246 Sonographic Right Ventricular Dysfunction Predicts Acute Heart Failure Outcomes Independent of Current Emergency Department Risk Measures

Abstract

Right ventricular dysfunction (RVD) on ultrasound is one of the strongest predictors of acute heart failure (AHF) risk in inpatient and outpatient studies but has not been studied in the ED. We sought to evaluate the performance of RVD-assessment on emergency physician (EP)-performed point of care ultrasound (POCUS) to predict AHF risk when compared to currently utilized measures of AHF risk stratification. Right Ventricular Evaluation in ED AHF (REED-AHF) is an ongoing prospective observational study at two urban-academic hospitals, supported by a grant from the Blue Cross Blue Shield of Michigan Foundation. EP POCUS has been performed in 66 (of planned 123) patients with suspected AHF ≤60 minutes after initiation of IV diuresis, vasodilator, or non-invasive positive pressure ventilation. Ten met exclusion criteria (failure to obtain consent within 24 hours of the POCUS, or ED physician indicated that AHF was not suspected by time of disposition), resulting in a 56-person sample thus far. Patients were followed (phone) at 30 days for the primary composite outcome of AHF-readmission, mortality, new onset dialysis, intubation, acute coronary intervention and/or ICU admission. Using logistic regression, tricuspid annular plane systolic excursion (TAPSE) and free-wall RV strain (fwRVLS) were evaluated in separate models as POCUS markers of RVD for prediction of the primary outcome, adjusted for ED measures of AHF risk specified a priori: troponin, age, estimated glomerular filtration rate, ejection fraction, and chronic obstructive pulmonary disease history. TAPSE and fwRVLS were normally distributed with mean and standard deviation of 20 +/- 6mm and -17 +/- 6 strain units, respectively. Mean age was 62 +/- 13 years, while mean ejection fraction was 31 +/- 13%. The composite outcome occurred in 20 patients (36%). TAPSE was independently associated with the composite outcome (odds ratio [OR]=0.42 per 6 mm increase; 95% confidence interval [CI]:0.20-0.90), while fwRVLS showed a trend towards significance (OR=0.37 per 6 unit improvement; 95% CI: 0.27-1.02). Area under the receiver operating curve (AUROC) for the models of TAPSE and fwRVLS were 0.72 (95% CI:0.58-0.86) and 0.75 (0.61-0.89), respectively. No other risk markers reached statistical significance after adjustment for TAPSE. Further analyses including time to POCUS image acquisition, comparison of TAPSE and fwRVLS cutoffs, and sensitivity analysis for other potential confounders are pending completion of the study enrollment. TAPSE obtained by EPs on POCUS independently predicted 30-day adverse outcomes. Conversely, pending completion of study enrollment, clinical risk-markers currently used for AHF risk-stratification to predict 30-day outcomes were non-significant after adjustment for TAPSE. Further studies are warranted to externally validate our results, and to assess the most effective and feasible clinical implementation of RV POCUS into a broader strategy of AHF risk-stratification by EPs.