CASE 6
CHF with Hypertention
Patient Details
Ms. Z.B.
Height: 59 Inches
Weight: 210 Pounds
Gender: Female
History
This 71-year-old obese, hypertensive Caucasian female has a history of congestive heart failure and is on diuretics. The patient is 70 pounds overweight and has a six month history of intermittent congestive heart failure. She is currently on diuretic therapy. In the past month she developed shortness of breath on walking a block.
Raw Data From the BVA-100
Control / - / 46.0 / 46.0 / 46.0 / 69 / 54 / 62 / -
Standard-1 / - / - / - / - / 11959 / 11947 / 11953 / -
Pat-Samp-1 / 12.5 / 45.0 / 46.0 / 45.5 / 7365 / 7456 / 7410 / 5345
Pat-Samp-2 / 20.2 / 46.0 / 46.0 / 46.0 / 7723 / 7784 / 7753 / 5146
Pat-Samp-3 / 28.2 / 46.0 / 46.0 / 46.0 / 7337 / 7318 / 7327 / 5447
Pat-Samp-4 / 34.0 / 46.0 / 47.0 / 46.5 / 7391 / 7533 / 7462 / 5390
Pat-Samp-5 / 39.2 / 47.0 / 47.0 / 47.0 / 7349 / 7349 / 7323 / 5536
Blood Vol. / 5132 cc / Ideal Vol. / 4567 cc / Excess / 565 cc / Devtn. / 12.4 %
Red Cell Vol. / 2127 cc / Ideal Vol. / 1646 cc / Excess / 481 cc / Devtn. / 29.2 %
Plasma Vol. / 3005 cc / Ideal Vol. / 2921 cc / Excess / 84 cc / Devtn. / 2.9 %
Statistics
Slope = 0.00170
Standard Deviation = 161.8 cc ( = 3.154 % )
Interpretation
Clinical Findings
1) Blood volume excess of 12.4%
2) Red cell mass excess of 29.2%
3) Hematocrit 46%
Techincal Analysis
Technical analysis consists of an evaluation five separate blood volume collection points with mathematical evaluation of consistency. Technical evaluation is reported as acceptable or unacceptable.
All five sampling points, tested in duplicate, were internally consistent with no significant deviations. The standard deviation for this analysis was 3.15% (161.8 ml). The slope was 0.00170 and is normal. The results for this blood volume measurement are technically acceptable.
Summary
The patient has a marked increase (29.2%) in her red cell mass and a 46% hematocrit. Blood volume is increased by 12.4%. This increase in hematocrit is secondary to diuretic therapy. Any increase in diuretic therapy may result in further hemoconcentration and increased blood viscosity. I would not, therefore, advise increasing diuretic therapy. I would suggest that the patient be placed on a inotropic medicine such as Digoxin. The increase in plasma and red cell volume is secondary to congestive heart failure. Improvement in cardiac function may result in decreased blood volume. This patient should be considered for therapeutic phlebotomy followed by possible increase in diuretic therapy to normalize her blood volume. Weight reduction may result in a significant improvement of symptoms.
CASE 7
CHF with Hyperchlesterolemia
Patient Details
Mr R.I.
Height: 70 Inches
Weight: 236 Pounds
Gender: Male
History
This fifty-nine year old Caucasian male complains of chest pain and shortness of breath on exertion. Previous medical history includes cardiomyopathy with left ventricular enlargement, a perfusion defect of the inferior heart wall extending to the apex which is consistent with multiple infarcts, hyperchlesterolemia, and heart murmur. Previous surgeries include angioplasty and coronary artery bypass surgery. The patient is taking the following medications: Cozaar, Imdur, Coareg, aspirin, Lasix, K+durietic, Zantac and allopurinol. The patient's blood pressure today was 102/64. Patient referred for a blood volume analysis to evaluate his congestive heart failure therapy.
Raw Data From the BVA-100
Control / - / 41.0 / 41.0 / 41.0 / 41 / 55 / 48 / -
Standard-1 / - / - / - / - / 13714 / 13865 / 13790 / -
Pat-Samp-1 / 12.4 / 40.0 / 40.0 / 40.0 / 2840 / 2859 / 2850 / 7441
Pat-Samp-2 / 17.6 / 39.0 / 39.0 / 39.0 / 2815 / 2912 / 2863 / 7301
Pat-Samp-3 / 22.8 / 38.0 / 38.0 / 38.0 / 2826 / 2843 / 2835 / 7276
Pat-Samp-4 / 28.3 / 39.0 / 39.0 / 39.0 / 2745 / 2858 / 2802 / 7466
Pat-Samp-5 / 34.7 / 39.0 / 38.0 / 38.5 / 2771 / 2838 / 2804 / 7406
Blood Vol. / 7335 cc / Ideal Vol. / 5791 cc / Excess / 1545 cc / Devtn. / 26.7%
Red Cell Vol. / 2710 cc / Ideal Vol. / 2348 cc / Excess / 362 cc / Devtn. / 15.4%
Plasma Vol. / 4626 cc / Ideal Vol. / 3443 cc / Excess / 1183 cc / Devtn. / 34.3%
Statistics
Slope = 0.00025
Standard Deviation = 133.6 cc ( = 1.821% )
Interpretation
Clinical Findings
1) Total blood volume excess of 26.7% [± 8% normal; 9-16% mild; 17-24% moderate; 25-23% severe]
2) Red cell volume excess of 15.4% [± 10% normal; 11-20% mild]
3) Plasma volume excess of 34.3%
4) Hematocrit of 39%
Technical Analysis
Technical analysis consists of an evaluation of five separate blood volume collection points with mathematical evaluation of consistency. Technical evaluation is reported as acceptable or unacceptable.
All five individual sampling points, tested in duplicate, were internally consistent with no significant deviations. The standard deviation for this analysis was 1.82% (133.6ml). The slope was 0.00025 and is normal. The results for this blood volume measurement are technically acceptable.
Summary
The blood volume analysis on this patient indicates a severe hypervolemia and mild red cell excess, which is consistent with congestive heart failure. Since there is excess in the red cell volume, this patient may benefit from a therapeutic phlebotomy, which had been an accepted treatment in the past. If a phlebotomy should be considered, the patient's blood systolic blood pressure should be adjusted to 120mm Hg if the patient can tolerate it. Renal perfusion may increase at a slightly higher blood pressure. However the initial phlebotomy should be limited to 100- 250 ml and not the normal amount of 450 ml. to evaluate the response. Since the patient's blood pressure is low, his pressure should be monitored often to avoid any hypotensive episode, which may lead to syncope. It may be necessary to lower the vasodilator therapy to avoid this hypertensive episode. Care should also be given in adjusting this patient's fluid balance to avoid any hyperuricemia.
CASE 8
CHF with Osteoarthritis
Patient Details
Mr. O.L.
Height: 69 Inches
Weight: 199 Pounds
Gender: Male
History
This patient is an eighty-nine year old Caucasian male with a history of congestive heart failure, status post cerebral vascular accident two years ago, atrial fibrillation, Osteoarthritis, slow growing colon carcinoma and an expanded blood volume. He was admitted to Montefiore Hospital for an emergency pacemaker insertion for complete heart block. The insertion of pacemaker was delayed due to elevated I N R ratio. This patient's medications include Coumadin, Digoxin 0.125mg daily, and Moduretic one tablet 5 times/week. The patient's weight has been stable over these four months. Patient had a pre-admission BUN of 36 which dropped to 22. He has been referred for a blood volume to evaluate his congestive heart failure therapy post cardiac pacemaker insertion.
Raw Data From the BVA-100
Control / - / 33.0 / 34.0 / 33.5 / 36 / 22 / 29 / -
Standard-1 / - / - / - / - / 12953 / 12842 / 12897 / -
Pat-Samp-1 / 12.3 / 31.0 / 32.0 / 31.5 / 2770 / 2853 / 2811 / 6270
Pat-Samp-2 / 17.9 / 32.0 / 32.0 / 32.0 / 2839 / 2799 / 2819 / 6293
Pat-Samp-3 / 24.5 / 33.0 / 32.0 / 32.5 / 2940 / 2672 / 2806 / 6363
Pat-Samp-4 / 30.8 / 32.0 / 32.0 / 32.0 / 2711 / 2850 / 2781 / 6381
Pat-Samp-5 / 35.9 / 31.0 / 32.0 / 31.5 / 2760 / 2825 / 2792 / 6313
Blood Vol. / 6251 cc / Ideal Vol. / 5226 cc / Excess / 1024 cc / Devtn. / 19.6 %
Red Cell Vol. / 1887 cc / Ideal Vol. / 2119 cc / Deficit / 232 cc / Devtn. / -11.0 %
Plasma Vol. / 4364 cc / Ideal Vol. / 3107 cc / Excess / 1257 cc / Devtn. / 40.4 %
Statistics
Slope = 0.00048
Standard Deviation = 56.5 cc ( = 0.904 % )
Interpretation
Clinical Findings
1) Total blood volume excess 19.6%
2) Red cell volume deficit of 11.0%
3) Plasma volume excess of 40.4%
4) Hematocrit of 32%
Techincal Analysis
Technical analysis consists of an evaluation of five separate blood volume collection points with mathematical evaluation of consistency. Technical evaluation is reported as acceptable or unacceptable.
All five sampling points, tested in duplicate, were internally consistent with no significant deviations. The standard deviation for this analysis was 1.429% (51.4 ml). The slope was 0.00252 and is normal. The results for this blood volume measurement are technically acceptable.
Summary
This patient's February 1999 test still shows marked expansion of blood volume. However, the patient now presents with a further expansion of his plasma volume to 40.4%, a mild red cell volume deficit (-11.0%) and a low hematocrit of 32%. This change from the results of October 1998 is most likely due to bleeding episodes. The patient lost approximately 30% of his red cell volume since October. Patients on anticoagulation therapy who have small bleeds usually do not have a detectable site, but it can be presumed to be gastrointestinal and in this case secondary to colon carcinoma. The use of erythropoietin is not indicated to increase his red cell volume as the patient's red cell volume is only slightly below normal. Dieresis of this patient would decrease his total blood volume excess and tend to normalize his hematocrit. Improvement from the pacemaker may also eliminate failure. The patient's elevated BUN was due to his congestive heart failure and not due to pre-renal azotemia.