Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial

Abstract

AimsAlthough acute decompensated heart failure (ADHF) is a common cause of dyspnoea, its diagnosis still represents a challenge. Lung ultrasound (LUS) is an emerging point-of-care diagnostic tool, but its diagnostic performance for ADHF has not been evaluated in randomized studies. We evaluated, in patients with acute dyspnoea, accuracy and clinical usefulness of combining LUS with clinical assessment compared to the use of chest radiography (CXR) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in conjunction with clinical evaluation.This was a randomized trial conducted in two emergency departments. After initial clinical evaluation, patients with acute dyspnoea were classified by the treating physician according to presumptive aetiology (ADHF or non-ADHF). Patients were subsequently randomized to continue with either LUS or CXR/NT-proBNP. A new diagnosis, integrating the results of both initial assessment and the newly obtained findings, was then recorded. Diagnostic accuracy and clinical usefulness of LUS and CXR/NT-proBNP approaches were calculated. A total of 518 patients were randomized. Addition of LUS had higher accuracy [area under the receiver operating characteristic curve (AUC) 0.95] than clinical evaluation alone (AUC 0.88) in identifying ADHF (P < 0.01). In contrast, use of CXR/NT-proBNP did not significantly increase the accuracy of clinical evaluation alone (AUC 0.87 and 0.85, respectively; P > 0.05). The diagnostic accuracy of the LUS-integrated approach was higher then that of the CXR/Nt-proBNP-integrated approach (AUC 0.95 vs. 0.87, p < 0.01). Combining LUS with the clinical evaluation reduced diagnostic errors by 7.98 cases/100 patients, as compared to 2.42 cases/100 patients in the CXR/Nt-proBNP group.

Expert consensus document: Reporting checklist for quantification of pulmonary congestion by lung ultrasound in heart failure

“…A scoring system, in which a minimum number of B‐lines in one intercostal space per zone is used to define a zone as ‘positive.’ Positive zones are then summed to delineate a cut‐off value. For example, ≥3 B‐lines in two zones on each hemithorax are consistent with a diagnosis of pulmonary oedema in dyspnoeic patients presenting to the emergency department …”

June 2019 at a glance: from genetics to haemodynamics, biomarkers and imaging for the prediction of outcomes

“…Combining lung ultrasound with clinical evaluation reduced diagnostic errors by 7.98 cases/100 patients, as compared to only 2.42 cases/100 patients in the chest X‐ray/NT‐proBNP group. This study shows the greater accuracy of lung ultrasound compared with the standard approach for the diagnosis of HF in the emergency department …”

“…Lung ultrasound plays a major role in the assessment of patients with acute and chronic HF . Pivetta et al . tested its usefulness for the diagnosis of HF in 518 patients with breathlessness in the emergency department in a prospective, randomized, study.…”

Lung ultrasound for the diagnosis of acute heart failure: time to upgrade current indication?

“…In this issue of the Journal, the study by Pivetta et al . is the first randomized controlled trial that examined the accuracy and clinical usefulness of a strategy that combines clinical assessment with LUS as compared to clinical assessment plus chest X‐ray (CXR) and NP testing for the diagnosis of AHF.…”

“…Recently, shorter time‐to‐first administration of intravenous furosemide has been associated with improved in‐hospital survival of AHF patients . Since Pivetta et al . have shown that the integrated LUS strategy decreases time to confirmation of AHF diagnosis by approximately 95% as compared to integrated CXR/NP strategy, it may be hypothesized that the LUS strategy would facilitate earlier commencement of decongestive therapy and probably lead to better outcomes.…”