Handcarried echocardiography to assess hemodynamics in acute decompensated heart failure. Curr Heart Fail Rep. 2010;7:219-227. [PMID: 20890689 DOI: 10.1007/s11897-010-0030-8]

Non-Invasive Assessment of Congestion by Cardiovascular and Pulmonary Ultrasound and Biomarkers in Heart Failure

Worsening chronic heart failure (HF) is responsible for recurrent hospitalization and increased mortality risk after discharge, irrespective to the ejection fraction. Symptoms and signs of pulmonary and systemic congestion are the most common cause for hospitalization of acute decompensated HF, as a consequence of increased cardiac filling pressures. The elevated cardiac filling pressures, also called hemodynamic congestion, may precede the occurrence of clinical congestion by days or weeks. Since HF patients often have comorbidities, dyspnoea, the main symptom of HF, may be also caused by respiratory or other illnesses. Recent studies underline the importance of the diagnosis and treatment of hemodynamic congestion before HF symptoms worsen, reducing hospitalization and improving prognosis. In this paper we review the role of integrated evaluation of biomarkers and imaging technics, i.e., echocardiography and pulmonary ultrasound, for the diagnosis, prognosis and treatment of congestion in HF patients.

Impact of Daily Bedside Echocardiographic Assessment on Readmissions in Acute Heart Failure: A Randomized Clinical Trial

Acute heart failure (AHF) management is challenging, with high morbidity and readmission rates. There is little evidence of the benefit of HF monitoring during hospitalization. The aim of the study was to assess whether daily bedside echocardiographic monitoring (JetEcho) improved outcomes in AHF. In this prospective, open, two parallel-arm study (clinicaltrials.gov: NCT02892227), participants from two university hospitals were randomized to either standard of care (SC) or daily treatment adjustment including diuretics guided by JetEcho evaluating left ventricular filling pressure and volemia. The primary outcome was 30-day readmission rate. Key secondary outcomes were six-month cumulative incidence death, worsening HF during hospitalization and increasing of myocardial and renal biomarkers. From 250 included patients, 115 were finally analyzed in JetEcho group and 112 in SC group. Twenty-two (19%) patients were readmitted within 30 days in JetEcho group and 17 (15%) in SC group (relative risk [RR] 1.26; 95% confidence interval [CI], 0.70−2.24; p = 0.4). Worsening HF occurred in 17 (14%) patients in the JetEcho group and 24 (20%) in the SC group (RR 0.7; 95% [CI] 0.39 to 1.2; p = 0.2). No significant difference was found between the two groups concerning natriuretic peptides and renal function (p > 0.05 for all). The cumulative incidence rate of death from any cause at six months from discharge was 8.7% in the JetEcho group and 11.6% in the SC group (HR 0.63, 95% [CI] 0.3−1.4, p = 0.3). In AHF patients, a systematic daily bedside echocardiographic monitoring did not reduce 30-day readmission rate for HF and short-term clinical outcomes.

Management of acute heart failure: Contribution of daily bedside echocardiographic assessment on therapy adjustment with impact measure on the 30-day readmission rate (JECICA)

There are currently one million heart failure (HF) patients in France and the rate is progressively increases due to population aging. Acute decompensation of HF is the leading cause of hospitalization in people over 65 years of age with a 25% re-hospitalization rate in the first month. Expenses related to the management of HF in France in 2013 amounted to more than one billion euros, of which 65% were for hospitalizations alone. The management of acute decompensation is a challenge, due to the complexity of clinical and laboratory evaluation leading to therapeutic errors, which in turn leads to longer hospitalization, high early re-hospitalization and complications. Therapeutic adjustment, especially diuretic, in the acute phase (during hospitalization) affects early re-hospitalization rates (within 30 days). These adjustments can be based on clinical estimation and laboratory parameters, but echocardiography has been shown to be superior in estimating filling pressures (FP) compared to clinical and laboratory parameters.

We hypothesize that a simple daily bedside echocardiographic assessment could provide a reproducible estimation of FP with an evaluation of mitral inflow and the inferior vena cava (IVC). This could allow a more reliable estimate of the true blood volume of the patient and thus lead to a more suitable therapeutic adjustment. This in turn should lead to a decrease in early re-admission rate (primary endpoint) and potentially decrease six-month mortality and rate of complications.

Serial lung and IVC ultrasound in the assessment of congestive heart failure

Background

Management of congestive heart failure (CHF) is dependent on clinical assessments of volume status, which are subjective and imprecise. Point-of-care ultrasound (POCUS) is useful in the diagnosis of CHF, but how POCUS findings correlate with therapy remains unknown. This study aimed to determine whether the changes in clinical evaluation of CHF with treatment are mirrored with changes in the number of B lines on lung ultrasound (LUS) and inferior vena cava (IVC) size. In this prospective observational study, investigators performed serial clinical and ultrasound assessments within 24 h of admission (T1), day 1 in hospital (T2) and within 24 h of discharge (T3). Clinical assessments included an evaluation of the jugular venous distension (JVD), hepatojugular reflux (HJR), pulmonary rales and a clinical congestion score was calculated. Ultrasound assessment included the IVC size and collapsibility, and the number of B lines in an 8-point scan.

Results

Fifty consecutive patients were recruited with a mean age of 71.2 years (SD 12.7). Mean clinical congestion score on admission was 5.6 (SD 1.4) and declined significantly over time to 1.3 (0.91), as did the JVP, HJR and pulmonary rales. No significant changes were found in the IVC size between T1 [1.9 (0.65)] and T3 [2.0 (0.50)] or in the IVC collapsibility index [T1 0.3 (0.19) versus T3 0.25 (0.16)]. The mean number of B lines decreased from 11 (6.1) at T1 to 8.3 (5.5) at T3, although this decrease did not reach statistical significance. Spearman correlation between JVP and HJR versus IVC collapsibility and total B lines did not yield significant results.

Conclusions

Clinical exam findings correlate over time during the management of CHF, whereas LUS and IVC results did not. The number of B lines did decrease with therapy, but did not reach statistical significance likely because the sampled population was small and had only mild heart failure. Further studies are warranted to further explore the use of lung ultrasound in this patient population.

Hand-carried ultrasound use in clinical nephrology: Case report

BACKGROUND

Correctly assessing and managing volume status are critical elements of daily care for patients managed by nephrologists. However, intravascular volume is difficult to assess by physical examination alone.

METHODS

We present vignettes illustrating the potential for using hand-carried ultrasound (HCU) to improve volume assessment in common clinical scenarios faced by the renal consultant in the hospital setting. These include patients with acute kidney injury and patients treated with hemodialysis.

RESULTS

We used HCU to provide essential information about volume status which is otherwise not readily available. HCU allowed objective assessment of volume status, helping with clinical management of hospitalized patients and potentially avoiding harm.

CONCLUSION

HCU can complement physical examination for volume assessment in hospitalized patients with acute kidney injury or those on hemodialysis. Our report highlights the need for systematic research in this area.

Outpatient Use of Focused Cardiac Ultrasound to Assess the Inferior Vena Cava in Patients With Heart Failure

Accurate assessment of volume status is critical in the management of patients with heart failure (HF). We studied the utility of a pocket-sized ultrasound device in an outpatient cardiology clinic as a tool to guide volume assessment. Inferior vena cava (IVC) size and collapsibility were assessed in 95 patients by residents briefly trained in focused cardiac ultrasound (FCU). Cardiologist assessment of volume status and changes in diuretic medication were also recorded. Patients were followed for occurrence of 30-day events. There was a 94% success rate of obtaining IVC size and collapsibility, and agreement between visual and calculated IVC parameters was excellent. Most patients were euvolemic by both FCU IVC and clinical bedside assessment (51%) and had no change in diuretic dose. Thirty-two percent had discrepant FCU IVC and clinical volume assessments. In clinically hypervolemic patients, the FCU evaluation of the IVC suggested that the wrong diuretic management plan might have been made 46% of the time. At 30 days, 14 events occurred. The incidence of events increased significantly with FCU IVC imaging categorization, from 11% to 23% to 36% in patients with normal, intermediate, and plethoric IVCs. By comparison, when grouped in a binary manner, there was no significant difference in event rates for patients who were deemed to be clinically volume overloaded. Assessment of volume status in an outpatient cardiology clinic using FCU imaging of the IVC is feasible in a high percentage of patients. A group of patients were identified with volume status discordant between FCU IVC and routine clinic assessment, suggesting that IVC parameters may provide a valuable supplement to the in-office physical examination.

Inferior Vena Cava and Hemodynamic Congestion

BACKGROUND

Among the indices able to replace invasive central venous pressure (CVP) measurement for patients with acute decompensated heart failure (ADHF) the diameters of the inferior vena cava (IVC) and their respiratory fluctuations, so-called IVC collapsibility index (IVCCI), measured by echocardiography, have recently gained ground as a quite reliable proxy of CVP.

OBJECTIVES

The aims of our study were to compare three different ways of evaluating cardiac overload by using the IVC diameters and/or respiratory fluctuations and by calculating the inter-method agreement.

PATIENTS AND METHODS

Medical records of patients hospitalized for right or bi-ventricular acute decompensated heart failure from January to December 2013 were retrospectively evaluated. The predictive significance of the IVC expiratory diameter and IVC collapsibility index (IVCCI) was analyzed using three different methods, namely a) the criteria for the indirect estimate of right atrial pressure by Rudski et al. (J Am Soc Echocardiogr. 2010); b) the categorization into three IVCCI classes by Stawicki et al. (J Am Coll Surg. 2009); and c) the subdivision based on the value of the maximum IVC diameter by Pellicori et al. (JACC Cardiovasc Imaging. 2013).

RESULTS

Among forty-seven enrolled patients, those classified as affected by persistent congestion were 22 (46.8%) using Rudski's criteria, or 16 (34%) using Stawicki's criteria, or 13 (27.6%) using Pellicori's criteria. The inter-rater agreement was rather poor by comparing Rudski's criteria with those of Stawicki (Cohen's kappa = 0.369; 95% CI 0.197 to 0.54), as well as by comparing Rudski's criteria with those of Pellicori (Cohen's kappa = 0.299; 95% CI 0.135 to 0.462). Further, a substantially unsatisfactory concordance was also found for Stawicki's criteria compared to those of Pellicori (Cohen's kappa= 0.468; 95% CI 0.187 to 0.75).

CONCLUSIONS

The abovementioned IVC ultrasonographic criteria for hemodynamic congestion appear clearly inconsistent. Alternatively, a sequential or simultaneous combination of clinical scores of congestion, IVC ultrasonographic indices, and circulating levels of natriuretic peptides could be warranted.

Diagnostic point-of-care ultrasound for hospitalists

We review the literature on diagnostic point-of-care ultrasound applications most relevant to hospital medicine and highlight gaps in the evidence base. Diagnostic point-of-care applications most relevant to hospitalists include cardiac ultrasound for left ventricular systolic function, pericardial effusion, and severe mitral regurgitation; lung ultrasound for pneumonia, pleural effusion, pneumothorax, and pulmonary edema; abdominal ultrasound for ascites, aortic aneurysm, and hydronephrosis; and venous ultrasound for central venous volume assessment and lower extremity deep venous thrombosis. Hospitalists and other frontline providers, as well as physician trainees at various levels of training, have moderate to excellent diagnostic accuracy after brief training programs for most of these applications. Despite the evidence supporting the diagnostic accuracy of point-of-care ultrasound, experimental evidence supporting its clinical use by hospitalists is limited to cardiac ultrasound.

Update on point of care ultrasound in the care of the critically ill patient

One of the most exciting developments to come to the aid of the critically ill patient in recent years is not new at all, but rather has been repackaged and evolved to a level where point-of-care use by critical care physicians has been made possible. Critical care or point-of-care ultrasound dates back more than twenty years, but has come to prominence in the last 5 years and is spreading quickly. Multiple critical care societies have taken up ultrasound policy and training and one organization has been formed that concentrates only on point-of-care ultrasound in critical settings and interventions. The amount of literature generated on the topic is increasing rapidly and hardly a major clinical journal exists that has not published ultrasound related topics.