Palazzuoli Alberto, Evangelista Isabella, Beltrami Matteo, Pirrotta Filippo, Tavera Maria Cristina, Gennari Luigi, Ruocco Gaetano
Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, Viale Bracci 14, 53100 Siena, Italy.
Department of Internal Medicine, ASST Ovest Milanese, 20013 Magenta, Italy.
J Clin Med. 2022 Mar 16;11(6):1642. doi: 10.3390/jcm11061642.
Congestion is the main cause of hospitalization in patients with acute heart failure (AHF), however its precise assessment by simple clinical evaluation remains elusive. The recent introduction of the lung ultrasound scan (LUS) allowed to physicians to more precisely quantify pulmonary congestion. The aim of this study was to compare clinical congestion (CC) with LUS and B-type natriuretic peptide (BNP) in order to achieve a more complete evaluation and to evaluate the prognostic power of each measurement. Methods: All patients were submitted to clinical evaluation for blood sample analysis and LUS at admission and before discharge. LUS protocol evaluated the number of B-lines for each chest zone by standardized eight site protocol. CC was measured following ESC criteria. The mean difference between admission and discharge congestion logBNP and B-lines values were calculated. Combined end points of death and rehospitalization was calculated over 180 days. Results: 213 patients were included in the protocol; 133 experienced heart failure with reduced ejection fraction (HFrEF), and 83 presented with heart failure with preserved ejection fraction (HFpEF). Patients with HFrEF had a more increased level of BNP (1150 (812−1790) vs. 851 (694−1196); p = 0.002) and B lines total number (32 (27−38) vs. 30 (25−36); p = 0.05). A positive correlation was found between log BNP and Blines number in both HFrEF (r = 0.57; p < 0.001) and HFpEF (r = 0.36; p = 0.001). Similarly, dividing B-lines among tertiles the upper group (B-lines ≥ 36) had an increased clinical congestion score. Among three variables at admission only B-lines were predictive for outcome (AUC 0.68 p < 0.001) but not LogBNP and CC score. During 180 days of follow-up, univariate analysis showed that persistent ΔB-lines <−32.3% (HR 6.54 (4.19−10.20); p < 0.001), persistent ΔBNP < −43.8% (HR 2.48 (1.69−3.63); p < 0.001) and persistent ΔCC < 50% (HR 4.25 (2.90−6.21); p < 0.001) were all significantly related to adverse outcome. Multivariable analysis confirmed that persistent ΔB-lines (HR 4.38 (2.64−7.29); p < 0.001), ΔBNP (HR 1.74 (1.11−2.74); p = 0.016) and ΔCC (HR 3.38 (2.10−5.44); p < 0.001 were associated with the combined end point. Conclusions: a complete clinical laboratory and LUS assessment better recognized different congestion occurrence in AHF. The difference between admission and discharge B-lines provides useful prognostic information compared to traditional clinical evaluation.
充血是急性心力衰竭（AHF）患者住院的主要原因，然而，通过简单的临床评估对其进行精确评估仍然困难重重。最近引入的肺部超声扫描（LUS）使医生能够更精确地量化肺充血情况。本研究的目的是比较临床充血（CC）与LUS及B型利钠肽（BNP），以实现更全面的评估，并评估每种测量方法的预后能力。方法：所有患者在入院时和出院前均接受临床评估，包括血样分析和LUS检查。LUS方案通过标准化的八个部位方案评估每个胸部区域的B线数量。CC按照欧洲心脏病学会（ESC）标准进行测量。计算入院和出院时充血情况、logBNP和B线值之间的平均差异。计算180天内死亡和再次住院的综合终点。结果：213例患者纳入该方案；133例射血分数降低的心力衰竭（HFrEF）患者，83例射血分数保留的心力衰竭（HFpEF）患者。HFrEF患者的BNP水平升高更明显（1150（812 - 1790）对851（694 - 1196）；p = 0.002），B线总数也更多（32（27 - 38）对30（25 - 36）；p = 0.05）。在HFrEF（r = 0.57；p < 0.001）和HFpEF（r = 0.36；p = 0.001）中，log BNP与B线数量均呈正相关。同样，将B线分为三分位数，较高组（B线≥36）的临床充血评分增加。入院时的三个变量中，只有B线对结局有预测作用（曲线下面积0.68，p < 0.001），而LogBNP和CC评分无此作用。在180天的随访期间，单因素分析显示，持续性ΔB线< - 32.3%（风险比6.54（4.19 - 10.20）；p < 0.001）、持续性ΔBNP < - 43.8%（风险比2.48（1.69 - 3.63）；p < 0.001）和持续性ΔCC < 50%（风险比4.25（2.90 - 6.21）；p < 0.001）均与不良结局显著相关。多因素分析证实，持续性ΔB线（风险比4.38（2.64 - 7.29）；p < 0.001）、ΔBNP（风险比1.74（1.11 - 2.74）；p = 0.016）和ΔCC（风险比3.38（2.10 - 5.44）；p < 0.001）与综合终点相关。结论：完整的临床实验室检查和LUS评估能更好地识别AHF中不同的充血情况。与传统临床评估相比，入院和出院时B线的差异提供了有用的预后信息。
