Lung ultrasound for the diagnosis of acute heart failure: time to upgrade current indication?

Vulnerable period in heart failure: a window of opportunity for the optimization of treatment - a statement by Mexican experts

Acute heart failure (HF) is associated with poor prognosis. After the acute event, there is a vulnerable period during which the patient has a marked risk of readmission or death. Therefore, early optimization of treatment is mandatory during the vulnerable period. The objective of this article is to provide recommendations to address the management of patients with HF during the vulnerable period from a practical point of view. A group of Mexican experts met to prepare a consensus document. The vulnerable period, with a duration of up to 6 months after the acute event - either hospitalization, visit to the emergency department or the outpatient clinic/day hospital - represents a real window of opportunity to improve outcomes for these patients. To best individualize the recommendations, the management strategies were divided into three periods (early, intermediate and late vulnerable period), including not only therapeutic options but also evaluation and education. Importantly, the recommendations are addressed to the entire cardiology team, including physicians and nurses, but also other specialists implicated in the management of these patients. In conclusion, this document represents an opportunity to improve the management of this population at high risk, with the aim of reducing the burden of HF.

Effect Evaluation of Cardiac Resynchronization Therapy in Elderly Patients with Heart Failure by Ultrasound Image under QuickOpt Algorithm

This research was aimed at analyzing the application value of echocardiography and QuickOpt algorithm in optimizing parameters of cardiac resynchronization therapy (CRT) in elderly patients with heart failure. 50 elderly patients who were diagnosed with chronic heart failure and underwent CRT were chosen as the research objects. According to the different optimization methods, the patients were divided into the echocardiography group and QuickOpt algorithm group, 25 cases in each group. The general data, optimized intervals, corresponding maximum aortic velocity time integrals (aVTIs), cardiac ultrasound indicators, and ventricular arrhythmia episodes of the patients in the two groups were analyzed. The results showed that there was no significant difference in the optimized sensed atrioventricular (SAV), paced atrioventricular (PAV), and ventricle to ventricle (VV) intervals and the corresponding aVTIs obtained by echocardiography and QuickOpt (P > 0.05). The consistency analysis revealed that the aVTIs in the SAV, PAV, and VV intervals presented a good consistency (P < 0.01), which were obtained by the echocardiography and QuickOpt functional optimization; the concordance correlation coefficient (CCC) in them was 96.16%, 98.03%, and 95.48%, respectively. The left ventricular ejection fraction (LVEF) showed an increasing trend over time in both groups, while the left ventricular end systolic volume (LVESV), left ventricular end diastolic volume (LVEDV), and morphological right ventricle (MRV) showed the downward trends over time, and the differences between two groups were not significant (P > 0.05). For the premature ventricular contraction (PVC) of ventricular arrhythmia episodes, there was no significant difference between the two groups in log (PVCs) and log (PVC runs) (P > 0.05). It was also found that both echocardiography and QuickOpt algorithm could improve the cardiac function of patients with heart failure significantly and reduce ventricular arrhythmia episodes and ventricular remodeling via optimized CRT; there was no difference in the improvement effect of the two optimization methods. However, echocardiography was inferior to QuickOpt algorithm in terms of time-consuming optimization in the intervals. This provided a reference for the clinical diagnosis and treatment of elderly patients with heart failure.

Comparison between standard and ultrasound-integrated approach for risk stratification of syncope in the emergency department

This prospective cohort enrolled all patients above 16 years of age presenting to the in the emergency department (ED) for a reported syncope was designed to test the accuracy of a point-of-care ultrasound (POCUS) integrated approach in risk stratification. The emergency physician responsible for the patient care was asked to classify the syncope risk after the initial clinical assessment and after performing POCUS evaluation. All risk group definitions were based on the 2018 European Society of Cardiology guidelines. Thirty days after the index event, all participants were followed up to assess the frequency of short-term serious outcomes as defined in the San Francisco Syncope Rule (SFSR) cohorts. We estimated the accuracy of clinical and POCUS-integrated evaluation in predicting SFSR outcomes. Between February 2016 and January 2018, 196 patients were enrolled [109 women (55.6%)]. Median age was 64 years (interquartile range 31 years). After a follow-up of 30 days, 19 patients experienced 20 SFSR outcomes. Positive and negative likelihood ratios were 1.73 (95% CI 0.87-3.44) and 0.84 (95% CI 0.62-1.12) for the clinical evaluation, and 5.93 (95% CI 2.83-12.5) and 0.63 (95% CI 0.45-0.9) for the POCUS-integrated evaluation. The POCUS-integrated approach would reduce the diagnostic error of the clinical evaluation by 4.5 cases/100 patients. This cohort study suggested that the integration of the clinical assessment with POCUS results in patients presenting to the ED for non-high-risk syncope may increase the accuracy of predicting the risk of SFSR outcomes and the usefulness of the clinical assessment alone.

Prognostic value of B lines detected with lung ultrasound in acute heart failure. A systematic review

Pulmonary ultrasound is a simple diagnostic tool with immediate results for the assessment of pulmonary congestion in patients with heart failure (HF), allowing optimization of treatment by monitoring the dynamic changes identified. We aimed to evaluate the prognostic significance of the presence of B lines detected by lung ultrasound during hospitalization for heart failure. A search was conducted for scientific articles in PubMed, Embase, Google Scholar, and Cochrane databases including clinical trials, reviews, systematic reviews, and original articles that were related to the prognostic value of lung ultrasound in patients with HF in the last 5 years from 2016 to 2021. Studies including individuals aged ≥18 years evaluating the prognostic value of lung ultrasound in HF were included. Fourteen articles met inclusion criteria for analysis (three reviews, three systematic reviews with meta-analysis, six prospective studies, and two retrospective studies). The presence of more than 30-40 B lines at admission were considered a risk factor for readmission or mortality as was persistent pulmonary congestion with the presence of ≥15 B-lines. The presence of pulmonary congestion detected by lung ultrasound in acute heart failure has prognostic significance in terms of mortality and hospital readmission. Clinical trials are needed to evaluate whether diuretic therapy guided by lung ultrasound and the presence of B lines can reduce readmission and mortality in these patients.

It’s Not All about Echocardiography. Open the Lung Window for the Cardiac Emergencies

In the acute cardiac care setting, undifferentiated clinical presentations such as dyspnea, chest pain, shock, and cardiac arrest are common diagnostic challenges for the clinician. Lung ultrasonography is a well-established diagnostic tool which can be integrated in simplified decision making algorithms during the initial approach of the patient, in order to differentiate accurately cardiac from non-cardiac causes and improve the management of time-sensitive cardiovascular emergencies.

Heart failure in the last year: progress and perspective

Research about heart failure (HF) has made major progress in the last years. We give here an update on the most recent findings. Landmark trials have established new treatments for HF with reduced ejection fraction. Sacubitril/valsartan was superior to enalapril in PARADIGM-HF trial, and its initiation during hospitalization for acute HF or early after discharge can now be considered. More recently, new therapeutic pathways have been developed. In the DAPA-HF and EMPEROR-Reduced trials, dapagliflozin and empagliflozin reduced the risk of the primary composite endpoint, compared with placebo [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.65-0.85; P < 0.001 and HR 0.75; 95% CI 0.65-0.86; P < 0.001, respectively]. Second, vericiguat, an oral soluble guanylate cyclase stimulator, reduced the composite endpoint of cardiovascular death or HF hospitalization vs. placebo (HR 0.90; 95% CI 0.82-0.98; P = 0.02). On the other hand, both the diagnosis and treatment of HF with preserved ejection fraction, as well as management of advanced HF and acute HF, remain challenging. A better phenotyping of patients with HF would be helpful for prognostic stratification and treatment selection. Further aspects, such as the use of devices, treatment of arrhythmias, and percutaneous treatment of valvular heart disease in patients with HF, are also discussed and reviewed in this article.

Discharge-ready volume status in acute decompensated heart failure: a survey of hospitalists

Acute decompensated heart failure is the leading cause of hospitalization in older adults. Clinical practice guidelines recommend patients should be euvolemic at hospital discharge – yet accurate assessment of volume status is recognized to be exceptionally challenging. This conundrum led us to investigate how hospitalists are assessing volume status and discharge- readiness of patients hospitalized with heart failure. We collected audience response data during a didactic heart failure presentation at the 2019 Society of Hospital Medicine annual meeting. Respondents (n = 216), 76% of whom were practicing physician hospitalists caring for more than 20 acute heart failure patients per year, were presented six questions. Eighteen percent of respondents reported not being able to determine the completeness of decongestion on discharge and 32% reported that complete decongestion was not a treatment target. These findings suggest important differences between guideline recommendations and how hospitalists treat heart failure in current clinical practice.