Focused echocardiography and lung ultrasound protocol for guiding treatment in acute heart failure

Abstract

Aims: There is little evidence-based therapy existing for acute heart failure (AHF), hospitalizations are lengthy and expensive, and optimal monitoring of AHF patients during in-hospital treatment is poorly defined. We evaluated a rapid cardiothoracic ultrasound (CaTUS) protocol, combining focused echocardiographic evaluation of cardiac filling pressures, that is, medial E/e' and inferior vena cava index, with lung ultrasound (LUS) for guiding treatment in hospitalized AHF patients.

Methods and results: We enrolled 20 consecutive patients hospitalized for AHF, whose in-hospital treatment was guided using the CaTUS protocol according to a pre-specified treatment protocol targeting resolution of pulmonary congestion on LUS and lowering cardiac filling pressures. Treatment results of these 20 patients were compared with those of a standard care sample of 100 patients, enrolled previously for follow-up purposes. The standard care sample had CaTUS performed daily for follow-up and received standard in-hospital treatment without ultrasound guidance. All CaTUS exams were performed by a single experienced sonographer. The CaTUS-guided therapy resulted in significantly larger decongestion as defined by reduction in symptoms, cardiac filling pressures, natriuretic peptides, cumulative fluid loss, and resolution of pulmonary congestion (P < 0.05 for all) despite a shorter mean length of hospitalization. Congestion parameters were significantly lower also at discharge (P < 0.05 for all), without any significant difference in these parameters on admission. The treatment arm displayed better survival regarding the combined endpoint of 6 month all-cause death or AHF re-hospitalization (log rank P = 0.017). No significant difference in adverse events occurred between the groups.

Conclusions: The CaTUS-guided therapy for AHF resulted in greater decongestion during shorter hospitalization without increased adverse events in this small pilot study and might be associated with a better post-discharge prognosis.

Keywords: Acute heart failure; Cardiac filling pressures; Echocardiography; Lung ultrasound; Prognosis; Pulmonary congestion; Treatment.

Conflict of interest statement

None declared.

© 2017 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.

Figures

Figure 1

Cardiothoracic ultrasound protocol showing B‐lines on lung ultrasound as a sign of congestion, pleural fluid, a typical mitral inflow, and tissue Doppler signals used to calculate the E/e′ ratio, as well as a subcostal view of the IVC. E/e′, E/e′ ratio medially; IVC, inferior vena cava.

Figure 2

Six‐month survival regarding (A) all‐cause mortality and (B) the composite endpoint of all‐cause mortality or hospitalization for AHF in LUS responders, that is, patients who experienced resolution of pulmonary congestion on lung ultrasound, compared with that in non‐responders. AHF, acute heart failure; LUS, lung ultrasound.

Figure 3

Six‐month survival regarding the composite endpoint of all‐cause death or hospitalization for AHF in the treatment arm, receiving cardiothoracic ultrasound‐guided therapy, as compared with that in the standard care arm. AHF, acute heart failure.