Details:<\/span><\/p>\n \u00a0<\/span>–1005 patients from\u00a07 Italian ERs presented with acute dyspnea, and the ER MD was asked to categorize the dyspnea diagnosis as either from ADHF or noncardiogenic dyspnea, based on their\u00a0initial clinical assessment (this was not prescribed but left up to the ER MD, to simulate a real-world situation)\u00a0and after LUS. All patients also\u00a0had CXR’s. After patient discharge, independent reviewers\u00a0 determined the cause of the dyspnea.<\/span><\/p>\n –544 (51.4%) patients were in community hospitals, 461 (45.9%) academic medical centers. Median age 77, 46.2% women, 41.8% smokers, 40.7% with COPD, 63.5%\u00a0hypertensive, 20.2% with congestive heart failure (CHF),\u00a025.8% with ischemic cardiomyopathy\/CAD, 27.9% diabetic. Most on lots of meds. So, pretty sick group overall<\/span><\/p>\n Results:<\/span><\/p>\n –final diagnosis of ADHF was in 463 patients (46%), with very high agreement between the 2 physician adjudicators of the diagnosis. \u00a081.7% of the\u00a0patients were admitted to the hospital.<\/span><\/p>\n –clinical workup and LUS alone were much more accurate than CXR (p<0.01):<\/span><\/p>\n –I\u00a0included below 2 of their summary figures. The one to the left is the summary sensitivity, specificity, etc in the whole group (top) and in those who had\u00a0BNP\/NT-pro-BNP<\/span>\u00a0sent. The \u00a0figure on the right is the ROC curves, showing that clinical evaluation plus LUS were remarkably accurate: they achieved sensitivity, specificity and AUC values for diagnosis of ADHF of 97.0%, 97.4%, and 0.972!!! CXR\u00a0had sensitivity as low as 69.5% (which is higher than in some studies…..) — so, absence of CXR findings does not even come close to excluding a diagnosis of ADHF!!<\/span><\/p>\n –the net reclassification improvement (NRI), an estimate of the % of subjects moving from one diagnosis to another, of the LUS approach vs standard clinical workup was 19.1% (p<0.01)<\/span><\/p>\n –the accuracy of BNP\/NT-pro-BNP values (available on subgroup of 486 patients) was significantly lower than the LUS approach (p<0.01):\u00a0the sensitivity\/specificity was 85%\/61.7% with AUC of 0.733, again being not nearly as sensitive as LUS.<\/span><\/p>\n –there was near perfect intraobserver\u00a0agreement\u00a0in reading LUS (0.97) among experts, and a really good agreement (0.92) for ER MDs with limited LUS training (<10 examinations performed)<\/span><\/p>\n \n \u00a0 \u00a0<\/span>One of the strengths of this study is that it incorporated the\u00a0clinical pretest probability (the “LUS-implemented” approach), which was much more accurate than LUS alone, which was better than CXR\u00a0(though, to be fair, they did not look at a “CXR-implemented approach”, but the stand-alone CXR was still\u00a0really inferior to the stand-alone\u00a0LUS). \u00a0In this study LUS was done as a rapid, bedside test, with a positive test for\u00a0ADHF defined as “bilateral presence of 2 or more zones showing the presence of at least 3 B-lines: vertical, hyperechoic reverberation artifacts extending from the pleural line to\u00a0the bottom\u00a0of the screen”, these artifacts are presumably from interstitial fluid in the lung<\/span>. This was\u00a0a stricter definition of a “positive” LUS than in prior studies, which could explain the\u00a0greater accuracy here —\u00a0prior studies have found more limited LUS accuracy (as low as 54%) in ADHF diagnosis<\/span>. One potential bias in this study is that the same MD who made the initial clinical diagnosis also performed the LUS and was therefore not blinded to the results of the clinical workup in interpreting the LUS.<\/span><\/p>\n S<\/span>o, bottom line: this study comes on the tail of\u00a0one earlier this year showing better accuracy of LUS\u00a0than CXR for pneumonia (see here<\/a>). Together, these studies\u00a0reinforce the potential to use a noninvasive and nonradiation-associated evaluation for\u00a0both CHF\u00a0and pneumonia.\u00a0Although this was an ER-based study, it is likely to be applicable to patients who come into primary care with decompensated heart failure, though i<\/span>t would be great\u00a0to have a community-based study done\u00a0— the majority of patients with ADHF I\u00a0see at the health center\u00a0are not sent to the ER or admitted. \u00a0I treat these patients\u00a0based on clinical assessment and CXR, with very close followup,\u00a0and they do fine clinically. But I imagine that the availability of LUS would allow for a more assured diagnosis.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":" By: Dr. Geoffrey Modest A potentially very useful multicenter\u00a0study was just published finding that lung ultrasound (LUS) was better than chest xray (CXR) in the diagnosis of acute decompensated heart failure (ADHF)\u00a0in patients presenting to\u00a0the emergency room (ER) with dyspnea (see\u00a0CHEST 2015; 148(1): 202 – 210). This is an increasingly common issue, with evidently very […]<\/p>\n![\"untitled\"](\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/files\/2015\/08\/untitled.png\")
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