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Cohen A, Li T, Bielawa N, Nello A, Gold A, Gorlin M, Nelson M, Carlin E, Rolston D. Right Ventricular "Bubble Time" to Identify Patients With Right Ventricular Dysfunction. Ann Emerg Med 2024; 84:182-194. [PMID: 38597847 DOI: 10.1016/j.annemergmed.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 01/10/2024] [Accepted: 02/08/2024] [Indexed: 04/11/2024]
Abstract
STUDY OBJECTIVE We propose a novel method of evaluating right ventricular (RV) dysfunction in the emergency department (ED) using RV "bubble time"-the duration of time bubbles from a saline solution flush are visualized in the RV on echocardiography. The objective was to identify the optimal cutoff value for RV bubble time that differentiates patients with RV dysfunction and report on its diagnostic test characteristics. METHODS This prospective diagnostic accuracy study enrolled a convenience sample of hemodynamically stable patients in the ED. A sonographer administered a 10-mL saline solution flush into the patient's intravenous catheter, performed a bedside echocardiogram, and measured RV bubble time. Subsequently, the patient underwent a comprehensive cardiologist-interpreted echocardiogram within 36 hours, which served as the gold standard. Patients with RV strain or enlargement of the latter found on an echocardiogram were considered to have RV dysfunction. Bubble time was evaluated by a second provider, blinded to the initial results, who reviewed the ultrasound clips. The primary outcome measure was the optimal cutoff value of RV bubble time that identifies patients with and without RV dysfunction. RESULTS Of 196 patients, median age was 67 year, and half were women, with 69 (35.2%) having RV dysfunction. Median RV bubble time among patients with RV dysfunction was 62 seconds (interquartile range [IQR]: 52, 93) compared with 21 seconds (IQR: 12, 32) among patients without (P<.0001). The optimal cutoff value of RV bubble time for identifying patients with RV dysfunction was 40 or more seconds, with a sensitivity of 0.97 (95% CI 0.93 to 1.00) and specificity of 0.87 (95% CI 0.82 to 0.93). CONCLUSION In patients in the ED, an RV bubble time of 40 or more seconds had high sensitivity in identifying patients with RV dysfunction, whereas an RV bubble time of less than 40 seconds had good specificity in identifying patients without RV dysfunction. These findings warrant further investigation in undifferentiated patient populations and by emergency physicians without advanced ultrasound training.
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Affiliation(s)
- Allison Cohen
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY.
| | - Timmy Li
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Nicholas Bielawa
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Alexander Nello
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Allen Gold
- Department of Emergency Medicine, St. Barnabas Hospital, Bronx, NY
| | - Margaret Gorlin
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New Hyde Park, NY
| | - Mathew Nelson
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Edward Carlin
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Daniel Rolston
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
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Harrison NE, Ehrman R, Collins S, Desai AA, Duggan NM, Ferre R, Gargani L, Goldsmith A, Kapur T, Lane K, Levy P, Li X, Noble VE, Russell FM, Pang P. The prognostic value of improving congestion on lung ultrasound during treatment for acute heart failure differs based on patient characteristics at admission. J Cardiol 2024; 83:121-129. [PMID: 37579872 PMCID: PMC10859542 DOI: 10.1016/j.jjcc.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Lung ultrasound congestion scoring (LUS-CS) is a congestion severity biomarker. The BLUSHED-AHF trial demonstrated feasibility for LUS-CS-guided therapy in acute heart failure (AHF). We investigated two questions: 1) does change (∆) in LUS-CS from emergency department (ED) to hospital-discharge predict patient outcomes, and 2) is the relationship between in-hospital decongestion and adverse events moderated by baseline risk-factors at admission? METHODS We performed a secondary analysis of 933 observations/128 patients from 5 hospitals in the BLUSHED-AHF trial receiving daily LUS. ∆LUS-CS from ED arrival to inpatient discharge (scale -160 to +160, where negative = improving congestion) was compared to a primary outcome of 30-day death/AHF-rehospitalization. Cox regression was used to adjust for mortality risk at admission [Get-With-The-Guidelines HF risk score (GWTG-RS)] and the discharge LUS-CS. An interaction between ∆LUS-CS and GWTG-RS was included, under the hypothesis that the association between decongestion intensity (by ∆LUS-CS) and adverse outcomes would be stronger in admitted patients with low-mortality risk but high baseline congestion. RESULTS Median age was 65 years, GWTG-RS 36, left ventricular ejection fraction 36 %, and ∆LUS-CS -20. In the multivariable analysis ∆LUS-CS was associated with event-free survival (HR = 0.61; 95 % CI: 0.38-0.97), while discharge LUS-CS (HR = 1.00; 95%CI: 0.54-1.84) did not add incremental prognostic value to ∆LUS-CS alone. As GWTG-RS rose, benefits of LUS-CS reduction attenuated (interaction p < 0.05). ∆LUS-CS and event-free survival were most strongly correlated in patients without tachycardia, tachypnea, hypotension, hyponatremia, uremia, advanced age, or history of myocardial infarction at ED/baseline, and those with low daily loop diuretic requirements. CONCLUSIONS Reduction in ∆LUS-CS during AHF treatment was most associated with improved readmission-free survival in heavily congested patients with otherwise reassuring features at admission. ∆LUS-CS may be most useful as a measure to ensure adequate decongestion prior to discharge, to prevent early readmission, rather than modify survival.
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Affiliation(s)
- Nicholas E Harrison
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, USA.
| | - Robert Ehrman
- Wayne State University School of Medicine, Department of Emergency Medicine, Detroit, MI, USA
| | - Sean Collins
- Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN, USA
| | - Ankit A Desai
- Indiana University School of Medicine, Department of Medicine, Division of Cardiology, Indianapolis, IN, USA
| | - Nicole M Duggan
- Brigham and Womens Hospital, Department of Emergency Medicine, Boston, MA, USA
| | - Rob Ferre
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, USA
| | - Luna Gargani
- University of Pisa, Cardiology Unit, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Pisa, Italy
| | - Andrew Goldsmith
- Brigham and Womens Hospital, Department of Emergency Medicine, Boston, MA, USA
| | - Tina Kapur
- Brigham and Womens Hospital, Department of Radiology, Boston, MA, USA
| | - Katie Lane
- Indiana University School of Medicine, Department of Biostatistics, Indianapolis, IN, USA
| | - Phillip Levy
- Wayne State University School of Medicine, Department of Emergency Medicine, Detroit, MI, USA
| | - Xiaochun Li
- Indiana University School of Medicine, Department of Biostatistics, Indianapolis, IN, USA
| | - Vicki E Noble
- Case Western Reserve University, Department of Emergency Medicine, Cleveland, OH, USA
| | - Frances M Russell
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, USA
| | - Peter Pang
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, USA
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Shaker MM, Taha HS, Kandil HI, Kamal HM, Mahrous HA, Elamragy AA. Prognostic significance of right ventricular dysfunction in patients presenting with acute left-sided heart failure. Egypt Heart J 2024; 76:2. [PMID: 38165525 PMCID: PMC10761637 DOI: 10.1186/s43044-023-00432-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND The prognostic value of right ventricular (RV) function in chronic heart failure (HF) has lately been well established. However, research on its role in acute heart failure (AHF) is sparse. RESULTS This study comprised 195 patients, aged between 18 and 80 years, with acute left-sided heart failure (HF) and a left ventricular ejection fraction (LVEF) < 50%. Patients with LVEF ≥ 50%, mechanical ventilatory or circulatory support, poor echocardiographic windows, prosthetic valves, congenital heart diseases, infective endocarditis, and/or life expectancy < 1 year due to non-cardiac causes were excluded. The study participants' mean age was 57.7 ± 10.9 years, and 74.9% were males. Coronary artery disease was present in 80.5% of patients. The mean LVEF was 31% ± 8.7. RV dysfunction (RVD), defined as tricuspid annular plane systolic excursion (TAPSE) < 17 mm, RV S' < 9.5 cm/s and/or RV fractional area change (FAC) < 35%, was identified in 48.7% of patients. The RV was dilated in 67.7% of the patients. RVD was significantly associated with a longer HF duration, atrial fibrillation, and idiopathic dilated cardiomyopathy. The primary outcome, a 6-month composite of cardiovascular death or hospitalization for worsening HF (HHF), occurred in 42% of the participants. Cardiovascular mortality and HHF occurred in 30.5% and 23.9% of the patients, respectively. The primary endpoint and longer CCU stays were significantly more common in patients with RVD than in those with normal RV function. RV dilatation was significantly associated with the primary outcome, whether alone or in combination with RVD. Multivariate regression analysis showed that only RV global longitudinal strain (GLS) independently predicted poor outcomes. CONCLUSIONS RVD and RV dilatation strongly predict CV death and HHF in patients with AHF and LVEF < 50%. Multivariate analysis showed that RV GLS was the only predictor of a composite of CV death and HHF.
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Affiliation(s)
- Mirna M Shaker
- Department of Cardiology, Faculty of Medicine, Cairo University, 27 Nafezet Sheem El Shafae St Kasr Al Ainy, Cairo, 11562, Egypt
| | - Hesham S Taha
- Department of Cardiology, Faculty of Medicine, Cairo University, 27 Nafezet Sheem El Shafae St Kasr Al Ainy, Cairo, 11562, Egypt.
| | - Hossam I Kandil
- Department of Cardiology, Faculty of Medicine, Cairo University, 27 Nafezet Sheem El Shafae St Kasr Al Ainy, Cairo, 11562, Egypt
| | - Heba M Kamal
- Department of Cardiology, Faculty of Medicine, Cairo University, 27 Nafezet Sheem El Shafae St Kasr Al Ainy, Cairo, 11562, Egypt
| | - Hossam A Mahrous
- Department of Cardiology, Faculty of Medicine, Cairo University, 27 Nafezet Sheem El Shafae St Kasr Al Ainy, Cairo, 11562, Egypt
| | - Ahmed A Elamragy
- Department of Cardiology, Faculty of Medicine, Cairo University, 27 Nafezet Sheem El Shafae St Kasr Al Ainy, Cairo, 11562, Egypt
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Xu P, Nasr B, Li L, Huang W, Liu W, Wang X. Correlation analysis between lung ultrasound scores and pulmonary arterial systolic pressure in patients with acute heart failure admitted to the emergency intensive care unit. JOURNAL OF INTENSIVE MEDICINE 2024; 4:125-132. [PMID: 38263970 PMCID: PMC10800768 DOI: 10.1016/j.jointm.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/01/2023] [Accepted: 08/18/2023] [Indexed: 01/25/2024]
Abstract
Background No convenient, inexpensive, and non-invasive screening tools exist to identify pulmonary hypertension (PH) - left heart disease (LHD) patients during the early stages of the disease course. This study investigated whether different methods of lung ultrasound (LUS) could be used for the initial investigation of PH-LHD. Methods This was a single-center prospective observational study which was performed in the Zigong Fourth People's Hospital. We consecutively enrolled patients with heart failure (HF) admitted to the emergency intensive care unit from January 2018 to May 2020. Transthoracic echocardiography and LUS were performed within 24 h before discharge. We used the Spearman coefficient for correlation analysis between ultrasound scores and pulmonary arterial systolic pressure (PASP). Bland-Altman plots were generated to inspect possible bias, and receiver operating characteristic (ROC) curves were calculated to assess the relationship between ultrasound scores and an intermediate and high echocardiographic probability of PH-LHD. Results Seventy-one patients were enrolled in this study, with an overall median age of 79 (interquartile range: 71.5-84.0) years. Among the 71 patients, 36 (50.7%) cases were male, and 26 (36.6%) had an intermediate and high echocardiographic probability of PH. All four LUS scores in patients with an intermediate and high probability of PH were significantly higher than in patients with a low probability of PH (P <0.05). The correlation coefficient (r) between different LUS scoring methods and PASP was moderate for the 6-zone (r=0.455, P <0.001), 8-zone (r=0.385, P=0.001), 12-zone (r=0.587, P <0.001), and 28-zone (r=0.535, P <0.001) methods. In Bland-Altman plots, each of the four LUS scoring methods had a good agreement with PASP (P <0.001). The 8-zone and 12-zone methods showed moderately accurate discriminative values in differentiating patients with an intermediate and high echocardiographic probability of PH (P <0.05). Conclusions LUS is a readily available, inexpensive, and risk-free method that moderately correlates with PASP. LUS is a potential screening tool used for the initial investigation of PH-LHD, especially in emergencies or critical care settings.
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Affiliation(s)
- Ping Xu
- Emergency Department, Zigong Fourth People's Hospital, Zigong, China
- Institute of Medical Big Data, Zigong Academy of Artificial Intelligence and Big Data for Medical Science, Zigong, China
- Artificial Intelligence Key Laboratory of Sichuan Province, Zigong, China
| | - Basma Nasr
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Liang Li
- Emergency Department, Zigong Fourth People's Hospital, Zigong, China
| | - Wenbin Huang
- Emergency Department, Zigong Fourth People's Hospital, Zigong, China
| | - Wei Liu
- Emergency Department, Zigong Fourth People's Hospital, Zigong, China
- Institute of Medical Big Data, Zigong Academy of Artificial Intelligence and Big Data for Medical Science, Zigong, China
| | - Xuelian Wang
- Emergency Department, Zigong Fourth People's Hospital, Zigong, China
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Harrison NE, Ehrman R, Pang P, Armitage S, Abidov A, Perkins D, Peacock J, Montelauro N, Gupta S, Favot MJ, Levy P. The significance of historical troponin elevation in acute heart failure: Not as reassuring as previously assumed. Acad Emerg Med 2023; 30:1223-1236. [PMID: 37641846 PMCID: PMC10863562 DOI: 10.1111/acem.14798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Historical cardiac troponin (cTn) elevation is commonly interpreted as lessening the significance of current cTn elevations at presentation for acute heart failure (AHF). Evidence for this practice is lacking. Our objective was to determine the incremental prognostic significance of historical cTn elevation compared to cTn elevation and ischemic heart disease (IHD) history at presentation for AHF. METHODS A total of 341 AHF patients were prospectively enrolled at five sites. The composite primary outcome was death/cardiopulmonary resuscitation, mechanical cardiac support, intubation, new/emergent dialysis, and/or acute myocardial infarction (AMI)/percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG) at 90 days. Secondary outcomes were 30-day AMI/PCI/CABG and in-hospital AMI. Logistic regression compared outcomes versus initial emergency department (ED) cTn, the most recent electronic medical record cTn, estimated glomerular filtration rate, age, left ventricular ejection fraction, and IHD history (positive, negative by prior coronary workup, or unknown/no prior workup). RESULTS Elevated cTn occurred in 163 (49%) patients, 80 (23%) experienced the primary outcome, and 29 had AMI (9%). cTn elevation at ED presentation, adjusted for historical cTn and other covariates, was associated with the primary outcome (adjusted odds ratio [aOR] 2.39, 95% confidence interval [CI] 1.30-4.38), 30-day AMI/PCI/CABG, and in-hospital AMI. Historical cTn elevation was associated with greater odds of the primary outcome when IHD history was unknown at ED presentation (aOR 5.27, 95% CI 1.24-21.40) and did not alter odds of the outcome with known positive (aOR 0.74, 95% CI 0.33-1.70) or negative IHD history (aOR 0.79, 95% CI 0.26-2.40). Nevertheless, patients with elevated ED cTn were more likely to be discharged if historical cTn was also elevated (78% vs. 32%, p = 0.025). CONCLUSIONS Historical cTn elevation in AHF patients is a harbinger of worse outcomes for patients who have not had a prior IHD workup and should prompt evaluation for underlying ischemia rather than reassurance for discharge. With known IHD history, historical cTn elevation was neither reassuring nor detrimental, failing to add incremental prognostic value to current cTn elevation alone.
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Affiliation(s)
| | - Robert Ehrman
- Indiana University School of Medicine, Department of Emergency Medicine
| | - Peter Pang
- Indiana University School of Medicine, Department of Emergency Medicine
| | - Sarah Armitage
- Wayne State University School of Medicine, Department of Emergency Medicine
| | - Aiden Abidov
- Wayne State University School of Medicine, Department of Medicine, Division of Cardiology
| | - Daniel Perkins
- Indiana University School of Medicine, Department of Emergency Medicine
| | - Johnathon Peacock
- Indiana University School of Medicine, Department of Emergency Medicine
| | | | - Sushane Gupta
- Wayne State University School of Medicine, Department of Emergency Medicine
| | - Mark J Favot
- Wayne State University School of Medicine, Department of Emergency Medicine
| | - Phillip Levy
- Wayne State University School of Medicine, Department of Emergency Medicine
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Xu P, Ye L, Li L, Huang W, Liu W, Huang K. Comparison of the prognostic value, feasibility, and reproducibility among different scoring methods of 8‑point lung ultrasonography in patients with acute heart failure. Intern Emerg Med 2023; 18:2321-2332. [PMID: 37747589 DOI: 10.1007/s11739-023-03433-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023]
Abstract
There is no strong evidence that one of the B-line quantification approaches is clinically superior to the others, as the use of lung ultrasound (LUS) protocol becomes more commonplace in the treatment of heart failure (HF). This study, thus, aimed to evaluate to the prognostic value, feasibility, and reproducibility for selecting optimal B-line quantification methods. We enrolled patients with HF admitted to the emergency intensive care unit (EICU) in a single-center, prospective, observational study. LUS were performed before EICU discharge, and six B-line quantification methods were used to calculate scores. A total of 71 patients were enrolled. There was a moderately good discriminative value between six quantification methods and the composite outcome. The calibration curve of six B-line quantification methods for the probability of the composite outcome showed good agreement between prediction and observation. Decision curve presented that six B-line quantification methods presented similar net benefits at the entire range of threshold probabilities. Image interpretation time of Quantitative methods 1 and 2 was significantly less than that of other methods. Intraclass correlation coefficients (ICC) for B-pattern scoring systems (Quantitative methods 1 and 2) between two experts demonstrated the excellent level of clinical significance. Despite the similar discrimination, calibration and clinical usefulness, pattern-B scoring systems have the benefit of the feasibility and reproducibility over other methods.
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Affiliation(s)
- Ping Xu
- Emergency Department, Zigong Fourth People's Hospital, 19 Tanmulin Road, Zigong, 643000, Sichuan, China.
- Institute of Medical Big Data, Zigong Academy of Artificial Intelligence and Big Data for Medical Science, Zigong, China.
| | - Li Ye
- Emergency Department, Fushun People's Hospital, Fushun, Sichuan, China
| | - Liang Li
- Emergency Department, Zigong Fourth People's Hospital, 19 Tanmulin Road, Zigong, 643000, Sichuan, China
| | - Wenbin Huang
- Emergency Department, Zigong Fourth People's Hospital, 19 Tanmulin Road, Zigong, 643000, Sichuan, China
| | - Wei Liu
- Emergency Department, Zigong Fourth People's Hospital, 19 Tanmulin Road, Zigong, 643000, Sichuan, China
- Institute of Medical Big Data, Zigong Academy of Artificial Intelligence and Big Data for Medical Science, Zigong, China
| | - Kui Huang
- Department of Health Management Center, Zigong Fourth People's Hospital, Zigong, China
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Point-of-Care Ultrasound and the Discovery of Pulmonary Arterial Hypertension in a Teenager. Pediatr Emerg Care 2022; 38:702-704. [PMID: 36449741 DOI: 10.1097/pec.0000000000002881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
We present a case of a teenage patient with new-onset cardiac symptoms discovered to have primary pulmonary arterial hypertension. Point-of-care ultrasound used early in the patient's presentation identified significant right-sided heart dilatation and dysfunction despite the patient's relatively unrevealing physical examination. This article emphasizes the utility of performing focused cardiac ultrasound in pediatric patients early in their presentation. We briefly review focused cardiac ultrasound technique and highlight relevant literature.
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Harrison NE, Favot MJ, Gowland L, Lenning J, Henry S, Gupta S, Abidov A, Levy P, Ehrman R. Point-of-care echocardiography of the right heart improves acute heart failure risk stratification for low-risk patients: The REED-AHF prospective study. Acad Emerg Med 2022; 29:1306-1319. [PMID: 36047646 PMCID: PMC9671834 DOI: 10.1111/acem.14589] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Validated acute heart failure (AHF) clinical decision instruments (CDI) insufficiently identify low-risk patients meriting consideration of outpatient treatment. While pilot data show that tricuspid annulus plane systolic excursion (TAPSE) is associated with adverse events, no AHF CDI currently incorporates point-of-care echocardiography (POCecho). We evaluated whether TAPSE adds incremental risk stratification value to an existing CDI. METHODS Prospectively enrolled patients at two urban-academic EDs had POCechos obtained before or <1 h after first intravenous diuresis, positive pressure ventilation, and/or nitroglycerin. STEMI and cardiogenic shock were excluded. AHF diagnosis was adjudicated by double-blind expert review. TAPSE, with an a priori cutoff of ≥17 mm, was our primary measure. Secondary measures included eight additional right heart and six left heart POCecho parameters. STRATIFY is a validated CDI predicting 30-day death/cardiopulmonary resuscitation, mechanical cardiac support, intubation, new/emergent dialysis, and acute myocardial infarction or coronary revascularization in ED AHF patients. Full (STRATIFY + POCecho variable) and reduced (STRATIFY alone) logistic regression models were fit to calculate adjusted odds ratios (aOR), category-free net reclassification index (NRIcont ), ΔSensitivity (NRIevents ), and ΔSpecificity (NRInonevents ). Random forest assessed variable importance. To benchmark risk prediction to standard of care, ΔSensitivity and ΔSpecificity were evaluated at risk thresholds more conservative/lower than the actual outcome rate in discharged patients. RESULTS A total of 84/120 enrolled patients met inclusion and diagnostic adjudication criteria. Nineteen percent experiencing the primary outcome had higher STRATIFY scores compared to those event free (233 vs. 212, p = 0.009). Five right heart (TAPSE, TAPSE/PASP, TAPSE/RVDD, RV-FAC, fwRVLS) and no left heart measures improved prediction (p < 0.05) adjusted for STRATIFY. Right heart measures also had higher variable importance. TAPSE ≥ 17 mm plus STRATIFY improved prediction versus STRATIFY alone (aOR 0.24, 95% confidence interval [CI] 0.06-0.91; NRIcont 0.71, 95% CI 0.22-1.19), and specificity improved by 6%-32% (p < 0.05) at risk thresholds more conservative than the standard-of-care benchmark without missing any additional events. CONCLUSIONS TAPSE increased detection of low-risk AHF patients, after use of a validated CDI, at risk thresholds more conservative than standard of care.
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Affiliation(s)
- Nicholas E. Harrison
- Indiana University School of MedicineIndianapolisIndianaUSA,Wayne State UniversityDetroitMichiganUSA
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