Rayos
G
G
Wilson
J R
JR
D000328:Adult; D001794:Blood Pressure / Q000187:drug effects / Q000502:physiology; D002311:Cardiomyopathy, Dilated / Q000188:drug therapy / Q000503:physiopathology; D003971:Diastole / Q000187:drug effects / Q000502:physiology; D004232:Diuretics / Q000008:administration & dosage* / Q000009:adverse effects; D004305:Dose-Response Relationship, Drug; D004489:Edema, Cardiac / Q000188:drug therapy* / Q000503:physiopathology; D005080:Exercise Test / Q000187:drug effects*; D005260:Female; D005665:Furosemide / Q000008:administration & dosage* / Q000009:adverse effects; D006333:Heart Failure / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011669:Pulmonary Wedge Pressure / Q000187:drug effects / Q000502:physiology; D014882:Water-Electrolyte Balance / Q000187:drug effects* / Q000502:physiology; D016526:Workload
D004232:Diuretics; D005665:Furosemide