Point-of-care ultrasound diagnoses acute decompensated heart failure in the ED regardless of examination findings

The Inter-rater Reliability of Echocardiographic Diastolic Function Evaluation Among Emergency Physician Sonographers

STUDY OBJECTIVES

In a patient with dyspnea and suspected CHF, the evaluation of diastolic function involves: tissue Doppler of the mitral annulus and 2) pulsed wave Doppler of the mitral inflow. We aimed to 1) determine the inter-rater reliability for overall diastolic function and 2) evaluate the reliability of the individual Doppler measurements.

METHODS

A convenience sample of adult emergency department patients was prospectively enrolled by 8 EPs who had participated in a 1-hour didactic session. Patients were selected if they had a history of CHF or suspected abnormal diastolic function due to chronic hypertension. Diastolic function was considered to be abnormal if Tissue Doppler of the septal e' was <8 cm/s and if the lateral e' was <10 cm/s. In cases of discordance, the E/e' ratio was calculated with ≤8 considered normal and >8 considered abnormal. A Kappa coefficient. Bland-Altman plot and a fixed effect regression model were used in the analysis.

RESULTS

Thirty-two patients were enrolled, and 3 (9.4%) were excluded due to technical inadequacy. The inter-rater reliability among sonographers for overall interpretation was very good: κ = 0.86 (95% CL [0.67, 1.0]). Based on the Bland-Altman plot, was no consistent bias between readers. There was no evidence to conclude that the readings differed among sonographers: septal e' (p = 0.77), lateral e' (p = 0.89) and E (p = 0.15).

CONCLUSION

EP sonographers obtained similar Doppler measurements for diastolic function evaluation with very good inter-rater reliability for the assessment of overall diastolic function.

Accuracy of Point-of-Care B-Line Lung Ultrasound in Comparison to NT-ProBNP for Screening Acute Heart Failure

AIM

The objective of this pilot study was to determine the accuracy of point-of-care B-line lung ultrasound in comparison to NT Pro-BNP for screening acute heart failure.

MATERIALS AND METHODS

An 8-zone lung ultrasound was performed by experienced sonographers in patients presenting with acute dyspnea in the ED. AHF was determined as the final diagnosis by 2 independent reviewers.

RESULTS

Contrary to prior studies, B-line ultrasound in our study was highly specific, but moderately sensitive for identifying patients with AHF. There was a strong association between elevated NT-proBNP levels and an increased number of B-lines.

CONCLUSION

In conclusion, point-of-care lung ultrasound is a helpful tool for ruling in or ruling out important differential diagnoses in ED patients with acute dyspnea.

Focused Ultrasound in the Emergency Department for Patients with Acute Heart Failure

The emergency department (ED) plays a key role in the initial diagnosis and management of acute heart failure (AHF). Despite the advent of novel biomarkers and traditional methods of assessment, such as history, examination, and chest X-ray, diagnosis of the dyspnoeic ED patient is, at times, very challenging. Focused cardiac and pulmonary ultrasound has emerged as a valid, facile and efficient method to aid in the initial diagnosis and management of AHF.

Diagnostic performance of cardiopulmonary ultrasound performed by the emergency physician in the management of acute dyspnea

OBJECTIVE

The etiologic diagnosis of acute dyspnea in the emergency department (ED) remains difficult, especially for elderly patients or those with previous cardiorespiratory medical history. This may lead to inappropriate treatment and potentially a higher mortality rate. Our objective was to evaluate the performance of cardiopulmonary ultrasound compared with usual care for the etiologic diagnosis of acute dyspnea in the ED.

METHODS

Patients admitted to the ED for acute dyspnea underwent upon arrival a cardiopulmonary ultrasound performed by an emergency physician, in addition to standard care. The performances of the clinical examination, chest x-ray, N-terminal brain natriuretic peptide (NT-proBNP), and cardiopulmonary ultrasound were compared with the final diagnosis made by 2 independent physicians.

RESULTS

One hundred thirty patients were analyzed. For the diagnosis of acute left-sided heart failure, cardiopulmonary ultrasound had an accuracy of 90% (95% confidence interval [CI], 84-95) vs 67% (95% CI, 57-75), P = .0001 for clinical examination, and 81% (95% CI, 72-88), P = .04 for the combination "clinical examination-NT-proBNP-x-ray". Cardiopulmonary ultrasound led to the diagnosis of pneumonia or pleural effusion with an accuracy of 86% (95% CI, 80-92) and decompensated chronic obstructive pulmonary disease or asthma with an accuracy of 95% (95% CI, 92-99). Cardiopulmonary ultrasound lasted an average of 12 ± 3 minutes.

CONCLUSIONS

Cardiopulmonary ultrasounds performed in the ED setting allow one to rapidly establish the etiology of acute dyspnea with an accuracy of 90%.