Inferior Vena Cava And Lung Ultrasound-guided Therapy For The Reduction Of Clinical Events In Acute Heart Failure - Caval Us-hf Trial

Abstract

<h3>Introduction</h3> Readmissions for acute heart failure (AHF) are frequent, mostly due to persistent congestion on discharge. However, as the optimal evaluation of decongestion is not clearly defined, it is necessary to implement new tools to identify subclinical congestion to guide treatment. <h3>Objective</h3> To develop a therapeutic algorithm guided by lung (LUS) and inferior vena cava (IVC) ultrasound protocol in patients with AHF.Methods: Design of the interventions was carried out between August 2020-January 2021, and was developed in 3 phases: (1)Systematic and narrative review on the use of ultrasound-guided therapy, and treatments algorithms proposed by scientific societies; (2)Panel of experts for the creation of the CAVAL US protocol for the evaluation of right (VCI) and left (LUS) congestion and (3)Algorithms adaptation to our setting with the incorporation of CAVAL US protocol. <h3>Results</h3> Diuretic treatment algorithms were adapted and incorporated into the CAVAL US protocol as part of the daily congestion evaluation (Figure 1). The ultrasound results were divided into 3 categories (Figure 2): Group A) without or mild congestion, Group B) signs of moderate congestion, and Group C) severe signs of congestion and identified as poor prognostic factors. To define persistent congestion, we chose the cut-off point of >5 B lines, since it has been identified as a risk factor for rehospitalization due to AHF or death at six months; and for severe congestion >30 B lines were determined, as they predict hospitalization for HF or mortality at 90 days. <h3>Conclusion</h3> Through a systematic approach we have developed an evidence-based therapeutic algorithm to guide therapeutic interventions in the recently initiated CAVAL US randomized controlled trial. That will investigate whether lung and IVC ultrasound-guided therapy complementing clinical evaluation, reduces the combined end point of readmission, unplanned visit for worsening HF or death at 90 days in AHF.