Identification of Need for Ultrasound Enhancing Agent Study (the IN-USE Study)

Incidence of Severe Adverse Drug Reactions to Ultrasound Enhancement Agents in a Contemporary Echocardiography Practice

OBJECTIVES

Prior data indicate a very rare risk of serious adverse drug reaction (ADR) to ultrasound enhancement agents (UEAs). We sought to evaluate the frequency of ADR to UEA administration in contemporary practice.

METHODS

We retrospectively reviewed 4 US health systems to characterize the frequency and severity of ADR to UEA. Adverse drug reactions were considered severe when cardiopulmonary involvement was present and critical when there was loss of consciousness, loss of pulse, or ST-segment elevation. Rates of isolated back pain and headache were derived from the Mayo Clinic Rochester stress echocardiography database where systematic prospective reporting of ADR was performed.

RESULTS

Among 26,539 Definity and 11,579 Lumason administrations in the Mayo Clinic Rochester stress echocardiography database, isolated back pain or headache was more frequent with Definity (0.49% vs 0.04%, P < .0001) but less common with Definity infusion versus bolus (0.08% vs 0.53%, P = .007). Among all sites there were 201,834 Definity and 84,943 Lumason administrations. Severe and critical ADR were more frequent with Lumason than with Definity (0.0848% vs 0.0114% and 0.0330% vs 0.0010%, respectively; P < .001 for each). Among the 3 health systems with >2,000 Lumason administrations, the frequency of severe ADR with Lumason ranged from 0.0755% to 0.1093% and the frequency of critical ADR ranged from 0.0293% to 0.0525%. Severe ADR rates with Definity were stable over time but increased in more recent years with Lumason (P = .02). Patients with an ADR to Lumason since the beginning of 2021 were more likely to have received a COVID-19 vaccination compared with matched controls (88% vs 75%; P = .05) and more likely to have received Moderna than Pfizer-Biotech (71% vs 26%, P < .001).

CONCLUSION

Severe and critical ADR, while rare, were more frequent with Lumason, and the frequency has increased in more recent years. Additional work is needed to better understand factors, including associations with recently developed mRNA vaccines, which may be contributing to the increased rates of ADR to UEA since 2021.

Validation of administrative claims to identify ultrasound enhancing agent use

BACKGROUND

Ultrasound enhancing agents (UEAs) are an invaluable adjunct to stress and transthoracic echocardiography (STE) to improve left ventricular visualization. Despite multiple single center studies evaluating UEA use, investigation into the rates, sources of variation, and outcomes of UEA use on a national level in the United States (US) has been limited by lack of validation of UEA codes for claims analyses.

METHODS

We conducted a retrospective cross-sectional study, 2019-2022, using linked multicenter electronic medical record (EMR) data from > 30 health systems linked to all-payor claims data representing > 90% of the US population. Individuals receiving STE in both EMR and claims data on the same day during the study window were included. UEA receipt as identified by presence of a Current Procedural Terminology (CPT) or National Drug Code (NDC) for UEA use within 1-day of the index STE event. We evaluated the performance of claims to identify UEA use, using EMR data as the gold standard, stratified by inpatient and outpatient status.

RESULTS

Amongst 54,525 individuals receiving STE in both EMR and claims data, 12,853 (23.6%) had a UEA claim in EMR, 10,461 (19.2%) had a UEA claim in claims, and 9140 (16.8%) had a UEA claim in both within the 1-day window. The sensitivity, specificity, accuracy, positive, and negative predictive values for UEA claims were 71.1%, 96.8%, 90.8%, 87.4%. and 91.6% respectively. However, amongst inpatients, the sensitivity of UEA claims was substantially lower (6.8%) compared to outpatients (79.7%).

CONCLUSIONS

While the overall accuracy of claims to identify UEA use was high, there was substantial under-capture of UEA use by claims amongst inpatients. These results call into question published rates of UEA use amongst inpatients in studies using administrative claims, and highlight ongoing need to improve inpatient coding for UEA use.

High-definition blood flow imaging improves quantification of left ventricular volumes and ejection fraction

AIMS

The accuracy and reproducibility of echocardiography to quantify left ventricular ejection fraction (LVEF) is limited due to image quality. High-definition blood flow imaging is a new technique which improves cavity delineation without the need for medication or intravenous access. We sought to examine the impact of high-definition blood flow imaging on accuracy and reproducibility of LV systolic function assessment.

METHODS AND RESULTS

Prospective observational study of consecutive patients undergoing 2D and 3D transthoracic echocardiography (TTE), high-definition blood flow imaging, and cardiac magnetic resonance (CMR) within 1 h of each other. Left ventricular systolic function characterized by left ventricular end-systolic volumes and left ventricular end-diastolic volumes and LVEF were measured. Seventy-six patients were included. Correlation of 2D TTE with CMR was modest (r = 0.68) with a worse correlation in patients with three or more segments not visualized (r = 0.58). High-definition blood flow imaging was feasible in all patients, and the correlation of LVEF with CMR was excellent (r = 0.88). The differences between 2D, high-definition blood flow, and 3D TTE compared to CMR were 5 ± 9%, 2 ± 5%, and 1 ± 3%, respectively. The proportion of patients where the grade of LV function was correctly classified improved from 72.3% using 2D TTE to 92.8% using high-definition blood flow imaging. 3D TTE also had excellent correlation with CMR (r = 0.97) however was only feasible in 72.4% of patients.

CONCLUSION

High-definition blood flow imaging is highly feasible and significantly improves the diagnostic accuracy and grading of LV function compared to 2D echocardiography.

Impact of ultrasound enhancing agents on clinical management

PURPOSE OF REVIEW

Ultrasound enhancing agents (UEAs), microbubbles which are composed of lipid or albumin shells containing high molecular weight gases with nonlinear acoustic properties in the ultrasound field, are important components of the diagnostic armamentarium in echocardiography. This review highlights the substantial value of UEAs in delineating endocardial border definition and influencing downstream decision-making in cardiovascular ultrasound.

RECENT FINDINGS

In this article, we review recent updates to the clinical applications of UEAs, special circumstances regarding use, the impact of use on downstream testing and cost-effectiveness, and recommended approaches for optimizing workflow in the echocardiography laboratory with UEAs.

SUMMARY

In multiple studies, UEAs have been identified as a useful tool in echocardiography, improving study accuracy and reader confidence, while reducing downstream testing and procedures and resulting in significant changes in clinical management. Despite their proven efficacy and cost-effectiveness, recent studies have suggested utilization remains low, in part due to perceived concerns and workflow issues that impair uptake. With an increasingly broader list of indications for echocardiography, UEAs will continue to play an important role in the diagnosis and management of patients with cardiovascular and noncardiovascular diseases.

The Effect of Obesity on Echocardiographic Image Quality

BACKGROUND

Increased body mass index (BMI) may reduce transthoracic echocardiogram (TTE) image quality, resulting in increased requirements for ultrasound enhancing agents (UEA), as recommended by the American Society of Echocardiography (ASE), and a greater incidence of non-diagnostic studies.

METHODS

Over a 5-month period 1,108 TTEs were analysed as to (1) whether they could answer the clinical question posed by the ordering physician (i.e. were diagnostic vs non diagnostic), and (2) whether they required UEAs according to the ASE guidelines. Patient characteristics were gathered from the medical record.

RESULTS

12.9% of TTEs were non-diagnostic (21.0% of TTEs in the obese population [BMI≥30 kg/m²] vs 7.8% in the non-obese [p<0.001]). Predictors of a non-diagnostic study were BMI (OR 1.09, [95% CI 1.06-1.11], p<0.0001), male gender (OR 1.54, [1.06-2.25], p=0.02), and inpatient status (OR 1.75, [1.20-2.55], p=0.004). Obesity (BMI≥30) was strongly associated with non-diagnostic studies (OR 3.22, [2.23-4.51], p<0.001). Factors associated with increased requirement of UEAs were BMI (OR 1.10, [1.08-1.12], p<0.0001), age (OR 1.02, [1.01-1.03], p<0.0001) and inpatient status (OR 1.7, [1.29-2.24], p<0.05). Obesity (BMI>30) was strongly associated with contrast requirement (OR 3.16, [2.43-4.10], p<0.0001).

CONCLUSIONS

Body mass index, male gender and inpatient status were associated with an increased incidence of non-diagnostic studies. Body mass index, age and inpatient status were associated with an increased requirement for UEAs.

Routine Use of Contrast on Admission Transthoracic Echocardiography for Heart Failure Reduces the Rate of Repeat Echocardiography during Index Admission

BACKGROUND

The authors retrospectively evaluated the impact of ultrasound enhancing agent (UEA) use in the first transthoracic echocardiographic (TTE) examination, regardless of baseline image quality, on the number of repeat TTEs and length of stay (LOS) during a heart failure (HF) admission.

METHODS

There were 9,115 HF admissions associated with admission TTE examinations over a 4-year period (5,337 men; mean age, 67.6 ± 15.0 years). Patients were grouped into those who received UEAs (contrast group) in the first TTE study and those who did not (noncontrast group). Repeat TTE examinations were classified as justified if performed for concrete clinical indications during hospitalization.

RESULTS

In the 9,115 admissions for HF (5,600 in the contrast group, 3,515 in the noncontrast group), 927 patients underwent repeat TTE studies (505 in the contrast group, 422 in the noncontrast group), which were considered justified in 823 patients. Of the 104 patients who underwent unjustified repeat TTE studies, 80 (76.7%) belonged to the noncontrast group and 24 to the contrast group. Also, UEA use increased from 50.4% in 2014 to 74.3%, and the rate of unjustified repeat studies decreased from 1.3% to 0.9%. The rates of unjustified repeat TTE imaging were 2.3% and 0.4% (in the noncontrast and contrast groups, respectively), and patients in the contrast group were less likely to undergo unjustified repeat examinations (odds ratio, 0.18; 95% CI, 0.12-0.29; P < .0001). The mean LOS was significantly lower in the contrast group (9.5 ± 10.5 vs 11.1 ± 13.7 days). The use of UEA in the first TTE study was also associated with reduced LOS (linear regression, β₁ = -0.47, P = .036), with 20% lower odds for odds of prolonged (>6 days) LOS.

CONCLUSIONS

The routine use of UEA in the first TTE examination for HF irrespective of image quality is associated with reduced unjustified repeat TTE testing and may reduce LOS during an index HF admission.