Acute heart failure: the role of focused emergency cardiopulmonary ultrasound in identification and early management

Non-Invasive Assessment of Congestion by Cardiovascular and Pulmonary Ultrasound and Biomarkers in Heart Failure

Worsening chronic heart failure (HF) is responsible for recurrent hospitalization and increased mortality risk after discharge, irrespective to the ejection fraction. Symptoms and signs of pulmonary and systemic congestion are the most common cause for hospitalization of acute decompensated HF, as a consequence of increased cardiac filling pressures. The elevated cardiac filling pressures, also called hemodynamic congestion, may precede the occurrence of clinical congestion by days or weeks. Since HF patients often have comorbidities, dyspnoea, the main symptom of HF, may be also caused by respiratory or other illnesses. Recent studies underline the importance of the diagnosis and treatment of hemodynamic congestion before HF symptoms worsen, reducing hospitalization and improving prognosis. In this paper we review the role of integrated evaluation of biomarkers and imaging technics, i.e., echocardiography and pulmonary ultrasound, for the diagnosis, prognosis and treatment of congestion in HF patients.

The Utility of N-Terminal Pro-Brain Natriuretic Peptide as an Adjunct Diagnostic Tool for Acute Heart Failure in Acute Dyspneic Patients Coming to the Emergency Department: A Retrospective Review of Our Early Experience

Acute dyspnea is one of the prevalent reasons for admission to the emergency department. The use of N-terminal pro-B-type natriuretic peptide (NT-proBNP) as an adjunct for assessing acute dyspnea is not a common practice in many public hospitals in Malaysia. This retrospective review is part of our clinical audit to determine the utility of NT-proBNP as an adjunct to non-standardised clinical evaluation in identifying acute heart failure (HF) in patients with persistent dyspnea (24 h) post-admission. In this cohort of 30 patients with acute dyspnea, NT-proBNP was positive in 20 patients (87%) with acute HF. Three patients (13%) who were treated for septic shock recorded a NT-proBNP false-positive. NT-proBNP demonstrated an overall sensitivity of 90%, a specificity of 70%, a positive predictive value of 85.7% and a negative predictive value of 77.8% in identifying acute HF. These results reinforce that age-stratified NT-proBNP cut-off values are useful for ruling-in or -out acute HF. Thus, NT-proBNP should be considered a crucial point of care, testing to decifer the conundrum of acute dyspneic patients.

Feasibility of a pilot study on point-of-care biomarkers in spontaneous intracerebral hemorrhage in an emergency setting

Background and aims

Stroke is a worldwide leading cause of death and disability and spontaneous intracerebral hemorrhage (sICH) has significant economic and social impact, regardless of recent efforts towards outcome-bettering acute interventions. The aim of the study was to assess the feasibility of a prospective observational research regarding point-of-care (POC) biomarkers in sICH, conducted in a level one emergency department (ED).

Methods

Patients with acute (<8 hours) sICH were enrolled in this study. Patients presenting a Glasgow Coma Scale score <8, secondary causes of intracerebral hemorrhage, seizures, recent ischemic events, known thromboembolic disease, anticoagulant treatment, severe pre-stroke disability, terminal disease, scheduled neurosurgery/hemostatic treatment were excluded. Feasibility was defined as ED inclusion and follow-up rates, time-to-inclusion, and frequency of missing data. Baseline demographic, imaging and POC biochemical status of the study group were documented, including inflammatory (complete blood count, C-reactive protein), metabolic (glucose, hepatic, and renal function) and cardiovascular markers (cardiac troponin I, D-dimer).

Results

The inclusion rate was 2.16 patients/month with a final sample of 35 patients out of 239 potentially eligible patients. The median time from symptom onset to ED presentation was 128 minutes (IQR 96-239), with 21/35 patients having presented within the first 3 hours from ictus. Median times between symptoms' onset to Computer Tomography (CT) scan and ED presentation to CT scan were 170 minutes (IQR 126-317) and 25 minutes (IQR 17-62), respectively. The median time from patient's presentation to CBC result was 12 minutes (IQR 6.5-20), with 21/35 study participants having the results available within 15 minutes from ED arrival. The median cohort age was 72-years, with a 19/16 male/female ratio. Hypertension was the most frequent risk factor (77%), along with ischemic heart disease (31%) and diabetes (29%). One-third of the hypertensive patients did not undergo blood pressure lowering treatment. Median values of POC biomarkers on ED admission were within normal range.

Conclusions

It was feasible to determine point-of-care biomarkers in spontaneous intracerebral hemorrhage on admission in ED, despite the urgency of the medical condition.

Continuous positive airway pressure therapy in the management of hypercapnic cardiogenic pulmonary edema

Continuous positive airway pressure (CPAP) therapy or non-invasive ventilation (NIV) represent the first line therapy for acute cardiogenic pulmonary edema (CPE) together with medical therapy. CPAP benefits in acute CPE with normo-hypocapnia are known, but it is not clear whether the use of CPAP is safe in the hypercapnic patients. The aim of this study is to evaluate CPAP efficacy in the treatment of hypercapnic CPE. We enrolled 9 patients admitted to the emergency room with diagnosis of acute CPE based on history, clinical examination, arterial blood gas analysis (ABG) and lung-heart ultrasound examination. We selected patients with hypercapnia (pCO2 >50 mmHg) and bicarbonate levels <30 mEq/L. All patients received medical therapy with furosemide and nitrates and helmet CPAP therapy. All patients received a second and a third ABG, respectively at 30 and 60 min. Primary end-points of the study were respiratory distress resolution, pCO2 reduction, pH improvement, lactates normalization and the no need for non-invasive ventilation or endo-tracheal intubation. All patients showed resolution of respiratory distress with CPAP weaning and shift to Venturi mask with no need for NIV or endo-tracheal intubation. Serial ABG tests showed clear reduction in CO2 levels with improvement of pH and progressive lactate reduction. CPAP therapy can be effective in the treatment of hypercapnic CPE as long as the patients have no signs of chronic hypercapnia on ABG and as long as the diagnosis of heart failure is supported by bedside lung-heart ultrasound examination.

Assessing congestion in acute heart failure using cardiac and lung ultrasound - a review

Introduction: Acute heart failure (AHF) is one of the leading causes of hospital admissions and is characterized by systemic and pulmonary congestion, which often precedes the overt clinical signs and symptoms. Echocardiography in the management of chronic HF is well described; however, there are less evidence regarding echocardiography and lung ultrasound (LUS) in the acute setting.Areas covered: We have summarized current evidence regarding the use of echocardiography and LUS for assessing congestion in patients with AHF. We discuss the value and reliability of handheld/pocketsize ultrasound devices in AHF.Expert opinion: Echocardiography is an essential tool for the diagnostic work up in patients with AHF. No individual parameter reliably detects congestion, thus the physician must integrate several measurements from the right and left heart. Novel methods and advances in cardiac imaging and clinical chemistry make it possible to detect congestion at an early stage. LUS is particularly helpful in assessing congestion, and it has demonstrated diagnostic, therapeutic, and prognostic value in AHF. LUS is relatively easy to learn and allows for quick assessment of the presence of pulmonary congestion and pleural effusion. We recommend integration of LUS for routine management of patients with AHF.

Ultrasound indices of congestion in patients with acute heart failure according to body mass index

BACKGROUND

The inverse relationship between body mass index (BMI) and natriuretic peptide levels complicates the diagnosis of heart failure (HF) in obese patients. Assessment of congestion with ultrasound could facilitate HF diagnosis but it is unclear if any relationship exists amongst BMI, inferior vena cava (IVC) diameter and the number of B-lines.

METHODS

We performed a comprehensive echocardiographic evaluation within 24 h from hospital admission in patients with HF, including lung B-lines and IVC diameter, and studied their relationship with BMI and outcome.

RESULTS

216 patients (median age 81 (77-86) years) were enrolled. Median number of B-lines was 31 (IQR 26-38), median IVC diameter was 23 (22-25) mm and median BNP 991 (727-1601) pg/mL. BMI was inversely correlated with B-lines (r = - 0.50, p < 0.001), but not with IVC diameter (r = - 0.04, p = 0.58). Compared to overweight patients (BMI 25-29.9 kg/m2; n = 100) or with a normal BMI (BMI < 25 kg/m2; n = 59), obese patients (BMI ≥ 30 kg/m2; n = 57) had lower B-lines [28 (24-33) vs 30 (26-35), and vs 38 (32-42), respectively; p < 0.001] but similar IVC diameter. During the first 60 days of follow-up, there were 53 primary events: 29 patients died and 24 had a HF-related hospitalisation. B-lines and IVC diameter were independently associated with an increased risk. However, B-lines were less likely to predict outcome in the subgroup of patients with a BMI ≥ 30 kg/m².

CONCLUSIONS

Assessment of IVC diameter or B-lines in patients admitted with AHF identifies those at greater risk of death or HF readmission. However, assessment of B-lines might be influenced by BMI.

Echocardiography Tips in the Emergency Room

The emergency room is a principal entrance for the initial management of patients with acute heart failure. Echocardiography may be performed by cardiologists and noncardiologists in the emergency room. Echocardiographic studies require effective technical skills and precise diagnostic knowledge. This article contributes to physicians in the emergency room, general practitioners in training, and medical staff who engage in emergency medicine. This article emphasized the role of echocardiography in light of pathophysiology of acute heart failure in the emergency room and refining the clinical workflow by integrating conventional and innovative knowledge for the initial management of acute heart failure.

Prognostic Significance of an Early Echocardiographic Evaluation of Right Ventricular Dimension and Function in Acute Heart Failure

OBJECTIVE

Sparse and contradictory data are available on the prognostic role of an early echocardiographic examination in patients with acute decompensated heart failure (ADHF). We planned a prospective study to illustrate which early echocardiographic parameter would be better related to prognosis in such patients.

METHODS

In a consecutive series of patients with ADHF with either reduced (n=209) or preserved (n=172) left ventricular ejection fraction (LVEF), a complete echocardiographic examination was performed within 12 hours of admission. The endpoint of the study was death or rehospitalization at 6 months from hospital discharge.

RESULTS

After 6 months from discharge, 73 died and 96 were rehospitalized due to cardiovascular causes. In multivariable analysis, a right ventricular end-diastolic diameter (RVEDD) >40 mm (P = .02), a tricuspid annular plane systolic excursion (TAPSE) <19 mm (P= .004), and an inferior vena cava diameter >22 mm (P = .02) were associated with 6-month events. LVEF and LV diastolic function were not predictive of events. Pulmonary artery systolic pressure (PASP) >45 mmHg and TAPSE/PASP <0.425 were associated with prognosis in univariate but not in multivariable analysis. Conversely, the TAPSE/RVEDD ratio (dichotomized at its median value of 0.461) was an independent predictor of outcome in multivariable analysis (P< .001).

CONCLUSIONS

In patients hospitalized for ADHF, early echocardiographic identification of right ventricular dilatation and dysfunction predicts a poor outcome better than LV systolic and/or diastolic dysfunction.

Imaging in patients with suspected acute heart failure: timeline approach position statement on behalf of the Heart Failure Association of the European Society of Cardiology

Acute heart failure is one of the main diagnostic and therapeutic challenges in clinical practice due to a non-specific clinical manifestation and the urgent need for timely and tailored management at the same time. In this position statement, the Heart Failure Association aims to systematize the use of various imaging methods in accordance with the timeline of acute heart failure care proposed in the recent guidelines of the European Society of Cardiology. During the first hours of admission the point-of-care focused cardiac and lung ultrasound examination is an invaluable tool for rapid differential diagnosis of acute dyspnoea, which is highly feasible and relatively easy to learn. Several portable and stationary imaging modalities are being increasingly used for the evaluation of cardiac structure and function, haemodynamic and volume status, precipitating myocardial ischaemia or valvular abnormalities, and systemic and pulmonary congestion. This paper emphasizes the central role of the full echocardiographic examination in the identification of heart failure aetiology, severity of cardiac dysfunction, indications for specific heart failure therapy, and risk stratification. Correct evaluation of cardiac filling pressures and accurate prognostication may help to prevent unscheduled short-term readmission. Alternative advanced imaging modalities should be considered to assist patient management in the pre- and post-discharge phase, including cardiac magnetic resonance, computed tomography, nuclear studies, and coronary angiography. The Heart Failure Association addresses this paper to the wide spectrum of acute care and heart failure specialists, highlighting the value of all available imaging techniques at specific stages and in common clinical scenarios of acute heart failure.

Rapid cardiothoracic ultrasound protocol for diagnosis of acute heart failure in the emergency department

OBJECTIVES

The aim of this study was to evaluate the performance of a rapid cardiothoracic ultrasound protocol (CaTUS), combining echocardiographically derived E/e' and lung ultrasound (LUS), for diagnosing acute heart failure (AHF) in patients with undifferentiated dyspnea in an emergency department (ED).

PATIENTS AND RESULTS

We enrolled 100 patients with undifferentiated dyspnea from a tertiary care ED, who all had CaTUS done immediately upon arrival in the ED. CaTUS was positive for AHF with an E/e' > 15 and congestion, that is bilateral B-lines or bilateral pleural fluid, on LUS. In addition, an inferior vena cava index was also recorded to analyze whether including a central venous pressure estimate would add diagnostic benefit to the CaTUS protocol. All 100 patients had a brain natriuretic peptide (BNP) sample withdrawn, and 96 patients underwent chest radiography in the ED, which was analyzed later by a blinded radiologist. The reference diagnosis of AHF consisted of either a BNP of more than 400 ng/l or a BNP of less than 100 ng/l in combination with congestion on chest radiography and structural heart disease on conventional echocardiography.CaTUS had a sensitivity of 100% (95% confidence interval: 91.4-100%), a specificity of 95.8% (95% confidence interval: 84.6-99.3%), and an area under the curve of 0.979 for diagnosing AHF (P<0.001). The diagnostic accuracy of CaTUS was higher than of either E/e' or LUS alone. Adding the inferior vena cava index to CaTUS did not improve diagnostic accuracy. CaTUS seemed helpful also for differential diagnostics of dyspnea, mainly regarding pneumonias and pulmonary embolisms.

CONCLUSION

CaTUS, combining E/e' and LUS, provided excellent accuracy for diagnosing AHF.

Expanded algorithm for managing patients with acute decompensated heart failure

Heart failure is a complex disease process, the manifestation of various cardiac and noncardiac abnormalities. General treatment approaches for heart failure have remained the same over the past decades despite the advent of novel therapies and monitoring modalities. In the same vein, the readmission rates for heart failure patients remain high and portend a poor prognosis for morbidity and mortality. In this context, development and implementation of improved algorithms for assessing and treating HF patients during hospitalization remains an unmet need. We propose an expanded algorithm for both monitoring and treating patients admitted for acute decompensated heart failure with the goal to improve post-discharge outcomes and decrease rates of rehospitalizations.

A plea for an early ultrasound-clinical integrated approach in patients with acute heart failure. A proactive comment on the ESC Guidelines on Heart Failure 2016

BACKGROUND

The European Association of Cardiology (ESC) Guidelines on the diagnosis and treatment of acute heart failure (AHF) indicate prompt therapy initiation and performance of relevant investigations as paramount. Specifically, echocardiography prior to treatment is advocated only with hemodynamic instability, and the evaluation of clinical signs of peripheral perfusion and congestion is suggested as guidance for early interventions. Given the growing body of evidence on the diagnostic/monitoring capabilities of bedside ultrasound (including focused cardiac ultrasound, comprehensive echocardiography, lung ultrasound), we discuss the potential benefit of an integrated clinical/ultrasound approach at the very early stages of acute heart failure.

METHODS AND RESULTS

We proposed a narrative review of the current evidence on the clinical-ultrasound integrated approach to AHF, with special emphasis on the components of the early diagnostic-therapeutic workup where cardiac, inferior vena cava and lung ultrasound showed high diagnostic accuracy and the capability of substantially changing an exclusively clinically-oriented patient management. A proactive comment to the ESC guidelines is made, suggesting an integration of clinical and biochemical assessment, as defined by guidelines, with combined bedside ultrasound on may help in the definition of AHF pathophysiology and treatment.

CONCLUSION

A multi-organ integrated clinical-ultrasound approach should be advocated as part of the clinical-diagnostic workup at AHF very early phase. Whenever competence and technology available, bedside ultrasound, along with clinical and biochemical assessment, should target AHF profiling, identify the cause of AHF, and subsequently aid disease course and response to treatment monitoring.

Lessons learned in acute heart failure

Acute heart failure (HF) is a global pandemic with more than one million admissions to hospital annually in the US and millions more worldwide. Post-discharge mortality and readmission rates remain unchanged and unacceptably high. Although recent drug development programmes have failed to deliver novel therapies capable of reducing cardiovascular morbidity and mortality in patients hospitalized for worsening chronic HF, hospitalized HF registries and clinical trial databases have generated a wealth of information improving our collective understanding of the HF syndrome. This review will summarize key insights from clinical trials in acute HF and hospitalized HF registries over the last several decades, focusing on improving the management of patients with HF and reduced ejection fraction.

Admission inferior vena cava measurements are associated with mortality after hospitalization for acute decompensated heart failure

BACKGROUND

Prognostication of patients hospitalized with acute decompensated heart failure (ADHF) is important to patients, providers, and healthcare systems. Few bedside tools exist to prognosticate patients hospitalized with ADHF.

OBJECTIVE

The objective of this study was to assess the relationship between inferior vena cava (IVC) diameter and postdischarge mortality in patients hospitalized with ADHF.

DESIGN

Prospective observational study.

SETTING

A 247-bed urban teaching hospital in Spain PATIENTS: Ninety-seven patients hospitalized with ADHF.

INTERVENTION

None.

MEASUREMENTS

The IVC diameter and collapsibility were measured by a hospitalist at the time of admission and discharge. Primary outcome was 90-day all-cause mortality. Secondary outcomes were readmission rates at 90 and 180 days, and 180-day all-cause mortality. Patients were followed for 180 days.

RESULTS

Data from 80 patients were analyzed. From admission to discharge, a significant improvement in IVC maximum (IVC_max ) diameter (2.12 vs 1.87 cm; P < 0.001) and IVC collapsibility (25.7% vs 33.1%; P < 0.001) was seen in the total study cohort. During the 90-day follow-up period, 11 patients (13.7%) died. An admission IVC_max diameter ≥1.9 cm was associated with a higher mortality rate at 90 days (25.4% vs 3.4%; P = 0.009) and 180 days (29.3% vs 3.4%; P = .003). In a multivariate Cox proportional hazards regression analysis, admission IVC_max diameter was an independent predictor of 90-day mortality (hazard ratio [HR]: 5.88; 95% confidence interval [CI]: 1.21-28.10; P = 0.025) and 90-day readmission (HR: 3.20; 95% CI: 1.24-8.21; P = 0.016).

CONCLUSION

In patients hospitalized with acute decompensated heart failure, a dilated IVC by bedside ultrasound at the time of admission is associated with a higher 90-day mortality after hospitalization. Journal of Hospital Medicine 2016;11:778-784. © 2016 Society of Hospital Medicine.

[Hemodynamic monitoring in intensive care and emergency medicine : Integration of clinical signs and ultrasound findings]

Hemodynamic monitoring is required in critically ill patients presenting with circulatory shock. Besides the clinical evaluation, noninvasive technologies can be used. Guidelines on volume resuscitation and cardiogenic shock already recommend bedside ultrasound as a diagnostic tool. To differentiate the cause of circulatory shock and monitor the effects of therapies, hemodynamic monitoring is necessary. This review discusses possibilities of the different invasive and noninvasive monitoring tools with a focus on the integration of clinical and sonographic parameters.