Prevalence, pattern and clinical relevance of ultrasound indices of congestion in outpatients with heart failure

Abstract

Aims Even if treatment controls symptoms, patients with heart failure may still be congested. We aimed at assessing the prevalence and clinical relevance of congestion in outpatients with chronic heart failure. Methods and results We recorded clinical and ultrasound [lung B‐lines; inferior vena cava (IVC) diameter; internal jugular vein diameter before and after a Valsalva manoeuvre (JVD ratio)] features of congestion in heart failure patients during a routine check‐up. Of 342 patients who attended, predominantly in New York Heart Association class I or II (n = 257; 75%), 242 (71%) had at least one feature of congestion, either clinical (n = 139; 41%) or by ultrasound (n = 199; 58%). Amongst patients (n = 203, 59%) clinically free of congestion, 31 (15%) had ≥ 14 B‐lines, 57 (29%) had a dilated IVC (> 2.0 cm), 38 (20%) had an abnormal JVD ratio (< 4), 87 (43%) had at least one of these, and 27 (13%) had two or more. During a median follow‐up of 234 (interquartile range 136–351) days, 60 patients (18%) died or were hospitalized for heart failure. In univariable analysis, each clinical and ultrasound measure of congestion was associated with increased risk but, in multivariable models, only higher N‐terminal pro‐B‐type natriuretic peptide and IVC, and lower JVD ratio, were associated with the composite outcome. Conclusions Many patients with chronic heart failure with few symptoms have objective evidence of congestion and this is associated with an adverse prognosis. Whether using these measures of congestion to guide management improves outcomes requires investigation.

Highlights in heart failure

“…230 Clinical signs have a major role for the prognostic assessment and treatment selection in the patients with acute HF. 235,236 Inferior vena cava diameter and jugular venous distension are indexes of venous congestion and right ventricular filling pressure. A low blood pressure identifies the patient with low cardiac output and peripheral hypoperfusion, and these patients have the highest mortality during followup.…”

“…Among them, the most important is by far systolic blood pressure. 236 Among laboratory exams, the role for the diagnosis and prognostic stratification of acute HF patients is wellestablished. 15,231,232 A decrease in blood pressure after treatment is also an ominous prognostic sign and a possible reason of the lack of efficacy of drugs with vasodilating activity when administered to patients who are not hypertensive.…”

“…34, 234 The assessment of lung B-lines by lung ultrasound allows an accurate estimate of lung congestion and has prognostic value. 235,236 Inferior vena cava diameter and jugular venous distension are indexes of venous congestion and right ventricular filling pressure. 236 Among laboratory exams, the role for the diagnosis and prognostic stratification of acute HF patients is wellestablished.…”

“…235,236 Inferior vena cava diameter and jugular venous distension are indexes of venous congestion and right ventricular filling pressure. 236 Among laboratory exams, the role for the diagnosis and prognostic stratification of acute HF patients is wellestablished. 4,237 Hypochloraemia has emerged as a main prognostic variable with also a potential role as a cause of HF decompensation as it may cause activation of the reninangiotensin system.…”

Caring for people with heart failure and many other medical problems through and beyond the COVID‐19 pandemic: the advantages of universal access to home telemonitoring

“….patient more closely in their care. Better control of congestion will have favourable effects of atrial and ventricular remodelling, arrhythmias and pulmonary hypertension, which should improve prognosis [8][9][10]. A health maintenance strategy can be personalised and delivered by a friendly, local healthcare team.…”