Subclinical Congestion Research Articles

Portal Vein Pulsatility: A Valuable Approach for Monitoring Venous Congestion and Prognostic Evaluation in Acute Decompensated Heart Failure.

The severity of systemic congestion is associated with increased portal vein flow pulsatility (PVP). To determine the usefulness of PVP as a marker of decongestion and prognosis in acute decompensated heart failure (ADHF) patients. 105 patients, 60% of whom were men, were hospitalized with ADHF, and their PVP index (PVPI) was calculated (maximum velocity-minimum velocity/maximum velocity) × 100 on admission and before discharge, along with their EVEREST score, inferior vena cava diameter (IVC), NT-proBNP, serum sodium, and glomerular filtration rate. A PVPI ≥ 50% was defined as a marker of systemic congestion. After treatment with loop diuretics, a decrease in PVPI of >50% before discharge was considered a marker of decongestion The patients were classified into two groups (G): G1-PVPI decrease ≥ 50% (54 patients) and G2-PVPI decrease < 50% (51 patients). At discharge, compared to G2, G1 patients had lower mean PVPI (14.2 vs. 38.9; p < 0.001), higher serum Na (138 vs. 132 mmol/L, p = 0.03), and a higher number of patients with a significant (>30%) NT-proBNP decrease (42 vs. 27, p = 0.007). PVPI correlated with IVC (r = 0.55, p < 0.001), NT-proBNP (r = 0.21, p = 0.04), and serum Na (r = -0.202, p = 0.04). A total of 55% of patients had worsening renal failure (G1 63% vs. G2 48%, p = 0.17). After 90 days, G2 patients had higher mortality (27.45% vs. 3.7 p = 0.001) and rehospitalization (49.01% vs. 33.33%, p < 0.001). In multivariate regression analysis, PVPI was an independent predictor of rehospitalization (OR 1.05, 95% CI 1.00-1.10, p = 0.048). Portal vein flow pulsatility, a meaningful marker of persistent subclinical congestion, is related to short-term prognosis in ADHF patients.

Killip and Kimball classification in the Ultrasound era: Is it time to redefine?

Lung ultrasound is a tool that is increasingly gaining strength in the initial evaluation of the patient in the emergency department and in critical care areas, making it particularly useful for cardiologists. In patients with ST elevation and acute myocardial infarction it has been observed that 25-45% of patients are wrongly classified as Class I in the Killip and Kimball classification after lung ultrasound (subclinical congestion). The clinical relevance of this finding lies in the fact that the greater the number of B lines, the greater short- and long-term the mortality is. An important advantage is that no prolonged time for learning the technique is required. More studies are needed to evaluate the role and importance of subclinical congestion in patients with acute myocardial infarction. Unfortunately, ultrasound is not widely available in developing countries, so the physical examination will continue to play an important role in the initial evaluation of patients with acute myocardial infraction.

Inferior vena CAVA and lung ultraSound-guided therapy in acute heart failure: A randomized pilot study (CAVAL US-AHF study)

The optimal assessment of systemic and lung decongestion during acute heart failure is not clearly defined. We evaluated whether inferior vena cava (IVC) and pulmonary ultrasound (CAVAL US) guided therapy is superior to standard care in reducing subclinical congestion at discharge in patients with AHF. CAVAL US-AHF was an investigator-initiated, single-center, single-blind, randomized controlled trial. A daily quantitative ultrasound protocol using the 8-zone method was used and treatment was adjusted according to an algorithm. The primary endpoint was the presence of more than 5 B-lines and/or an increase in IVC diameter and collapsibility at discharge. And secondary endpoint exploratory outcome was the composite of readmission for HF, unplanned visit for worsening HF or death at 90 days RESULTS: Sixty patients were randomized to CAVAL US (n = 30) or control (n = 30). The primary endpoint was achieved in 4 patients (13.3%) in the CAVAL US group and 20 patients (66.6%) in the control group (P < .001). A significant reduction in HF readmission, unplanned visit for worsening HF or death at 90 days was seen in the CAVAL US group (13.3% vs 36.7%; log rank P = .038). Other endpoints such as NT-proBNP reduction at discharge showed a nonstatistically significant reduction in the CAVAL US group (48% IQR 27-67 vs 37% -3-59; P = .09). Safety outcomes were similar in both groups. IVC and lung ultrasound-guided therapy in AHF patients significantly reduced subclinical congestion at discharge. CAVAL US-AHF provides preliminary evidence for the potential use of a simple technique to guide decongestive therapy during hospitalization for AHF, which may reduce the composite outcome at 90 days.

Point of Care Ultrasound (POCUS) in the Management of Heart Failure: A Narrative Review.

Assessing for volume overload is a key component of both short and long-term management of heart failure patients. Physical examination findings are neither sensitive nor specific for detecting congestion, and subclinical congestion may not be evident at the time of examination. Point of care ultrasound (POCUS) is an efficient and non-invasive way to assess heart failure patients for volume overload. The aim of our narrative review is to summarize how each of the following ultrasound modalities can be used to assess for congestion in the heart failure population: 2D and Doppler echocardiography, lung ultrasound, inferior vena cava ultrasound, internal jugular vein ultrasound, and venous excess grading. While each of these modalities has their limitations, their use in the acute and outpatient space offers the potential to reduce heart failure readmissions and mortality.

Killip scale reclassification according to lung ultrasound: Killip pLUS.

The Killip scale remains a fundamental tool for prognostic assessment in ST-segment elevation myocardial infarction (STEMI) due to its simplicity and predictive value. Lung ultrasound (LUS) has emerged as a valuable adjunct for diagnosing and predicting outcomes in heart failure (HF) and STEMI patients, even those with subclinical congestion. We created a new classification (Killip pLUS), which reclassifies Killip I and II patients into an intermediate category (Killip I pLUS) based on LUS results. This category included Killip I patients and ≥1 positive zone (≥3 B-lines) and Killip II with 0 positive zones. We aimed to evaluate this new classification by comparing it with the Killip scale and a previous LUS-based reclassification scale (LUCK scale). Lung ultrasound was performed within 24 h of admission in a multicentre cohort of 373 patients admitted for STEMI. In-hospital mortality and major adverse cardiovascular events within one year after admission, comprising mortality or readmission for HF, acute coronary syndrome, or stroke, were analysed. When predicting in-hospital mortality, the global comparison of these three classifications was statistically significant: Killip pLUS area under the curve (AUC) 0.90 (95% CI 0.85-0.95) vs. Killip AUC 0.85 (95% CI 0.73-0.96) vs. LUCK 0.83 (95% CI 0.70-0.95), P = 0.024. To predict events during follow-up, the comparison between scales was also significant: Killip pLUS 0.77 (95% CI 0.71-0.85) vs. Killip 0.72 (95% CI 0.65-0.79) vs. LUCK 0.73 (95% CI 0.66-0.81), P = 0.033. The Killip pLUS scale provides enhanced risk stratification compared to the Killip and LUCK scales while preserving simplicity.

Subclinical congestion in patients presenting with acute coronary syndrome

Abstract Funding Acknowledgements None. Introduction Patients admitted due to acute coronary syndrome (ACS) are stratified using Killip class for the severity of the post myocardial infarction (MI) heart failure (HF). Killip class classification is mainly based on clinical examination and overt signs and symptoms are usually needed to be present. Purpose To evaluate subclinical congestion with lung ultrasound (LUS) in patients presenting with acute coronary syndrome. Methods For a period of 4 years, we recorded the patients presented to the emergency department of our hospital due to acute coronary syndrome (HF) and no symptoms or signs of heart failure (Killip class I). LUS was performed on admission and patients were classified as having either "wet lung" (&amp;gt;3 b-lines in at least 3 lung fields) or "dry lung". Baseline characteristcs, laboratory findings as well as the result of the coronary angiogram were alse recorded. Results 286 patients were recorded, with mean age 71,2 years, 43,35% were female and 56,6% male. 36.01% of the patients presented with ST elevation MI (STEMI) and 63.98% with non ST elevation MI (NSTEMI). 34.2% of patients were classified as having "wet lung". Of them, 63.98% were STEMI patients and 36.1% NSTEMI. 27.2% were males and 72.8% females and 64.6% older than 60 years old. 10.7% had on admission left ventricular ejection fraction (LVEF) &amp;gt;50% whereas 89.3 % had LVEF &amp;lt;50%.Finally, 12,7% were found to have 1 vessel disease, 23.4% 2 vessel disease and 63.9% 3 vessel disease. Compared to patients classified as having "dry lung", patients with "wet lung" stayed in the hospital 74 days (vs 3.2, p&amp;lt;0.01), and their mean troponin levels were 10721 pg/ml (vs 3254 pg/ml, p&amp;lt;0.01). "Wet lung" patients were found to have mean GFR 56,2 mL/min/1.73 m² (vs 86.7 mL/min/1.73 m² , p&amp;lt;0.05). Conclusion 34.2% of the patients admitted due to ACS Killip 1, were classified as having "wet lung" when examined with LUS, suggesting a status of subclinical congestion. These patients were most often STEMI patients, female and of older age and were found to have reduced LVEF. Compared to the "dry lung" patients had higher troponin levels and most oftenly impaired renal function. LUS could help identify these patients, that although they seem to be asymptomatic in terms of HF, they probably need closer monitoring.

Prognostic Significance of Lung Ultrasound for Heart Failure Patient Management in Primary Care: A Systematic Review.

Background: Heart failure (HF) affects around 60 million individuals worldwide. The primary aim of this study was to evaluate the efficacy of lung ultrasound (LUS) in managing HF with the goal of reducing hospital readmission rates. Methods: A systematic search was conducted on PubMed, Embase, Google Scholar, Web of Science, and Scopus, covering clinical trials, meta-analyses, systematic reviews, and original articles published between 1 January 2019 and 31 December 2023, focusing on LUS for HF assessment in out-patient settings. There is a potential for bias as the effectiveness of interventions may vary depending on the individuals administering them. Results: The PRISMA method synthesized the findings. Out of 873 articles identified, 33 were selected: 19 articles focused on prognostic assessment of HF, 11 centred on multimodal diagnostic assessments, and two addressed therapeutic guidance for HF diagnosis. LUS demonstrates advantages in detecting subclinical congestion, which holds prognostic significance for readmission and mortality during out-patient follow-up post-hospital-discharge, especially in complex scenarios, but there is a lack of standardization. Conclusions: there are considerable uncertainties in their interpretation and monitoring changes. The need for an updated international consensus on the use of LUS seems obvious.

Hydration status in patients hospitalized with acute decompensated heart failure depending on the severity of glucose metabolism disorder

Aim. To study the hydration status according to clinical parameters and laboratory and instrumental research findings at admission and discharge in patients hospitalized with acute decompensated heart failure (ADHF), depending on the severity of glucose metabolism disorder.Materials and methods. The study included 280 patients (53% men, average age 70.1 ± 10.8 years) with ADHF. 72.5% of patients had arterial hypertension in the medical history, 60% of patients had coronary artery disease. In all patients, the level of glycated hemoglobin (HbA1c) was determined to assess the glucose metabolism status. The patients were divided into groups depending on the results obtained: at HbA1c values &lt; 5.7%, patients were included in the group without glucose metabolism disorders, at HbA1c of 5.7–6.4% – in the prediabetes group, at HbA1c ≥ 6.5% – in the type 2 diabetes group. The patients underwent a standard physical examination at admission and at discharge, as well as a clinical and comprehensive assessment of congestion (determination of N-terminal pro B-type natriuretic peptide (NT-proBNP), lung ultrasound, liver Fibroscan testing, including calculation of a controlled attenuation parameter, bioimpedance analysis of the body).Results. The frequency of glucose metabolism disorders in patients hospitalized with ADHF was 57.5% (n = 161), while prediabetes was detected in 17.1% of patients (n = 48) and type 2 diabetes – in 40.4% (n = 113) of cases. Congestion at admission was detected in all patients. A significantly higher frequency of residual (61%) and a lower frequency of subclinical congestion (10%) were revealed in patients with ADHF and type 2 diabetes, compared to patients without glucose metabolism disorders (39% for residual congestion, 27% for subclinical congestion) and prediabetes (40% for residual congestion, 25% for subclinical congestion), respectively. There were no significant differences in the frequency of euvolemia at discharge, depending on the glucose metabolism disorder.Conclusion. Тo assess congestion phenomena at discharge, it is necessary to use clinical, laboratory, and instrumental assessments for patients with ADHF and glucose metabolism disorders. However, in patients with ADHF and prediabetes, it is preferable to focus on the laboratory and instrumental assessment of congestion, while in patients with ADHF and type 2 diabetes, both clinical and laboratory and instrumental assessment of congestion should be performed.

Inferior vena cava and lung ultrasound-guided therapy in acute heart failure (CAVAL US-AHF study): a randomized controlled trial

Abstract Background The 90-day readmission rate for hospitalized patients with acute heart failure (AHF) ranges from 25% to 30%, mostly due to persistent congestion at discharge. Since the optimal assessment of decongestion has not been clearly defined, there is an opportunity to implement new tools to identify subclinical congestion to guide treatment. Purpose To evaluate whether inferior vena cava (IVC) and pulmonary ultrasound (CAVAL US)-guided therapy in patients with AHF reduces subclinical congestion at discharge. A secondary objective was to investigate whether CAVAL US-guided therapy leads to improved outcomes al 90 days. Methods In this single-center, single-blind, randomized controlled trial, adult patients with AHF were randomized within 24 hours of hospital admission to the CAVAL US-guided strategy or clinically-guided decongestive therapy. A quantitative ultrasound protocol was used and patients were stratified into 3 groups according to the degree of congestion. All patients underwent lung and IVC ultrasound and were blinded to group allocation. The treating medical team was blinded to the results of the ultrasound evaluation in the control group and adjusted the treatments in the intervention group according to an individualized therapeutic algorithm. The primary endpoint was the presence of more than 5 B-lines and/or an increase in IVC diameter with and without collapsibility at discharge. The secondary endpoints were the composite of HF readmission, unplanned visit for worsening HF or death at 90 days and pro-B-type natriuretic peptide (NT-proBNP) reduction at discharge in %. Results Sixty patients were randomized to CAVAL US (n=30) or control (n=30). The mean age was 76.7±13 years, 68.3% were male and the mean left ventricular ejection fraction was 44% ± 15. The primary outcome occurred in 4 patients (13.3%) in the CAVAL US group and 20 patients (66.6%) in the control group (p&amp;lt;.001). A reduction in HF readmission, unplanned visit for worsening HF or death at 90 days was seen in the CAVAL US group (13.3% vs 36.7%; log rank p=0.038). Other secondary endpoints such as NT-proBNP reduction at discharge showed a non-statistically significant reduction in the CAVAL US group (48% IQR 27-67 vs 37% -3-59; p=0.09). The mean hospital stay was 4.5±5 days in the CAVAL US group and 3.3±1.6 days in the control group (p=0.26), with a trend toward higher total furosemide use in the CAVAL US group (170 mg IQR 120-240 vs 120 mg IQR 80-200, p=0.08). Safety outcomes were similar in both groups (p&amp;gt;0.05). Conclusion IVC and lung ultrasound-guided therapy in AHF patients significantly reduced subclinical congestion at discharge. CAVAL US-AHF provides evidence for the use of a simple, safe and non-invasive technique to guide decongestive therapy during hospitalization for AHF, that reduced the risk of HF readmission, unplanned visit for worsening HF, or death at 90 days without prolonging hospital stay.Subclinical congestion at dischargeKM secondary endpoint

Heart Failure with Reduced Ejection Fraction: The Role of Cardiovascular and Lung Ultrasound beyond Ejection Fraction.

Heart failure with reduced ejection fraction (HFrEF) is considered a major health care problem with frequent decompensations, high hospitalization and mortality rates. In severe heart failure (HF), the symptoms are refractory to medical treatment and require advanced therapeutic strategies. Early recognition of HF sub- and decompensation is the cornerstone of the timely treatment intensification and, therefore, improvement in the prognosis. Echocardiography is the gold standard for the assessment of systolic and diastolic functions. It allows one to obtain accurate and non-invasive measurements of the ventricular function in HF. In severely compromised HF patients, advanced cardiovascular ultrasound modalities may provide a better assessment of intracardiac hemodynamic changes and subclinical congestion. Particularly, cardiovascular and lung ultrasound allow us to make a more accurate diagnosis of subclinical congestion in HFrEF. The aim of this review was to summarize the advantages and limitations of the currently available ultrasound modalities in the ambulatory monitoring of patients with HFrEF.

#2875 CONGESTION PHENOTYPES AND DECONGESTION PATTERNS ASSESSED BY POCUS IN HAEMODIALYSIS PATIENTS: A PILOT STUDY

Abstract Background and Aims Despite the evolution of hemodialysis (HD) in recent years, cardiovascular diseases continue to be the main cause of death in this group of patients. Congestion is one of the factors associated with the highest morbidity and mortality. Unfortunately, there is no gold standard for the proper assessment of dry weight; in fact, physical examination, and even newer techniques such as bioimpedance have poor sensitivity, are difficult to interpret in some cases and fail to discriminate between tissular and vascular congestion. Recently, the use of Point-of-care Ultrasonography (PoCUS) has emerged as the fifth pillar of the conventional physical examination that allows dynamic assessment of congestion and enables congestion to be phenotyped. The aims of the present study were: 1. to phenotype congestion in HD patients and 2. to establish patterns of decongestion according to changes in phenotypes over the course of a HD session. Method Descriptive study carried out in HD units of two tertiary hospitals. Patients with more than three months on HD were included. Excluding patients with short life expectancy or who had an acute complication. In addition to the congestive composite score (CCS), a PoCUS evaluation was performed at the beginning and the end of the HD session on long dialysis interval. Tissular congestion was assessed by lung ultrasound and vascular congestion was assessed by evaluation of the inferior vena cava diameter and portal vein pulsation by pulsed Doppler. Four phenotypes of congestion were established: phenotype A: no congestion, phenotype B: predominance of tissue congestion, phenotype C: predominance of vascular congestion and phenotype D: mixed congestion. In addition, 4 patterns of decongestion were established: pattern 1: absence of congestion at the beginning and end of the HD session, pattern 2: change of phenotype from B, C or D to A, pattern 3: change in congestion phenotype and pattern 4: persistence in the same congestion phenotype as at the beginning. Results 20 patients were included, mean age: 70.5±11.3 years, 14 (70%) were male, CCS: 3 (1.5 – 7.5), interdialysis weight gain: 2.93±0.95 kg and mean UF: 2,570±868mL. 75% of patients reached the prescribed dry weight. At the beginning of the session the distribution of phenotypes was: phenotype A: 35%, phenotype B: 25%, phenotype C: 25% and phenotype D: 15%. At the end of the HD session: phenotype A: 55%, phenotype B: 30%, phenotype C: 10% and phenotype D: 5%. At the end of the HD session 45% of the patients persisted with ultrasound congestion. As for the patterns of decongestion: pattern 1: 35% of patients, pattern 2: 10%, pattern 3: 10% and pattern 4: 35%. 45% of patients persisted with some phenotype of congestion at the end of the session. An inverse correlation was found between age and phenotype at baseline (Rho: -0.506; p = 0.023). No correlation was found between dry weight and UF with decongestion patterns. Conclusion These results show the persistence of echographic congestion at the end of the HD session in a significant number of patients, suggesting that subclinical congestion is more frequent than clinically observed. Further studies are warranted to confirm these results.

Subclinical congestion assessed by lung ultrasound in ST segment elevation myocardial infarction

ObjectiveWe evaluated the prognostic value of subclinical congestion assessed by lung ultrasound (LUS) in patients admitted for ST segment elevation myocardial infarction (STEMI).MethodsThis was a multicentre study that prospectively enrolled...

Multi-organ sonographic assessment of congestion has incremental prognostic value in outpatients with heart failure irrespective of left ventricular ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Congestion is a key driver of symptoms, disease progression and prognosis for patients with heart failure (HF), irrespective of left ventricular ejection fraction (LVEF). However, clinically overt congestion is often undiagnosed unless severe. Recent research has shown that ultrasonographic quantification of systemic venous (i.e. inferior vena cava), renal venous and lung (B-lines) congestion is feasible and identifies HF patients with a worse prognosis. Purpose Whether a simultaneous multi-organ evaluation of congestion by ultrasound may improve risk stratification in HF is unknown. In the present study, we assessed signs of ultrasonographic congestion in the inferior vena cava, lungs and kidneys in HF patients across the LVEF spectrum and investigated their association with pathophysiology, clinical characteristics and prognosis. Methods We prospectively enrolled 326 patients with a prior clinical diagnosis of HF attending a routine follow-up visit. We also enrolled 102 consecutive patients with cardiovascular risk factors (including hypertension, type II diabetes mellitus or chronic ischaemic heart disease) and no history of HF; these latter patients had NT-proBNP levels &amp;lt;125 ng/L, LVEF &amp;gt;50%, and were not taking loop diuretics. All patients underwent a complete clinical assessment, blood and urine tests, and an ultrasound evaluation. Ultrasound congestion was defined as inferior vena cava ≥21 mm, highest tertile of lung B-lines or discontinuous renal venous flow. Results The final population consisted of 310 HF patients (median age 77 years, median NT-proBNP 1037 ng/L, 51% with LVEF &amp;lt;50%), and 101 subjects without HF. Among the 224 HF patients (72%) with no clinical signs of congestion, 95 (42%) had at least one sign of congestion by ultrasound (p&amp;lt;0.0001). HF patients with ≥2 ultrasound signs were older, had greater neurohormonal activation (i.e., higher NT-proBNP; Figure 1), lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range 6–15) months, 77 HF patients (19%) died or were hospitalized for HF. HF patients without ultrasonographic evidence of congestion had a similar outcome to subjects without HF (reference; HR 1.02, 95% CI 0.86 – 1.35), while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4–63.6), even after adjusting for multiple clinical variables and NT-proBNP (Figure 2). Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a 28% net reclassification improvement (p=0.03). Conclusion Simultaneous assessment of pulmonary, systemic venous and kidney congestion by ultrasound identifies a high prevalence of sub-clinical congestion associated with poor outcomes in HF, irrespective of LVEF. The speed of investigation, along with the widespread availability and relatively low cost of ultrasound, makes this protocol easy to implement for real-time assessment of congestion.

Prognostic value of subclinical congestion assessed by lung ultrasound in STEMI patients in a short-term follow-up

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This project received a Scholarship for Training and Research from the Association of Ischemic Heart Disease and Cardiological Critical Care of the Spanish Society of Cardiology and an Original Research Projects Grant from the Catalan Society of Cardiology. Background Heart failure (HF) is an important prognostic factor in ST-segment elevation myocardial infarction (STEMI). Although most STEMI patients are Killip-Kimball class I (KK-I) at admission, there is a risk of developing HF during hospitalization and follow-up. Lung ultrasound (LUS) is an easy, fast, and accurate technique that allows pulmonary congestion to be diagnosed even in pre-clinical stages. Several risk scores have been developed to identify low-risk STEMI patients, nonetheless any of these scores include LUS assessment. Purpose We evaluated the prognostic value of subclinical congestion assessed by LUS at hospital admission in patients with KK-I STEMI. Primary endpoint was a composite of readmission for HF or new acute coronary syndrome or death during 30-day follow-up. Methods This was a multicenter study prospectively enrolling 300 patients admitted for KK-I STEMI. LUS was performed during the first 24 hours after revascularization by and independent operator and B-lines were counted off-line differentiating between patients with wet lung (≥ 3 B-lines in at least one lung field) or dry lung. To assess whether LUS could improve the predictive capacity of current risk scales, a model with categorical result of LUS (dry/wet lung) and categorical result of Zwolle score (low/higher risk) was compared to the isolated result of Zwolle score and net reclassification index (NRI) was calculated. Results Wet lung patients had a higher risk of developing the follow-up composite endpoint (hazard ratio [HR] 10.8, 95% CI 2.6-45.2, p=0.001). After adjusting by a propensity score including age, sex, hypertension, chronic kidney disease (glomerular filtration rate &amp;lt;60ml/min/1,73m2), previous atrial fibrillation/flutter, anterior STEMI, and LVEF, a LUS finding of wet lung remained an independent risk factor for the composite endpoint (adjusted HR 5.4, 95% CI 1.0-28.7, p=0.049). LUS was able to predict de composite endpoint with 62.5% sensitivity, 86.8% specificity, 11.1% positive predictive value and 98.9% negative predictive value. LUS improved the predictive capacity of the Zwolle score (net reclassification improvement = 0.99, 95% CI 0.29-1.69, p=0.006) to predict the composite endpoint. CONCLUSIONS Early subclinical pulmonary congestion identified by LUS in KK-I STEMI patients at hospital admission is a strong predictor of adverse outcomes at 30-day follow-up. Patients without subclinical congestion have a very low risk of adverse outcomes and can potentially benefit from an early discharge. LUS improves the predictive ability of the Zwolle risk score, allowing a more accurate identification of low-risk patients.

The incremental value of multi-organ assessment of congestion using ultrasound in outpatients with heart failure.

We investigated the prevalence and clinical value of assessing multi-organ congestion by ultrasound in heart failure (HF) outpatients. Ultrasound congestion was defined as inferior vena cava of ≥21 mm, highest tertile of lung B-lines, or discontinuous renal venous flow. Associations with clinical characteristics and prognosis were explored. We enrolled 310 HF patients [median age: 77 years, median NT-proBNP: 1037 ng/L, 51% with a left ventricular ejection fraction (LVEF) <50%], and 101 patients without HF. There were no clinical signs of congestion in 224 (72%) patients with HF, of whom 95 (42%) had at least one sign of congestion by ultrasound (P < 0.0001). HF patients with ≥2 ultrasound signs were older, and had greater neurohormonal activation, lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range: 6-15) months, 77 patients (19%) died or were hospitalized for HF. HF patients without ultrasound evidence of congestion had a similar outcome to patients without HF [reference; hazard ratio (HR) 1.02, 95% confidence interval (CI) 0.86-1.35], while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4-63.6), even after adjusting for multiple clinical variables and NT-proBNP. Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a net reclassification improvement of 28% (P = 0.03). Simultaneous assessment of pulmonary, venous, and kidney congestion by ultrasound is feasible, fast, and identifies a high prevalence of sub-clinical congestion associated with poor outcomes.

Design and rationale of the inferior vena CAVA and Lung UltraSound-guided therapy in Acute Heart Failure (CAVAL US-AHF Study): a randomised controlled trial

BackgroundBetween 25% and 30% of patients hospitalised for acute heart failure (AHF) are readmitted within 90 days after discharge, mostly due to persistent congestion on discharge. However, as the optimal...

Prognostic Value of Integral Assessment of Congestion in Patients Hospitalized with Acute Decompensated Chronic Heart Failure

Background: Systemic congestion is the leading pathophysiological mechanism of decompensated heart failure (HF), and hospitalization and poor prognosis. Unfortunately, patients are discharged with residual congestion, possibly due to the lack of a clear strategy for its assessment. The existing criteria for discharge of patients from the hospital are more often based on a subjective assessment and poorly correlate with the state of hemodynamic stabilization, and the search for methods for detecting congestion remains relevant. Objective: The objective is to determine the prognostic value of an integrated assessment of congestion based on novel diagnostic methods in patients hospitalized with acute decompensated chronic HF (ADCHF). Methods: Single-center prospective study in 171 patients hospitalized with ADCHF. All patients underwent physical examination, paraclinical (laboratory and instrumental) investigations-N-terminal pro-brain natriuretic peptide (NT-proBNP) level, lung ultrasound, transient elastography (TE), bioimpedance vector analysis (BIVA) on admission and discharge. Clinical congestion was assessed in accordance with the HF Association consensus document. Clinical outcomes were assessed by structured telephone survey 1, 3, 6, 12 months after discharge. Combined rates of all-cause mortality and re-admissions were used as the study endpoint. Results: Patients hospitalized with ADCHF had the following congestion status at discharge as assessed by individual methods (TE, lung ultrasound, BIVA and NT-proBNP): The incidence of clinical residual Congestion I ranged 33%–39%, the incidence of subclinical congestion was 12%–24%, and patients with euvolemia accounted for 19%–32%. According to the integral assessment of hydration status, the incidences of clinical residual Congestion I, subclinical congestion, and euvolemia were 57%, 31% and 12%, respectively. The study has demonstrated a significant worsening of all congestion parameters with increasing number of methods (1–4) that had detected congestion. Patients with congestion detected at discharge by 2, 3, or 4 methods were at a significantly higher risk of all-cause mortality or readmission. TE + NT-proBNP had a higher prognostic value in regard to the risk of endpoint event, while the combination of all four methods was the most predictive. Conclusions: Patients hospitalized with ADCHF should undergo an integral assessment of residual and subclinical congestion at discharge. The introduction of integral congestion assessment into the routine practice will help identify patients with less favorable prognosis in terms of the risk of death and re-admission, as well as to enhance pharmacologic therapy and follow-up.

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

<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.

Integral assessment of congestion in patients with acute decompensated heart failure

Aim. To assess the prognostic value of the integral assessment using various modern methods for diagnosing congestion in patients hospitalized with acute decompensated heart failure (ADHF).Material and methods. This single-center prospective study included 165 patients with ADHF. All patients underwent a standard clinical and paraclinical examination, including assessing NT-proBNP levels, lung ultrasound B-lines, liver transient elastography, bioelectrical impedance vector analysis (BIVA) at admission and discharge. To assess clinical congestion, the Heart Failure Association consensus document scale was used. Long-term clinical outcomes were assessed by telephone survey 1, 3, 6, 12 months after discharge. As an end point, the allcause mortality and readmissions were estimated.Results. In patients hospitalized with ADHF, at discharge, differences were found in the incidence of residual congestion according to certain paraclinical methods — from 22 to 38%, subclinical — from 14,5 to 27%. When using the integral assessment of stagnation, the incidence of residual and subclinical congestion was 53,6% and 35%, respectively. Patients with residual congestion had more severe symptoms of congestion, compared with those with subclinical congestion. Patients in whom congestion was detected by 4 methods, in contrast to those by 1, 2, and 3 methods, had worse clinical and paraclinical parameters. There was a significant increase in the risk of all-cause mortality and readmission in the presence of congestion, identified by 3 (hazard ratio, 9,4 (2,2-40,6); p&lt;0,001) and 4 methods (hazard ratio, 15,2 (3,3-68,1); p&lt;0,001).Conclusion. For patients hospitalized with ADHF, integral assessment of residual and subclinical congestion at should be performed at discharge. The introduction of an integral assessment of congestion into routine practice will allow to identify a group of patients with more unfavorable prognostic characteristics in relation to the risk of death and readmissions, as well as to intensify drug therapy and followup at the outpatient stage.

Prognostic Role of Subclinical Congestion in Heart Failure Outpatients: Focus on Right Ventricular Dysfunction.

Background: subclinical pulmonary and peripheral congestion is an emerging concept in heart failure, correlated with a worse prognosis. Very few studies have evaluated its prognostic impact in an outpatient setting and its relationship with right-ventricular dysfunction. The study aims to investigate subclinical congestion in chronic heart failure outpatients, exploring the close relationship between the right heart-pulmonary unit and peripheral congestion. Materials and methods: in this observational study, 104 chronic HF outpatients were enrolled. The degree of congestion and signs of elevated filling pressures of the right ventricle were evaluated by physical examination and a transthoracic ultrasound to define multiparametric right ventricular dysfunction, estimate the right atrial pressure and the pulmonary artery systolic pressure. Outcome data were obtained by scheduled visits and phone calls. Results: ultrasound signs of congestion were found in 26% of patients and, among this cohort, half of them presented as subclinical, affecting their prognosis, revealing a linear correlation between right ventricular/arterial coupling, the right-chambers size and ultrasound congestion. Right ventricular dysfunction, TAPSE/PAPS ratio, clinical and ultrasound signs of congestion have been confirmed to be useful predictors of outcome. Conclusions: subclinical congestion is widespread in the heart failure outpatient population, significantly affecting prognosis, especially when right ventricular dysfunction also occurs, suggesting a strict correlation between the heart-pulmonary unit and volume overload.