The additive prognostic value of B-lines and heart rate reserve during “kindergarten” stress echocardiography

Abstract Background B-lines by lung ultrasound (LUS) were added to stress echo (SE) as a direct sign of pulmonary congestion useful to establish an objective link between dyspnoea symptoms and acute heart failure. They are feasible with “kindergarten” training of few hours and pocket size instruments. Aim To assess the prognostic value of “kindergarten SE” only based on B-lines and imaging-independent heart rate reserve (HRR). Methods We enrolled 2,149 patients (age 63±16 yrs, 831 women, 39%) with known or suspected coronary artery diseasereferred for exercise (n=1,015), dipyridamole (n=1,039), adenosine (n=16) or dobutamine (n=79) SE. By LUS, we adopted the 4-site simplified scan, each site scored from 0=normal A-lines, to 10=coalescing B-lines. HRR was assessed as peak/rest ratio of heart rate. All patients were followed-up. Results Interpretable HRR and LUS data were obtained in all patients (feasibility=100%). Abnormal B-lines (≥2) at peak stress were present in 756 patients (35%). Abnormal HRR (≤1.80 for exercise and dobutamine and ≤1.22 for vasodilator) was found in 986 patients (46%), both positivity in 388 patients (18%). During a median follow-up time of 15 months, 137 spontaneous events occurred in 120 patients: 38 deaths, 28 myocardial infarctions, 60 acute heart failures, 11 strokes. B-lines ≥2 and/or reduced HRR were independently associated with adverse outcome (see figure). At multivariable analysis, a three-fold increased risk of death was observed when both B-lines and HRR were abnormal (Hazard ratio: 3.097, 95% Confidence Intervals 1.095–8.754, p=0.03). Conclusions A super-simplified stress test (“SE without SE”) with simple heart rate assessment by EKG and LUS for B-lines evaluates key variables such as chronotropic incompetence (due to reduced sympathetic reserve) and pulmonary congestion (due to backward acute heart failure) and allows an accurate prediction of outcome. Figure 1 Funding Acknowledgement Type of funding source: None

Download Full-text

The prognostic value of lung ultrasound in aortic stenosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.376 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

G Agoston ◽

I Szabo ◽

L Gargani ◽

N Nemeth ◽

B Morvai-Illes ◽

...

Keyword(s):

Heart Failure ◽

Aortic Stenosis ◽

Prognostic Value ◽

Lung Ultrasound ◽

Systolic Pressure ◽

Pulmonary Artery Systolic Pressure ◽

Pulmonary Congestion ◽

Severe Aortic Regurgitation ◽

Increased Risk ◽

B Lines

Abstract Funding Acknowledgements Type of funding sources: None. Background Aortic stenosis (AS) is a progressive disease and once symptomatic and heart failure (HF) develops is associated with poor prognosis. The degree of the pathophysiological and structural changes in AS are associated with poor survival. Pulmonary congestion is an almost universal finding in patients with HF. Lung ultrasound (LUS) evaluation of B-lines has been proposed as a simple, non-invasive tool to assess pulmonary congestion. Aim To assess pulmonary congestion with LUS in patients with AS and to define the prognostic value of B-lines. Methods 84 consecutive patients (43 women, mean age 74 ± 9 years) with moderate or severe AS were enrolled. Exclusion criteria were as follows: moderate or severe aortic regurgitation, moderate or severe mitral regurgitation, cardiomyopathies, pulmonary disease, renal failure. At baseline, all patients underwent comprehensive echocardiography examination and LUS according to 28 scanning-site assessment. Patients were followed-up after enrollment to establish the prognostic value of LUS. A composite endpoint was considered, including: aortic valve replacement due to deterioration of patient condition or progression of AS from moderate to severe, death (any cause), hospitalization due to acute heart failure or progression of chronic heart failure which required hospitalization. Results We found a severe number of B-lines (total B-lines ≥30) in 31% of AS patients. The number of B-lines was correlated with estimated pulmonary artery systolic pressure (p < 0,005, r= 0,52) and increased along with NYHA class (p < 0,001) Figure 1. Patients with ≥30 B-lines had more events during the 13,4 ± 6 months follow-up (p < 0,001, Log-rank: 10,7; Figure 2). Conclusion Assessing B-lines in AS is a simple, feasible method to detect pulmonary congestion. The number of B-lines correlates with hemodynamic changes caused by AS and with the functional status of the patients. A severe degree of sonographic pulmonary congestion is associated with an increased risk of adverse events. Abstract Figure. FC class vs. Blines and prognostic value

Download Full-text

Prognostic value of integrated cardiopulmonary ultrasound in inpatients with acute heart failure with preserved and reduced ejection fraction and without heart failure

European Heart Journal ◽

10.1093/ehjci/ehaa946.1215 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

N.R Pugliese ◽

F Frassi ◽

P Frumento ◽

E Poggianti ◽

M Mazzola ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Acute Heart Failure ◽

Prognostic Value ◽

Multivariable Analysis ◽

Composite Endpoint ◽

Signs And Symptoms ◽

Reduced Ejection Fraction ◽

B Lines

Abstract Objective To assess the prognostic value of B-lines integrated with echocardiography in patients admitted to a Cardiology Department, with and without acute heart failure (AHF). Background Lung-ultrasound (LUS) B-lines are sonographic signs of pulmonary congestion and can be used in the differential diagnosis of dyspnea to rule in or rule out AHF. Their prognostic value at admission is less established, as well as the different role in AHF with reduced and preserved ejection fraction (HFrEF and HFpEF), or patients admitted for cardiac conditions but without overt signs and symptoms of AHF. Methods A total of 1021 consecutive in-patients (69±12 years) admitted for various cardiac conditions were enrolled. Patients were classified into three groups: 1) acute HFrEF; 2) acute HFpEF; 3) no AHF. All patients underwent on the admission an echocardiogram coupled with LUS, according to standardised protocols. Results Patients were followed-up for a median of 14.4 months (interquartile range: 4.6–24.3) for death and HF readmission (composite endpoint). During the follow-up, 126 events occurred. Kaplan-Meier survival analyses showed admission B-lines >30 identified patients with worse outcome at follow-up in the overall population and each of the three groups (Figure). At multivariable analysis (Table), admission B-lines >30, EF <50%, tricuspid regurgitation velocity >2.8 m/s and tricuspid annular plane systolic excursion (TAPSE) <17 mm resulted in independent predictors of the composite endpoint. B-lines >30 had a strong predictive value in HFpEF and non-AHF, but not in HFrEF. Conclusions Ultrasound B-lines can detect subclinical pulmonary interstitial edema in patients thought to be free of congestion, and provide useful information not only for the diagnosis but also for the prognosis in different cardiac conditions. Their added prognostic value among standard echocardiographic parameters is stronger in patients with HFpEF compared to HFrEF. Figure 1 Funding Acknowledgement Type of funding source: None

Download Full-text

Prognostic value of discharge heart rate in acute heart failure patients: More relevant in atrial fibrillation?

IJC Heart & Vasculature ◽

10.1016/j.ijcha.2019.100444 ◽

2020 ◽

Vol 26 ◽

pp. 100444

Author(s):

Agra Bermejo Rosa ◽

Pascual-Figal Domingo ◽

Gude Sampedro Francisco ◽

Delgado Jiménez Juan ◽

Vidal Pérez Rafael ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Heart Rate ◽

Acute Heart Failure ◽

Prognostic Value ◽

Heart Failure Patients

Download Full-text

P1479 Prognostic value of integrated cardiopulmonary ultrasound in heart failure patients with reduced and preserved ejection fraction

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.904 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

L Gargani ◽

N Pugliese ◽

F Frassi ◽

S Masi ◽

P Landi ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Prognostic Value ◽

Lung Ultrasound ◽

Univariate Analysis ◽

Vena Cava ◽

Pulmonary Congestion ◽

Echocardiographic Parameters ◽

Ultrasound Assessment ◽

B Lines

Abstract Background Lung-ultrasound B-lines are the sonographic sign of pulmonary congestion and are present in patients with heart failure (HF). Their role as a diagnostic marker is quite established since they can be used for the differential diagnosis of dyspnea to both rule in or rule out HF, whereas their prognostic value at admission is less known. Purpose To assess the prognostic value of B-lines at admission in patients admitted to a Cardiology Department with a diagnosis of HF with reduced (HFrEF) and preserved (HFpEF) ejection fraction. Methods We enrolled a total of 310 consecutive in-patients (aged 69 ± 12 years, 751 males) who underwent on admission a two-dimensional and Doppler echocardiographic evaluation coupled with lung ultrasound assessment of B-lines, according to standardised protocols. The total number of B-line was obtained by summing the number of B-lines from 28 scanning sites on the anterior and lateral right and left hemithorax, as previously described. Results All patients were followed-up for a median period of 15 (interquartile range: 5-28) months for death and HF readmission. During the follow-up, 79 events occurred. Among standard echocardiographic parameters, ejection fraction (EF) <50%, tricuspid annular plane systolic excursion (TAPSE) < 17 mm, pulmonary artery systolic pressure (PASP) ³35 mmHg, inferior vena cava diameter >21 mm and total B-lines ³30 were predictors of events at univariate analysis, whereas only B-lines ³30 (hazard ratio [HR] 2.06; 95% conﬁdence interval [CI] 1.04-4.10) and TAPSE <17 mm (HR 0.53; CI 0.29-0.97) were independent predictors at multivariate analysis. When analysing separately HFpEF patients (105 patients, 33.9%), B-lines ³30 was the only independent predictor of events (HR 6.11; CI 1.49-25.05) (Figure). Conclusions B-lines are a simple, user-friendly, bedside echographic sign of pulmonary congestion, that provides useful information not only for the diagnosis but also for the prognosis of HF patients. Their added value among standard echocardiographic parameters is stronger in patients with HFpEF compared to HFrEF. An integrated cardiopulmonary ultrasound assessment at HF admission provides excellent value for both diagnostic and prognostic stratification. Abstract P1479 Figure

Download Full-text

Prognostic value of pulmonary congestion assessed by lung ultrasound imaging during heart failure hospitalisation: A two-centre cohort study

Scientific Reports ◽

10.1038/srep39426 ◽

2016 ◽

Vol 6 (1) ◽

Cited By ~ 24

Author(s):

Stefano Coiro ◽

Guillaume Porot ◽

Patrick Rossignol ◽

Giuseppe Ambrosio ◽

Erberto Carluccio ◽

...

Keyword(s):

Heart Failure ◽

Poor Prognosis ◽

Prognostic Value ◽

Lung Ultrasound ◽

Systolic Arterial Pressure ◽

Lung Ultrasonography ◽

Pulmonary Congestion ◽

Prognostic Role ◽

Heart Failure Hospitalisation ◽

B Lines

Abstract Pulmonary congestion assessed at discharge by lung ultrasonography predicts poor prognosis in heart failure (HF) patients. We investigated the association of B-lines with indices of hemodynamic congestion [BNP, E/e’, pulmonary systolic arterial pressure (PAPs)] in HF patients, and their prognostic value overall and according to concomitant atrial fibrillation (AF), reduced (≤40%) ejection fraction (EF), and timing of quantification during hospitalisation for heart failure (HHF). In 110 HHF patients, B-lines were highly discriminative of BNP >400 pg/ml (AUC ≥ 0.80 for all), and moderately discriminative of PAPs >50 mmHg (AUC = 0.68, 0.56 to 0.80); conversely, B-lines poorly discriminated average E/e’ ≥ 15, except at discharge. B-line count significantly predicted mid-term recurrent HHF or death (overall and in subgroups), regardless of AF status, EF, and timing of quantification during HHF (all p for interaction >0.10). regardless, B-lines ≥30 at discharge were most predictive of outcome (HR = 7.11, 2.06–24.48; p = 0.002) while B-lines ≥45 early during HHF were most predictive of outcome (HR = 9.20, 1.82–46.61; p = 0.007). Lung ultrasound was able to identify patients with high BNP levels, but not with increased E/e’, also showing a prognostic role regardless of AF status, EF or timing of quantification; best B-line cut-off appears to vary according to the timing of quantification during hospitalization.

Download Full-text

PREDISCHAGE LUNG ULTRASOUND AS A PREDICTOR OF REHOSPITALIZATION OR MORTALITY ACUTE HEART FAILURE PATIENTS

International journal of Research science and Management - September-2020 ◽

10.29121/ijrsm.v7.i8.2020.5 ◽

2020 ◽

Vol 7 (8) ◽

pp. 28-34

Keyword(s):

Heart Failure ◽

Heart Disease ◽

Acute Heart Failure ◽

Lung Ultrasound ◽

Independent Predictor ◽

Hypertensive Heart Disease ◽

Functional Class ◽

Pulmonary Congestion ◽

Class Iii ◽

B Lines

Backgroud: Persistent congestion is a major cause of rehospitalization in patients with acute heart failure (AHF). Lung Ultrasound (LUS) is an easy and valid examination in assessing pulmonary congestion. The number of B-lines correlates very strongly with the amount of extravascular lung fluid (EVLW). The aim of this study is to determine if LUS pre-discharge can predict rehospitalization or mortality. Methods: This single centered cohort study included 127 consecutive AHF patients. LUS on 28 antorolateral chest wall segment was done double blindly before discharging the patient to calculate the B-line. Clinical data, Composite Congestion Score (CCS) and echocardiography were collected. Cox proportional hazard regression analysis was performed to assess the independent predictor of rehabilitation or mortality during 120 days of observation. Results: The patients were 57.4 ± 7.8 years old, most were male (66.9%), with LV EF 36.7 ± 7.2%. The etiology of heart failure was caused by coronary heart disease (56.7%) and hypertensive heart disease (40.9%). The median number of B-lines was 24 (15 - 39). Hospitalization or death occurred in 43 patients (33.8%) during the median observation of 120 days (73-120). Patients with B-line pre-discharge ≥30 had a lower mean survival (log rank X2 48.14; p <0.001). In multivariate analysis, B-line pre-discharge ≥30 was the strongest independent predictor of rehabilitation or mortality (HR 4.71; 95% CI 2.15 - 10.32). Other independent predictors are Composite Congestion Score (CCS) ≥ 3 (HR 4.26; 95% CI 2.07 - 8.77) and NYHA functional class III (HR 2.87; 95% CI 1.49 - 5, 53). Conclusion: Persistent pulmonary congestion in AHF patients as assessed by B-line pre-discharge ≥30 is a strong independent predictor of rehospitalization or mortality. LUS could potentially help to guide the timing of discharge from AHF hospitalization, the follow-up scheduling and the therapy tailoring. Further randomized clinical studies are needed to definitely support the routine use of LUS.

Download Full-text

Predictors of Post-discharge Mortality Among Patients Hospitalized for Acute Heart Failure

Cardiac Failure Review ◽

10.15420/cfr.2017:12:1 ◽

2017 ◽

Vol 3 (2) ◽

pp. 122 ◽

Cited By ~ 14

Author(s):

Ovidiu Chioncel ◽

Sean P Collins ◽

Stephen J Greene ◽

Peter S Pang ◽

Andrew P Ambrosy ◽

...

Keyword(s):

Heart Failure ◽

Risk Stratification ◽

Acute Heart Failure ◽

Treatment Strategies ◽

Critical Event ◽

Care Providers ◽

Post Discharge ◽

Risk Of Death ◽

Increased Risk ◽

Long Term Prognosis

Acute Heart Failure (AHF) is a “multi-event disease” and hospitalisation is a critical event in the clinical course of HF. Despite relatively rapid relief of symptoms, hospitalisation for AHF is followed by an increased risk of death and re-hospitalisation. In AHF, risk stratification from clinically available data is increasingly important in evaluating long-term prognosis. From the perspective of patients, information on the risk of mortality and re-hospitalisation would be helpful in providing patients with insight into their disease. From the perspective of care providers, it may facilitate management decisions, such as who needs to be admitted and to what level of care (i.e. floor, step-down, ICU). Furthermore, risk-stratification may help identify patients who need to be evaluated for advanced HF therapies (i.e. left-ventricle assistance device or transplant or palliative care), and patients who need early a post-discharge follow-up plan. Finally, risk stratification will allow for more robust efforts to identify among risk markers the true targets for therapies that may direct treatment strategies to selected high-risk patients. Further clinical research will be needed to evaluate if appropriate risk stratification of patients could improve clinical outcome and resources allocation.

Download Full-text

Activity of the adrenomedullin system to personalise post-discharge diuretic treatment in acute heart failure

Clinical Research in Cardiology ◽

10.1007/s00392-021-01909-9 ◽

2021 ◽

Author(s):

Nikola Kozhuharov ◽

Leong Ng ◽

Desiree Wussler ◽

Ivo Strebel ◽

Zaid Sabti ◽

...

Keyword(s):

Heart Failure ◽

Acute Heart Failure ◽

Plasma Concentrations ◽

Biologically Active ◽

Post Discharge ◽

Diuretic Treatment ◽

System Activity ◽

Risk Of Death ◽

Increased Risk

Abstract Background Quantifying the activity of the adrenomedullin system might help to monitor and guide treatment in acute heart failure (AHF) patients. The aims were to (1) identify AHF patients with marked benefit or harm from specific treatments at hospital discharge and (2) predict mortality by quantifying the adrenomedullin system activity. Methods This was a prospective multicentre study. AHF diagnosis and phenotype were centrally adjudicated by two independent cardiologists among patients presenting to the emergency department with acute dyspnoea. Adrenomedullin system activity was quantified using the biologically active component, bioactive adrenomedullin (bio-ADM), and a prohormone fragment, midregional proadrenomedullin (MR-proADM). Bio-ADM and MR-proADM concentrations were measured in a blinded fashion at presentation and at discharge. Interaction with specific treatments at discharge and the utility of these biomarkers on predicting outcomes during 365-day follow-up were assessed. Results Among 1886 patients with adjudicated AHF, 514 patients (27.3%) died during 365-day follow-up. After adjusting for age, creatinine, and treatment at discharge, patients with bio-ADM plasma concentrations above the median (> 44.6 pg/mL) derived disproportional benefit if treated with diuretics (interaction p values < 0.001). These findings were confirmed when quantifying adrenomedullin system activity using MR-proADM (n = 764) (interaction p values < 0.001). Patients with bio-ADM plasma concentrations above the median were at increased risk of death (hazard ratio 1.87, 95% CI 1.57–2.24; p < 0.001). For predicting 365-day all-cause mortality, both biomarkers performed well, with MR-proADM presenting an even higher predictive accuracy compared to bio-ADM (p < 0.001). Conclusions Quantifying the adrenomedullin’s system activity may help to personalise post-discharge diuretic treatment and enable accurate risk-prediction in AHF.

Download Full-text

P1655Lung ultrasound B-lines in patients with acute heart failure and comorbidities

European Heart Journal ◽

10.1093/eurheartj/ehz748.0413 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

L Gargani ◽

M Zavagli ◽

G Barbarisi ◽

C Marchiani ◽

G Bandini ◽

...

Keyword(s):

Heart Failure ◽

Acute Heart Failure ◽

Lung Ultrasound ◽

High Variability ◽

Chronic Obstructive ◽

Pulmonary Congestion ◽

Lung Water ◽

Obstructive Pulmonary Disease ◽

Time Points ◽

B Lines

Abstract Background Lung ultrasound assessment of B-lines is a sonographic method for a semi-quantitative evaluation of extravascular lung water, that can be employed to asssess and monitor pulmonary congestion in acute heart failure. Purpose To assess the degree and changes in B-lines during hospitalization for acute heart failure, independently of the etiology, and their correlation with patients' comorbidities. Methods Two-hundred and forty-one complete antero-lateral B-lines assessments were recorded in an old population of 73 patients (mean age 83.0±7.6 years, 54.8% males) admitted with a diagnosis of acute heart failure (AHF). Chronic obstructive pulmonary disease (COPD) was present in 30% patients, chronic kidney disease (CKD) was present in 31% patients, a previously known cardiac condition was present in 73% of patients. B-lines were evaluated according to standard protocol at admission (T1), at 24 hours (T2), 48 hours (T3) and at discharge (T4). NT-proBNP was assessed at admission and at discharge. Results Mean antero-lateral B-lines at T1 were 42±39 with a statistically significant reduction at T3 (25±23, p<0.001) and at T4 (16±22, p<0.001), but not at T2 (37±38, p=0.41) (see figure), with high variability in the percentage of B-lines reduction among patients, at all time points, and with 34% of patients with still significant pulmonary congestion at discharge (≥15 B-lines). B-lines number and changes did not differ in patients with and without COPD, CKD, or a previously known heart/valvular disease. A weak, albeit significant correlation was found between the percentage of B-lines change between admission and discharge and total diuresis (R=-0.25, p<0.05), delta (T3 values - T1 values) glomerular filtration rate (R=0.30, p<0.05) and delta NT-proBNP (R=0.31, p<0.05). Dynamic changes of B-lines over time Conclusions In older patients hospitalized with AHF with multiple comorbidities, B-lines are present at admission and significantly reduce at 48 hours, although with high variability among different patients at all time points, and persistent significant congestion at discharge in about one third of patients. Lung ultrasound B-lines provide a specific and dynamic information about the degree and changes of pulmonary congestion, which is additive to other patient's characteristics.

Download Full-text