Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients†

Platz, Elke
Lewis, Eldrin F.
Uno, Hajime
Peck, Julie
Pivetta, Emanuele
Merz, Allison A.
Hempel, Dorothea
Wilson, Christina
Frasure, Sarah E.
Jhund, Pardeep S.
Cheng, Susan
Solomon, Scott D.

¹Department of Emergency Medicine, Brigham and Women's Hospital, Boston, USA
²Harvard Medical School, Boston, USA
³Cardiovascular Division, Brigham and Women's Hospital, Boston, USA
⁴Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, USA
⁵Royal College of Surgeons in Ireland, Dublin, Ireland
⁶Division of Emergency Medicine and High Dependency Unit, Cancer Epidemiology Unit, Department of Medical Sciences, AOU Città della Salute e della Scienza di Torino, Torino, Italy
⁷University of Turin, Turin, Italy
⁸Department of Emergency Medicine and Cardiovascular Division, Brigham and Women's Hospital, Boston, USA
⁹Department of Cardiology, Angiology and Intensive Care, University Medical Center Mainz, Mainz, Germany
¹⁰Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
¹¹BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK

Corresponding author. Tel: +1 617 525 7932, Fax: +1 617 264 6848, Email: [email protected]

† Institution at which work was performed: Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Received August 12, 2015

Received in revised form October 23, 2015

Accepted December 15, 2015

European Heart Journal 37(15):p 1244-1251, April 14, 2016. | DOI: 10.1093/eurheartj/ehv745

Aims

Pulmonary congestion is a common and important finding in heart failure (HF). While clinical examination and chest radiography are insensitive, lung ultrasound (LUS) is a novel technique that may detect and quantify subclinical pulmonary congestion. We sought to independently relate LUS and clinical findings to 6-month HF hospitalizations and all-cause mortality (composite primary outcome).

Methods

We used LUS to examine 195 NYHA class II–IV HF patients (median age 66, 61% men, 74% white, ejection fraction 34%) during routine cardiology outpatient visits. Lung ultrasound was performed in eight chest zones with a pocket ultrasound device (median exam duration 2 min) and analysed offline.

Results

In 185 patients with adequate LUS images in all zones, the sum of B-lines (vertical lines on LUS) ranged from 0 to 13. B-lines, analysed by tertiles, were associated with clinical and laboratory markers of congestion. Thirty-two per cent of patients demonstrated ≥3 B-lines on LUS, yet 81% of these patients had no findings on auscultation. During the follow-up period, 50 patients (27%) were hospitalized for HF or died. Patients in the third tertile (≥3 B-lines) had a four-fold higher risk of the primary outcome (adjusted HR 4.08, 95% confidence interval, CI 1.95, 8.54; P < 0.001) compared with those in the first tertile and spent a significantly lower number of days alive and out of the hospital (125 days vs. 165 days; adjusted P < 0.001).

Conclusions

Pulmonary congestion assessed by ultrasound is prevalent in ambulatory patients with chronic HF, is associated with other features of clinical congestion, and identifies those who have worse prognosis.