From the Guidelines
The cold and wet hemodynamic profile is a clinical classification used in heart failure patients that indicates poor cardiac output (cold) combined with fluid congestion (wet). This profile is characterized by signs of hypoperfusion such as cool extremities, decreased mentation, and narrow pulse pressure, along with evidence of fluid overload including pulmonary rales, elevated jugular venous pressure, and peripheral edema, as described in the guidelines for the diagnosis and management of heart failure in adults 1.
Key Characteristics
- Poor cardiac output
- Fluid congestion
- Signs of hypoperfusion (cool extremities, decreased mentation, narrow pulse pressure)
- Evidence of fluid overload (pulmonary rales, elevated jugular venous pressure, peripheral edema) Patients with this profile typically have the worst prognosis among heart failure presentations and require prompt intervention, which may involve hospitalization for further adjustment of therapy 1.
Treatment Approach
Treatment usually involves:
- Intravenous diuretics like furosemide to address congestion
- Inotropic support such as dobutamine or milrinone to improve cardiac output Careful hemodynamic monitoring is essential, often requiring central venous pressure or pulmonary artery catheter measurements in severe cases, as recommended in the guidelines for the management of fluid status in heart failure patients 1. This profile occurs because the failing heart cannot maintain adequate forward flow, leading to tissue hypoperfusion, while simultaneously causing backward pressure that results in fluid accumulation in the lungs and periphery.
Goal of Therapy
The goal of therapy is to improve cardiac output while simultaneously reducing congestion to move the patient toward a "warm and dry" profile. In patients with reduced ejection fraction experiencing a symptomatic exacerbation of heart failure requiring hospitalization, it is recommended that therapies known to improve outcomes, such as ACEIs or ARBs and beta-blocker therapy, be continued in most patients in the absence of hemodynamic instability or contraindications 1. Invasive hemodynamic monitoring should be performed to guide therapy in patients who are in respiratory distress or with clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment 1. Medications should be reconciled in every patient and adjusted as appropriate on admission to and discharge from the hospital, with careful measurement of fluid intake and output, vital signs, body weight, and clinical signs and symptoms of systemic perfusion and congestion 1. Overall, the management of the cold and wet hemodynamic profile requires a comprehensive approach that addresses both the cardiac output and fluid congestion, with careful monitoring and adjustment of therapy to improve patient outcomes.
From the Research
Hemodynamic Profile Definition
- A cold and wet hemodynamic profile is characterized by low cardiac output and fluid retention, often seen in patients with acute decompensated heart failure 2.
- This profile is associated with signs of end-organ dysfunction, such as renal and hepatic damage, and is a predictor of poor prognosis in heart failure patients 3.
Clinical Characteristics
- Patients with a cold and wet hemodynamic profile often have severe symptoms of heart failure, including fluid retention and low blood pressure 2.
- The physical examination may reveal signs of fluid overload, such as edema and pulmonary congestion, as well as signs of poor perfusion, such as cool extremities and decreased urine output 2.
- The cold and wet profile is often associated with a higher risk of adverse outcomes, including death and hospitalization 2, 4.
Management
- The management of patients with a cold and wet hemodynamic profile typically involves the use of inotropic agents, such as dobutamine and milrinone, to increase cardiac output and improve perfusion 5, 6.
- Other therapies, such as diuretics and vasodilators, may also be used to reduce fluid overload and improve hemodynamics 6.
- In some cases, mechanical circulatory support, such as an intra-aortic balloon pump or left ventricular assist device, may be necessary to support the patient's circulation 5, 4.
Prognosis
- The prognosis for patients with a cold and wet hemodynamic profile is generally poor, with a high risk of death and hospitalization 2, 3.
- However, early recognition and treatment of this profile can improve outcomes and reduce the risk of adverse events 3.
- The use of a standardized classification framework and invasive hemodynamic parameters can help guide management and improve outcomes in patients with mixed cardiogenic shock, which can include a cold and wet hemodynamic profile 4.