Stefano Coiro

Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure

Residual pulmonary congestion at discharge is associated with poor prognosis in heart failure (HF), but its quantification through physical examination is challenging. Ultrasound imaging of lung comets (B‐lines) could improve congestion evaluation. The aim of this study was to assess the short‐term prognostic value of B‐lines after discharge from HF hospitalisation compared with other indices of haemodynamic congestion (BNP, E/e, and inferior vena cava diameter) or clinical status (NYHA class).

Serum Chloride and Sodium Interplay in Patients With Acute Myocardial Infarction and Heart Failure With Reduced Ejection Fraction: An Analysis From the High-Risk Myocardial Infarction Database Initiative.

Background— Serum chloride levels were recently found to be independently associated with mortality in heart failure (HF). Methods and Results— We investigated the relationship between serum chloride and clinical outcomes in 7195 subjects with acute myocardial infarction complicated by reduced left ventricular function and HF. The studied outcomes were all-cause mortality, cardiovascular mortality, and hospitalization for HF. Both chloride and sodium had a nonlinear association with the studied outcomes (P<0.05 for linearity). Patients in the lowest chloride tertile (chloride ⩽100) were older, had more comorbidities, and had lower sodium levels (P<0.05 for all). Serum chloride showed a significant interaction with sodium with regard to all studied outcomes (P for interaction <0.05 for all). The lowest chloride tertile (⩽100 mmol/L) was associated with increased mortality rates in the context of lower sodium (⩽138 mmol/L; adjusted hazard ratio [95% confidence interval] for all-cause mortality=1.42 (1.14–1.77); P=0.002), whereas in the context of higher sodium levels (>141 mmol/L), the association with mortality was lost. Spline-transformed chloride and its interaction with sodium did not add significant prognostic information on top of other well-established prognostic variables (P>0.05 for all outcomes). Conclusions— In post–myocardial infarction with systolic dysfunction and HF, low serum chloride was associated with mortality (but not hospitalization for HF) in the setting of lower sodium. Overall, chloride and its interaction with sodium did not add clinically relevant prognostic information on top of other well-established prognostic variables. Taken together, these data support an integrated and critical consideration of chloride and sodium interplay.

Integrative Assessment of Congestion in Heart Failure Throughout the Patient Journey

Congestion is one of the main predictors of poor patient outcome in patients with heart failure. However, congestion is difficult to assess, especially when symptoms are mild. Although numerous clinical scores, imaging tools, and biological tests are available to assist physicians in ascertaining and quantifying congestion, not all are appropriate for use in all stages of patient management. In recent years, multidisciplinary management in the community has become increasingly important to prevent heart failure hospitalizations. Electronic alert systems and communication platforms are emerging that could be used to facilitate patient home monitoring that identifies congestion from heart failure decompensation at an earlier stage. This paper describes the role of congestion detection methods at key stages of patient care: pre-admission, admission to the emergency department, in-hospital management, and lastly, discharge and continued monitoring in the community. The multidisciplinary working group, which consisted of cardiologists, emergency physicians, and a nephrologist with both clinical and research backgrounds, reviewed the current literature regarding the various scores, tools, and tests to detect and quantify congestion. This paper describes the role of each tool at key stages of patient care and discusses the advantages of telemedicine as a means of providing true integrated patient care.

Impact of Changes in Consensus Diagnostic Recommendations on the Echocardiographic Prevalence of Diastolic Dysfunction

The diagnosis of diastolic dysfunction (DD) is based on consensus recommendations [(1,2)][1], although classification is difficult because of a multiplicity of echocardiographic indexes and substantial overlap between values in healthy subjects and in patients. Recently, a joint task force of the

Association of beta-blocker treatment with mortality following myocardial infarction in patients with chronic obstructive pulmonary disease and heart failure or left ventricular dysfunction: a propensity matched-cohort analysis from the High-Risk Myocardial Infarction Database Initiative

To determine the influence of baseline beta‐blocker use on long‐term prognosis of myocardial infarction (MI) survivors complicated with heart failure (HF) or with left ventricular dysfunction and with history of chronic obstructive pulmonary disease (COPD).

Lung ultrasound ‐ The extension of clinical examination in patients with acute heart failure: Reply

We thank Sperandeo and colleagues for their interest in our study1 and for this opportunity to expand on our vision regarding the strength and possible future use of lung ultrasound (LUS). With regard to probe issues, since the first landmark paper of Lichtenstein2 on differential diagnosis of acute dyspnoea, cardiac equipment has been used in all published studies with acute heart failure (AHF) patients. In keeping with the available literature, the ‘International evidence-based recommendations for point-of-care lung ultrasound’3 do not recommend the use of a specific probe for B-line quantification. In this context, we do believe that, especially owing to the increasing availability of hand-held echo machines with cardiac probes, a heart–lung integrated approach is very useful. Additionally, our average B-line count at discharge is perfectly in line with another study using different echocardiographic equipment.4 Hence, regardless of this possible overestimation of B-lines using a cardiology phased array probe, B-line count was very strongly associated with outcome which, in the end, is what matters most. Regarding the imaging of patients exclusively in the supine position, this corresponds to the method of imaging described to date.5 However, we do agree that imaging the posterior chest wall could be of great interest. However, further studies should evaluate the prognostic usefulness of alternative chest ultrasound protocols. Sperandeo et al. suggested that the association between B-line count and outcome in our study could be overestimated due to a possible association of co-morbidities associated both with higher B-line count and worse outcome. Yet, as rightfully observed by the authors, these co-morbidities were exclusion criteria for our study. We consequently assessed the ‘pure’ association between B-lines and outcome at discharge of AHF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sperandeo et al. also questioned LUS reproducibility. Numerous reports have reported excellent reproducibility6 even between beginners with minimal training and experienced echocardiographers. We do believe that B-lines are, as reported by others,6 ‘the kindergarten of echography’ and have tremendous potential to become the extension of the clinical examination in patients admitted for AHF during routine bedside evaluation, the ‘superstethoscope’ of the future.7 Finally, adding point-of-care ultrasonography in the emergency department to routine exams (clinical and biology) improves the diagnostic accuracy of AHF, reducing misdiagnoses.8 We do agree that the impact of this implementation in routine care of patients with AHF at every step of the patient’s journey (i.e. during acute pre-hospital care, in the emergency department, during hospitalization in the medical ward, and at discharge) on outcome should be assessed in proper clinical trials. Given the tremendous importance of congestion in HF, the frequent residual congestion observed using classical strategies, and the handiness of LUS, we firmly believe that a LUS-based strategy of HF patient care could result in game-changing clinical practice in the near future. Conflict of interest: N.G. received Board Membership fees from Novartis. T.C. received speaker’s honoraria from Bayer, The Medicines Company, Novartis, Eli Lilly, Daiichi-Sankyo, Astra Zeneca, and Roche Diagnostic, and also received fees as a member of the Advisory Board of Eli Lilly, Daiichi Sankyo, Astra Zeneca, and Novartis. S.C. has no conflicts to declare.

Prognostic Value of Right Ventricular Dysfunction in Heart Failure With Reduced Ejection Fraction: Superiority of Longitudinal Strain Over Tricuspid Annular Plane Systolic Excursion

Background— In heart failure (HF) with reduced ejection fraction, right ventricular (RV) impairment, as defined by reduced tricuspid annular plane systolic excursion, is a predictor of poor outcome. However, peak longitudinal strain of RV free wall (RVFWS) has been recently proposed as a more accurate and sensitive tool to evaluate RV function. Accordingly, we investigated whether RVFWS could help refine prognosis of patients with HF with reduced ejection fraction in whom tricuspid annular plane systolic excursion is still preserved. Methods and Results— A total of 200 patients with HF with reduced ejection fraction (age, 66±11 years; ejection fraction, 30±7%) with preserved tricuspid annular plane systolic excursion (>16 mm) underwent RV function assessment using speckle-tracking echocardiography to measure peak RVFWS. After a median follow-up period of 28 months, 62 (31%) patients reached the primary composite end point of all-cause death/HF rehospitalization. Median RVFWS was −19.3% (interquartile range, −23.3% to −15.0%). By lasso-penalized Cox-hazard model, RVFWS was an independent predictor of outcome, along with Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure-HF score, Echo-HF score, and severe mitral regurgitation. The best cutoff value of RVFWS for prediction of outcome was −15.3% (area under the curve, 0.68; P<0.001; sensitivity, 50%; specificity, 80%). In 50 patients (25%), RVFWS was impaired (ie, ≥−15.3%); event rate (per 100 patients per year) was greater in them than in patients with RVFWS <−15.3% (29.5% [95% confidence interval, 20.4–42.7] versus 9.4% [95% confidence interval, 6.7–13.1]; P<0.001). RVFWS yielded a significant net reclassification improvement (0.584 at 3 years; P<0.001), with 68% of nonevents correctly reclassified. Conclusions— In patients with HF with reduced ejection fraction with preserved tricuspid annular plane systolic excursion, RV free-wall strain provides incremental prognostic information and improved risk stratification.

Reproducibility of echocardiographic assessment of 2D-derived longitudinal strain parameters in a population-based study (the STANISLAS Cohort study)

Global peak systolic longitudinal strain (PLS) derived from speckle tracking echocardiography (STE) is a widely used left ventricular deformation parameter. Modern ultrasound systems with improved temporal resolution and new software now allow automated multilayer analysis; however, there is limited evidence regarding its reproducibility. We performed intra- and inter-observer analyses within a population-based cohort study using conventional quantitative strain analysis (GE Healthcare). Fifty patients (49u2009±u200914 years) were randomly selected among the fourth visit of the STANISLAS Cohort. Multilayer PLS (transmural, subendocardial, and subepicardial), and strain rate (peak systolic, early and late diastolic) were evaluated. Peak systolic shortening (PSS) and early positive systolic strain (EPS) were calculated, as well as post-systolic index (PSI) and pre-stretch index (PST), two additional strain-derived parameters. Intra-observer intraclass correlation coefficients (ICC) were >0.75 for all analyzed parameters. The mean relative intra-observer differences were <5% for all considered parameters, and their 1.96 SDs were <15% for multilayer PLS, strain rate and PSS, but not for EPS, PSI and PST. Inter-observer ICCs were >0.70 (the majority being >0.80). The mean relative inter-observer differences were <7.5% for all considered parameters, with 1.96 SDs of relative differences being <21% for multilayer PLS, strain rate and PSS, but not for EPS, PSI and PST. In this population-based study, in subjects without or with a limited number of cardiovascular risk factors and no previous cardiovascular events, deformation parameters were found to be highly reproducible, except for EPS, PSI and PST, which showed moderately higher variability. Quantitative strain analysis appears to be an effective clinical and research tool, providing insights regarding longitudinal deformation using a simple three-step post-processing procedure.

Prognostic value of pulmonary congestion assessed by lung ultrasound imaging during heart failure hospitalisation: A two-centre cohort study

Pulmonary congestion assessed at discharge by lung ultrasonography predicts poor prognosis in heart failure (HF) patients. We investigated the association of B-lines with indices of hemodynamic congestion [BNP, E/e’, pulmonary systolic arterial pressure (PAPs)] in HF patients, and their prognostic value overall and according to concomitant atrial fibrillation (AF), reduced (≤40%) ejection fraction (EF), and timing of quantification during hospitalisation for heart failure (HHF). In 110 HHF patients, B-lines were highly discriminative of BNP >400u2009pg/ml (AUCu2009≥u20090.80 for all), and moderately discriminative of PAPs >50u2009mmHg (AUCu2009=u20090.68, 0.56 to 0.80); conversely, B-lines poorly discriminated average E/e’u2009≥u200915, except at discharge. B-line count significantly predicted mid-term recurrent HHF or death (overall and in subgroups), regardless of AF status, EF, and timing of quantification during HHF (all p for interaction >0.10). regardless, B-lines ≥30 at discharge were most predictive of outcome (HRu2009=u20097.11, 2.06–24.48; pu2009=u20090.002) while B-lines ≥45 early during HHF were most predictive of outcome (HRu2009=u20099.20, 1.82–46.61; pu2009=u20090.007). Lung ultrasound was able to identify patients with high BNP levels, but not with increased E/e’, also showing a prognostic role regardless of AF status, EF or timing of quantification; best B-line cut-off appears to vary according to the timing of quantification during hospitalization.

Exercise elicits dynamic changes in extravascular lung water and haemodynamic congestion in heart failure patients with preserved ejection fraction: Exercise elicits dynamic changes in extravascular lung water and haemodynamic congestion in heart failure patients with preserved ejection fraction

Heart failure (HF) with preserved ejection fraction (HFpEF) represents about 50% of HF cases, and is a leading cause of morbidity and mortality.1 Typically, HFpEF patients are asymptomatic at rest but develop dyspnoea and pulmonary congestion with exercise or increased blood pressure, partly driven by impairment of diastolic function. In acute HF, a cascade of events starts with increased left ventricular (LV) filling pressures (‘haemodynamic congestion’) causing interstitial and alveolar oedema (‘pulmonary congestion’), before the appearance of signs and symptoms of congestion.2 In HFpEF, dynamic changes in diastolic function can be assessed by exercise test3; with exercise, diastolic stiffness induces acute elevation in invasively-measured wedge pressure.4 It is assumed that pulmonary congestion contributes to exercise intolerance; yet, there is no direct evidence of it. Lung ultrasonography (LUS), being capable of non-invasively scanning the pulmonary interstitium, might be well-suited to investigate this issue.5 Using standard cardiac transducers on chest echography, typical signals (‘B-lines’) can be visualized, which are strongly associated with echocardiographic and bio-humoral indices of congestion.6 Recently, LUS has been shown to reproducibly detect the rapid increase in pulmonary congestion typically seen when HF patients with reduced ejection fraction (HFrEF) exercise, through development or increase of B-lines.5,7,8 Additionally, stress B-line count correlates with natriuretic peptide concentration and estimated pulmonary pressures.8 Given the pathophysiological and clinical relevance of exercise response in HFpEF, it would be important to investigate pulmonary congestion also in this setting, as afforded by B-line assessment. However, this issue has remained largely unexplored. By LUS, we investigated changes in pulmonary congestion in response to exercise stress echocardiography (ESE) in HFpEF patients. B-lines were measured along with echocardiography and laboratory indices of congestion; findings were compared to those obtained in controls without HF.