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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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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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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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