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Blood Volume in Congestive Heart Failure

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Blood Volume in Congestive Heart Failure Blood Volume in Congestive Heart Failure R. W. Gunton, W. Paul J Clin Invest. 1955;34(6):879-886. https://doi.org/10.1172/JCI103144. Research Article Find the latest version: https://jci.me/103144/pdf BLOOD VOLUME IN CONGESTIVE HEART FAILURE' By R. W. GUNTON 2 AND W. PAUL (From the Department of Medicine and Radioisotope Laboratory, University of Toronto, and the Medical Service, Toronto General Hospital, Toronto, Canada) (Submitted for publication July 30, 1954; accepted September 8, 1954) Discussions of the mechanism of congestive disease did not have basal riles. All the patients were heart failure usually involve a consideration of acutely ill and presented the clinical picture of advanced "right-sided" heart failure. The etiological types of heart the blood volume (1, 2). The problem has en- disease and their frequency were: arteriosclerotic, 34; gaged the attention of many investigators: some hypertensive and arteriosclerotic, 26; hypertensive, 14; have found blood volume to be increased in con- rheumatic, 14; pulmonary, 11; congenital, 1; luetic, 1; gestive heart failure (3-7); others have found it amyloid, 1. to be normal (8, 9). This report is made to re- An initial blood volume determination was made usu- ally within twelve hours of admission to hospital. In cord the authors' observations in a study of 102 as many cases as possible it was repeated when all patients in heart failure. clinical signs of failure had disappeared. In this investigation the answers to three ques- Control patients were selected who did not have any tions were sought: 1. Is the blood volume of pa- known disease of heart, lungs or blood and who were not tients in congestive heart failure different from acutely ill. The commonest diagnoses in this group were diabetes, peptic ulcer, epilepsy and other neurological the blood volume of control patients without heart disorders, and convalescent pneumonia. In fifty-five of disease? 2. (a) Is there a change in blood vol- the control patients who remained largely confined to ume as patients improve from heart failure to the bed during their hospital stay, an initial blood volume de- compensated state? (b) If so, can this change be termination was made shortly after admission and was attributed solely to improvement in circulatory repeated after a varying interval of time. These patients were not strictly immobilized; some had bathroom privi- function or may it be due to bed rest alone? There leges. It was considered that their degree of activity did are several reports that a reduction in blood vol- not differ markedly from that of patients recovering from ume occurs with inactivity or bed rest (10-12). heart failure. These patients were not controls in the 3. Is there a change in blood volume in patients strictest sense of that term because they did not have who revert spontaneously from a state of compen- dietary salt restriction, digitalis and diuretics as did the patients in congestive heart failure. The repeat blood sation to heart failure? In the literature there are volume determinations on these subjects provided a group many answers to questions 1 and 2(a) but little of paired observations to test the reproducibility of the information relative to questions 2(b) and 3. In method and to show whether significant changes in blood our study particular attention has been devoted volume would result from ordinary bed rest. to these two questions. In some of the cardiac patients the opportunity oc- curred to measure the blood volume at the time of re- admission in heart failure, their blood volume having METHODS been determined on a prior occasion in the compensated Blood volume studies were made on 102 patients in state. An interval of several months often separated heart failure and on 107 control patients. The absolute the two admissions. No control observations were made criterion for the diagnosis of congestive heart failure for this group. was unequivocal elevation of jugular venous pressure as Blood volume was determined by the P' tagged red determined by clinical examination. No patient was in- blood cell method. Eight or ten cubic centimeters of cluded in this series in whom this finding was absent or the subject's blood were incubated for forty-five to sixty questionable. These patients had, in addition, the other minutes at 370 C. with 50 to 75 microcuries of P" in a signs of heart failure: orthopnea, basal rales, cardiac and sterile rubber-capped tube. The plasma was removed hepatic enlargement, and peripheral edema. A few after centrifugation and the cells washed twice with lacked detectable edema but presented all the other mani- sterile isotonic saline solution. The cells were then re- festations; some of the patients with pulmonary heart suspended in saline to approximately the original volume and, without delay, a 5.0 cc. aliquot was injected intra- 1 This work was supported by a Grant from the Na- venously from a calibrated syringe. One venous blood tional Research Council, Canada. sample was drawn from the opposite arm vein ten to 2 Senior Medical Research Fellow, National Research fifteen minutes after injection, using dry powdered Council, Canada. heparin as the anticoagulant. It was found, using this 879 880 R. W. GUNTON AND W. PAUL technique of preparati*, that the amouiit of PFi" the: the ratio'-of venous to body hetaitcrit may not be iden- supernatant saline of the final tagged-cell suspension tical in these three groups of patients will be considered comprised approximately 2 per cent of the injedted dose in the discussion. by comparison against a standard uraniumn source. No correction was made for this extra-cellular P' in the calculation. It was found also, as reported by others (6), that the radioactivity of venous blood measured at Heart failure group versus control group fifteen-minute intervals for a period of one hour after the intravenous injection did not vary significantly from The average values of total, red cell, and plasma the ten to fifteen-minute' value even in patients with volume for the group of 102 patients in heart heart failure. In the routine procedure the single sfama- . failure' are compared with those of 107 control ple wag therefore used, it being' considered that mixing in waswascompletecompleteat atthat time.time.- 'patients Table I. Male's in heart failure, have In the counting technique liquid samples were used. an excess of 983 cc.. of total volumee over the con- One cubic centimeter of the tagged-cell suspension trols; 'females an excess of 1,313 cc. Since the ("standard") was first hemolyzed and then -diluted to hematocrit values are very nearjy identical in the 200 cc. in 18 per cent dextrose, as described by. Reid and I two the excess is shared by red cell Orr tl13). The venous blood sample was' untreated.untreated. .t groups, the These samples were placed in specially prepared pyrex and plasma fractions in about the same proportionI glass beakers of identical internal diameter mounted as in normal blood. horizontally below the end window of a Geiger tube. The values for total, red sell and plasma vol- The depth of the fluid in the beakers was 12 mm. so that umes, expressed in cc. per kilogram of bodyr was . the 'principle of "infinite thickness" employed (13). w Five thousand to six 'thousand counts were recorded at 5 a rate of counting twenty timnes background. Counting vors in the heart failure group in whom it was of the venous blood sample was interrupted at five-minute possible to. determine "dry" body weight in the intervals for 'stirring to prevent settling of intact red compensated'.state'are given in Table'II. Males5 cells away from the importat upper layers of fluid. in heart failure had a mean total blood volume off The hematocrit of venous blood was read from duplicate samples after centrifugation at 3,000 r.p.m. for fory m- 90.7 cc. per Kg.; male controls 69.8 cc. per Kg utes. No correction was applied for trapped plasma. The Females in heart failure had a mean total bloodI PI calculations were made as follows: volume of 88.2 cc. per Kg.; female controls 60.6 per min. (standard) X 5.0 (vol. injected) X 200 (dil. factor) Tcc=countsBloodocounts per min. (venous sample) Red Cell Volume =Total Blood Volume X Hematocrit cc. per Kg. The mean differences were signifi- Plasma Volume =Total Blood Volume - Red. Cell cant: males, t =7.9; P < .001; females, t =6.5; Volume. P < .001. The technical accuracy of the method wras tested in vitro on bottles of blood, care being taken to arrange that TABLE I: the amount of radioactivity in the samples was similar Comparison of blood volume: Heart failure vs. controls * to that in the measuremnnts on humans. In nine succes- sive experiments the mean difference of the determined Blood volume (expressed in cc.) from actual volume was - 0.06 per cent (Standard Devi- Excess: ation : 4.08 per cent). This test of accuracy does not Heart Failure over include physiological errors. It is merely a test of the Controls failure controls accuracy of the diluting and counting techniques. Males 75 Cases 70 'Cases Because this is a tagged red cell method, only the- red Total B.V. 4,545 5,528 +983 cell volume will be directly measured. The values for Red cell V. 2,018 2,515 +497 total volume and plasma volume are dependent on the Plasma V. 2,527 3,013 +486 venous hematocrit.' Because total body hematocrit is Hematocrit 44.4% 45.5% Average age 49.5 yr. 64.5 yr.y geae . probably lower than venous hematocrit (1416) 'values given here for total volume and plasma volume may be Females 32 Cases 32 Cases low.
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