Emergency Department, University Hospital of Nancy, France.
Emergency Department, University Hospital of Nancy, France; Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre les Nancy France Groupe choc, INSERM U1116, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.
Chest. 2020 Jan;157(1):99-110. doi: 10.1016/j.chest.2019.07.017. Epub 2019 Aug 2.
Early appropriate diagnosis of acute heart failure (AHF) is recommended by international guidelines. This study assessed the value of several lung ultrasound (LUS) strategies for identifying AHF in the ED.
This prospective study, conducted in four EDs, included patients with diagnostic uncertainty based on initial clinical judgment. A clinical diagnosis score for AHF (Brest score) was quantified, followed by an extensive LUS examination performed according to the 4-point (BLUE protocol) and 6-, 8-, and 28-point methods. The primary outcome was AHF discharge diagnosis adjudicated by two senior physicians blinded to LUS measurements. The C-index was used to quantify discrimination.
Among the 117 included patients, AHF (n = 69) was identified in 27.4%, 56.2%, 54.8%, and 76.7% of patients with the 4-point (two bilateral positive points), 6-point, 8-point (≥ 1 bilateral positive point), and 28-point (B-line count ≥ 30) methods, respectively. The C-index (95% CI) of the Brest score was 72.8 (65.3-80.3), whereas the C-index of the 4-, 6-, 8-, and 28-point methods were 63.7 (58.5-68.8), 72.4 (65.0-79.8), 74.0 (67.1-80.9), and 72.4 (63.9-80.9). The highest increase in the C-index on top of the BREST score was observed with the 8-point method in the whole population (6.9; 95% CI, 1.6-12.2; P = .010) and in the population with an intermediate Brest score, followed by the 6-point method.
In patients with diagnostic uncertainty, the 6-point/8-point LUS method (using the 1 bilateral positive point threshold) improves AHF diagnosis accuracy on top of the BREST score.
ClinicalTrials.gov; No.: NCT03194243; URL: www.clinicaltrials.gov.
国际指南建议早期对急性心力衰竭（AHF）做出适当的诊断。本研究评估了几种肺部超声（LUS）策略在急诊科识别 AHF 的价值。
这是一项在四家急诊科进行的前瞻性研究，纳入了根据初始临床判断存在诊断不确定性的患者。量化了用于 AHF 的临床诊断评分（布雷斯特评分），随后根据 4 分（BLUE 方案）和 6 分、8 分和 28 分方法进行全面的 LUS 检查。主要结局是由两位对 LUS 测量结果不知情的高级医师判定的 AHF 出院诊断。使用 C 指数来量化判别能力。
在纳入的 117 名患者中，分别有 27.4%、56.2%、54.8%和 76.7%的患者使用 4 分（双侧各有两个阳性点）、6 分、8 分（至少有一个双侧阳性点）和 28 分（B 线计数≥30）方法诊断为 AHF（n=69）。布雷斯特评分的 C 指数（95%CI）为 72.8（65.3-80.3），而 4 分、6 分、8 分和 28 分方法的 C 指数分别为 63.7（58.5-68.8）、72.4（65.0-79.8）、74.0（67.1-80.9）和 72.4（63.9-80.9）。在整个人群中，8 分方法在 BREST 评分基础上对 C 指数的提高最大（增加 6.9；95%CI，1.6-12.2；P=0.010），其次是 6 分方法。
在诊断不确定的患者中，6 分/8 分 LUS 方法（使用单侧 1 个阳性点阈值）在 BREST 评分的基础上提高了 AHF 的诊断准确性。
ClinicalTrials.gov；编号：NCT03194243；网址：www.clinicaltrials.gov。
