Beyond clinical examination and natriuretic peptides: comprehensive quantification of congestion with ultrasound in ambulatory heart failure patients

Abstract

This article refers to 'Prevalence, pattern and clinical relevance of ultrasound indices of congestion in outpatients with heart failure' by P. Pellicori et al., published in this issue on pages 904-916.Clinical congestion plays a central role in the development of heart failure (HF)-related symptoms and is the cause of the majority of hospitalizations for HF (HHF). 1,2 Relieving congestion is consequently an important goal of HF management. 3 Physical examination in patients with HF has limited accuracy for the detection of congestion, 4 which supports using additional tools in the evaluation of HF patients to improve risk stratification and possibly guide patient management. In the latest European Society of Cardiology HF guidelines, using ultrasound measurement of inferior vena cava (IVC) diameter for assessment of volume status has a IIbC recommendation, whereas the use of thoracic ultrasound is cited in the text but does not have a formal recommendation. 3 The toolbox of sonographic methods that are relevant to congestion evaluation includes pulmonary congestion on lung ultrasound (LUS) (B-lines, pleural effusions), haemodynamic congestion on echocardiography (e.g. E/e' and systolic pulmonary artery pressure) and vascular ultrasound [IVC and jugular vein diameter (JVD) measurement]. LUS is a semi-quantitative, simple, and rapid method to assess pulmonary congestion 5 ; this technique produces vertical lines defined as 'B-lines' by scanning along the intercostal spaces using either a phased array or curvilinear transducer. Pulmonary congestion identified by LUS has been shown to be a strong predictor of outcomes following a HHF 6 -8 and in ambulatory patients with HF. 8,9 E/e' and elevated pulmonary artery pressures measured using echocardiography have been shown to be

Risk of readmission and death after hospitalization for worsening heart failure: Role of post‐discharge follow‐up visits in a real‐world study from the Grand Est Region of France

“…The mortality reduction derived from this combined follow-up could be explained by several factors including (i) better congestion management, e.g. including ultrasound-guided strategies, 26,27 which can reduce the detrimental burden of residual congestion, 1,28 and (ii) early implementation of fast-acting drugs such as sodium-glucose cotransporter 2 inhibitors or sacubitril/valsartan 4,[29][30][31] whose effect may be more pronounced in the most severe patients. 4,32 Importantly, the STRONG-HF trial recently highlighted that frequent outpatient visits, along with aggressive and rapid up-titration of current HF drugs is feasible and associated with a reduction in 180-day HF readmission or all-cause death.…”

Cardiac congestion assessed by natriuretic peptides oversimplifies the definition and treatment of heart failure

“… 10 In these echographic assessment, inferior vena cava and internal jugular vein allow to assess central congestion; intrarenal venous flow can facilitate detection of elevated venous pressures, which might help to assess diuretic responsiveness, whereas lung ultrasound enables detection and quantification of extravascular lung fluid. 11 Additionally, a comprehensive analysis of echocardiographic variables allows a non‐invasive assessment of intracardiac pressures ( Figure 1 ). As such, a more widespread adoption of non‐invasive techniques will complement clinical skills, which should allow for improved diagnosis and management of patients with known or suspected HF.…”