Pulmonary Congestion by Lung Ultrasound in Ambulatory Patients With Heart Failure With Reduced or Preserved Ejection Fraction and Hypertension

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Aims Even if treatment controls symptoms, patients with heart failure may still be congested. We aimed at assessing the prevalence and clinical relevance of congestion in outpatients with chronic heart failure. Methods and results We recorded clinical and ultrasound [lung B‐lines; inferior vena cava (IVC) diameter; internal jugular vein diameter before and after a Valsalva manoeuvre (JVD ratio)] features of congestion in heart failure patients during a routine check‐up. Of 342 patients who attended, predominantly in New York Heart Association class I or II (n = 257; 75%), 242 (71%) had at least one feature of congestion, either clinical (n = 139; 41%) or by ultrasound (n = 199; 58%). Amongst patients (n = 203, 59%) clinically free of congestion, 31 (15%) had ≥ 14 B‐lines, 57 (29%) had a dilated IVC (> 2.0 cm), 38 (20%) had an abnormal JVD ratio (< 4), 87 (43%) had at least one of these, and 27 (13%) had two or more. During a median follow‐up of 234 (interquartile range 136–351) days, 60 patients (18%) died or were hospitalized for heart failure. In univariable analysis, each clinical and ultrasound measure of congestion was associated with increased risk but, in multivariable models, only higher N‐terminal pro‐B‐type natriuretic peptide and IVC, and lower JVD ratio, were associated with the composite outcome. Conclusions Many patients with chronic heart failure with few symptoms have objective evidence of congestion and this is associated with an adverse prognosis. Whether using these measures of congestion to guide management improves outcomes requires investigation.

Section: Discussionmentioning

confidence: 99%

Prevalence, pattern and clinical relevance of ultrasound indices of congestion in outpatients with heart failure

Pellicori

Shah

Cuthbert

et al. 2019

111

101

“…Reporting of the setting of the study (e.g. pre‐hospital, ambulatory care, emergency department, hospital ward, intensive care unit) is also important, as HF patients will demonstrate a different spectrum of B‐lines reflecting the likely degree of pulmonary congestion in each setting; interpretation and comparison of studies must therefore take study setting into account ( Figures and ) …”

Section: Reporting Checklistmentioning

confidence: 99%

“…For B‐line quantification, two general approaches have been reported in HF cohorts ( Table ): A count‐based method, in which the sum of B‐lines in one intercostal space per zone across all zones is reported A scoring system, in which a minimum number of B‐lines in one intercostal space per zone is used to define a zone as ‘positive.’ Positive zones are then summed to delineate a cut‐off value.…”

Section: Reporting Checklistmentioning

confidence: 99%

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

Platz

Jhund

Girerd

et al. 2019

Self Cite

108

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.

“…Similarly, in a cohort of 195 NYHA class II–IV HF patients, three or more B‐lines (using an 8‐zone technique) was independently associated with a higher rate of 6‐month death or HHF (adjusted hazard ratio 4.08, 95% CI 1.95–8.54; P < 0.001) . Dwyer et al . reported similar results in low‐risk patients with HF.…”

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confidence: 70%

“…In Figure , we provide a brief overview of the current literature for the three steps of congestion assessment (i.e. clinical, laboratory, and imaging evaluation of congestion); we also detail current gaps in evidence and propose future research directions in the field …”

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confidence: 99%

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

Girerd

Platz

2019

Self Cite

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