Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis

Focused cardiac ultrasound and point-of-care NT-proBNP assay in the emergency room for differentiation of cardiac and noncardiac causes of respiratory distress in cats

OBJECTIVE

To assess the accuracy of focused cardiac ultrasound (FOCUS) and point-of-care N-terminal proBNP assay in the emergency setting for differentiation of cardiac from noncardiac causes of respiratory distress in cats.

DESIGN

Prospective diagnostic accuracy study between 2014 and 2016.

SETTING

Emergency room at an urban university teaching hospital.

ANIMALS

Forty-one client-owned cats presenting for evaluation of respiratory distress.

INTERVENTIONS

Emergency clinicians made an initial diagnosis of noncardiac or cardiac cause of respiratory distress based on physical examination (PE) findings and history. The diagnoses were updated after performing FOCUS and point-of-care N-terminal B-type natriuretic peptide (POC-BNP). Reference standard diagnosis was determined by agreement of a board-certified cardiologist and critical care specialist with access to subsequent radiographs and echocardiograms.

MEASUREMENTS AND MAIN RESULTS

Forty-one cats were enrolled. Three cats with incomplete data and 1 cat with an uncertain reference standard diagnosis were excluded. The remaining 37 cats were used for analysis: 21 cardiac and 16 noncardiac cases. The ratio of left atrial to aortic root diameter (LA:Ao) measured by FOCUS was significantly correlated with LA:Ao measured by echocardiography (R = 0.646, P < 0.0001). Emergency clinicians correctly diagnosed 27 of 37 (73.0%), yielding a PE positive percent agreement = 76.2% (95% CI, 52.8-91.8%) and negative percent agreement = 68.8% (95% CI, 41.3-89.0%). Five noncardiac and 5 cardiac cats were misdiagnosed. Post FOCUS, overall percent agreement improved to 34 of 37 (91.9%), with positive percent agreement = 95.2% (95% CI, 76.2-99.9%) and negative percent agreement = 87.5% (95% CI, 61.7-98.5%). The POC-BNP yielded an overall percent agreement = 32/34 (94.1%), positive percent agreement = 100% (95% CI, 82.4-100.0%), and negative percent agreement = 86.7% (95% CI, 59.5-98.3%) in differentiating cardiac versus noncardiac cases.

CONCLUSIONS

FOCUS evaluation of basic cardiac structure and LA:Ao by trained emergency clinicians improved accuracy of diagnosis compared to PE in cats with respiratory distress. FOCUS and POC-BNP are useful diagnostics in the emergent setting.

Point-of-care Lung Ultrasound Is More Sensitive than Chest Radiograph for Evaluation of COVID-19

INTRODUCTION

Current recommendations for diagnostic imaging for moderately to severely ill patients with suspected coronavirus disease 2019 (COVID-19) include chest radiograph (CXR). Our primary objective was to determine whether lung ultrasound (LUS) B-lines, when excluding patients with alternative etiologies for B-lines, are more sensitive for the associated diagnosis of COVID-19 than CXR.

METHODS

This was a retrospective cohort study of all patients who presented to a single, academic emergency department in the United States between March 20 and April 6, 2020, and received LUS, CXR, and viral testing for COVID-19 as part of their diagnostic evaluation. The primary objective was to estimate the test characteristics of both LUS B-lines and CXR for the associated diagnosis of COVID-19. Our secondary objective was to evaluate the proportion of patients with COVID-19 that have secondary LUS findings of pleural abnormalities and subpleural consolidations.

RESULTS

We identified 43 patients who underwent both LUS and CXR and were tested for COVID-19. Of these, 27/43 (63%) tested positive. LUS was more sensitive (88.9%, 95% confidence interval (CI), 71.1-97.0) for the associated diagnosis of COVID-19 than CXR (51.9%, 95% CI, 34.0-69.3; p = 0.013). LUS and CXR specificity were 56.3% (95% CI, 33.2-76.9) and 75.0% (95% CI, 50.0-90.3), respectively (p = 0.453). Secondary LUS findings of patients with COVID-19 demonstrated 21/27 (77.8%) had pleural abnormalities and 10/27 (37%) had subpleural consolidations.

CONCLUSION

Among patients who underwent LUS and CXR, LUS was found to have a higher sensitivity than CXR for the evaluation of COVID-19. This data could have important implications as an aid in the diagnostic evaluation of COVID-19, particularly where viral testing is not available or restricted. If generalizable, future directions would include defining how to incorporate LUS into clinical management and its role in screening lower-risk populations.

Prognostic value of lung ultrasonography and bioimpedance spectroscopy in patients with heart failure and reduced ejection fraction

Introduction

Chronic heart failure (HF) represents a major global public health problem, and despite significant advances in diagnosis and management over the past two decades, HF patients still have a poor prognosis. The aim of the study was to evaluate the relationship between lung congestion, as assessed by lung ultrasonography (LUS), bioimpedance spectroscopy, body fluid compartments, and echocardiographic parameters, and to determine the effect of these associations on all-cause mortality in HF patients.

Material and methods

Eligible patients with a left ventricular ejection fraction (LVEF) below 45% were identified via daily echocardiography assessments. Lung ultrasonography was performed with patients in the supine position, for a total of 28 sites per complete examination. The extracellular water (ECW) was determined using a BIS device.

Results

Our study included 122 patients (67.2% males) with a mean age of 67.2 years. In the multivariable linear regression analysis, including all the univariable predictors of lung congestion, only New York Heart Association (NYHA) class, ECW, estimated glomerular filtration rate (eGFR), and LVEF levels maintained an independent association with the number of B-lines. During the follow-up, 33 patients died. In multivariable Cox analysis, a B-line number of at least 15 remained significantly associated with all-cause mortality, independently of age, sex, diabetes, LVEF, estimated glomerular filtration rate, C-reactive protein, N-terminal pro-brain natriuretic peptide, or ECW values (adjusted HR = 3.84, 95% CI: 1.12-13.09).

Conclusions

We show for the first time in HF patients that pulmonary congestion, as assessed by LUS, is associated with the severity of NYHA class, LVEF, eGFR, and ECW, and it identifies those at increased risk of death.

BNP/NT-proBNP in pulmonary arterial hypertension: time for point-of-care testing?

Despite the advent of new therapies and improved outcomes in patients with pulmonary arterial hypertension (PAH), it remains a life-shortening disease and the time to diagnosis remains unchanged. Strategies to improve outcomes are therefore currently focused on earlier diagnosis and a treatment approach aimed at moving patients with PAH into a category of low-risk of 1-year mortality. B-type natriuretic peptide (BNP; or brain natriuretic peptide) and N-terminal prohormone of BNP (NT-proBNP) are released from cardiac myocytes in response to mechanical load and wall stress. Elevated levels of BNP and NT-proBNP are incorporated into several PAH risk stratification tools and screening algorithms to aid diagnosis of systemic sclerosis. We have undertaken a systematic review of the literature with respect to the use of BNP and NT-proBNP in PAH and the use of these biomarkers in the diagnosis and risk stratification of PAH, their relation to pulmonary haemodynamics and the potential for point-of-care testing to improve diagnosis and prognosis.

Shenmai Injection Improves Energy Metabolism in Patients With Heart Failure: A Randomized Controlled Trial

Background

In recent years, the application of Shenmai (SM) injection, a traditional Chinese medicine (TCM), to treat heart failure (HF) has been gradually accepted in China. However, whether SM improves energy metabolism in patients with HF has not been determined due to the lack of high-quality studies. We aimed to investigate the influence of SM on energy metabolism in patients with HF.

Methods

This single-blind, controlled study randomly assigned 120 eligible patients equally into three groups receiving SM, trimetazidine (TMZ), or control in addition to standard medical treatment for HF for 7 days. The primary endpoints were changes in free fatty acids (FFAs), glucose, lactic acid (LA), pyroracemic acid (pyruvate, PA) and branched chain amino acids (BCAAs) in serum. The secondary outcomes included the New York Heart Association (NYHA) functional classification, TCM syndrome score (TCM-s), left ventricular injection fraction (LVEF), left ventricular internal diastolic diameter (LVIDd), left ventricular internal dimension systole (LVIDs), and B-type natriuretic peptide (BNP).

Results

After treatment for 1 week, the NYHA functional classification, TCM-s, and BNP level gradually decreased in the patients in all three groups, but these metrics were significantly increased in the patients in the SM group compared with those in the patients in the TMZ and control groups (P < 0.05). Moreover, energy metabolism was improved in the NYHA III–IV patients in the SM group compared with those in the patients in the TMZ and control groups as evidenced by changes in the serum levels of FFA, LA, PA, and BCAA.

Conclusions

Integrative treatment with SM in addition to standard medical treatment for HF was associated with improved cardiac function compared to standard medical treatment alone. The benefit of SM in HF may be related to an improvement in energy metabolism, which seems to be more remarkable than that following treatment with TMZ.

Evaluating the impact of point-of-care ultrasonography on patients with suspected acute heart failure or chronic obstructive pulmonary disease exacerbation in the emergency department: A prospective observational study

Objectives

Acute heart failure and chronic obstructive pulmonary disease (COPD) are sometimes difficult to differentiate in the emergency department (ED). We sought to determine the clinical impact of point-of-care ultrasonography (POCUS) in ED patients with suspected acute heart failure or COPD.

Methods

We conducted a prospectively collected cohort study with health records review with frequency matching at The Ottawa Hospital between March and September 2017. We included patients aged 50 and older with shortness of breath or cough from suspected acute heart failure or COPD. Our primary outcome was ED length of stay. Secondary outcomes were time to disposition decision, time to appropriate treatment, and the incidence of adverse events. We analyzed time-to-event outcomes using Kaplan-Meier analysis and Cox regression analysis with POCUS analyzed as a time-dependent variable, and the incidence of adverse events using logistic regression analyses.

Results

There were 81 patients evaluated with lung POCUS and 243 matched patients who were not. Lung POCUS was not significantly associated with ED length of stay and time to disposition decision; however, patients evaluated with lung POCUS received disease-specific treatment faster compared with the non-POCUS group (adjusted hazard ratio, 1.50 [95% confidence interval, 1.05–2.15], a median time difference of 31 minutes). We found no significant differences in the incidence of adverse events.

Conclusions

In this study, use of lung POCUS resulted in no difference in ED length of stay and time to disposition decision, but was associated with faster administration of disease-specific treatments for elderly patients with suspected acute heart failure or COPD.

Investigation of focused cardiac ultrasound in the emergency room for differentiation of respiratory and cardiac causes of respiratory distress in dogs

OBJECTIVE

To determine whether focused cardiac ultrasound (FOCUS) performed by emergency and critical care (ECC) specialists or residents in training improves differentiation of cardiac (C) versus non-cardiac (NC) causes of respiratory distress in dogs compared to medical history and physical examination alone.

DESIGN

Prospective cohort study (May 2014 to February 2016).

SETTING

University hospital.

ANIMALS

Thirty-eight dogs presenting with respiratory distress.

INTERVENTIONS

FOCUS.

MEASUREMENTS AND MAIN RESULTS

Medical history, physical examination, and FOCUS were obtained at presentation. Emergency and critical care clinicians, blinded to any radiographic or echocardiographic data, categorized each patient (C vs NC) before and after FOCUS. Thoracic radiography (within 3 h) and echocardiography (within 24 h) were performed. Percent agreement was calculated against a reference diagnosis that relied on agreement of a board-certified cardiologist and ECC specialist with access to all diagnostic test results. Reference diagnosis included 22 dogs with cardiac and 13 dogs with noncardiac causes of respiratory distress. In 3 dogs a reference diagnosis was not established. Prior to FOCUS, positive and negative percent agreement to detect cardiac causes was 90.9% (95% CI, 70.8-98.9) and 53.9% (25.1-80.8), respectively. Overall agreement occurred in 27 of 35 dogs (77.1%). Two C and 6 NC cases were incorrectly categorized. Following FOCUS, positive and negative percent agreement to detect cardiac causes was 95.5% (77.2-99.9) and 69.2% (38.6-90.9), respectively. Overall agreement occurred in 30 of 35 dogs (85.7%). Three dogs with discrepant pre-FOCUS diagnoses were correctly re-categorized post-FOCUS. One C and 4 NC cases remained incorrectly categorized. No correctly categorized dogs were incorrectly re-categorized following FOCUS. The proportions of dogs correctly classified pre- versus post-FOCUS were not significantly different (P = 0.25).

CONCLUSIONS

FOCUS did not significantly improve differentiation of C vs NC causes of respiratory distress compared to medical history and physical examination alone.

Epidemiology of patients presenting with dyspnea to emergency departments in Europe and the Asia-Pacific region

OBJECTIVE

The primary objective of this study was to describe the epidemiology and management of dyspneic patients presenting to emergency departments (EDs) in an international patient population. Our secondary objective was to compare the EURODEM and AANZDEM patient populations.

PATIENTS AND METHODS

An observational prospective cohort study was carried out in Europe and the Asia-Pacific region. The study included consecutive patients presenting to EDs with dyspnea as the main complaint. Data were collected on demographics, comorbidities, chronic treatment, clinical signs and investigations, treatment in the ED, diagnosis, and disposition from ED.

RESULTS

A total of 5569 patients were included in the study. The most common ED diagnoses were lower respiratory tract infection (LRTI) (24.9%), heart failure (HF) (17.3%), chronic obstructive pulmonary disease (COPD) exacerbation (15.8%), and asthma (10.5%) in the overall population. There were more LRTI, HF, and COPD exacerbations in the EURODEM population, whereas asthma was more frequent in the AANZDEM population. ICU admission rates were 5.5%. ED mortality was 0.6%. The overall in-hospital mortality was 5.0%. In-hospital mortality rates were 8.7% for LRTI, 7.6% for HF, and 5.6% for COPD patients.

CONCLUSION

Dyspnea as a symptom in the ED has high ward and ICU admission rates. A variety of causes of dyspnea were observed in this study, with chronic diseases accounting for a major proportion.

Diagnostic value of MR-proANP for heart failure in patients with acute dyspnea：a meta-analysis

Objectives: This study aimed to review the diagnostic value of mid-regional pro-atrial natriuretic peptide (MR-proANP) for heart failure (HF) in patients who presented to the emergency department (ED) with acute dyspnoea.Methods: Relevant studies were searched on the databases of PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials, with publication date limited to 30 March 2018. Literature identification, quality assessment, data extraction, synthesis, and statistical analysis were performed by standard meta-analysis methods. Individual and pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated.Results: A total of eight studies were retrieved, involving 1562 HF patients and 2249 non-HF patients. The sensitivity for each included study ranged from 80 to 97%, with a pooled sensitivity of 90% (95% CI: 88-91%), while the specificity ranged from 37 to 86%, with a pooled specificity of 68% (95% CI: 66-70%). The pooled PLR for included studies was 2.88(95% CI: 2.12-3.93), with a pooled NLR of 0.16 (95% CI: 0.11-0.24), and a pooled DOR of 18.97 (95% CI: 11.73-30.68).Conclusions: With a decent sensitivity, MR-proANP is a useful biomarker for correctly identifying HF in patients with acute dyspnoea.

Should the ultrasound probe replace your stethoscope? A SICS-I sub-study comparing lung ultrasound and pulmonary auscultation in the critically ill

Background

In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. The aim of this study was to compare lung ultrasound and pulmonary auscultation for detecting pulmonary edema in critically ill patients.

Methods

This study was a planned sub-study of the Simple Intensive Care Studies-I, a single-center, prospective observational study. All acutely admitted patients who were 18 years and older with an expected ICU stay of at least 24 h were eligible for inclusion. All patients underwent clinical examination combined with lung ultrasound, conducted by researchers not involved in patient care. Clinical examination included auscultation of the bilateral regions for crepitations and rhonchi. Lung ultrasound was conducted according to the Bedside Lung Ultrasound in Emergency protocol. Pulmonary edema was defined as three or more B lines in at least two (bilateral) scan sites. An agreement was described by using the Cohen κ coefficient, sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy. Subgroup analysis were performed in patients who were not mechanically ventilated.

Results

The Simple Intensive Care Studies-I cohort included 1075 patients, of whom 926 (86%) were eligible for inclusion in this analysis. Three hundred seven of the 926 patients (33%) fulfilled the criteria for pulmonary edema on lung ultrasound. In 156 (51%) of these patients, auscultation was normal. A total of 302 patients (32%) had audible crepitations or rhonchi upon auscultation. From 130 patients with crepitations, 86 patients (66%) had pulmonary edema on lung ultrasound, and from 209 patients with rhonchi, 96 patients (46%) had pulmonary edema on lung ultrasound. The agreement between auscultation findings and lung ultrasound diagnosis was poor (κ statistic 0.25). Subgroup analysis showed that the diagnostic accuracy of auscultation was better in non-ventilated than in ventilated patients.

Conclusion

The agreement between lung ultrasound and auscultation is poor.

Trial registration

NCT02912624. Registered on September 23, 2016.

B-type natriuretic peptide levels and diagnostic accuracy: excess fluid volume

ABSTRACT Aim: To analyze the behavior of B-type natriuretic peptide (BNP) in the presence of defining characteristics (DCs) of the nursing diagnosis Excess fluid volume (00026) in patients hospitalized for acute decompensated heart failure. Methods: Cohort study of patients admitted with acute decompensated heart failure (September 2015 to September 2016) defined by Boston Criteria. Patients hospitalized for up to 36 h with BNP values ≥ 100 pg/ml were included; BNP values at baseline-final assessment were compared by Wilcoxon test, the number of DCs at baseline-final assessment was compared by paired t-test. Results: Sixty-four patients were included; there was a significant positive correlation between delta of BNP and the number of DCs present at initial clinical assessment. Conclusions: The behavior of BNP was correlated to the DCs indicating congestion. With clinical compensation, DCs and BNP decreased. The use of this biomarker may provide additional precision to the nursing assessment.

Lung Ultrasound for the Diagnosis and Management of Acute Respiratory Failure

For critically ill patients with acute respiratory failure (ARF), lung ultrasound (LUS) has emerged as an indispensable tool to facilitate diagnosis and rapid therapeutic management. In ARF, there is now evidence to support the use of LUS to diagnose pneumothorax, acute respiratory distress syndrome, cardiogenic pulmonary edema, pneumonia, and acute pulmonary embolism. In addition, the utility of LUS has expanded in recent years to aid in the ongoing management of critically ill patients with ARF, providing guidance in volume status and fluid administration, titration of positive end-expiratory pressure, and ventilator liberation. The aims of this review are to examine the basic foundational concepts regarding the performance and interpretation of LUS, and to appraise the current literature supporting the use of this technique in the diagnosis and continued management of patients with ARF.

Lung Ultrasound for the Cardiologist

For a cardiologist, lung ultrasound is an add-on to transthoracic echocardiography, just as lung auscultation is part of a cardiac physical examination. A cardiac 3.5- to 5.0-MHz transducer is generally suitable because the small footprint makes it ideal for scanning intercostal spaces. The image quality is often adequate, and the lung acoustic window is always patent. The cumulative increase in imaging time is <1 min for the 2 main applications targeted on pleural water (pleural effusion) and lung water (pulmonary congestion as multiple B-lines). In these settings, lung ultrasound outperforms the diagnostic accuracy of the chest radiograph, with a low-cost, portable, real-time, radiation-free method. A "wet lung" detected by lung ultrasound predicts impending acute heart failure decompensation and may trigger lung decongestion therapy. The doctors of tomorrow may still listen with a stethoscope to their patient's lung, but they will certainly be seeing it with ultrasound.

Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations

BACKGROUND

Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services.

METHODS

Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound.

RESULTS

On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies.

CONCLUSION

Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.

Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review

Heart failure is a common presentation to the emergency department (ED), which can be confused with other clinical conditions. This review provides an evidence-based summary of the current ED evaluation of heart failure. Acute heart failure is the gradual or rapid decompensation of heart failure, resulting from either fluid overload or maldistribution. Typical symptoms can include dyspnea, orthopnea, or systemic edema. The physical examination may reveal pulmonary rales, an S3 heart sound, or extremity edema. However, physical examination findings are often not sensitive or specific. ED assessments may include electrocardiogram, complete blood count, basic metabolic profile, liver function tests, troponin, brain natriuretic peptide, and a chest radiograph. While often used, natriuretic peptides do not significantly change ED treatment, mortality, or readmission rates, although they may decrease hospital length of stay and total cost. Chest radiograph findings are not definitive, and several other conditions may mimic radiograph findings. A more reliable modality is point-of-care ultrasound, which can facilitate the diagnosis by assessing for B-lines, cardiac function, and inferior vena cava size. These modalities, combined with clinical assessment and gestalt, are recommended.

Diagnostic accuracy and temporal impact of ultrasound in patients with dyspnea admitted to the emergency department

OBJECTIVE

Few studies have prospectively evaluated the diagnostic accuracy and temporal impact of ultrasound in the emergency department (ED) in a randomized manner. In this study, we aimed to perform a randomized, standard therapy controlled evaluation of the diagnostic accuracy and temporal impact of a standardized ultrasound strategy, versus standard care, in patients presenting to the ED with acute dyspnea.

METHODS

The patients underwent a standardized ultrasound examination that was blinded to the team caring for the patient. Ultrasound results remained blinded in patients randomized to the treating team but were unblinded in the interventional cohort. Scans were performed by trained emergency physicians. The gold standard diagnosis (GSDx) was determined by two physicians blinded to the ultrasound results. The same two physicians reviewed all data >30 days after the index visit.

RESULTS

Fifty-nine randomized patients were enrolled. The mean±standard deviation age was 54.4±11 years, and 37 (62%) were male. The most common GSDx was acute heart failure with reduced ejection fraction in 13 (28.3%) patients and airway diseases such as acute exacerbation of asthma or chronic obstructive pulmonary disease in 10 (21.7%). ED diagnostic accuracy, as compared to the GSDx, was 76% in the ultrasound cohort and 79% in the standard care cohort (P=0.796). Compared with the standard care cohort, the final diagnosis was obtained much faster in the ultrasound cohort (mean±standard deviation: 12±3.2 minutes vs. 270 minutes, P<0.001).

CONCLUSION

A standardized ultrasound approach is equally accurate, but enables faster ED diagnosis of acute dyspnea than standard care.

Prognostic Significance of Longitudinal Clinical Congestion Pattern in Chronic Heart Failure: Insights From TIME-CHF Trial

BACKGROUND

The relationship between longitudinal clinical congestion pattern and heart failure outcome is uncertain. This study was designed to assess the prevalence of congestion over time and to investigate its impact on outcome in chronic heart failure.

METHODS

A total of 588 patients with chronic heart failure older than 60 years of age with New York Heart Association (NYHA) functional class ≥II from the TIME-CHF study were included. The endpoints for this study were survival and hospitalization-free heart failure survival. Orthopnea, NYHA ≥III, paroxysmal nocturnal dyspnea, hepatomegaly, peripheral pitting edema, jugular venous distension, and rales were repeatedly investigated and related to outcomes. These congestion-related signs and symptoms were used to design a 7-item Clinical Congestion Index.

RESULTS

Sixty-one percent of patients had a Clinical Congestion Index ≥3 at baseline, which decreased to 18% at month 18. During the median [interquartile range] follow-up of 27.2 [14.3-39.8] months, 17%, 27%, and 47% of patients with baseline Clinical Congestion Index of 0, 1-2, and ≥3 at inclusion, respectively, died (P <.001). Clinical Congestion Index was identified as an independent predictor of mortality at all visits (P <.05) except month 6 and reduced hospitalization-free heart failure survival (P <.05). Successful decongestion was related to better outcome as compared to persistent congestion or partial decongestion (log-rank P <0.001).

CONCLUSIONS

The extent of congestion as assessed by means of clinical signs and symptoms decreased over time with intensified treatment, but it remained present or relapsed in a substantial number of patients with heart failure and was associated with poor outcome. This highlights the importance of appropriate decongestion in chronic heart failure.

Sensitivity and Specificity of B-Type Natriuretic Peptide in Diagnosing Heart Failure in Pregnancy

OBJECTIVE

To evaluate the performance of B-type natriuretic peptide as a diagnostic tool for heart failure in pregnant or postpartum women with singleton gestations.

METHODS

We conducted a retrospective study of diagnostic accuracy. We identified pregnant and postpartum women with B-type natriuretic peptide and echocardiography performed at an obstetric teaching hospital from 2007 to 2018. Women with known cardiac disease or multiple gestation were excluded. A panel of two cardiovascular disease experts, blinded to B-type natriuretic peptide values, determined the diagnosis of heart failure by consensus. Their judgement was based on detailed clinical features and parameters at the time of presentation with suspected heart failure. Where consensus could not be reached, differences were adjudicated by a third expert. A receiver operating characteristic curve estimated the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of B-type natriuretic peptide at various thresholds.

RESULTS

In total, 22 pregnant and 38 postpartum women were included in the cohort. Average age was 32±6.8 years. The most common clinical features at the time of presentation with suspected heart failure included preeclampsia (33/60, 55%), dyspnea (50/60, 83%), chest discomfort (34/60, 58%), and bilateral lower extremity edema (32/60, 53%). In total, 39 (65%) women had heart failure. The median B-type natriuretic peptide level was 326 pg/mL (interquartile range 200.5-390.5) in women with heart failure, as compared with 75.5 pg/mL (interquartile range 19-245) in women without heart failure (P<.01). The estimated optimal B-type natriuretic peptide cutoff was 111 (95% CI 78-291) pg/mL. Using this threshold, 45 (75%) women had an elevated B-type natriuretic peptide, which yielded a 95% sensitivity (95% CI 83-99), 62% specificity (95% CI 38-82), a positive likelihood ratio of 2.5 (95% CI 1.4-4.3), and a negative likelihood ratio of 0.1 (95% CI 0.0-0.3) for heart failure.

CONCLUSIONS

B-type natriuretic peptide is a useful clinical tool to evaluate pregnant and postpartum women with suspected heart failure.

Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease: A Systematic Review and Meta-analysis

BACKGROUND

Incorporating focused cardiac ultrasonography (FoCUS) into clinical examination could improve the diagnostic yield of bedside patient evaluation.

PURPOSE

To compare the accuracy of FoCUS-assisted clinical assessment versus clinical assessment alone for diagnosing left ventricular dysfunction or valvular disease in adults having cardiovascular evaluation.

DATA SOURCES

English-language searches of MEDLINE, Embase, and Web of Science from 1 January 1990 to 23 May 2019 and review of reference citations.

STUDY SELECTION

Eligible studies were done in patients having cardiovascular evaluation; compared FoCUS-assisted clinical assessment versus clinical assessment alone for the diagnosis of left ventricular systolic dysfunction, aortic or mitral valve disease, or pericardial effusion; and used transthoracic echocardiography as the reference standard.

DATA EXTRACTION

Three study investigators independently abstracted data and assessed study quality.

DATA SYNTHESIS

Nine studies were included in the meta-analysis. The sensitivity of clinical assessment for diagnosing left ventricular dysfunction (left ventricular ejection fraction <50%) was 43% (95% CI, 33% to 54%), whereas that of FoCUS-assisted examination was 84% (CI, 74% to 91%). The specificity of clinical assessment was 81% (CI, 65% to 90%), and that of FoCUS-assisted examination was 89% (CI, 85% to 91%). The sensitivities of clinical assessment and FoCUS-assisted examination for diagnosing aortic or mitral valve disease (of at least moderate severity) were 46% (CI, 35% to 58%) and 71% (CI, 63% to 79%), respectively. Both the clinical assessment and the FoCUS-assisted examination had a specificity of 94% (CI, 91% to 96%).

LIMITATION

Evidence was scant, persons doing ultrasonography had variable skill levels, and most studies had unclear or high risk of bias.

CONCLUSION

Clinical examination assisted by FoCUS has greater sensitivity, but not greater specificity, than clinical assessment alone for identifying left ventricular dysfunction and aortic or mitral valve disease; FoCUS-assisted examination may help rule out cardiovascular pathology in some patients, but it may not be sufficient for definitive confirmation of cardiovascular disease suspected on physical examination.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42019124318).

Accuracy of Several Lung Ultrasound Methods for the Diagnosis of Acute Heart Failure in the ED: A Multicenter Prospective Study

BACKGROUND

Early appropriate diagnosis of acute heart failure (AHF) is recommended by international guidelines. This study assessed the value of several lung ultrasound (LUS) strategies for identifying AHF in the ED.

METHODS

This prospective study, conducted in four EDs, included patients with diagnostic uncertainty based on initial clinical judgment. A clinical diagnosis score for AHF (Brest score) was quantified, followed by an extensive LUS examination performed according to the 4-point (BLUE protocol) and 6-, 8-, and 28-point methods. The primary outcome was AHF discharge diagnosis adjudicated by two senior physicians blinded to LUS measurements. The C-index was used to quantify discrimination.

RESULTS

Among the 117 included patients, AHF (n = 69) was identified in 27.4%, 56.2%, 54.8%, and 76.7% of patients with the 4-point (two bilateral positive points), 6-point, 8-point (≥ 1 bilateral positive point), and 28-point (B-line count ≥ 30) methods, respectively. The C-index (95% CI) of the Brest score was 72.8 (65.3-80.3), whereas the C-index of the 4-, 6-, 8-, and 28-point methods were 63.7 (58.5-68.8), 72.4 (65.0-79.8), 74.0 (67.1-80.9), and 72.4 (63.9-80.9). The highest increase in the C-index on top of the BREST score was observed with the 8-point method in the whole population (6.9; 95% CI, 1.6-12.2; P = .010) and in the population with an intermediate Brest score, followed by the 6-point method.

CONCLUSIONS

In patients with diagnostic uncertainty, the 6-point/8-point LUS method (using the 1 bilateral positive point threshold) improves AHF diagnosis accuracy on top of the BREST score.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03194243; URL: www.clinicaltrials.gov.

Expert consensus document: Reporting checklist for quantification of pulmonary congestion by lung ultrasound in heart failure

Lung ultrasound is a useful tool for the assessment of patients with both acute and chronic heart failure, but the use of different image acquisition methods, inconsistent reporting of the technique employed and variable quantification of 'B-lines,' have all made it difficult to compare published reports. We therefore need to ensure that future studies utilizing lung ultrasound in the assessment of heart failure adopt a standardized approach to reporting the quantification of pulmonary congestion. Strategies to improve patient care by use of lung ultrasound in the assessment of heart failure have been difficult to develop. In the present document, key aspects of standardization are discussed, including equipment used, number of chest zones assessed, the method of quantifying B-lines, the presence and timing of additional investigations (e.g. natriuretic peptides and echocardiography) and the impact of therapy. This consensus report includes a checklist to provide standardization in the preparation, review and analysis of manuscripts. This will serve as a guide for investigators and clinicians and enhance the quality and transparency of lung ultrasound research.

A decade of progress in critical care echocardiography: a narrative review

INTRODUCTION

This narrative review focusing on critical care echocardiography (CCE) has been written by a group of experts in the field, with the aim of outlining the state of the art in CCE in the 10 years after its official recognition and definition.

RESULTS

In the last 10 years, CCE has become an essential branch of critical care ultrasonography and has gained general acceptance. Its use, both as a diagnostic tool and for hemodynamic monitoring, has increased markedly, influencing contemporary cardiorespiratory management. Recent studies suggest that the use of CCE may have a positive impact on outcomes. CCE may be used in critically ill patients in many different clinical situations, both in their early evaluation of in the emergency department and during intensive care unit (ICU) admission and stay. CCE has also proven its utility in perioperative settings, as well as in the management of mechanical circulatory support. CCE may be performed with very simple diagnostic objectives. This application, referred to as basic CCE, does not require a high level of training. Advanced CCE, on the other hand, uses ultrasonography for full evaluation of cardiac function and hemodynamics, and requires extensive training, with formal certification now available. Indeed, recent years have seen the creation of worldwide certification in advanced CCE. While transthoracic CCE remains the most commonly used method, the transesophageal route has gained importance, particularly for intubated and ventilated patients.

CONCLUSION

CCE is now widely accepted by the critical care community as a valuable tool in the ICU and emergency department, and in perioperative settings.

Point-of-care ultrasound in end-stage kidney disease: beyond lung ultrasound

PURPOSE OF REVIEW

Following the miniaturization of ultrasound devices, point-of-care ultrasound (POCUS) has been proposed as a tool to enhance the value of physical examination in various clinical settings. The objective of this review is to describe the potential applications of POCUS in end-stage renal disease patients (ESRD).

RECENT FINDINGS

With basic training, the clinician can perform pulmonary, vascular, cardiac, and abdominal POCUS at the bedside of ESRD patients. Pulmonary ultrasound can be used to quantify pulmonary congestion and for the differential diagnosis of dyspnea. Ultrasound of the inferior vena cava combined with simple cardiac ultrasound can be used to promptly investigate the mechanism of hemodynamic instability. Vascular ultrasound can be used for troubleshooting of arteriovenous fistula problems and for catheter installation. Multiple potential applications of POCUS in the ESRD population are reviewed, including areas of future research.

SUMMARY

Acquiring basic skills in POCUS may improve patient care through the rapid identification of threats, improved diagnostic abilities for common symptoms, and safer procedures. The adoption of POCUS in undergraduate, internal medicine and nephrology training curriculums will likely lead to a gradual introduction of this technology in the care of ESRD patients.

Design and rationale of the B-lines lung ultrasound guided emergency department management of acute heart failure (BLUSHED-AHF) pilot trial

BACKGROUND

Medical treatment for acute heart failure (AHF) has not changed substantially over the last four decades. Emergency department (ED)-based evidence for treatment is limited. Outcomes remain poor, with a 25% mortality or re-admission rate within 30days post discharge. Targeting pulmonary congestion, which can be objectively assessed using lung ultrasound (LUS), may be associated with improved outcomes.

METHODS

BLUSHED-AHF is a multicenter, randomized, pilot trial designed to test whether a strategy of care that utilizes a LUS-driven treatment protocol outperforms usual care for reducing pulmonary congestion in the ED. We will randomize 130 ED patients with AHF across five sites to, a) a structured treatment strategy guided by LUS vs. b) a structured treatment strategy guided by usual care. LUS-guided care will continue until there are ≤15 B-lines on LUS or 6h post enrollment. The primary outcome is the proportion of patients with B-lines ≤ 15 at the conclusion of 6 h of management. Patients will continue to undergo serial LUS exams during hospitalization, to better understand the time course of pulmonary congestion. Follow up will occur through 90days, exploring days-alive-and-out-of-hospital between the two arms. The study is registered on ClinicalTrials.gov (NCT03136198).

CONCLUSION

If successful, this pilot study will inform future, larger trial design on LUS driven therapy aimed at guiding treatment and improving outcomes in patients with AHF.

Increased Plasma Soluble Fractalkine in Patients with Chronic Heart Failure and Its Clinical Significance

Fractalkine has been reported to play an important role in the pathophysiology of various cardiovascular disorders. This research aims to study the change of soluble fractalkine (sFKN) in plasma level of patients with chronic heart failure (CHF) and evaluate its prognostic value.A total of 96 patients with CHF and 45 healthy subjects were included in this study. The plasma levels of sFKN, brain natriuretic peptide (BNP), and Interleukin-18 (IL-18) were determined by ELISA kits when they were first admitted to the hospital. Left ventricular ejection fraction (LVEF) was measured by echocardiogram. Rehospitalization status within 1 year after the first hospitalization was also recorded.The plasma levels of sFKN, BNP, and IL-18 in patients with CHF were significantly higher than in the control group (P < 0.05). The concentrations of sFKN and BNP were increased with the severity of heart failure classified by NYHA classification (P < 0.05). There were no statistical differences among all CHF subgroups classified by etiology (P > 0.05). Plasma sFKN level in CHF group was positively correlated with BNP (r = 0.441, P < 0.001) and IL-18 (r = 0.592, P < 0.001). Receiver operating characteristic curve analysis showed that area under the curve values of FKN, BNP, and IL-18 were 0.885 (95%CI: 0.810 to 0.960, P < 0.001), 0.889 (95%CI: 0.842 to 0.956, P < 0.001), and 0.878 (95%CI: 0.801-0.954, P < 0.001), respectively. The concentrations of sFKN and BNP were increased in patients readmitted more than once within 1 year (P < 0.05).

Ability of non-physicians to perform and interpret lung ultrasound: A systematic review

BACKGROUND

Lung ultrasound is a useful tool in the assessment of pulmonary congestion in heart failure that is typically performed and interpreted by physicians at the point-of-care.

AIMS

To investigate the ability of nurses, students, and paramedics to accurately identify B-lines and pleural effusions for the detection of pulmonary congestion in heart failure and to examine the training necessary.

METHODS AND RESULTS

We conducted a systematic review and searched online databases for studies that investigated the ability of nurses, students, and paramedics to perform lung ultrasound and detect B-lines and pleural effusions. Of 979 studies identified, 14 met our inclusion criteria: five in nurses, eight in students, and one in paramedics. After 0-12 h of didactic training and 58-62 practice lung ultrasound examinations, nurses were able to identify B-lines and pleural effusions with a sensitivity of 79-98% and a specificity of 70-99%. In image adequacy studies, medical students with 2-9 h of training were able to acquire adequate images for B-lines and pleural effusions in 50-100%. Only one eligible study investigated paramedic-performed lung ultrasound which did not support the ability of paramedics to adequately acquire and interpret lung ultrasound images after 2 h of training.

CONCLUSIONS

Our findings suggest that nurses and students can accurately acquire and interpret lung ultrasound images after a brief training period in a majority of cases. The examination of heart failure patients with lung ultrasound by non-clinicians appears feasible and warrants further investigation.

A systematic review of clinical prediction rules for the diagnosis of chronic heart failure

Aims

This study sought to review the literature for clinical prediction models for the diagnosis of patients with chronic heart failure in the community and to validate the models in a novel cohort of patients with a suspected diagnosis of chronic heart failure.

Methods and results

MEDLINE and Embase were searched from 1946 to Q4 2017. Studies were eligible if they contained at least one multivariable model for the diagnosis of chronic heart failure applicable to the primary care setting. The CHARMS checklist was used to evaluate models. We also validated models, where possible, in a novel cohort of patients with a suspected diagnosis of heart failure referred to a rapid access diagnostic clinic.

In total, 5310 articles were identified with nine articles subsequently meeting the eligibility criteria. Three models had undergone internal validation, and four had undergone external validation. No clinical impact studies have been completed to date. Area under the curve (AUC) varied from 0.74 to 0.93 and from 0.60 to 0.65 in the novel cohort for clinical models alone with AUC up to 0.89 in combination with electrocardiogram and B‐type natriuretic peptide (BNP). The AUC for BNP was 0.86 (95% confidence interval 83.3–88.6%).

Conclusions

This review demonstrates that there are a number of clinical prediction rules relevant to the diagnosis of chronic heart failure in the literature. Clinical impact studies are required to compare the use of clinical prediction rules and biomarker strategies in this setting.

Early Treatment in Emergency Department Patients with Acute Heart Failure: Does Time Matter?

PURPOSE OF REVIEW

Acute heart failure accounts for over one million hospital discharges annually. Current guidelines suggest treatments for AHF should begin "without delay" but this time interval has not been clearly defined.

RECENT FINDINGS

Data suggest that certain treatments such as earlier treatment with diuretics and vasodilators may improve patient symptom relief, morbidity, and mortality. Secondary analyses of clinical trials of novel treatments under development have not shown similar results. The data are equivocal regarding the impact of early treatment in AHF on in-hospital and long-term morbidity and mortality. Improved clinical trial designs will help answer when and if "early" treatment should begin and whether it impacts short- and long-term outcomes in AHF.

Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis

IMPORTANCE

Standard tools used to diagnose pulmonary edema in acute decompensated heart failure (ADHF), including chest radiography (CXR), lack adequate sensitivity, which may delay appropriate diagnosis and treatment. Point-of-care lung ultrasonography (LUS) may be more accurate than CXR, but no meta-analysis of studies directly comparing the 2 tools was previously available.

OBJECTIVE

To compare the accuracy of LUS with the accuracy of CXR in the diagnosis of cardiogenic pulmonary edema in adult patients presenting with dyspnea.

DATA SOURCES

A comprehensive search of MEDLINE, Embase, and Cochrane Library databases and the gray literature was performed in May 2018. No language or year limits were applied.

STUDY SELECTION

Study inclusion criteria were a prospective adult cohort of patients presenting to any clinical setting with dyspnea who underwent both LUS and CXR on initial assessment with imaging results compared with a reference standard ADHF diagnosis by a clinical expert after either a medical record review or a combination of echocardiography findings and brain-type natriuretic peptide criteria. Two reviewers independently assessed the studies for inclusion criteria, and disagreements were resolved with discussion.

DATA EXTRACTION AND SYNTHESIS

Reporting adhered to the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy and the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Two authors independently extracted data and assessed the risk of bias using a customized QUADAS-2 tool. The pooled sensitivity and specificity of LUS and CXR were determined using a hierarchical summary receiver operating characteristic approach.

MAIN OUTCOMES AND MEASURES

The comparative accuracy of LUS and CXR in diagnosing ADHF as measured by the differences between the 2 modalities in pooled sensitivity and specificity.

RESULTS

The literature search yielded 1377 nonduplicate titles that were screened, of which 43 articles (3.1%) underwent full-text review. Six studies met the inclusion criteria, representing a total of 1827 patients. Pooled estimates for LUS were 0.88 (95% Cl, 0.75-0.95) for sensitivity and 0.90 (95% Cl, 0.88-0.92) for specificity. Pooled estimates for CXR were 0.73 (95% CI, 0.70-0.76) for sensitivity and 0.90 (95% CI, 0.75-0.97) for specificity. The relative sensitivity ratio of LUS, compared with CXR, was 1.2 (95% CI, 1.08-1.34; P < .001), but no difference was found in specificity between tests (relative specificity ratio, 1.0; 95% CI, 0.90-1.11; P = .96).

CONCLUSIONS AND RELEVANCE

The findings suggest that LUS is more sensitive than CXR in detecting pulmonary edema in ADHF; LUS should be considered as an adjunct imaging modality in the evaluation of patients with dyspnea at risk of ADHF.

Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial

AIMS

Although acute decompensated heart failure (ADHF) is a common cause of dyspnoea, its diagnosis still represents a challenge. Lung ultrasound (LUS) is an emerging point-of-care diagnostic tool, but its diagnostic performance for ADHF has not been evaluated in randomized studies. We evaluated, in patients with acute dyspnoea, accuracy and clinical usefulness of combining LUS with clinical assessment compared to the use of chest radiography (CXR) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in conjunction with clinical evaluation.

METHODS AND RESULTS

This was a randomized trial conducted in two emergency departments. After initial clinical evaluation, patients with acute dyspnoea were classified by the treating physician according to presumptive aetiology (ADHF or non-ADHF). Patients were subsequently randomized to continue with either LUS or CXR/NT-proBNP. A new diagnosis, integrating the results of both initial assessment and the newly obtained findings, was then recorded. Diagnostic accuracy and clinical usefulness of LUS and CXR/NT-proBNP approaches were calculated. A total of 518 patients were randomized. Addition of LUS had higher accuracy [area under the receiver operating characteristic curve (AUC) 0.95] than clinical evaluation alone (AUC 0.88) in identifying ADHF (P < 0.01). In contrast, use of CXR/NT-proBNP did not significantly increase the accuracy of clinical evaluation alone (AUC 0.87 and 0.85, respectively; P > 0.05). The diagnostic accuracy of the LUS-integrated approach was higher then that of the CXR/Nt-proBNP-integrated approach (AUC 0.95 vs. 0.87, p < 0.01). Combining LUS with the clinical evaluation reduced diagnostic errors by 7.98 cases/100 patients, as compared to 2.42 cases/100 patients in the CXR/Nt-proBNP group.

CONCLUSION

Integration of LUS with clinical assessment for the diagnosis of ADHF in the emergency department seems to be more accurate than the current diagnostic approach based on CXR and NT-proBNP.

Euvolemia-A critical target in the management of acute kidney injury

It has been clearly established that critically ill patients with sepsis require prompt fluid resuscitation. The optimal amount of fluid and when to taper this resuscitation is less clear. There is a growing evidence that fluid overload leads to acute kidney injury, and increased morbidity and mortality. A clinician's best intentions in resuscitating a patient can lead to too much of a good thing. Currently, there are several bedside tools to aid in determining a patient's response to a fluid challenge as well as in the assessment of the current volume status. Guidelines are not available on the exact rate of fluid overload removal and what medicinal or mechanical modality is most favorable. We discuss our experience and an examination of the literature on the problems with fluid overload, and how a patient may benefit from forced fluid removal.

Strain analysis for the identification of hypertensive cardiac end-organ damage in the emergency department

Hypertensive emergency is a life-threatening state. End-organ damage affecting the heart accounts for up to 52% of hypertensive emergencies commonly encountered in the emergency department. Recent evidence indicates that strain echocardiography with computerized speckle-tracking is more sensitive at identifying hypertension induced changes in the left ventricle (LV) mechanical function than traditional 2-D echocardiography. We present a case demonstrating the use of emergency physician performed point-of-care strain echocardiography to identify and quantify LV mechanical dysfunction during a hypertensive crisis and to monitor improvement over 6 h.

Complex assessment of patients with decompensated heart failure: The clinical value of impedance cardiography and N-terminal pro-brain natriuretic peptide

BACKGROUND

Acute decompensated heart failure (ADHF) is a serious clinical problem and a condition requiring immediate diagnostics, supporting the therapeutic decision adequate to the specific ADHF mechanism. N-terminal pro-brain natriuretic peptide (NT-proBNP) is an established biochemical marker of heart failure, strongly related to hemodynamic status. Impedance cardiography (ICG) provides non-invasive hemodynamic assessment that can be performed immediately at the bedside and revealed to be useful diagnostic tool in some clinical settings in cardiology.

OBJECTIVES

The aim of this study was to evaluate the usefulness of ICG in the admission diagnostics and monitoring the effects of treatment in patients hospitalized due to ADHF, with special emphasis on its relation to NT-proBNP.

METHODS

This study enrolled 102 patients, aged over 18 years, hospitalized due to ADHF. The subjects underwent detailed clinical assessment, including ICG and NT-proBNP at admission and at discharge day.

RESULTS

Among all analyzed ICG parameters thoracic fluid content (TFC), a marker of chest overload, was the most significantly correlated with NT-proBNP level (R = 0.46; p = 0.000001). In comparison with patients with low thoracic fluid content (TFC ≤ 35/kΩ), those with higher TFC values (>35/kΩ) exhibited a greater severity of symptoms (NYHA functional class); higher NT-proBNP levels; lower left ventricular ejection fraction (LVEF), stroke index (SI), and cardiac index (CI); as well as significantly higher systemic vascular resistance index (SVRI). These TFC-based subgroups showed no significant differences in terms of heart rate (HR), systolic blood pressure (SBP), or diastolic blood pressure (DBP).

CONCLUSIONS

The evaluation of hemodynamic parameters, especially TFC, seems to be a worthwhile addition to standard diagnostics, both at the stage of hospital admission and while monitoring the effects of treatment. Impedance cardiography is a useful method in evaluating individual hemodynamic profiles in patients with ADHF.

Preventable delays to intravenous furosemide administration in the emergency department prolong hospitalization for patients with acute heart failure

BACKGROUND

We sought to examine whether factors impacting the time to emergency department (ED) administration of intravenous (IV) furosemide were associated with the duration of hospital admission for patients with acute heart failure (AHF).

METHODS AND RESULTS

We conducted a single-center, retrospective analysis of patients presenting to the ED and admitted between January 1, 2007 and December 31, 2014 who received a dose of IV furosemide. A Cox proportional hazards model was used to examine the likelihood that a patient would be discharged home alive, adjusting for patient demographics, AHF severity (low, moderate, high), laboratory result timing, and known AHF confounders. We identified 695 patients who met study criteria with 430 (61.9%) in the low-severity group. In the overall model, every 60-minute delay in IV furosemide administration was associated with an 8% lower chance of successful discharge home relative to someone who received early furosemide (aHR 0.93, 95%CI 0.87, 0.98, P = 0.012). Subgroup analysis suggests this association was most impactful in low-acuity patients. Our adjusted analysis suggests delaying furosemide administration until after serum creatinine results resulted in a 41% lower chance of successful discharge home relative to someone who had furosemide administered prior to creatinine results (aHR 1.41, 95%CI 1.07, 1,84).

CONCLUSIONS

AHF patients, particularly those with lower severity, may benefit from rapid administration of IV furosemide in the ED. This suggests that a key determinant of hospital visit duration in this low-risk cohort is decongestion, which occurs sooner when IV therapy is begun early in the ED stay regardless of serum creatinine.

Lung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-analysis

BACKGROUND

Lung ultrasound can accelerate the diagnosis of life-threatening diseases in adults with respiratory symptoms.

OBJECTIVE

Systematically review the accuracy of lung ultrasonography (LUS) for emergency diagnosis of pneumonia, acute heart failure, and exacerbation of chronic obstructive pulmonary disease (COPD)/asthma in adults.

METHODS

PubMed, Embase, Scopus, Web of Science, and LILACS (Literatura Latino Americana e do Caribe em Ciências da Saúde; until 2016) were searched for prospective diagnostic accuracy studies. Rutter-Gatsonis hierarchical summary receiver operating characteristic method was used to measure the overall accuracy of LUS and Reitsma bivariate model to measure the accuracy of the different sonographic signs. This review was previously registered in PROSPERO (Centre for Reviews and Dissemination, University of York, York, UK; CRD42016048085).

RESULTS

Twenty-five studies were included: 14 assessing pneumonia, 14 assessing acute heart failure, and four assessing exacerbations of COPD/asthma. The area under the summary receiver operating characteristic curve of LUS was 0.948 for pneumonia, 0.914 for acute heart failure, and 0.906 for exacerbations of COPD/asthma. In patients suspected to have pneumonia, consolidation had sensitivity of 0.82 (95% confidence interval [CI] 0.74-0.88) and specificity of 0.94 (95% CI 0.85-0.98) for this disease. In acutely dyspneic patients, modified diffuse interstitial syndrome had sensitivity of 0.90 (95% CI 0.87-0.93) and specificity of 0.93 (95% CI 0.91-0.95) for acute heart failure, whereas B-profile had sensitivity of 0.93 (95% CI 0.72-0.98) and specificity of 0.92 (95% CI 0.79-0.97) for this disease in patients with respiratory failure. In patients with acute dyspnea or respiratory failure, the A-profile without PLAPS (posterior-lateral alveolar pleural syndrome) had sensitivity of 0.78 (95% CI 0.67-0.86) and specificity of 0.94 (95% CI 0.89-0.97) for exacerbations of COPD/asthma.

CONCLUSION

Lung ultrasound is an accurate tool for the emergency diagnosis of pneumonia, acute heart failure, and exacerbations of COPD/asthma.

Cardiogenic Shock

Cardiogenic shock (CS) is a physiologic state in which cardiac pump function is inadequate to perfuse the tissues. If CS is not rapidly recognized and treated, tissue hypoperfusion can quickly lead to organ dysfunction and patient death. Evaluation of patients with suspected CS should include an electrocardiogram, chest radiograph, laboratory studies, and bedside echocardiogram. Initial resuscitation is directed toward restoring cardiac output and tissue perfusion. Mechanical circulatory support is indicated for patients with CS who do not respond to pharmacologic therapy. Ultimately, these patients should undergo emergent reperfusion therapy with either percutaneous coronary intervention or coronary artery bypass grafting.

Diagnostic chest ultrasound for acute respiratory failure

Acute respiratory failure (ARF) is a common life-threatening medical condition, with multiple underlying aetiologies. Diagnostic chest ultrasound provides accurate diagnosis of conditions that commonly cause ARF, and may improve overall diagnostic accuracy in critical care settings as compared to standard diagnostic approaches. Respiratory physicians are becoming increasingly familiar with ultrasound as a part of routine clinical practice, although the majority of data to date has focused on the emergency and intensive care settings. This review will examine the evidence for the use of diagnostic chest ultrasound, focusing on different levels of imaging efficacy; specifically ultrasound test attributes, impacts on clinician behaviour and impact on health outcomes. The evidence behind use of multi-modality ultrasound examinations in ARF will be reviewed. It is hoped that readers will become familiar with the advantages and potential issues with chest ultrasound, as well as evidence gaps in the field.

Misconceptions in acute heart failure diagnosis and Management in the Emergency Department

INTRODUCTION

Acute heart failure (AHF) accounts for a significant number of emergency department (ED) visits, and the disease may present along a spectrum with a variety of syndromes.

OBJECTIVE

This review evaluates several misconceptions concerning heart failure evaluation and management in the ED, followed by several pearls.

DISCUSSION

AHF is a heterogeneous syndrome with a variety of presentations. Physicians often rely on natriuretic peptides, but the evidence behind their use is controversial, and these should not be used in isolation. Chest radiograph is often considered the most reliable imaging test, but bedside ultrasound (US) provides a more sensitive and specific evaluation for AHF. Diuretics are a foundation of AHF management, but in pulmonary edema, these medications should only be provided after vasodilator administration, such as nitroglycerin. Nitroglycerin administered in high doses for pulmonary edema is safe and effective in reducing the need for intensive care unit admission. Though classically dopamine is the first vasopressor utilized in patients with hypotensive cardiogenic shock, norepinephrine is associated with improved outcomes and lower mortality. Disposition is complex in patients with AHF, and risk stratification tools in conjunction with other assessments allow physicians to discharge patients safely with follow up.

CONCLUSION

A variety of misconceptions surround the evaluation and management of heart failure including clinical assessment, natriuretic peptide use, chest radiograph and US use, nitroglycerin and diuretics, vasopressor choice, and disposition. This review evaluates these misconceptions while providing physicians with updates in evaluation and management of AHF.

Sources of Variability in the Detection of B-Lines, Using Lung Ultrasound

Lung ultrasound (LUS) is a largely employed diagnostic tool but an operational protocol for implementation has never been proposed. The lack of standardization clearly introduces variability in LUS results. We enrolled adult patients presenting for acute dyspnea with a clinical suspect of etiology related to heart failure. We calculated agreement among four providers in assessing B-lines. We varied probes, depth, evaluation time and scanning areas and we estimated the importance of each factors on B-lines assessment. Overall agreement among raters varied from a kappa of 0.70 to 0.81. The mean number of B-lines was 5.44 (95% confidence interval, CI, 4.1-6.8). This estimate did not suffer variation by the depth used (0.03, 95% CI -0.2-0.2, more B-lines, using 19 cm versus 10 cm). The use of a convex probe and expertise in LUS reduced the number of artifacts by 1.7 (95% CI 1.5-1.9) and 1.1 in comparison with a phased array probe and naive operators. Evaluation time increased estimates by 1.2 (95% CI 1-1.5) and 2.9 (95% CI 2.7-3.9) B-lines for 4" and 7" clips (reference was 2" clips). This study suggests that the probe, the evaluation time and the level of expertise might affect the results of quantitative assessment of B-lines.