Early Intervention with Impedance-guided Heart Failure Management Improves Long-term Outcome: Insights from the IMPEDANCE-HF Trial

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Michael Kleiner Shochat, MD, BSc, PhD, FACC Daniel Kapustin, BSc Marat Fudim, MD, MHS Mark Kazatsker, MD Ilia Kleiner, MD Jean Marc Weinstein, MBBS, FRCP Gurusher Panjrath, MD, FACC, FAHA Guy Rozen, MD, MHA Ariel Roguin, MD, PhD Simcha R Meisel, MD, MSc, FACC


Background: Lung-impedance (LI) guided treatment of heart failure (HF) patients was shown to improve clinical outcomes.

Objectives: To perform a post-hoc analysis of the IMPEDANCE-HF extended trial in order to explore the mechanism underlying the improved outcome of the LI-guided compared with conventional therapy of HF patients.

Methods: The study included 290 HF patients with LVEF≤ 45% randomized 1:1 to LI-guided or conventional therapy. The normal LI (NLI), representing the dry lung status, was calculated upon enrollment. The level of pulmonary congestion (LPC) was represented by ΔLIR= [(measured LI/NLI)-1] × 100%.

Results: There were 11473 outpatient visits in the LI-guided group and 10245 visits in the control group during follow-up, or 15.5 and 15.9 visits/patient×year, respectively (p=0.74). The LI-guided patients were on average less congested during follow-up than those in the control group (by 20 %, p<0.01). Multivariate regression analysis showed that the likelihood of hospitalization for HF [hazard ratio (HR): 0.62, 95% confidence interval (CI): 0.52-0.72, p<0.01) and of all-cause mortality (HR: 0.83, 95%CI: 0.70-0.98, p=0.03] were lower in the LI-guided group than in the control group. In the LI-guided group, diuretic up-titration was 2-fold more frequent and at an earlier timepoint and at a 21% lower LPC (p<0.01). In both groups the diuretic response was more prominent when up-titration was done at a lower LPC (p<0.01).   

Conclusion LI-guided diuretic titration prompted earlier, and more frequent diuretic dose increase when the LPC was only beginning to increase and this resulted in a greater decongestive response with better clinical outcomes.


Keywords: heart failure, heart failure readmission, lung impedance, clinical outcome in heart failure patients, diuretic response

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How to Cite
SHOCHAT, Michael Kleiner et al. Early Intervention with Impedance-guided Heart Failure Management Improves Long-term Outcome: Insights from the IMPEDANCE-HF Trial. Medical Research Archives, [S.l.], v. 10, n. 5, june 2022. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/2766>. Date accessed: 04 june 2023. doi: https://doi.org/10.18103/mra.v10i5.2766.
Case Reports


1. O’Connor CM, Hasselblad V, Mehta RH, Tasissa G, Califf RM, Fiuzat M, et al. Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. Am Coll Cardiol. 2010;55(9):872–878.
2. Abraham WT, Adamson PB, Bourge RC, Aaron MF, Costanzo MR, Stevenson LW, et al. CHAMPION Trial Study Group. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomized controlled trial. Lancet. 2011;377(9766):658- 666.
3. Noveanu M, Breidthardt T, Potocki M, Reichlin T, Twerenbold R, Uthoff H, et al. Direct comparison of serial B-type natriuretic peptide and NT-proBNP levels for prediction of short- and long-term outcome in acute decompensated heart failure. Crit Care. 2011;15(1):R1. doi:10.1186/cc9398.
4. Kociol RD, Horton JR, Fonarow GC, Reyes EM, Shaw LK, O'Connor CM, et al. Admission, discharge, or change in B-type natriuretic peptide and long-term outcomes: data from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) linked to Medicare claims. Circ Heart Fail. 2011;4(5):628-636.
5. Demissei BG, Postmus D, Cleland JG, O'Connor CM, Metra M, Ponikowski P, et al. Plasma biomarkers to predict or rule out early post-discharge events after hospitalization for acute heart failure. Eur J Heart Fail. 2017;19(6):728-738. doi:10.1002/ejhf.766.
6. McDonald K, Troughton R, Dahlstrom U, Dargie H, Krum H, van der Meer P, et al. Daily home BNP monitoring in heart failure for prediction of impending clinical deterioration: results from the HOME HF study. Eur J Heart Fail. 2018;20(3):474–480. doi:10.1002/ejhf.1053.
7. Donadio C, Bozzoli L, Colombini E, Pisanu G, Ricchiuti G, Picano E, et al. Effective and timely evaluation of pulmonary congestion: qualitative comparison between lung ultrasound and thoracic bioelectrical impedance in maintenance hemodialysis patients. Medicine. 2015;94(6):e473.
8. Platz E, Campbell RT, Claggett B, Lewis EF, Groarke JD, Docherty KF, et al. Lung Ultrasound in Acute Heart Failure: Prevalence of Pulmonary Congestion and Short- and Long-Term Outcomes. JACC Heart Fail. 2019;7(10):849-858.
9. Platz E, Scott D. Solomon SD, McMurray J. Lung ultrasound: monitoring congestion in patients with heart failure. Eur J Heart Fail. 2019; 21(12):1614–1615. Doi: 10.1002/ejhf.1636.
10. Kleiner Shochat M, Shotan A, Trachtengerts V, Blondheim DS, Kazatsker M, Gurovich V, et al. A novel radiological score to assess lung fluid content during evolving acute heart failure in the course of acute myocardial infarction. Acute Card Care. 2011;13(2):81-86.
11. KleinerShochat M, Shotan A, Blondheim DS, Kazatsker M, Dahan I, Asif A, et al. Derivation of baseline lung impedance in chronic heart failure patients: use for monitoring pulmonary congestion and predicting admissions for decompensation. J Clin Monit Comput. 2015;29(3):341-349.
12. Kleiner Shochat M, Shotan A, Blondheim DS, Kazatsker M, Dahan I, Asif A, Rozenman Y, et al. Non-Invasive Lung IMPEDANCE-Guided Preemptive Treatment in Chronic Heart Failure Patients: A Randomized Controlled Trial (IMPEDANCE-HF Trial). J Card Fail. 2016;22(9):713-722.
13. Kleiner Shochat M, Fudim M, Shotan A, Blondheim D, Kazatsker M, Asif A, et al. Prediction of readmissions and mortality in patients with heart failure: lessons from the IMPEDANCE-HF extended trial. ESC Heart Fail. 2018;5(5):788-799. doi: 10.1002/ehf2.12330.
14. Kleiner Shochat M, Kapustin D, Fudim M, Ambrosy AP, Glantz J, Kazatsker, et al. The Degree of the Predischarge Pulmonary Congestion in Patients Hospitalized for Worsening Heart Failure Predicts Readmission and Mortality. Cardiology. 2021;146(1):49–59. Doi: 10.1159/000510073.
15. Yancy CW, Januzzi J, Allen L, Butler J, Davis L, Fonarow GC, et al. 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. JACC. 2018;71(2):201-230. Doi: 10.1016/j.jacc.2017.11.025.
16. Packer M, Abraham WT, Mehra MR, Yancy CW, Lawless CE, Mitchell JE, et al; Prospective Evaluation and Identification of Cardiac Decompensation by ICG Test (PREDICT) Study Investigators and Coordinators. Utility of impedance cardiography for the identification of short-term risk of clinical decompensation in stable patients with chronic heart failure. JACC. 2006;47(11):2245-52.
17. Abraham J, Bharmi R, Jonsson O, Oliveira GH, Artis A, Valika A, et al. Association of Ambulatory Hemodynamic Monitoring of Heart Failure With Clinical Outcomes in a Concurrent Matched Cohort Analysis. JAMA Cardiol. 2019;4(6):556-563. Doi:10.1001/jamacardio.2019.1384.
18. Saad MM, Kamal J, Moussaly E, Karam B, Mansour W, Gobran E, et al. Relevance of B-Lines on Lung Ultrasound in Volume Overload and Pulmonary Congestion: Clinical Correlations and Outcomes in Patients on Hemodialysis. Cardiorenal Med 2018;8(20):83–91.
19. HarjolaVP, Mullens W, Banaszewski M, Bauersachs J, Brunner HP, Chioncel O, et al. Organ dysfunction, injury and failure in acute heart failure: from pathophysiology to diagnosis and management. A review on behalf of the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail. 2017;19(7):821–836. doi: 10.1002/ejhf.872.
20. Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin Z, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010;363(24):2301–2309.
21. Felker GM, Anstrom KJ, Adams KF, Ezekowitz JA, Fiuzat M, Houston-Miller N, et al. Effect of Natriuretic Peptide-Guided Therapy on Hospitalization or Cardiovascular Mortality in High-Risk Patients With Heart Failure and Reduced Ejection Fraction: A Randomized Clinical Trial. JAMA. 2017;318(8):713-720. Doi:10.1001/jama.2017.10565.
22. Fiuzat M, Ezekowitz J, AlemayehuW, Westerhout CM, Sbolli M, Cani D et al. Assessment of Limitations to Optimization of Guideline-Directed Medical Therapy in Heart Failure From the GUIDE-IT Trial: A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol. 2020;5(7):757-764.
23. Greene SJ, Butler J, Albert NM. Albert, DeVore AD, Sharma PP, et al. Medical Therapy for Heart Failure With Reduced Ejection Fraction. The CHAMP-HF Registry. JACC. 2018;72:351–366.