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Received: 16 May 2016 Revised: 22 September 2016 Accepted: 5 October 2016

DOI: 10.1111/echo.13409

O R I G I N A L I N V E S T I G AT I O N

Inferior vena cava collapsibility index, renal dysfunction,

and adverse outcomes in patients with broad spectrum
cardiovascular disease

Yong-Hyun Kim MD1|Sunwon Kim MD1|Jin-Seok Kim MD1|Sang-Yup Lim MD1|

Wan-Joo Shim MD2|Jeong-Cheon Ahn MD1|Woo-Hyuk Song MD1

1
Cardiovascular Division,Department of
Internal Medicine,Korea University Ansan
Hospital, Ansan-si, Korea
2
Cardiovascular Center,Korea University
Anam Hospital, Seoul, Korea
Correspondence
Woo-Hyuk Song, MD, PhD, Cardiovascular
Division, Department of Internal Medicine,
Korea University Ansan Hospital,
Danwon-gu, Ansan-si, Gyeonggi-do, Korea.
Email: cardiologist@hanmail.net
Aims: The clinical implication of the inferior vena cava collapsibility index (IVCCI) has
not been well evaluated in patients with various cardiovascular diseases.
Method and results: The relationships between clinical characteristics and echocardi-
ographic indicators of the systemic intravascular volume status [IVCCI; the ratio of the
early transmitral and early myocardial diastolic velocities (E/Em)] were evaluated at
baseline, and the clinical status during follow-up was compared across the IVCCI lev-
els. Among 1166 patients (mean age=63.813.4years), 934, 171, and 61 had high
(50%), intermediate (25%50%), and low (<25%) IVCCIs, respectively. Age-, sex-, and
body mass index-adjusted serum creatinine (sCr) levels were highest in patients with
low IVCCI (P=.002) and E/Em >15 (P<.001). During follow-up (1108463days), 67
patients died, and 38 of these deaths were cardiovascular related. Age, body mass
index, heart failure (HF), sCr levels, and a low IVCCI (vs high IVCCI: hazard ratio
[HR]=3.193, 95% confidence interval [CI]=1.2977.857, P=.012) were associated with
all-cause mortality in multivariable analysis. HF, diuretic use, and a low IVCCI (vs high
IVCCI: HR=4.428, 95% CI=1.40613.104, P=.007) were significantly associated with
cardiovascular mortality.
Conclusion: A low IVCCI was significantly associated with reduced renal function and
was an independent risk factor for adverse outcomes, regardless of underlying cardio-
vascular disease and renal function.

KEYWORDS
cardiovascular death, heart failure, inferior vena cava, renal function

1| INTRODUCTION
Elevated jugular venous pressure (JVP), which indicates increased right
atrial pressure, is a diagnostic criterion for heart failure (HF).1 Because
elevated JVP is also associated with poor cardiovascular outcomes in
patients with HF, it was suggested that JVP should be examined during
2,3
the initial clinical presentation.
The morphology of the inferior vena cava (IVC) is routinely eval-
uated during two-dimensional (2D) echocardiography, and poorly
collapsible IVC during full inspiration indicates increased right atrial
pressure.4,5 Given that increased right atrial pressure can be deter-
mined via IVC collapsibility, evaluating the IVC status would be an
easier and more reliable method than JVP for estimating right atrial
pressure in clinical practice because JVP measurements are often dis-
cordant between examiners.68
Renal dysfunction is a poor prognostic factor in patients with
cardiovascular disease and is common in patients with HF. The in-
travascular volume must be large enough to maintain renal function
within the normal range, but overexpansion of the intravascular vol-
ume can lead to renal dysfunction by causing renal vein congestion in

Echocardiography 2016; 19 wileyonlinelibrary.com/journal/echo 2016, Wiley Periodicals, Inc. | 1

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2 KIM etal.
patients with HF.911 Therefore, when using noninvasive 2D echocar-
diography to evaluate the relationship between the systemic volume
status and renal function, it would be reasonable to determine the
IVC collapsibility index (IVCCI) along with an established parameter
of effective intravascular volume status such as the ratio of the early
transmitral blood flow velocity and early diastolic myocardial tissue
velocity (E/Em).
On the other hand, because most of the previous studies on IVC
congestion were carried out in patients with overt symptomatic HF
or advanced chronic kidney disease, little is known about the clinical
implication of the IVCCI in patients without HF. In this study, we ex-
amined the hypothesis that systemic venous congestion, as indicated
by the IVC collapsibility index (IVCCI), is related to renal dysfunction
and is associated with adverse clinical outcomes in patients with vari-
ous cardiovascular diseases, independent of underlying cardiovascular
or renal function.
2| SUBJECTS AND METHODS
From 2008 to 2012, we searched for patients with both documented
cardiovascular disease and baseline two-dimensional echocardiogra-
phy data in an institutional medical database; patients that met these
criteria were enrolled in the study. Anthropometric information and
medical histories were obtained through medical records review. The
presence of diabetes mellitus, hypertension, hyperlipidemia, coronary
artery disease, HF, valvular heart disease, cerebrovascular disease,
chronic kidney disease, and other etiologies of cardiovascular diseases
were also determined from the medical records.
Severely ill patients who needed intensive care, patients on renal
replacement therapy, patients on mechanical ventilator therapy, pa-
tients with severe tricuspid regurgitation, and patients with uninter-
pretable IVC images were excluded from the study.
A cardiologist (Y.H.K.), who was blinded to the study results, de-
termined the IVCCI by reviewing every set of two-dimensional echo-
cardiography images that had been stored in Digital Imaging and
Communications in Medicine (DICOM) file format. The diameter of
the IVC was measured within 2cm from the right atrium; the min-
imum diameter was obtained during full forced inspiration, whereas
the maximum diameter was obtained during expiration.4,12 The IVCCI
was determined by the ratio of the minimum and maximum diameters
of the IVC according to the following formula8:
IVCCI =(maximum diameter of the IVC minimum diameter of the IVC)
(maximum diameter of the IVC)
Patients were assigned to one of three groups according to the
IVCCI: high IVCCI (>50%) group; intermediate IVCCI (25%-50%)
group; and low IVCCI (<25%) group. In accordance with previous stud-
4,5
ies, the right atrial pressure was estimated to be <10, 1015, and
>15mm Hg, respectively, in these three groups.
The E/Em is typically regarded as an indicator of effective intravas-
cular volume status in patients with HF. The left ventricular (LV) filling
pressure was considered normal when the E/Em was <8, whereas the
LV filling pressure was considered high when the E/Em was >15. The
grade of LV filling pressure was considered indeterminate when the
range of the E/Em was 815.13 The Em was obtained from the septal
side of the mitral annulus in apical four-chamber images during spec-
tral Doppler echocardiography. Pulmonary vascular resistance was
noninvasively obtained by Doppler echocardiography with Abbass
formula.14
Left atrial diameter was obtained from two-dimensional paraster-
nal long-axis images. LV mass was calculated using Devereux formula
and normalized by body surface area. A modified biplane Simpsons
method was used to obtain the LV ejection fraction.
The causes of death were obtained from the electronic database
of the Korea University Ansan Hospital. All patient data were de-
identified for analysis. The institutional review board of the hospital
approved this retrospective cohort study.
2.1|Statistics
We used the Students t-test or one-way analysis of variance to com-
pare continuous variables, the chi-square or Fishers exact test to
compare categorical variables, and Pearsons correlation test to evalu-
ate the relationship between pairs of continuous variables.
Because glomerular filtration rate (GFR) is estimated by serum
creatinine (sCr), age, sex, and body size according to the currently
recommended formulae,15 we used age-, sex-, and body mass index
adjusted sCr as an indicator of renal function rather than using esti-
mated GFR in the relationships between renal function, the IVCCI and
E/Em levels, via analysis of covariance (ANCOVA). Pairwise compari-
sons based on the estimated marginal means were conducted using a
Bonferroni adjustment for multiple comparisons.
KaplanMeier curves were constructed for all-cause and cardio-
vascular mortality, and log-rank tests were used for the comparison
of event-free survival, categorized according to the IVCCI and E/Em.
Cox proportional hazards analysis was conducted to determine
the independent risk factors for all-cause and cardiovascular mortality.
The covariables for multivariable analysis were selected based on uni-
variable analysis and clinical relevance. The covariables were entered
in the multivariable model when their P-value in univariable analysis
was <.10. During multivariable analysis, covariables with P-value of
>.10 were removed using stepwise backward elimination. To avoid
overfitting, the number of candidate covariables of interest was limited
to one variable per five or more clinical events.16,17
Intra-observer reproducibility was assessed by performing re-
peated measurements of IVC diameters and IVCCI in 30 randomly
selected patients, 3weeks after the first measurements to avoid recall
bias. A second observer (S.K) blinded to the results of the first observer
assessed inter-observer reproducibility in the same samples. Intraclass
correlation coefficients (ICC) were obtained as absolute agreement
using two-way mixed model.
Differences were considered significant when the two-sided P-
value was <.05. Statistical analyses were performed using SPSS ver-
sion 18.0 (SPSS, Chicago, IL, USA).
KIM etal. |
3

3|RESULTS of diabetes mellitus and hypertension were found between the

We collected 2034 patients with both documented cardiovascu-
lar disease and baseline two-dimensional echocardiography data.
After severely ill patients, patients on renal replacement therapy,
patients on mechanical ventilator therapy, patients with severe tri-
cuspid regurgitation were excluded, there were 1330 patients with
both cardiovascular disease and echocardiography data. After 164
patients with uninterpretable IVC images were further excluded,
1166 patients were finally enrolled. The mean patient age was
63.813.4years, and 676 patients (58%) were men. The study in-
cluded 348 patients with diabetes mellitus (29.8%), 634 with hy-
pertension (54.4%), 263 with hyperlipidemia (22.6%), 729 with
coronary artery disease (62.5%), 143 with valvular heart disease
(12.3%), 102 with cerebrovascular disease (8.7%), and 301 patients
with HF (25.8%).
The number of patients with high, intermediate, and low IVCCIs
was 934 (80.1%), 171 (14.7%), and 61 (5.2%), respectively. The E/Em
was measured for 1048 patients, and the numbers of patients with
E/Em <8, 815, and >15 were 144 (13.7%), 597 (57.0%), and 307
(29.3%), respectively. No differences in age, sex and the prevalence
IVCCI groups; however, coronary artery disease was more prevalent
in the high IVCCI group, and valvular heart disease and HF were
more prevalent in the low IVCCI group. Both blood urea nitrogen and
sCr levels were higher in the low IVCCI group. The numbers of pa-
tients taking reninangiotensin-system antagonists, beta-blockers,
and diuretics were 394 (33.8%), 211 (18.1%), and 232 (19.9%), re-
spectively. The prescription rate for diuretics was higher in the low
IVCCI group, while the prescription rates for reninangiotensin-
system antagonists and beta-blockers were not different among the
groups (Table1).
The patients in the low IVCCI group appeared to have a higher
left ventricular mass index, larger left atrial size, lower left ventricular
ejection fraction, and higher E/Em (Table2).
A weak correlation was found between the E/Em and IVCCI
when both were entered as continuous variables (r=.166, P=.000).
On the sCr-IVCCI plot, the sCr levels were different across the IVCCI
groups when the data were adjusted for age, sex, and body mass index
(P=.002). Further, a significant difference in sCr levels was found be-
tween the three groups based on the E/Em when using multivariable-
adjusted data (P<.001) (Figure1A, B).

T A B L E 1 Clinical characteristics of the

High (n=934) Intermediate Low (n=61)
patients according to the inferior vena cava
meanSD or (n=171) meanSD meanSD or
collapsibility index at baseline
n (%) or n (%) n (%) P

Age (y) 63.513.0 65.014.0 66.516.6 .106

Male (%) 544 (58.2) 100 (58.5) 32 (52.5) .668
Body mass index (kg/m2) 24.83.6 23.93.5 24.54.9 .026
Hypertension, n (%) 516 (55.2) 88 (41.5) 30 (49.2) .464
Diabetes, n (%) 268 (28.7) 61 (35.7) 19 (31.1) .181
Hyperlipidemia, n (%) 227 (24.3) 28 (16.4) 8 (13.1) .014
Coronary artery disease, n (%) 615 (65.8) 87 (50.9) 27 (44.3) .000
Valvular heart disease, n (%) 81 (8.7) 42 (24.6) 20 (32.8) .000
Cerebrovascular disease, n (%) 86 (9.2) 11 (6.4) 5 (8.2) .492
Heart failure, n (%) 215 (23.0) 59 (34.5) 27 (44.3) .000
Chronic kidney disease, n (%) 24 (2.6) 8 (4.7) 4 (6.6) .094
Hemoglobin (g/dL) 13.42.0 12.82.3 12.82.0 .000
Blood urea nitrogen (mg/dL) 18.19.1 20.812.6 23.614.9 .000
Serum creatinine (mg/dL) 1.2 0.4 1.20.5 1.40.7 .005
Sodium (mmol/L) 140.23.1 139.83.4 138.83.4 .002
Potassium (mmol/L) 4.20.5 4.10.6 4.20.6 .082
Chloride (mmol/L) 103.93.7 103.94.7 102.93.8 .163
Glucose (mg/dL) 124.142.1 135.751.0 139.662.9 .001
Total cholesterol (mg/dL) 166.441.4 156.541.7 153.743.4 .003
LDL cholesterol (mg/dL) 100.637.3 94.339.7 97.537.3 .145
Triglycerides (mg/dL) 145.6144.9 141.2189.6 129.599.4 .722
RAS antagonist, n (%) 322 (34.5) 51 (29.8) 21 (34.4) .489
-blocker, n (%) 171 (18.3) 32 (18.7) 8 (13.1) .577
Diuretics, n (%) 147 (15.8) 60 (35.1) 25 (41.0) .000

HDL, high-density lipoprotein; LDL, low-density lipoprotein, RAS, reninangiotensin system.

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4 KIM etal.

T A B L E 2 Echocardiographic
High (n=934) Intermediate Low (n=61)
characteristics of the patients according to
meanSD (n=171) meanSD meanSD P
the inferior vena cava collapsibility index at
LV mass index (g/m2) 102.731.7 111.735.4 113.250.1 .001 baseline
Left atrium diameter (mm) 39.87.2 43.69.7 44.19.4 .000
LV ejection fraction (%) 54.312.1 49.015.4 44.916.5 .000
E (cm/s) 69.625.3 81.635.3 82.931.4 .000
Em (cm/s) 5.71.9 5.71.9 5.52.5 .832
E/Em 13.46.8 16.010.1 17.610.4 .000
TR flow velocity (m/s) 2.40.4 2.70.8 2.70.5 .000
Pulmonary vascular resistance 1.70.9 2.11.1 2.31.4 .000
(Wood units)
IVC diameter, expiration (cm) 1.50.5 1.80.5 1.80.6 .000
IVC diameter, inspiration (cm) 0.30.2 1.10.4 1.50.6 .000
IVC collapsibility index (%) 77.712.4 39.36.9 16.85.1 .000

LV, left ventricular; E, early transmitral flow velocity; Em, early myocardial diastolic velocity; TR, tricus-
pid regurgitation; IVC, inferior vena cava.

F I G U R E 1 Age-, sex-, and body mass indexadjusted relationships between serum creatinine (sCr) levels, the inferior vena cava collapsibility
index (IVCCI), and the early mitral flow velocity/early myocardial diastolic ratio (E/Em). (A, B) The mean sCr level is highest at low IVCCI and
at higher E/Em, which suggests that overexpansion of the systemic intravascular volume has a detrimental effect on renal function

The patients were observed for 1108463days, and 67 patients
(5.8%) died during follow-up. These included 38 cardiovascular deaths
(19 coronary deaths, 15 HF deaths, and four deaths from cerebrovas-
cular accident), 14 deaths attributable to malignant neoplasm, and 13
deaths from unidentified causes.
In the KaplanMeier survival plots, the low IVCCI group had the
highest all-cause mortality (P<.001) and cardiovascular mortality rates
(P=.004) across the groups. The group with E/Em >15 also had higher
mortality rates (Figure2).
Age, body mass index, the presence of HF, sCr levels, and the IVCCI
were significantly associated with all-cause mortality in multivariable
Cox proportional hazard analysis. Mortality was more than threefold
higher in patients with low IVCCI compared with those with high IVCCI
(vs high IVCCI: hazard ratio [HR]=3.193, 95% CI=1.2977.857, P=.012).
The presence of HF, diuretic use, and low IVCCI (vs high IVCCI:
HR=4.428, 95% CI=1.40613.104, P=.007) were significantly associ-
ated with cardiovascular mortality after multivariable analysis (Tables3
and 4). Interestingly, E/Em was not associated with all-cause mortality
or cardiovascular mortality in multivariable analysis.
The intra-observer ICC for IVCCI was 0.973 (95% CI=0.9440.987,
P<.001), and the inter-observer ICC was 0.883 [95% CI=0.7570.944,
P<.001] (Table5).
KIM etal.
F I G U R E 2 All-cause and cardiovascular mortality across the groups based on the inferior vena cava collapsibility index (IVCCI) and the early
mitral flow velocity/early myocardial diastolic ratio (E/Em). (A, B) All-cause mortality and cardiovascular mortality based on the IVCCI. (C, D) All-
cause mortality and cardiovascular mortality based on the E/Em
4|DISCUSSION
Elevated JVP, which is included in most of the diagnostic criteria used
for HF, was demonstrated to have a detrimental effect on mortality or
2,18
hospitalization for HF.
Like elevated JVP, a congested IVC is also indicative of elevated
right atrial pressure, as the IVC is the counterpart of the superior vena
cava and it has functions that are equivalent to those of the superior
vena cava.19
In this study, we demonstrated that the low IVCCI is not only associ-
ated with renal dysfunction, but also a useful prognosticator of adverse
cardiovascular events in patients with various cardiovascular diseases,
independent of underlying cardiovascular disease and renal function.
Decades ago, Winton investigated the influence of renal vein ob-
struction in dogs on the formation of urine and concluded a fraction
of renal vein pressure was transmitted back to raise glomerular capil-
lary pressure, which eventually determined the formation of urine.20
Besides, reduced glomerular filtration rate by experimentally induced
|
5
hypervolemia in dogs was independent of cardiac systolic function and
renal blood flow.21 In recent human studies, right atrial pressure was
demonstrated to be a hemodynamic parameter that correlated with
baseline renal function and adverse cardiovascular events.12,22 In pa-
tients with HF, renal vein congestion was described as a contributor to
worsening renal function as well as reduced renal blood flow.911,23 In
a non-HF population, an epidemiologic association was also demon-
strated between an increased central venous pressure and reduced
glomerular filtration rate.10
In line with previous studies, age-, sex-, and body mass index
adjusted sCr in our study was elevated in patients with parameters
of increased central venous pressure (low IVCCI or high E/Em), and
sCr was significantly associated with all-cause mortality in multivari-
able analysis. Our findings suggest that systemic venous congestion
contributes to the development of renal dysfunction and supports
the notion that there is an optimal range of intravascular volume, at
which both maximum cardiac output and minimum systemic conges-
tion are ensured.24
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6 KIM etal.

T A B L E 3 Clinical and echocardiographic parameters associated with all-cause mortality during follow-up: multivariate analysis

Univariable analysis Multivariable analysis

HR 95% CI P HR 95% CI P

Age 1.056 1.0331.080 .000 1.037 1.0091.066 .010

Male 1.118 0.6841.828 .656
Body mass index 0.853 0.7920.918 .000 0.876 0.7960.963 .006
Diabetes mellitus 1.426 0.8692.340 .160
Hypertension 1.243 0.7652.021 .380
Hyperlipidemia 0.702 0.3671.339 .283
Coronary artery disease 0.585 0.3620.945 .028
Valvular heart disease 2.402 1.3694.213 .002
Cerebrovascular disease 1.450 0.6933.034 .324
Heart failure 2.746 1.6974.442 .000 2.201 1.1724.132 .014
Serum creatinine 2.023 1.6372.500 .000 1.577 1.0402.392 .032
LV ejection fraction 0.970 0.9550.985 .000
LV mass index 1.009 1.0041.014 .000
Pulmonary vascular 1.220 1.0651.397 .004
resistance
RAS antagonists 0.637 0.3671.104 .108
Diuretics 2.896 1.7774.720 .000
E/Em (categorical)
<8 (Reference)
815 1.911 0.5756.345 .290
>15 4.551 1.38314.971 .013
IVC collapsibility index
High (Reference) (Reference)
Intermediate 1.767 0.9503.287 .072 1.354 0.6063.024 .460
Low 4.409 2.2738.550 .000 3.193 1.2977.857 .012

E/Em, ratio of early transmitral flow velocity and early myocardial diastolic velocities; IVC, inferior vena cava; HR, hazard ratio; CI, confidence interval.

For the mechanism of worsening renal function in a patient with
elevated right atrial pressure and venous congestion, it is assumed
that increased pressure on efferent end of glomerular capillaries leads
23
to reduced net filtration pressure in glomeruli. In addition, nonhe-
modynamic factors such as activation of the neuro-hormonal system,
inflammatory reaction, endothelial dysfunction, and endotoxins from
the congested intestines and anemia could also play roles, although
2527
they are considered mediators rather than direct effectors.
awaits further investigations how systemic venous congestion is as-
sociated with renal dysfunction and adverse outcome in patients with
relatively preserved cardiac function.
The ability of the IVCCI to accurately estimate right atrial pressure
is controversial because IVC dilatations can be observed in individ-
uals with normal right atrial pressure and the correlations between
the IVCCI and right atrial pressure are moderate at best.8 However,
despite some probable misclassifications, elevated right atrial pressure
as estimated by the IVCCI was significantly associated with worse clin-
ical outcomes,8 and the IVCCI predicted the adjustment of diuretics
28
more accurately than clinical examination in patients with HF, which
highlight the clinical usefulness of the IVCCI regardless of its correla-
tion with right atrial pressure.
Interestingly, the E/Em was not associated with adverse outcomes
after multivariable adjustments in our study. Although the E/Em is
regarded as a good surrogate of pulmonary wedge pressure, this cor-
relation seems valid only in patients with HF.29,30 In fact, because only
49% of patients with HF had an E/Em >15 in our study, the E/Em may
It not have correctly represented pulmonary wedge pressure in our study
population. These results have an important implication in real practice,
because an E/Em >15 may be too lenient of a criterion to separate
patients at high risk of adverse events from those at low risk and, there-
fore, the prognostic value of the IVCCI may be superior to that of the E/
Em in a population where various cardiovascular diseases coexist.30,31
Despite the crucial role of physical examination, physicians are be-
coming less skilled at physical examination and dependent on modern
technology.6,32,33 Consequently, information regarding the jugular ve-
nous status was available for only a small portion of patients in clinical
studies of HF.1,18 It is noteworthy that the IVC status can be accu-
rately evaluated by a novice in cardiology,34 whereas elevated JVP is
KIM etal. |
7

T A B L E 4 Clinical and echocardiographic parameters associated with cardiovascular mortality during follow-up: multivariate analysis

Univariable analysis Multivariable analysis

HR 95% CI P HR 95% CI P

Age 1.045 1.0141.076 .004 1.031 0.9961.068 .086

Male 0.796 0.4061.561 .506
Body mass index 0.861 0.7770.954 .004 0.895 0.7901.013 .080
Diabetes mellitus 2.130 1.0864.177 .028 2.228 0.9505.223 .065
Hypertension 1.653 0.8173.341 .162
Hyperlipidemia 0.621 0.2401.605 .325
Coronary artery disease 0.632 0.3221.240 .182
Valvular heart disease 5.410 2.73210.715 .000
Cerebrovascular disease 1.940 0.6715.612 .221
Heart failure 4.111 2.0878.100 .000 3.475 1.3678.883 .009
Serum creatinine 2.285 1.7662.955 .000
LV ejection fraction 0.955 0.9360.975 .000
LV mass index 1.015 1.0101.020 .000
Pulmonary vascular 1.237 1.0361.478 .019
resistance
RAS antagonists 0.668 0.3121.432 .300
Diuretics 4.861 2.4789.534 .000 3.091 1.2107.897 .018
E/Em >15 (vs E/Em 815)a 5.074 2.41510.659 .000
IVC collapsibility index
High (Reference) (Reference)
Intermediate 2.247 0.9955.075 .051 1.586 0.5804.342 .369
Low 4.152 1.56511.013 .004 4.428 1.40613.104 .007

E/Em, ratio of early transmitral flow velocity and early myocardial diastolic velocities; IVC, inferior vena cava; HR, hazard ratio; CI, confidence interval.
a
Cardiovascular death was not observed in E/Em <8.

T A B L E 5 Intra-observer and inter-observer reproducibility test In summary, a low IVCCI indicative of IVC congestion was associ-
(n=30) ated with renal dysfunction and adverse outcomes in patients with a
broad spectrum of cardiovascular diseases, and this association was
ICC 95% CI P
not dependent on underlying cardiovascular disease and renal func-
Intra-observer variability
tion. Of note, IVCCI evaluation can be a reasonable substitute for JVP
IVC maximal .983 0.9650.992 <.001
in the diagnosis and prognosis, regardless of the presence of HF.
IVC minimal .992 0.9830.996 <.001
IVC collapsibility .973 0.9440.987 <.001
index 4.1|Limitation
Inter-observer variability Acquisition of right ventricular functional parameters such as right
IVC maximal .939 0.8720.971 <.001 ventricular fractional area change or tricuspid annular plane systolic
IVC minimal .967 0.9320.984 <.001 excursion might have strengthened quality of this study. However,
IVC collapsibility .883 0.7570.944 <.001 those parameters are not routinely measured in real practice and
index clinical usefulness of them is still controversial, while IVC is routinely
ICC, intraclass correlation coefficient; IVC, inferior vena cava. evaluated during 2D echocardiography to estimate right atrial pres-
sure. Therefore, we believe IVCCI provides enough clinical informa-
not easily identified even by experienced cardiologists.35,36 For these tion on the function of right-sided heart without additional costs and
reasons, IVCCI evaluation may be a reasonable alternative for JVP in efforts.
appraising right atrial pressure, treatment guidance, and prediction of We only used the IVCCI for the purpose of simplification, while
adverse outcomes, and routine evaluation of IVCCI in patients who the current guideline recommends incorporating the IVC size into the
undergo two-dimensional echocardiography is justified. estimation method.8,37 However, in the study on which the guideline
 |
8 KIM etal.
is based, one-third of the patients was in the status of postcardiac
transplantation, raising an issue with generalizability. 37
In contrast, the
population in our study where the IVCCI without size criteria showed
significant association with adverse outcomes was more analogous to
population in actual practice.
We could not obtain information on hospitalization for HF. The
inclusion of hospitalization might have enhanced the implications of
the IVCCI because hospitalization for aggravated HF has been used as
an outcome in many studies.
Compared with an age-matched Western population, the patients
in this study had a lower mean body mass index, which might lead to
more prevalent diaphragmatic respiration.38 Because diaphragmatic
respiration can result in a higher IVCCI, the generalization of our re-
sults for obese patients requires special attention.
5| CONCLUSION
Although an elevated JVP is an important diagnosis criterion and
prognosticator for HF, the JVP is often difficult to measure. Our study
demonstrated that overexpansion of the systemic intravascular vol-
ume, as represented by the IVCCI, is associated with reduced renal
function in patients with various cardiovascular diseases. Further, our
study demonstrated that a low IVCCI is an independent risk factor for
adverse outcomes in patients with a broad range of cardiovascular
diseases. Because diagnostic tools to measure effective intravascular
volume are sparse in clinical practice, and the IVCCI can be readily
obtained without great expertise in 2D echocardiography, we propose
that the IVC should be evaluated in every possible clinical setting of
cardiovascular diseases.
ACKNOWLE DG ME NTS
None
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How to cite this article: Kim, Y.-H., Kim, S., Kim, J.-S., Lim, S.-Y.,
Shim, W.-J., Ahn, J.-C. and Song, W.-H. (2016), Inferior vena cava
collapsibility index, renal dysfunction, and adverse outcomes in
patients with broad spectrum cardiovascular disease.
Echocardiography, 00: 19. doi: 10.1111/echo.13409