Curr Heart Fail Rep (2010) 7:219–227 DOI 10.1007/s11897-010-0030-8
Handcarried Echocardiography to Assess Hemodynamics in Acute Decompensated Heart Failure Sascha N. Goonewardena & Kirk T. Spencer
Published online: 2 October 2010 # Springer Science+Business Media, LLC 2010
Abstract Heart failure is a major source of cardiovascular morbidity, including acute decompensations requiring hospitalization. Because most therapeutic interventions in acute heart failure target optimization of cardiac output and volume status, accurate assessment of these parameters at the point of care is critical to guide management. However, physician bedside assessments of left ventricular (LV) function and volume status have limited accuracy. Traditional echocardiographic platforms, while useful for assessing ventricular and valvular function and volume status, have limitations for bedside use or frequent serial evaluation. Handcarried cardiac ultrasound devices, with their substantially lower costs, portability, and ease of use, circumvent many of the limitations of traditional echocardiographic platforms. The diagnostic capabilities of handcarried devices provide the opportunity for ultrasound assessment of LV function and serial bedside evaluation of volume status in patients with acutely decompensated heart failure. Keywords Acute decompensated heart failure . Handcarried ultrasound . LV ejection fraction . Volume status . Inferior vena cava
S. N. Goonewardena University of Michigan, Ann Arbor, MI 48109, USA K. T. Spencer (*) University of Chicago, 5841 South Maryland Avenue, MC5084, Chicago, IL 60637, USA e-mail:
[email protected]
Introduction Bedside Assessment of Volume Status and Ejection Fraction Heart failure (HF) is a major source of cardiovascular morbidity and is the leading cause of hospitalization among patients over the age of 65 years [1]. Once hospitalized, patients admitted with acute decompensated HF (ADHF) frequently are readmitted with similar symptoms [2]. Because most inpatient HF therapies are directed at alleviating symptoms through optimization of cardiac output and volume status, reliable assessment of these parameters is critical. Furthermore, categorization of patients with ADHF based on hemodynamic status can help to guide diagnosis and treatment (Table 1) [3]. Although invasive assessment with right heart catheterization (RHC) can accurately categorize the cardiac output and volume status of patients with ADHF, it is impractical for the routine evaluation of patients with HF and carries additional risks. Traditional bedside examination to assess volume status includes evaluation of the jugular venous pressure (JVP) as well as detecting the presence of hepatojugular reflux, edema, ascites, and rales. However, in patients with HF, these signs suffer from poor sensitivity and specificity in addition to significant inter- and intraobserver variability [4–6]. While an elevated JVP in patients with left HF does portend a poor prognosis [7], JVP often is difficult to ascertain accurately due to patient body habitus or poor examiner technique. Even when it is visualized, there can be significant discrepancies between JVP estimation of right atrial pressure (RAP) and invasive measurements [8, 9]. While more sophisticated bedside techniques, such as evaluating the change in blood pressure to Valsalva, have
220 Table 1 Hemodynamic profiling of patients with acute decompensated heart failure
Handcarried ultrasound devices can be used at the bedside to profile patients admitted with ADHF into one of these four groups. Rapid categorization of patients with ADHF allows diagnostic and therapeutic management strategies to be initiated that are appropriate for that specific profile ADHF—acute decompensated heart failure; EF—ejection fraction
attempted to improve bedside physical examination detection of elevated filling left ventricle (LV) filling pressure, this technique also has its limitations [10]. As such, there is a need for a more reliable bedside technique for determination of patient volume status. Along with volume status, assessment of LV ejection fraction (LVEF) is critical in the management of patients with ADHF. Assessment of LVEF is a class I recommendation in the American College of Cardiology guidelines for the management of patients with ADHF [11]. It is clear that bedside evaluation including physical examination, chest x-ray, and electrocardiogram is inadequate for accurate prediction of normal versus reduced LVEF [12]. When compared to a gold standard, bedside clinical evaluation of LVEF has demonstrated poor accuracy [12, 13]. Although some signs have fair to good sensitivity for identification of depressed LVEF (elevated JVP, pedal edema, rales, and cardiomegaly), they have very poor specificity. Other signs have fair to good specificity (S4 gallop and abnormal Q waves) but very poor sensitivity. No single bedside finding has both high sensitivity and high specificity, and all findings have poor negative and positive predictive value [12].
Bedside Assessment of Volume Status and Left Ventricular Ejection Fraction with Echocardiography As a surrogate for volume status, ultrasound measurement of the inferior vena cava (IVC) size along with its respirophasic variation has proven to be useful for estimating RAP. Multiple studies have demonstrated fair to excellent correlation between RAP and IVC parameters [14–16]. Depending on the patient population studied, the threshold value to distinguish specific RAP values has shown some variability. However, for broadly categorizing patients based on RAP, ultrasound assessment of IVC has significant utility [16]. Importantly, it is clear that echocardiographic evaluation of the IVC outperforms physical examination of the JVP for detecting elevated RAP [17•].
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Rather than estimating RAP, echocardiography also can be used to predict LV filling pressures, and therefore, may prove useful for bedside assessment of patients with HF [10]. The most promising technique involves interrogating mitral inflows in conjunction with myocardial tissue velocities [18, 19]. The ratio of the mitral inflow E velocity and the tissue Doppler E´ has been shown to correlate well with invasively measured pressures including pulmonary capillary wedge pressure (PCWP) [18, 19]. Tissue Doppler derived E/E´ has shown promise in predicting postdischarge events in patients with ADHF [20]. However, this technique requires more sophisticated ultrasound devices than those that have 2-dimensional and color Doppler capabilities. In addition, measurement of E/E´ requires substantial expertise to perform and interpret. Echocardiography is the test of choice for the bedside evaluation of LVEF in ADHF. Its strengths include that it is noninvasive, rapid, portable, without radiation, without need for dye, and relatively inexpensive. Echocardiographic assessment of LVEF clearly surpasses estimation of LV function made from clinical variables (including physical examination, electrocardiogram, and chest x-ray) [12]. Rapid identification of depressed LV systolic function by echocardiography in a patient with ADHF allows appropriate early triage and management to include afterload reduction and inotropes that otherwise may not be indicated if LVEF is demonstrated to be preserved.
Handcarried Cardiac Ultrasound While echocardiography has proven valuable to measure LVEF and estimate volume status, use of traditional platforms beyond the initial patient evaluation is limited. Traditional devices are large, expensive, and require significant expertise to operate, making them not readily available for bedside evaluation of patients. These limitations also make frequent serial bedside evaluation of a patient with ADHF impractical. The evolution of echocardiographic device technology has brought reduced size and portability and the introduction of a new genre of platforms collectively termed handcarried ultrasound (HCU) devices. These devices have the same advantages as traditional cardiac ultrasound platforms with the added benefits of reduced costs and small size, making point-ofcare use possible. The defining feature of HCU devices is their small size (typically less than 7 pounds), battery power, simplicity of operation, and relatively low cost (Table 2). Most devices have basic 2-dimensional and color Doppler imaging capabilities. HCU devices should be distinguished from
Curr Heart Fail Rep (2010) 7:219–227 Table 2 Features of echocardiographic devices by genre
2D—two-dimensional; 3D; three-dimensional; approx— approximate; HCU—handcarried ultrasound
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Features
Traditional echocardiographic platform
Small platforms
HCU
Pocket-sized ultrasound
2D imaging Color Doppler
Yes Yes
Yes Yes
Yes Yes
Yes Yes
Spectral Doppler Tissue Doppler 3D Multiple transducers Advanced analysis Stress package Cost (approx)
Yes Yes Yes Yes
Yes Yes Some Yes
Some Some No Some
No No No No
Yes
Yes
No
No
Yes $200,000+
Yes $30,000+
No $8000–$12,000
Weight Battery operated Screen size (approx)
250+lbs No 20′′+
10–30 lbs Yes 12′′+
No $15,000– $40,000 6–8 lbs Yes 10′′
“small” echocardiographic platforms that are positioned somewhere between traditional, full-featured platforms and very small, portable HCU devices. Although these small ultrasound platforms are technically light enough to be “carried” by a user, they are not portable in the same sense as 6- to 8-pound devices that can be carried easily on rounds by a health care provider. In addition, the extensive functionality of small ultrasound platforms, which may include packages for contrast echocardiography, stress, and transesophageal echocardiography, makes them quite expensive and complex, and therefore, not true HCU devices.
Bedside Assessment of Volume Status with Handcarried Ultrasound Devices In addition to well-known etiologies for hospital readmission (eg, dietary or medication noncompliance), inadequate in-hospital diuresis also is a major cause of readmission. Unfortunately, no reliable strategy exists that can be used to predict whether a patient’s volume status has been optimized to guide management of ADHF. HCU technology has the potential to bring the power of ultrasound to the point of care where daily decisions regarding volume status and adequacy of diuresis need to be made. Elevated JVP is a frequently used bedside marker of volume overload in patients with ADHF. Brennan et al. [17•] studied the ability of medical residents to detect an elevated RAP (>10 mm Hg) using a HCU device in 40 patients. After limited training (4 hours didactic and 20 HCU examinations), residents estimated RAP from HCU evaluation of the IVC and physical examination of the JVP.
<1 lb Yes 3.5′′
RAP measured by RHC was the gold standard. HCU estimation of RAP from IVC size and collapsibility was feasible in 90% of patients, whereas only 63% of patients had a usable jugular venous waveform. The sensitivity for detecting an elevated JVP was 82% with HCU and 14% from physical examination. Because elevated LV filling pressure is one of the targets of therapy in ADHF, investigators have looked at whether an enlarged IVC detected by HCU, a useful marker of elevated RAP, would predict elevated left-sided filling pressures. Blair et al. [21•] studied subjects undergoing RHC and looked for HCU predictors of elevated RAP as well as PCWP. They showed that an IVC size of 2.0 cm on HCU examination predicted not only an RAP over 10 mm Hg with 83% accuracy, but also a PCWP of 17 mm Hg or greater with 81% accuracy. This undoubtedly reflects the previously noted close relationship between RAP and PCWP in patients with advanced HF [22, 23]. Despite this overall agreement, there are cases where RAP and PCWP are significantly discordant in individual patients. Using a newer HCU device with traditional Doppler as well as tissue Doppler technology, Goonewardena et al. [24••] evaluated the accuracy of a clinical congestion score, physical examination estimated JVP, B-type natriuretic peptide (BNP), HCU IVC, and HCU E/E´ to predict a PCWP of 15 mm Hg or greater in patients referred for RHC because of symptoms consistent with HF [24••]. The clinical congestion score and JVP performed most poorly. In addition, physical examination of the JVP, despite being performed by an experienced HF physician, was only feasible in 68% of patients, well below the HCU IVC feasibility in nonexpert hands of 89%–90% [17•, 25]. BNP, HCU E/E’, and HCU IVC all demonstrated good accuracy
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with regards to estimating PCWP (84%, 80%, 80%). HCU IVC and BNP had the best area under the curve analysis (0.88 and 0.89). There was significant variability in all techniques, and an integrated assessment using several techniques appeared to perform the best. Nguyen et al. [26] also used an HCU device with tissue Doppler capabilities to assess volume status in patients with HF. A medical resident with 10 hours of training performed imaging. Using an HCU device, these physicians detected hypervolemia with a sensitivity of 86% and specificity of 92%. Unfortunately, the gold standard in this study was clinical estimation of volume status by an experienced HF specialist. Therefore, it cannot be stated definitively that the residents accurately predicted filling pressure, but the paper does conclude that inexperienced clinicians can replicate the examination findings of experienced clinicians with the aid of HCU device. Investigators have evaluated HCU in critical care patients in whom prediction of volume status frequently is needed at the bedside. Mark et al. [27] looked at the ability of level III trained physicians using HCU to estimate LV filling by visually assessing LV size. The HCU strategy estimated “filling status” was only in fair to moderate agreement with the standard in the study. This suboptimal result likely reflects more on the methodology than on the HCU technology. Estimation of LV filling using visual estimation of the LV cavity size is a poor marker of volume status. Brennan et al. [28] evaluated critical care patients with an HCU device in an attempt to predict fluid responsiveness, a surrogate of volume status. In this study, medical residents used an HCU device to record the brachial artery Doppler signal in 30 critically ill ventilated patients. The respirophasic change in brachial artery peak velocity was compared to arterial line–determined radial artery pulse pressure variation, which is an established predictor of volume responsiveness. These investigators found an excellent correlation between the noninvasive HCU and the invasive arterial line parameters of volume responsiveness. Investigators also have used HCU to estimate volume status in patients on hemodialysis. Using the OptiGo device (Philips Healthcare, Andover, MA), residents, trained with 4 hours of didactic and 20 supervised examinations, imaged 89 patients with end stage renal disease before and after their dialysis sessions [25]. These investigators showed that among patients presenting above dry weight predialysis, 39% appeared hypovolemic by HCU analysis of their IVC. Although there was no gold standard for assessment of volume status, patients predicted to be hypovolemic by HCU had more intradialytic cramping and hypotension, suggesting actual hypovolemia. There was a poor correlation between dry weight goals and HCU-predicted volume status. While not performed in patients with ADHF, this
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study again suggests a valuable role for bedside HCUdetermined volume status. In a study looking at patients with ADHF, Goonewardena et al. [29•] used HCU to assess the IVC size and respirophasic variation in 75 patients with ADHF admitted to a general cardiology service. Patients were imaged with HCU upon admission and at discharge by medical residents with limited ultrasound training. After an average length of stay of 4.1 days and net average diuresis of 4.4 liters, the overall IVC maximum size decreased from 2.3 cm to 2.0 cm and IVC respirophasic variation increased from 27% to 45%, consistent with a reduction in volume status. When patients were divided into those not readmitted and those who were readmitted within 30 days of discharge, the HCUdetermined IVC parameters were clearly different. Readmitted patients had slightly larger IVCs at admission (2.4 vs 2.2 cm) but had clearly larger IVC size at discharge (2.3 vs 1.7 cm). The IVC collapsibility was not statistically different at admission (23% readmitted, 31% not readmitted) but was clearly different at discharge (36% readmitted, 57% not readmitted). Patients in this study who were subsequently readmitted could not be distinguished from those who were not readmitted by age, HF class, EF, comorbidities, vital signs, net diuresis, length of stay, or symptoms. A wide variety of clinical (vitals and physical examination findings), patient (symptoms), and laboratory (including BNP) variables were collected and entered into a multivariate model as predictors of 30-day hospital readmission. Of variables at discharge, only serum sodium, BNP, IVC size, and IVC collapsibility were predictors of readmission, with IVC size and BNP as the most powerful predictors. These data demonstrated that IVC size, as a surrogate of volume status, could be assessed at the bedside by inexperienced users in patients with ADHF. More importantly, this work suggested that measurement of the IVC at the bedside may be used to reduce readmissions by identifying patients who require earlier more intensive therapy, more prolonged inpatient diuresis, or closer outpatient follow-up to prevent subsequent readmission. However, as seen with natriuretic peptides, association between change and outcomes does not necessarily translate into benefits of HCUguided strategy.
Bedside Assessment of Left Ventricle Ejection Fraction with Handcarried Ultrasound In addition to estimating volume status, a complete bedside hemodynamic profile of patients with ADHF requires an accurate assessment of LVEF. Although echocardiography is the test of choice for assessing LVEF, the small size of HCU devices results in a compromise of image quality that
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may limit their usefulness at the bedside. Despite this, when used by experienced echocardiographers (physicians with level II or III echocardiographic training or sonographers), HCU devices have proven quite accurate for estimating LV systolic function [30–33]. HCU agreement with full platform echocardiographic devices for identification of LV systolic dysfunction when used by experienced imagers is 86%–98% [30–34]. In the largest of these accuracy studies (n=562), cardiac sonographers using an HCU identified LVEF less than 50% with a sensitivity and specificity of 96% and 98% [30]. While HCU circumvents the impracticality of having a large full-featured echocardiographic platform at the bedside for acute hemodynamic characterization of a patient with ADHF, sonographer or cardiologists are not immediately available in many situations. A growing use of cardiac HCU is the performance of directed bedside evaluation by noncardiologist physicians. When HCU devices are used by less–well-trained users, the diagnostic accuracy declines [35, 36•, 37•, 38]. In the hands of internists, hospitalists, and intensivists with limited echocardiographic training, the sensitivity for detection of LV systolic dysfunction has ranged from 73% to 100% with specificities of 64%–96% (Table 3) [35, 36•, 37•, 38–40, 41•, 42–45]. While inexperienced users cannot replicate the accuracy of echocardiographers or sonographers, it is clear that HCU offers significant gains over physical examination for determination of LVEF [41•, 44–48]. After 20 hours of training, including 5 hours of hands-on experience, residents were able to detect LV systolic dysfunction in 97% of cases, a significant increase from the 79% of cases correctly discovered from history and physical examination [44]. A recent study looked at hospitalists whose training included hands-on imaging practice, 6 hours of didactic interpretation experience, and access to a DVD of 20 cases for learning interpretation [41•]. While the frequency with which the hospitalists classified LV function using the HCU exactly the same as
Table 3 Accuracy of health care providers with limited training using HCU to identify LV systolic dysfunction
HCU—handcarried ultrasound; LV—left ventricle; N/R—not reported
expert cardiologists was somewhat low in this study (59%), this likely reflects that a four-level classification of LV systolic function was used rather than a binary one (ie, present vs absent). Despite this limitation, physicians using HCU surpassed their ability to correctly classify LV systolic function by physical examination alone (46%). The difference between hospitalist’s HCU and physical examination was particularly noticeable in subjects with LV systolic dysfunction, in which nearly 3 times as many patients were correctly identified with HCU than by physical examination. Another study demonstrated that medical students using HCU detected LV systolic dysfunction with higher sensitivity (86%) than an experienced cardiologist’s physical examination (45%) [45]. The medical students’ specificity using HCU also was higher (89% vs 69%). Kirkpatrick et al. [49] studied the ability of nurses to identify LV systolic dysfunction with HCU. Imaging from a parasternal window only, nurses identified all cases of LV systolic dysfunction (sensitivity 100%) [49]. However, in this screening study with a low overall incidence of LV systolic dysfunction (4.7%), there were many false positive findings leading to a poor positive predictive value.
The Future of Handcarried Ultrasound in Acute Decopensated Heart Failure What Devices? There is a dual movement in device development, on one hand providing more features and on the other hand, further miniaturization. Development of devices with more features and functionality could lead to inappropriate HCU use. Clinicians with focused training in basic HCU may attempt to use the more advanced features of HCU devices. Using HCU tools without specific training and expertise could lead to patient misdiagnosis and
Study
Imager
Patients, n
Sensitivity
Specificity
DeCara et al. [35] Lucas et al. [36•] Melamed et al. [38] Fedson et al. [39] Ghani et al. [40] Kirkpatrick et al. [49] Croft et al. [44] Kobal et al. [48] Kirkpatrick et al. [42] Vignon et al. [43]
Resident Hospitalist Intensivist Internist Internist Nurses Resident Medical student Internist Resident
151 314 44 103 88 63 72 61 49 61
95% 85% 92% 73% 75% 100% 100% 86% 100% 88%
N/R 88% 80% 64% 91% 83% 96% 82% 95% 89%
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harm. In addition, expansion of HCU device capabilities undoubtedly will increase the price of these devices. More expensive HCU platforms will only limit the scope and generalized use of these devices in ADHF. Inexpensive platforms that optimize the balance between 2dimensional image quality and miniaturization rather than smaller fuller-featured platforms would best support the use of HCU in patients with ADHF. Pocket-sized devices now have been developed [50]. If IVC size and LVEF can be reliably determined with these devices in a broad range of patients, they may prove to be the most useful bedside modality in patients with ADHF. Which Patients? The diagnosis of HF is a clinical one, but once that diagnosis has been made, all patients admitted with ADHF are candidates for HCU. Patients admitted when complete echocardiographic services are not available are ideal candidates for HCU. Determination of LVEF in the late evening or on a weekend would allow initiation of therapies more appropriate for HF with preserved or reduced LVEF hours to days before the report of the complete echocardiogram becomes available. Although these patients may be imaged off-hours with HCU, it is paramount that all patients with HF receive complete echocardiographic evaluation when those services become available. Even if patients are admitted during “working hours” of the echocardiography lab and have a complete study performed, evaluation with HCU should occur at the bedside to establish baseline volume status parameters. These indices can be followed with HCU to allow titration or intensification of volume removal therapies and assist in determination of the appropriateness for potential discharge. What Should Clinicians Look for with Handcarried Ultrasound? Clinicians with less than level II training in echocardiography should evaluate patients with HF for LVEF and volume status only. While identifying a normal or depressed LVEF with HCU does not complete a patient’s imaging evaluation, it has identified one of the major factors needed for early triage and management. Further evaluation for pericardial disease, diastolic function, valvular heart disease, and regional wall motion abnormalities should wait for the complete echocardiographic examination. The comprehensive skill set and high-end equipment needed to use echocardiography for evaluation of these pathologies is appropriate for practitioners with advanced training. Likewise, evaluation of factors that predict longer-term prognosis in patients with HF
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(eg, pulmonary pressures, severity of mitral regurgitation, left atrial size, LV hypertrophy, right ventricular function and diastolic function grade) need not be evaluated on the night of admission with HCU. However, it would be prudent to make inexperienced users performing HCU familiar with a few pathologies that can be identified readily from the parasternal window, such as large pericardial effusions. What Locations? It is clear that to be most helpful in managing patients with ADHF, HCU use needs to occur at the bedside. This is where rapid clinical decisions can be translated into immediate therapeutic management strategies. Bedside HCU in the emergency room may allow rapid assignment to the correct hemodynamic profile and may allow earlier initiation of appropriate therapy. Inpatientward bedside HCU would supplement daily assessment of volume status and assist in ongoing management of diuresis and evaluation of discharge appropriateness. There is evidence that bedside HCU on the day of discharge may help identify patients at risk for early readmission [29••]. Identification of these patients may allow their assignment to a more aggressive outpatient strategy or perhaps signify a need for more prolonged or intensification of inpatient therapy or referral to a HF specialist or disease management program. Which Health Care Providers? It is clear that nonsonographer or nonechocardiographer personnel will need to use these devices for maximal benefit in patients with ADHF. Expert imagers cannot be available at all hours of the day, and many patients hospitalized with ADHF are managed primarily by physicians without imaging expertise. Yet, these physicians need to make the bedside therapeutic decisions and to determine appropriateness for discharge. It seems realistic that hospitalists may be a target for early adoption. Hospitalists care for many patients with ADHF and have a frequent bedside presence. Many also have acquired some ultrasound experience by using it to help guide bedside procedures. It is possible that nonphysicians or physician extenders could be trained to use HCU in ADHF [49]. In this futuristic scenario, vital signs on admission of a patient with ADHF would include pulse, blood pressure, temperature, weight, IVC size, and LVEF. What Training? Another aspect critical to the advancement of this technology is the need for standard guidelines for the use of HCU devices
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by physicians without formal level II or III training in echocardiography. Training should be evidence-based, and for ADHF, should focus on correct classification of patient EF and volume status. Preliminary data suggest that 4 hours of didactic learning and 20 supervised examinations may allow noncardiologists enough expertise to use HCU as a tool to assess the IVC as a surrogate for volume status [17•, 21•, 25, 29••]. While more advanced techniques such as issue Doppler imaging (TDI) also can be used to assess volume status, it remains unclear that the additional cost of TDIcapable HCU devices and the extra training required to use this technique have incremental benefit. Initial experience suggests that simple 2-dimensional parameters may perform as well in patients with HF as more complex tissue Doppler measurements [24••]. Significant data already exist demonstrating that noncardiologists can be trained to identify normal versus abnormal LV systolic function with reasonable accuracy. However, published HCU training protocols have varied widely and have included 2–20 hours of didactic education; 4–20 hours of hands-on training; and the performance of 20–35 supervised studies [35, 36•, 37•, 38, 40, 41•].
Conclusions The emergence of HCU devices has opened new avenues to help guide hemodynamic profiling and management of patients with ADHF. These devices have been used to accurately assess LV systolic function, even when used by physicians with limited training in echocardiography. Rapid detection of LV systolic dysfunction at the point of care may allow earlier initiation of treatment specific to LV systolic dysfunction, such as inotropic therapy or aggressive afterload reduction, while avoiding treatment that is contraindicated. Handcarried devices also have shown promise in assessing patient volume status, which is difficult to do accurately with traditional bedside evaluation. HCU could be utilized to improve the management of patients with ADHF by providing more patient hemodynamic information in a fast and reproducible fashion. Larger multicenter studies with more diverse patient populations are necessary to define the role of these devices in the management of patients with ADHF more clearly. The cost effectiveness of these strategies also deserves study. In addition, specific training protocols need to be established to educate physicians without prior echocardiographic experience on the use and limitations of HCU.
Disclosures No potential conflicts of interest relevant to this article were reported.
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References Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1. Lloyd-Jones D, Adams RJ, Brown TM, et al.: Executive summary: heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation 2010, 121:948–954. (Published erratum appears in Circulation 2010, 121:e259.) 2. Krumholz HM, Parent EM, Tu N, et al.: Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. Arch Intern Med 1997, 157:99–104. 3. Nohria A, Lewis E, Stevenson LW: Medical management of advanced heart failure. JAMA 2002, 287:628–640. 4. Drazner MH, Hellkamp AS, Leier CV, et al.: Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial. Circ Heart Fail 2008, 1:170–177. 5. Stevenson LW, Perloff JK: The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA 1989, 261:884–888. 6. Chakko S, Woska D, Martinez H, et al.: Clinical, radiographic, and hemodynamic correlations in chronic congestive-heart-failure: conflicting results may lead to inappropriate care. Am J Med 1991, 90:353–359. 7. Drazner MH, Rame JE, Stevenson LW, Dries DL: Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001, 345:574–581. 8. Chan KL, Currie PJ, Seward JB, et al.: Comparison of three Doppler ultrasound methods in the prediction of pulmonary artery pressure. J Am Coll Cardiol 1987, 9:549–554. 9. Currie PJ, Seward JB, Chan KL, et al.: Continuous wave Doppler determination of right ventricular pressure: a simultaneous Doppler-catheterization study in 127 patients. J Am Coll Cardiol 1985, 6:750–756. 10. Sanders GP, Mendes LA, Colucci WS, Givertz MM: Noninvasive methods for detecting elevated left-sided cardiac filling pressure. J Card Fail 2000, 6:157–164. 11. Jessup M, Abraham WT, Casey DE, et al.: 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009, 119:1977–2016. 12. Thomas JT, Kelly RF, Thomas SJ, et al.: Utility of history, physical examination, electrocardiogram, and chest radiograph for differentiating normal from decreased systolic function in patients with heart failure. Am J Med 2002, 112:437–445. 13. Rovai D, Morales MA, Di Bella G, et al.: Echocardiography and the clinical diagnosis of left ventricular dysfunction. Acta Cardiol 2008, 63:507–513. 14. Kircher BJ, Himelman RB, Schiller NB: Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol 1990, 66:493–496. 15. Ommen SR, Nishimura RA, Hurrell DG, Klarich KW: Assessment of right atrial pressure with 2-dimensional and Doppler echocardiography: a simultaneous catheterization and echocardiographic study. Mayo Clin Proc 2000, 75:24–29. 16. Brennan JM, Blair JE, Goonewardena S, et al.: Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr 2007, 20:857–861.
226 17. • Brennan JM, Blair JE, Goonewardena S, et al.: A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure. Am J Cardiol 2007, 99:1614–1616. This paper demonstrated that residents could identify elevated RAP more effectively doing a brief HCU examination of the IVC than by examining the JVP. 18. Nagueh SF, Middleton KJ, Kopelen HA, et al.: Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 1997, 30:1527–1533. 19. Ommen SR, Nishimura RA, Appleton CP, et al.: Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures—A comparative simultaneous Doppler-Catheterization study. Circulation 2000, 102:1788–1794. 20. Dokainish H, Zoghbi WA, Lakkis NM, et al.: Incremental predictive power of B-type natriuretic peptide and tissue Doppler echocardiography in the prognosis of patients with congestive heart failure. J Am Coll Cardiol 2005, 45:1223–1226. 21. • Blair JE, Brennan JM, Goonewardena SN, et al.: Usefulness of hand-carried ultrasound to predict elevated left ventricular filling pressure. Am J Cardiol 2009, 103:246– 247. This paper demonstrated that not only is HCU examination of the IVC capable of predicting elevated RAP, but this finding correlates very well with elevated PCWP, which is the target of therapy in ADHF. 22. Drazner MH, Hamilton MA, Fonarow G, et al.: Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure. J Heart Lung Transplant 1999, 18:1126–1132. 23. Butman SM, Ewy GA, Standen JR, et al.: Bedside cardiovascular examination in patients with severe chronic heart-failure: importance of rest or inducible jugular venous distension. J Am Coll Cardiol 1993, 22:968–974. 24. •• Goonewardena SN, Blair JE, Manuchehry A, et al.: Use of hand carried ultrasound, B-type natriuretic peptide, and clinical assessment in identifying abnormal left ventricular filling pressures in patients referred for right heart catheterization. J Card Fail 2010, 16:69–75. This important paper demonstrated that HCUdetermined IVC plethora and elevated E/E’ performed well in determining an elevated PCWP in patients with suspected HF. The HCU parameters outperformed physical examination and clinical assessment. 25. Brennan JM, Ronan A, Goonewardena S, et al.: Handcarried ultrasound measurement of the inferior vena cava for assessment of intravascular volume status in the outpatient hemodialysis clinic. Clin J Am Soc Nephrol 2006, 1:749–753. 26. Nguyen VT, Ho JE, Ho CY, et al.: Handheld echocardiography offers rapid assessment of clinical volume status. Am Heart J 2008, 156:537–542. 27. Mark DG, Hayden GE, Ky B, et al.: Hand-carried echocardiography for assessment of left ventricular filling and ejection fraction in the surgical intensive care unit. J Crit Care 2009, 24:470.e1–470.e7 28. Brennan JM, Blair JEA, Hampole C, et al.: Radial artery pulse pressure variation correlates with brachial artery peak velocity variation in ventilated subjects when measured by internal medicine residents using hand-carried ultrasound devices. Chest 2007, 131:1301–1307. 29. •• Goonewardena S, Gemignani A, Ronan A, et al.: Comparison of handcarried ultrasound assessment of the inferior vena cava and N-terminal Pro-Brain natriuretic peptide for predicting re-admission after hospitalization for acute decompensated heart failure. JACC Cardiovasc Imag-
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30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
ing 2008, 1:595–601. This landmark paper demonstrated that HCU-determined IVC size at discharge predicted readmission after hospitalization for ADHF better than clinical, physical examination, or laboratory factors. Galasko G, Lahiri A, Senior R: Portable echocardiography: an innovative tool in screening for cardiac abnormalities in the community. Eur J Echocardiogr 2003, 4:119–127. Scholten C, Rosenhek R, Binder T, et al.: Hand-held miniaturized cardiac ultrasound instruments for rapid and effective bedside diagnosis and patient screening. J Eval Clin Pract 2005, 11:67–72. Vourvouri EC, Schinkel AF, Roelandt JR, et al.: Screening for left ventricular dysfunction using a hand-carried cardiac ultrasound device. Eur J Heart Fail 2003, 5:767–774. Xie T, Chamoun AJ, McCulloch M, et al.: Rapid screening of cardiac patients with a miniaturized hand-held ultrasound imager: comparisons with physical examination and conventional two-dimensional echocardiography. Clin Cardiol 2004, 27:241–245. Borges AC, Knebel F, Walde T, et al.: Diagnostic accuracy of new handheld echocardiography with Doppler and harmonic imaging properties. J Am Soc Echocardiogr 2004, 17:234–238. DeCara JM, Lang RM, Koch R, et al.: The use of small personal ultrasound devices by internists without formal training in echocardiography. Eur J Echocardiogr 2003, 4:141–147. • Lucas BP, Candotti C, Margeta B, et al.: Diagnostic accuracy of hospitalist-performed hand-carried ultrasound echocardiography after a brief training program. J Hosp Med 2009, 4:340–349. In this study, hospitalists identified LV systolic dysfunction with a sensitivity of 85% and specificity of 88% after a 27-hour training program. • Martin LD, Howell EE, Ziegelstein RC, et al.: Hospitalist performance of cardiac hand-carried ultrasound after focused training. American Journal of Medicine 2007;120:1000–1004. The authors found that after 35 training echocardiograms, hospitalists can accurately determine LV systolic function with an agreement of 80% with traditional platforms interpreted by experts. Melamed R, Sprenkle MD, Ulstad VK, et al.: Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest 2009, 135:1416–1420. Fedson S, Neithardt G, Thomas P, et al.: Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service. J Am Soc Echocardiogr 2003, 16:901–905. Ghani SN, Kirkpatrick JN, Spencer KT, et al.: Rapid assessment of left ventricular systolic function in a pacemaker clinic using a hand-carried ultrasound device. J Interv Card Electrophysiol 2006, 16:39–43. • Martin LD, Howell EE, Ziegelstein RC, et al.: Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination? Am J Med 2009, 122:35–41. According to this study, hospitalist use of HCU significantly increases their ability to correctly classify LV systolic function over physical examination alone. Kirkpatrick JN, Ghani SN, Spencer KT: Hand carried echocardiography screening for LV systolic dysfunction in a pulmonary function laboratory. Eur J Echocardiogr 2008, 9:381–383. Vignon P, Dugard A, Abraham J, et al.: Focused training for goaloriented hand-held echocardiography performed by noncardiologist residents in the intensive care unit. Intensive Care Med 2007, 33:1795–1799.
Curr Heart Fail Rep (2010) 7:219–227 44. Croft LB, Duvall WL, Goldman ME: A pilot study of the clinical impact of hand-carried cardiac ultrasound in the medical clinic. Echocardiography 2006, 23:439–446. 45. Kobal SL, Trento L, Baharami S, et al.: Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol 2005, 96:1002–1006. 46. Kimura BJ, Amundson SA, Willis CL, et al.: Usefulness of a hand-held ultrasound device for bedside examination of left ventricular function. Am J Cardiol 2002, 90:1038–1039. 47. Kimura BJ, Bocchicchio M, Willis CL, Demaria AN: Screening cardiac ultrasonographic examination in patients with suspected
227 cardiac disease in the emergency department. Am Heart J 2001, 142:324–330. 48. Kobal SL, Atar S, Siegel RJ: Hand-carried ultrasound improves the bedside cardiovascular examination. Chest 2004, 126:693– 701. 49. Kirkpatrick JN, Belka V, Furlong K, et al.: Effectiveness of echocardiographic imaging by nurses to identify left ventricular systolic dysfunction in high-risk patients. Am J Cardiol 2005, 95:1271–1272. 50. Egan M, Ionescu A: The pocket echocardiograph: a useful new tool? Eur J Echocardiogr 2008, 9:721–725.
