Using Lung Ultrasound to Diagnose and Manage Acute Heart Failure

Transcription

1 Using Lung Ultrasound to Diagnose and Manage Acute Heart Failure Jennifer Martindale, MD Assistant Professor Department of Emergency Medicine SUNY Downstate/Kings County Hospital Brooklyn, NY

2 What is acute heart failure? New onset or recurrence of gradually or rapidly worsening signs and symptoms of heart failure (HF) necessitating urgent or emergency therapeutic intervention Gheorghiade M et al. Acute heart failure syndromes: current state and framework for future research. Circulation 2005;112: Pulmonary congestion caused by elevated cardiac filling pressures Martindale JL

3 The diagnosis of acute heart failure is often missed. H&P, CXR, ECG Misclassification rate 25% Bayes-Genis et al. NT-proBNP in the emergency diagnosis and inhospitable monitoring. European J Heart Failure Villacorata H, et al. The role of B-type natriuretic peptide. Are Bras Cardiol McCullough, et al. B-type natriuretic peptide and clinical judgment. Circulation BNP Collins SP et al. The combined utility of S3 and BNP. J Cardiac Fail Collins SP, et al. s3 detection as a diagnostic and prognostic aid. Ann Emerg Med Lockage A, et al. BNP testing and the accuracy of heart failure diagnosis. Cir Heart Failure %

4 Exam findings are insensitive. + LR - LR 2.8 ( ) 0.8 ( ) 4.0 ( ) 0.9 ( ) 1.8 ( ) 0.6 ( ) 1.9 ( ) 0.7 ( ) Martindale JL, Wakai A, Collins S, Levy PD, Diercks D, Hiestand B, Fermann G, desouza I, and Sinert R. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-Analysis. Academic Emergency Medicine. Academic Emergency Medicine. March 2016.

5 Standard diagnostic tests help somewhat. N + LR - LR Pulmonary Edema ( ) 0.48 ( ) Pleural Effusions ( ) 0.89 ( ) Reduced EF ( ) 0.24 ( ) Martindale JL, Wakai A, Collins S, Levy PD, Diercks D, Hiestand B, Fermann G, desouza I, and Sinert R. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-Analysis. Academic Emergency Medicine. Academic Emergency Medicine. March 2016.

6 Intermediate BNP values aren t very useful. H2N HOOC 100 pg/ml 1000 pg/ml Large grey zone.

7 Artifacts generated by lung ultrasound are useful.

8 Two bilateral lung zones with B-lines is a positive lung US

9 Lung ultrasound has good discriminatory value. Pre-Test Probability of AHF LR Post-Test Probability 95% 46% 1% 2 % 5 % 10% 20% 30% 40% 50% 60% 70% % 80% 70% 60% 50% 40% 30% 20% 10% 5% 86%: + Lung US 81%: BNP pg/ml 80%: Pulmonary Edema on CXR 78%: Reduced EF Bedside Echo 62%: BNP pg/ml 29%: No Pulmonary Edema on CXR 11%: - Lung US 10%: BNP pg/ml 6%: NT-ProBNP pg/ml 80% 2% 90% 1%

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11 Volume overload is only part of the picture. Cardiac Remodeling Increased filling pressures Decreased cardiac output Increased sympathetic tone Endothelin Norepinephrine Vasopressin Angiotensin Venous congestion Increased vasoconstriction Endothelial dysfunction Decreased renal perfusion H20 retention Na+ retention Renin

12 Dyspnea occurs late in the course of AHF. Hemodynamic derangement (Elevated filling pressures) Pulmonary congestion Clinical congestion %

13 Our current measures of clinical improvement are limited. Weight Loss Costanzo et al. Ultrafiltration versus intravenous diuretics in patients hospitalized for acute decompensated heart failure. JACC Gheorghiade et al. Short-term clinical effects of tolvaptan vasopressin antagonist in patients hospitalized for heart failure: the EVERST clinical status trial. JAMA Serial BNP Singer et al. Rapid Emergency Department Heart Failure Outpatients Trial (REDHOT II) Circ Heart Failure Binanay et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness. the ESCAPE trial. JAMA Serum Creatinine Self-reported Dyspnea

14 Dyspnea is subjective. Measuring it is difficult. 10 cm I can breathe normally 5 Point Likert Scale: 2.1 cm I can t breathe at all Please rate your shortness of breath. 1 No shortness of breath 2 Mild shortness of breath 3 Moderate shortness of breath 4 Severe shortness of breath 5 Worst Possible shortness of breath

15 The sum of B-lines correlates with heart failure severity. # B-Lines 50 I II III IV NYHA Class # B-Lines 50 Nl Abnl Restrictive Pseudonormal Diastolic dysfunction Frassi et al. Clinical and Echocardiographic Determinants of Ultrasound Lung Comets. Eur J Echocardiography NT-proBNP r=0.69, p< Gargani et al. Ultrasound Lung Comets for the Differential Diagnosis of Acute Cadiogenic Edema: A Comparison wit Natriuretic Peptides. Euro J Heart Failure Extravascular Lung Water (Thermodilution) Pulmonary Capillary Wedge Pressure Agricola et al. Ultrasound comet-tail images: a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water. Chest r=0.42, p=0.001 r=0.48, p<

16 Let the counting begin.

17 Increase with exercise. B-lines change in real-time. B-line score PCWP Agricola, et al. Assessment of stress-induced pulmonary interstitial edema by chest ultrasound during exercise echocardiography. J Am Soc Echo Decrease with dialysis. Lines (% of pre-hd) N=34 TIME (min) Mallamaci et al. Detection of Pulmonary Congestion by Chest Ultrasound in Dialysis Patients. JACC: Cardiovascular Imaging Noble et al. Ultrasound Assessment for Extravascular Lung Water in Patients Undergoing Hemodialysis. Chest 2009.

18 B-Lines clear in response to inpatient AHF treatment. N=70 Right Thoracic area Positive Zone (Admission US) Positive Zone (Discharge US ) Anterior superior 51 (73%) 3 (4.3%) Anterior medium 54 (77%) 2 (2.9%) Anterior basal 65 (93%) 4 (5.7%) Lateral superior 64 (91%) 5 (7.1%) Lateral medium 67 (96%) 10 (14%) Lateral basal 68 (97%) 21 (30%) Anterior superior 52 (74%) 6 (8.6%) Left Anterior medium 58 (83%) 6 (8.6%) Lateral superior 63 (90%) 6 (8.6%) Lateral medium 70 (100%) 11 (16%) Lateral basal 70 (100%) 20 (29%) Volpicelli et al. Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. American Journal of Emergency Medicine

19 RALES Repeated Assessment of Lung Edema with Sonography ED with CC: dyspnea AHFS working dx SBP 180 mmhg B-Lines present bilaterally AHF Treatment in ED Dyspnea Score x-2 cm Disposition Decision T1 T2 T3 Vital Signs Dyspnea Score X Lung Ultrasound 1 Vital Signs Lung Ultrasound 2 Vital Signs Dyspnea Score Lung Ultrasound 3

20 Hypertensive AHF is about volume redistribution. Increase in Preload LVH Sympathetic Surge Increase in Afterload Epi + NE Splanchnic Circulation Arterial Hypertrophy Decreased aortic elastance IVC Pulmonary edema is severe. Response to treatment is dramatic.

21 Clinical and sonographic improvement is rapid. Prehospital SBP > 200 mmhg SL TNG x 6; NIV T1 BP: 193/101 HR: 88 RR: 26 O2: 96% on BIPAP FIO min T2 BP 164/83 HR: 79 RR: 24 O2: 93% on RA 5PLS: 4 Severe shortness of breath 3 Moderate shortness of breath I can breathe normally I can t breathe at all 8.8 cm 6 cm

22 B-Lines BE-GONE! 96 min

23 Post-discharge outcomes are poor. Rehospitalization 30-day 25% Gheorghiade M et al. Rehospitalization for heart failure. JACC day 1-year Mortality 5-year 10.4% 22% 42.3% Go et al. Heart Disease and Stroke Statistics. Circulation 2013

24 Residual congestion at discharge predicts re-hospitalization. N=60 Heart Failure Hospitalization N=100 Event-free survival (%) B-lines <20 B-lines > = 20 Time (days) Coiro S, et al. Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. European J HF Time (days) Gargani et al. Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure. Cardiovasc Ultrasound

25 Future studies to plan for. Pilot Study Hypertensive AHF Phenotype Observational Study All Phenotypes Prognostic Measure ED Course ED Course Hospitalization Readmission Effect Size Variability Inter-rater reliability Different rates of B-line clearance SPE Score at Discharge Randomized Trial B-Line Resolution Standard Discharge Criteria Readmission Mortality Compare sonographic-targeted treatment to standard management

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