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Case Report
Clujul Medical
HEMODYNAMIC MONITORING USING THORACIC
BIOIMPEDANCE – AN OPTIMAL SOLUTION FOR THE
TREATMENT OF HYPERTENSION
ANCA DANIELA FARCAS, FLORIN PETRU ANTON, MIHAELA MOCAN,
LUMINITA ANIMARIE VIDA-SIMITI
Internal Medicine Department, Iuliu Hatieganu University of Medicine and
Pharmacy Cluj-Napoca, Romania
Internal Medicine Department, Emergency County Clinical Hospital Cluj-
Napoca, Romania
Abstract
Hypertension is a major issue of public health because of its increasing
prevalence and multiple complications caused by failing to achieve an efcient blood
pressure control. Considering hypertension as a hemodynamic disorder allows to
prescribe a tailored therapy guided by individual hemodynamic parameters, therefore
leading to an increased rate of control. We present the case of a 59 years old diabetic,
dyslipidemic and obese male who, although treated with 5 classes of antihypertensive
drugs had uncontrolled hypertension that caused left ventricular failure. Using the
HOTMAN system of hemodynamic monitoring using thoracic electrical bioimpedance
allowed a quick identication of the cause and guided the therapy, achieving blood
pressure control after 5 days of treatment. Treating hypertension by identifying the
underlying hemodynamic imbalance allows prescribing a tailored therapy and shortens
the initiation and stabilization phases of treatment.
Keywords: hypertension, hemodynamic, treatment, bio-impedance,
antihypertensive treatment
DOI: 10.15386/cjmed-1085
Manuscript received: 23.06.2018
Received in revised form: 06.07.2018
Accepted: 23.07.2018
Address for correspondence: orinantonfr@yahoo.com
Hypertension is a signicant and well-known risk
factor for cardiovascular diseases, associated with high
mortality. In Romania the prevalence of hypertension is
45.1% and on the rise in the last 7 years, possibly caused by
increased incidence of risk factors such as unhealthy diet,
obesity, diabetes or dyslipidemia [1].
Although 72.2% of patients receive treatment [2] and
although 51.9% of them receive 2 or 3 medications, only
30.8% reach blood pressure (BP) goals [1], thus making
hypertension in Romania an ”unsolved equation” [2].
In spite of major advances in treatment and efforts
to follow the guidelines, a signicant number of patients are
still poorly controlled even in other European countries [3].
This might be caused by the current paradigm
that views hypertension merely as a BP disorder and not
as a hemodynamic imbalance. Published data suggest
that prescribing antihypertensive therapy guided by
hemodynamic parameters gathered using thoracic electrical
bioimpedance would increase the BP control rate [4,5].
The HOTMAN system (HEMO SAPIENS,
INC). uses thoracic electrical bioimpedance to identify
hemodynamic imbalances in hypertensive patients, thus
allowing the physician to choose optimal therapy and
appropriate dosage for each patient [6].
Case report
A 59-year-old male with very high-risk stage 3
hypertension, type 2 diabetes with diabetic chronic kidney
disease (CKD) and neuropathy, dyslipidemia and obesity
is referred for edema, resting dyspnea and nocturnal
paroxysmal dyspnea in the last 2 weeks. The patient has
difcult BP control with repeated peaks reaching 180/100
mmHg. Clinical examination shows a patient with
abdominal obesity, edema, pulmonary rales, BP 160/100
mmHg, pulse 65 bpm and no heart murmurs. Current
medication includes valsartan 160 mg bid, lercanidipin
10mg od, moxonidine 0.4 mg od, indapamide 1.5mg od
and nebivolol 5mg od. Laboratory workup shows fasting
plasma glucose 124 mg/dl, HbA1c 7.1%, LDL-cholesterol
69mg/dl, HDL-cholesterol 55 mg/dl, triglycerides 178
mg/dl, creatinine 1.1 mg/dl, creatinine clearance 72.8 ml/
Case Report
Clujul Medical
min/1.73m², microalbuminuria - 189mg/dl and potassium
4.3 mEq/l. Echocardiogram shows mild concentric left
ventricular (LV) hypertrophy (LV posterior wall thickness
12 mm, interventricular septal thickness 12 mm), grade I
mitral regurgitation and grade I diastolic dysfunction. The
patient’s diagnosis is very high-risk grade 3 hypertension,
hypertensive and ischemic heart disease, grade I mitral
regurgitation and acute LV failure. In order to control LV
failure symptoms and prevent further complications, tight
BP control is required – BP needs to be brought below
130/80 mmHg.
For a patient with diabetic CKD and hypertension
under treatment with 5 types of antihypertensive drugs
(angiotensin receptor blocker, calcium antagonist,
indapamide, beta-blocker and a centrally acting agent)
what other medication could be added? The European
hypertension guidelines suggests adding an alpha-receptor
blocker.
Another answer to this question could be provided by
the HOTMAN F100 system (HEMO SAPIENS, INC). The
system uses the thoracic electrical bioimpedance to gather
hemodynamic data on volemia, vasoactivity, inotropy and
chronotropy that are specic to each hypertensive patient.
Using these parameters the device allows a virtual
modeling of therapy and provides information on the
impact of changes in therapy. For this patient, HOTMAN
monitoring shows a status with 86% hypervolemia and no
vasoconstriction (Figure 1).
“Virtual therapy” shows that adding a vasodilator
would achieve a 40% hyperdinamic/normotensive status
with 83% hypervolemia and 30% hyperchronotropy, as
shown in Figure 2.
Achieving the BP goal therefore requires the addition
of a diuretic, as shown in “virtual therapy” (Figure 3).
The patient’s treatment already includes indapamide
– a thiazide diuretic which has both vasodilator and diuretic
effects, therefore it is continued – thus a combination of
loop diuretic (Furosemide) and kalium-sparing diuretic
(Spironolactone) is added, in order to reduce the hypervolemia
by a combined diuretic effect and also to avoid hypokalemia.
After ve days of treatment with the new regimen
the patient is asymptomatic, BP is normal (110/70 mmHg)
and HOTMAN monitoring shows a normodynamic/
normotensive status with only 37% hypervolemia (Figure 4).
HOTMAN monitoring after 20 days of treatment
with Valsartan 160 mg bid, Lercanidipine 10 mg od,
Moxonidine 0.4 mg od, Indapamide 1.5 mg od, Nebivolol
5 mg od, Furosemide 40 mg od and Spironolactone 50 mg
od shows a normotensive/normodynamic status with 40%
hypervolemia (Figure 5).
Figure 1. Hemodynamic status at rst evaluation.
Case Report
Clujul Medical
Figure 2. Worsened hemodynamic status after adding a vasodilatator.
Figure 3. Improved hemodynamic status after adding a diuretic
Case Report
Clujul Medical
Figure 4. Hemodynamic status after 5 days of new treatment.
Figure 5. A normotensive/normodynamic status after 20 days of new treatment.
Case Report
Clujul Medical
Discussion
We present the case of a patient treated with 5
classes of antihypertensive drugs that failed to reach BP
goal and who had cardiac dysfunction due to organ damage
– a widespread scenario found in daily practice. Using a
trial-and-error approach to therapy would not bring any
benets and would actually prolong or even worsen the
current status of the patient, whereas using the HOTMAN
monitoring allowed a quick and accurate identication of
the optimal type of medication needed and achieving better
BP control. Besides, using noninvasive hemodynamic
monitoring in BP control was proven to be extremely
useful [7,8], both in newly diagnosed patients and long-
time but uncontrolled hypertension [9,10], and ultimately
improved the outcome for hypertensive patients [11].
A meta-analysis of 7 studies enrolling 1087 patients has
shown that prescribing medication using hemodynamic
monitoring protocols leads to an average control rate of
72.6% [7]. The study of Sramek et al. achieved BP control
in 75% of patients already treated with 2 or more drugs,
after only 3 weeks of treatment [12].
Conclusion
Hemodynamic monitoring in hypertension with
thoracic electrical bioimpedance using the HOTMANTM
F100 system (HEMO SAPIENS, INC.) provides valuable
data for hypertension treatment. Following the system’s
recommendations leads to an expedited stabilization of
the patients’ status, therefore shortening the initiation and
stabilization phases of the treatment, which can often be a
frustrating period, both for the physician and for the patient.
References
1. Dorobantu M, Tautu OF, Dimulescu D, Sinescu C, Gusbeth-
Tatomir P, Arsenescu-Georgescu C, et al. Perspectives on
hypertension’s prevalence, treatment and control in a high
cardiovascular risk East European country: data from the
SEPHAR III survey. J Hypertens. 2018;36(3):690-700.
2. Dorobanţu M, Darabont R, Ghiorghe S, Arsenescu-Georgescu
C, Macarie C, Mitu F, et al. Hypertension prevalence and control
in Romania at a seven-year interval. Comparison of SEPHARI
and II surveys. J Hypertens. 2014;32(1):39-47.
3. Banegas JR, López-García E, Dallongeville J, Guallar E, Halcox
JP, Borghi C, et al. Achievement of treatment goals for primary
prevention of cardiovascular disease in clinical practice across
Europe: the EURIKA study. Eur Heart J. 2011;32(17):2143-2152.
4. Chacón-Lozsán F. Non-Invasive Hemodynamic Analyses to
Guide Pharmacotherapy of High Blood Pressure: Mini-Review.
Journal of Cardiology & Cardiovascular Therapy 2017;3(3):1-3.
5. Krzesiński P, Gielerak G, Stańczyk A, Piotrowicz K, Skrobowski
A. Who benets more from hemodynamically guided hypotensive
therapy? The experience from two randomized, prospective and
controlled trials. Ther Adv Cardiovasc Dis. 2016;10(1):21-29.
6. Farcas AD, Stoia MA, Anton FP, Goidescu CM, Vida-Simiti
L. Improving blood pressure control beyond the guidelines.
European heart journal. 2016;37:212-213.
7. Chacón-Lozsán F, Rodriques-Torres M, Rojas R. Hemodynamic
Management of High Blood Pressure. Therapeutic Advances in
Cardiology. 2017;1(3):73-79.
8. Viigimaa M, Talvik A, Wojciechowska W, Kawecka-Jaszcz
K, Toft I, Stergiou GS, et al. Identication of the hemodynamic
modulators and hemodynamic status in uncontrolled hypertensive
patients. Blood Press. 2013;22(6):362-370.
9. Hernández-Hernández R, Domenech M, Coca A. 481
Hemodynamic evaluation and selection of hypertension treatment.
Journal of Hypertension. 2012;30:e142-e143.
10. Krzesiński P, Gielerak GG, Kowal JJ. A “patient-tailored”
treatment of hypertension with use of impedance cardiography:
a randomized, prospective and controlled trial. Med Sci Monit.
2013;19:242-250.
11. Sramek B.Bo, Badila E, Bartos D, Târziu C, Ghiorge S.
Treating hypertension as a hemodynamic disorder results in three-
fold improvement in outcomes. American Society of Hypertension
- 23rd Annual Scientic Meeting and Exposition, 2008. Abstract
Number: 350091. Available from:
http://www.hemodynamicsociety.org/ash2008.html
12. Shramek B.Bo, Tinky JA, Hojerova M, Cervenka V.
Normohemodynamic goal-oriented antihypertensive therapy
improves the outcome. The American Society of Hypertension,
11th Scientic Meeting, New York. 1996. Available from: http://
www.hemodynamicsociety.org/abstract.html