Virtual Forrester profiling integrating bioelectrical impedance analysis and pulse wave analysis provides a practical, quantitative and reproducible framework for non-invasive haemodynamic assessment with significant differences in MACE-free survival among the four profiles.
Key Findings
Results
A virtual Forrester classification using non-invasive BIA and PWA measurements successfully stratified 558 patients into four haemodynamic profiles with distinct clinical characteristics.
558 patients with available STI and BIA data were included from a retrospective study of consecutive cardiology admissions between January 2020 and December 2022
161 patients were classified as Warm and Dry, 209 as Warm and Wet, 90 as Cold and Dry, and 98 as Cold and Wet
Systolic time intervals (STIs) were calculated as the ratio of pre-ejection period to left ventricular ejection time using pulse wave analysis
Extracellular water/total body water thresholds from BIA were used to define Wet versus Dry status
Results
The four virtual Forrester profiles showed significant differences in MACE-free survival during follow-up.
84 MACEs occurred during the follow-up period
Kaplan-Meier analysis showed significant differences in MACE-free survival among the four profiles (log-rank p=0.01)
The Warm and Dry profile had the most favourable prognosis
Major adverse cardiovascular events (MACEs) were the primary endpoint
Results
Wet group patients exhibited a distinct clinical profile compared to Dry group patients.
Wet groups were older and had higher B-type natriuretic peptide levels
Wet groups had lower skeletal muscle mass and haemoglobin
Wet groups demonstrated more renal impairment compared to Dry groups
Results
Cold group patients were characterized by lower left ventricular ejection fraction compared to Warm groups.
Cold groups exhibited lower left ventricular ejection fraction as the primary distinguishing feature from Warm groups
STI (ratio of pre-ejection period to left ventricular ejection time) served as the non-invasive surrogate for cardiac output/perfusion status defining Cold versus Warm profiles
Background
The study was designed to develop a non-invasive alternative to the Forrester classification, which traditionally requires invasive right heart catheterisation.
The Forrester classification is described as 'a cornerstone for assessing haemodynamic status in heart failure' but its clinical application is restricted by the invasiveness of right heart catheterisation
The study integrated BIA and PWA to create a reproducible non-invasive framework
PWA measurements were conducted within 1 month of BIA in consecutive cardiology inpatients
The study was retrospective in design
What This Means
This research suggests that doctors can assess how well a patient's heart is pumping and whether they have excess fluid in their body using two non-invasive tests — bioelectrical impedance analysis (BIA, which uses small electrical signals to measure body fluid composition) and pulse wave analysis (PWA, which analyzes the shape of the pulse to estimate heart function). By combining results from these two tests, the researchers were able to sort 558 hospitalized heart patients into four groups that mirror a well-established clinical classification system called the Forrester classification, which normally requires an invasive procedure threading a catheter into the heart.
The four patient groups showed meaningfully different health profiles: patients with excess fluid (the 'Wet' groups) tended to be older, had worse kidney function, lower muscle mass, and higher levels of a heart stress hormone called BNP. Patients with poor heart pumping (the 'Cold' groups) had lower ejection fractions, a standard measure of how much blood the heart pumps per beat. Over the follow-up period, 84 major heart-related events occurred, and survival analysis showed the group with both good heart function and no fluid overload ('Warm and Dry') had the best outcomes, while other groups fared progressively worse.
This research suggests that combining these two simple, non-invasive bedside tests could give clinicians a practical and reproducible way to categorize heart failure patients' haemodynamic status — information that was previously only obtainable through invasive procedures. This could help guide treatment decisions for a broader range of patients without the risks associated with cardiac catheterization.
Nishikawa T, Higaki A, Kurokawa K, Abe A, Horie R, Miyabe R, et al.. (2026). Complementary cardiac functional assessment using systolic time intervals and bioelectrical impedance analysis.. Open heart. https://doi.org/10.1136/openhrt-2026-004041