Chest
Volume 148, Issue 1, July 2015, Pages 202-210
Journal home page for Chest

Original Research
Pulmonary Vascular Disease
Lung Ultrasound-Implemented Diagnosis of Acute Decompensated Heart Failure in the ED

https://doi.org/10.1378/chest.14-2608Get rights and content

BACKGROUND

Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED.

METHODS

We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS (“LUS-implemented” diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared.

RESULTS

The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% [95% CI, 95%-98.3%]; specificity, 97.4% [95% CI, 95.7%-98.6%]) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% [95% CI, 81.8%-88.4%]; specificity, 90% [95% CI, 87.2%-92.4%]), chest radiography alone (sensitivity, 69.5% [95% CI, 65.1%-73.7%]; specificity, 82.1% [95% CI, 78.6%-85.2%]), and natriuretic peptides (sensitivity, 85% [95% CI, 80.3%-89%]; specificity, 61.7% [95% CI, 54.6%-68.3%]; n = 486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%.

CONCLUSIONS

The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED.

TRIAL REGISTRY

Clinicaltrials.gov; No.: NCT01287429; URL: www.clinicaltrials.gov

Section snippets

Study Design

This was a prospective, observational, multicenter, cohort study conducted in seven Italian EDs (two academic, one university-affiliated, and four community hospitals). Patients were enrolled from October 2010 to September 2012; each center recruited for a 6-month period. The protocol was approved by the institutional review board of the “Città della Salute e della Scienza di Torino” Hospital (project approval number 2CEI-105/0068893) and by the institutional review boards of the other

Patients

Of 1,007 patients eligible for this study, two denied consent to enrollment; therefore, 1,005 patients were included in the analyses. Of these, 544 (54.1%) were enrolled in community hospitals and 461 (45.9%) in academic or university-affiliated centers. Sixty-two emergency physicians participated in the study, each enrolling a median number of 44 patients (IQR, 22).

Final diagnosis was ADHF for 463 patients (46%) and noncardiac dyspnea for 542 (54%). Interrater agreement between the two expert

Discussion

In this study, we found that, in adult subjects with acute dyspnea in the ED, a LUS-implemented approach had higher diagnostic accuracy than other commonly used diagnostic tools (ie, initial clinical workup, CXR, LUS alone, and BNP/NT-pro-BNP levels) in differentiating ADHF from noncardiac causes of acute dyspnea. To overcome LUS limitations in ADHF diagnosis,1, 6, 35, 36 we adopted an integrated approach that paired LUS with the pretest probability of the clinical assessment. Moreover, we

Acknowledgments

Author contributions: E. P., A. G., E. L., F. M., and G. A. C. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. E. P. served as principal author. E. P., A. G., E. L., M. M. M., I. B., F. M., and G. A. C. contributed to the study concept; E. P., A. G., E. L., M. T., G. P., E. F., G. V., P. B., A. B., A. I., S. L., G. C., M. M. M., F. M., and G. A. C. contributed to the study design and data acquisition;

References (45)

  • KL Anderson et al.

    Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and lung ultrasonography

    Am J Emerg Med

    (2013)
  • CW Knudsen et al.

    Diagnostic value of B-Type natriuretic peptide and chest radiographic findings in patients with acute dyspnea

    Am J Med

    (2004)
  • X García et al.

    Noninvasive assessment of acute dyspnea in the ED

    Chest

    (2013)
  • AS Maisel et al.

    Impact of age, race, and sex on the ability of B-type natriuretic peptide to aid in the emergency diagnosis of heart failure: results from the Breathing Not Properly (BNP) multinational study

    Am Heart J

    (2004)
  • LK Morrison et al.

    Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea

    J Am Coll Cardiol

    (2002)
  • LW Eurlings et al.

    Multimarker strategy for short-term risk assessment in patients with dyspnea in the emergency department: the MARKED (Multi mARKer Emergency Dyspnea)-risk score

    J Am Coll Cardiol

    (2012)
  • CS Wang et al.

    Does this dyspneic patient in the emergency department have congestive heart failure?

    JAMA

    (2005)
  • P Ray et al.

    Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis

    Crit Care

    (2006)
  • MM Redfield

    Heart failure—an epidemic of uncertain proportions

    N Engl J Med

    (2002)
  • PA McCullough et al.

    B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational Study

    Circulation

    (2002)
  • JJ McMurray et al.

    ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC

    Eur Heart J

    (2012)
  • ND Gillespie et al.

    Cross sectional study of contribution of clinical assessment and simple cardiac investigations to diagnosis of left ventricular systolic dysfunction in patients admitted with acute dyspnoea

    BMJ

    (1997)
  • Cited by (283)

    View all citing articles on Scopus

    Partial data from this study were presented at the European Society of Cardiology 2013 Annual Meeting, August 31-September 4, 2013, Amsterdam, The Netherlands; American College of Emergency Physicians 2012 Scientific Assembly, October 8-11, 2012, Denver, CO; and the American Institute of Ultrasound in Medicine 2013 Annual Meeting, April 7-11, 2013, New York, NY.

    FUNDING/SUPPORT: The authors have reported to that no funding was received for this study.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

    View full text