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6
Journal of the Cardioprogress Foundation
Leading articLe
Lung ultrasound in patients with
decompensated heart failure with preserved or reduced left ventricular ejection fraction:
a prospective study
F. Cabello Montoya, A.F. Safarova*, Zh.D. Kobalava, A.E. Soloveva, T.V. Lobzhanizde
Peoples' Friendship University of Russia, Moscow, Russia Vinogradov Clinical City Hospital, Moscow, Russia
Authors
Elisa F. Cabello Montoya, M. D., student of the Department of Internal Medicine with the subspecialty of cardiology and functional diagnostics named after Moiseev V.S.,Peoples' Friendship University of Russia, Moscow, Russia
Ayten Safarova Fuad Kyzy, M. D., Ph. D., professor of the Department of Internal Medicine with the subspecial- ty of cardiology and functional diagnostics named after Moiseev V.S.,Peoples' Friendship University of Russia, physician of the Department of Functional Diagnostics, Vinogradov Clinical City Hospital, Moscow, Russia Zhanna D. Kobalava, M. D, Ph. D., doctor of sciences, professor, head of the Department of Internal Medicine with the subspecialty of cardiology and functional diagnostics named after V.S. Moiseev,Peoples' Friendship University of Russia, Moscow, Russian Federation
Anzhela E. Soloveva, M. D., Ph. D., assistant professor of the Department of Internal Medicine with the sub- specialty of cardiology and functional diagnostics named after Moiseev V.S.,Peoples' Friendship University of Russia, Moscow, Russian Federation
Tinatin V. Lobzhanizde, M. D., Ph. D., assistant professor of the Department of Internal Medicine with the subspecialty of cardiology and functional diagnostics named after Moiseev V.S.,Peoples' Friendship University of Russia, Moscow, Russia
Objective. To estimate the prognostic value of left ventricular ejection fraction (LVEF) and B-lines (lung ultrasound) in patients with decompensated heart failure (DHF).
Material and methods. 162 patients with DHF underwent routine physical examination and 8-zone scanning lung ultrasound (66 % men, average age 68 ± 12 years, 97 % with arterial hypertension, 44 % with myocardial infarction, 60 % with atrial fibrillation, ejection fraction (EF) 40 ± 14 %, EF <40 %, 46 %, NT-proBNP 4246 (1741;
* Corresponding author. Tel.: +79031025731. E-mail: [email protected]
during admission and discharge. The sum of B-lines <5 was considered normal, 6-15, 16-30 and > 30 — mild, moderate and severe pulmonary congestion, respectively.
Results. LVEF > 50 % was detected in 49 of 162 (30.2 %) patients with DHF on admission, EF 40-49 % — in 38 (23.5 %), EF <40 % — in 75 (46.3 %). 31 % of patients had mild pulmonary congestion during initial lung ultrasound, 68 % — severe.
By the time of discharge 33, 15 and 4 % of patients had mild, moderate and severe pulmonary congestion, respectively. During multivariate regression analysis, which included sex, age, functional class of HF and swelling of jugular veins by the time of discharge, the sum of B-lines >5 was independently associated with increased all-cause mortality (hazard ratio (HR) 2.86 with 95 % CI 1,15-7,13, p = 0.024) during one year of follow-up after discharge and the sum of B-lines >15 — with a high probability of HF readmission (HR 2.83, CI 1,41-5,67, p = 0,003). There was no significant correlation between LVEF, all-cause mortality (HR 0.72, 95 % CI) 0.61-1.41, p = 0.880) and HF readmission (HR 0.52, CI 0.24-1.09, p = 0.169) during one year of follow-up after discharge. Conclusion. Heart failure hospitalization is associated with poor long-term prognosis and an increased cardiovascular risk, regardless of LVEF. Lung ultrasound may be a simple, available non-invasive method for assessing the severity of pulmonary congestion, control its progression and may have prognostic value in patients with DHF. Keywords: decompensated heart failure, left ventricular ejection fraction, B-lines, prognosis.
conflicts of interest: nothing to declare. Received: 03.04.2019 Introduction
Pulmonary congestion is one of the most common cause of admission in patients with HF. Persistent clinical symptoms and signs of pulmonary congestion during discharge and outpatient examination are strong predictors of adverse outcomes. Clinical and radiological symptoms and signs of minor pulmonary congestion can be less obvious than severe congestion. One of the strongest markers of the severity and prognosis of pulmonary congestion is the concentration of NTproBNP, especially during discharge or outpatient examination, when patients are taking stable doses of diuretics [1].
It is remarkable that increased level of NTproBNP can be also observed in patients with DHF, heart rhythm disturbances, renal dysfunction, and obesity. Guidelines for the management of heart failure recommend to use ultrasound to assess ventricular function, valvular pathology, pulmonary artery pressure, collapse of the inferior vena cava, and, finally, to examine lungs, especially in patients with DHF (class IIb, level of evidence: C) [2].
Complex use of biomarkers and heart and lung ultrasound allows to assess pathophysiology and etiology of heart failure, as well as the severity of congestion [3]. B-lines that can be seen during lung ultrasound are artifacts caused by the accumulation of extravascular fluid. The number of B-lines correlates with the severity of pulmonary edema [4]. Lung ultrasound is simple,
Accepted: 16.05.2019
accurate, fast, and affordable method to assess pulmonary stasis and detect interstitial lung disease [5].
Even though the detection of B-lines increases diagnostic accuracy, its relationship with other noninvasive markers of lung congestion haven't been studied yet, especially in patients with HF depending on the left ventricular ejection fraction (LVEF). LVEF has been used for the stratification of patients with HF for a long time, but it is relatively subjective.
Approximately half of patients with HF have reduced LVEF <40 % (HFrEF) and > 50 % — preserved LVEF (HFpEF) [2]. Patients with heart failure with midrange LVEF from 40 to 49 % (HFmrEF) are at the «gray zone» and require additional studies to assess clinical pic- ture, hemodynamics, laboratory and echocardiography (EchoCG) data. A meta-analysis that included 606.762 patients with HF showed that patients with HFmrEF have a lower all-cause mortality compared with HFrEF [RR 0.9; 95 % CI = 0.85-0.94, p <0.001] [6].
It is also remarkable that patients with HFrEF have higher rate of non-cardiological mortality compared with HFmrEF (RR, 1.31; 95 % CI 1.22-1.41, p <0.001).
At the same time, there is evidence of adverse long-term outcomes of pulmonary congestion ultrasound signs during discharge in patients with decom-pensated and stable HF [7]. There haven't been any prospective studies of pulmonary congestion prognostic value and its relationship with LVEF among Russian population in patients with HF.
The objective of this study was to assess the prog- nostic value of LVEF and pulmonary congestion, eval- uated using lung ultrasound in three subgroups of patients with DHF.
Materials and methods
162 patients with DHF were included into the prospective single-center observational study (66 % of men, average age 68 ± 12 years, arterial hypertension 97 %, myocardial infarction 44 %, atrial fibrillation 60 %, ejection fraction (EF) 40 ± 14 %, EF <40 %,
46 %, NT-proBNP 4246 (1741; 6837) pg / ml) (Table 1).
Inclusion criteria were: a rapid increase of symptoms and/or signs of HF, structural and functional changes of the heart, and an increased NT-proBNP in patients with acute HF. Exclusion criteria were: acute coronary syndrome, terminal stage of chronic kidney disease, severe anemia, primary pulmonary pathology (pneumonia, COPD or chronic BA and severe hydrothorax requiring thoracentesis).
Table 1. Clinical and demographic characteristics of patients (n=162)
Parameter Value
Sex (m/w), n (%) 107 (66)/ 55 (34)
Age, years (M±SD) 68±12
The duration of HF, years (Me (IQR)) 2 (0,3;5)
HF functional class, NYHA, n (%) I II III I 3 (2) 3 (2) 78 (48) 78 (48)
V
Left ventricular ejection fraction (EF), % (M±SD) 40±14
NT-proBNP, pg/ml (Me (IQR)) 4246 (1741; 6837)
Comment: HF — heart failure
All patients underwent standard physical examination during admission and discharge (Table 2). Dyspnea at rest and on exertion, orthopnea, moist
bubbling rales and jugular veins distention were the main symptoms and signs of pulmonary congestion.
Echocardiography and lung ultrasound (MicroMaxx SONOSITE) were performed during the first 12 hours of admission, according to the recommendations [8, 9]. Systolic and diastolic volumes and LVEF were de- termined by Simpson method in two- and four-cham- ber positions. Patients were divided into three groups depending on LVEF (PV> 50 %; PV 40-49 %; PV <40 %).
The number of B-lines in each zone were counted using abdominal probe of lung ultrasound in eight zones of chest anterolateral surfaces. B-lines are reverberation artifacts shaped as laser beams arising from the pleural line to the screen edge [10, 11]. Over 5 B-lines can serve as a sign of pulmonary congestion: minor (6-15 B-lines), moderate (16-30 B-lines) and severe (>30 B-lines) [10]. Residual pulmonary congestion was diagnosed if clinical and/or ultrasound signs of pulmonary congestion were presented during discharge.
The outcomes (all-cause mortality and readmission with DHF) were estimated after 1,3,6,12 months after discharge by phone calls.
The study complies the Declaration of Helsinki and was approved by the Ethical Committee of the RUDN Medical Institute (Peoples' Friendship University of Russia). All participants gave written informed con- sent.
Statistical data processing was performed using the STATISTICA 8.0 (Statsoft) software and SPSS 22.0. Quantitative variables were described as arithmetic mean (M) and standard deviation of mean (SD) (in case of normal distribution) or as median (Me) and interquartile range (IQR) (in case of asymmetric dis- tribution). The significance of differences between quantitative variables of the groups was evaluated using the Mann-Whitney U-test. Qualitative variables
Signs Admissio Discharge P
n N=162 N=162
Dyspnea At rest, n (%) On exertion, n (%) 54 (33,3) 162 (100) 0 (0) 68 (41,9) <0,001 <0,001
Orthopnea, n (%) 127 (78,3) 31 (19,1) <0,001
Rales, n (%) 141 (87,0) 21 (13) <0,001
Jugular vein distension>8 cm, n (%) 39 (24) 25 (15) <0,001
Jugular vein distension, cm (Me (IQR)) 7 (5;8) 5 (5;6) <0,001
Hepatomegaly, n (%) 82 (50,6) 27 (17) <0,001
The largest size of the liver, cm (M±SD) 10,9±2 9,2±1,6 <0,001
Ascites, n (%) 27 (16,6) 2 (1,2) <0,001
Leg swelling, n (%) 150 (92,6) 53 (32,7) <0,001
Comment: Data are presented as median, 25th and 75th percentile (Me (IQR)), arithmetic mean (M) and standard deviation of the mean (SD).
Table 2. Symptoms of congestion during admission and discharge
were represented by absolute (n) and relative (%) val- ues. The significance of differences in different points of the same group was assessed using the Wilcoxon signed-rank test. The survival probability was es- timated by Kaplan — Meyer survival curves and the comparison — using the log-rank test. The effect of pulmonary congestion on the risk of death or read- mission with HF was assessed by one- and multivari- ate Cox's regression analysis. The p value = 0.05 was considered significant.
Results
During discharge 49 (30.2 %) patients had LVEF >50 %; 38 (23.5 %) — LVEF 40-49 %, 75 (46.3 %) — EF <40 %
among 162 patients with DHF. Patients with LVEF
<40 % had a higher level of NT-proBNP during admission, higher incidence of coronary artery disease (CAD), lower SBP, higher frequency of male patients compared with patients with EF> 40 % (Table 3).
Pulmonary congestion was mostly moderate and severe according to lung ultrasound: in 67 % of cases — severe, in 32 % — moderate, in 1 % — minor. During discharge there was the decrease in the fre- quency of severe pulmonary congestion — in 4 % of cases, frequency of moderate — in 15 %, of minor — in 33 %, and in 48 % of cases pulmonary congestion was absent according to the lung ultrasound (Fig. 1).
Patients during admission with severe pulmonary congestion did not differ from patients with non-severe form by clinical and demographic characteristics according to ultrasound, functional class of HF, LVEF and other structural and functional parameters of the
Table 3. Clinical and demographic characteristics of patients with DHF depending on LVEF
Parameter EF>50 % EF 40-49 % EF<40 % P
Age, years, (Me (IQR)) 78 (69; 82) 70 (63; 77) 62 (57; 71) 0.015
Men, n (%) 24 (49) 20 (53) 62 (83) 0.001
AH, n (%) 49 (100) 37 (97) 71 (95) 0.240
CAD, n (%) 13 (27) 17 (45) 41 (55) 0.008
Dyslipidemia, n (%) 15 (31) 19 (50) 27 (36) 0.166
Type 2 DM, n (%) 19 (40) 15 (39) 28 (37) 0.972
AF, n (%) 26 (53) 22 (58) 49 (65) 0.379
HR, bpm, (Me (IQR)) 80 (72; 100) 88 (80; 110) 98 (83; 120) 0.214
SBP, mmHg 150 (130; 170) 149 (130; 165) 130 (110; 150) 0.005
DBP, mmHg 80 (80;90) 80 (80;90) 80 (70;87) 0.148
RR per minute 23±2.8 23±3 23±3.7 0.296
Dyspnea at rest, n (%) 19 (39) 10 (26) 25 (33.3) 0.473
Orthopnea, n (%) 38 (78) 30 (79) 59 (79) 0.984
Rales, n (%) 42 (86) 33 (89) 66 (88) 0.932
Jugular vein distension >8 cm, n (%) 10 (20) 7 (18) 22 (29) 0.339
Jugular vein distension, cm, (Me (IQR)) 5 (5; 7) 5 (5; 7) 6 (5; 8) 0.086
Hepatomegaly, n (%) 22 (45) 17 (45) 43 (57) 0.187
NT-proBNP during admission, pg/ml, (Me (IQR)) 2521 (1390; 5092) 3298 (1621; 5520) 5039 (3139; 8131) 0.012
NT-proBNP during discharge, pg/ml, (Me (IQR)) 1217 (644; 2524) 1842 (484; 5165) 3339 (1782; 6019) 0.139
Duration of admission, days. 9.4±3.5 9.6±2.2 9±3.8 0.056
□
Severe Moderate Minor
Admission 1%
32%
H Severe
□ Moderate
□ Minor
I—I Absent
Discharge 4%
15%
33%
Figure 1. The dynamics of lung congestion according to lung ultrasound
myocardium, but had higher frequency of jugular vein distention, radiological signs of venous stasis in the lungs, and higher level of NT-proBNP (Table 4).
Table 4. Clinical and laboratory parameters depending on the presence of initial lung congestion during lung ultrasound
Signs Summary of B-lines < 30 N=53 Summary of B-lines > 30 N=109 P
Men, n (%) 31 (58.5) 76 (70) 0.156
Age, years (M±SD) 68±11 69±13 0.633
HF functional class, NYHA, n (%) I II III I V 0 (0) 1 (2) 23 (43) 29 (55) 3(2.7) 2(1.8) 55 (50) 49 (45) 0.469
Ejection fraction, % 43.1±12.7 39±14 0.086
NT-proBNP, pg/ml (Me (IQR)) 3328 (1439;4610 ) 4988 (2301 ;7134) 0.004
Symptoms and signs during admission
Dyspnea at rest, n (%) 16 (30) 38 (35) 0.553
Dyspnea on exertion, n (%) 53 (100) 109 (100)
Orthopnea, n (%) 43 (81) 84 (77) 0.555
Rales, n (%) 44 (83) 97 (89) 0.288
Jugular vein distension, cm (Me (IQR)) 5.7±1.6 6.5±1.6 0.030
Hepatomegaly, n (%) 30 (56.6) 52 (48) 0.341
Ascites, n (%) 5 (9.4) 22 (20) 0.084
Leg swelling, n (%) 50 (94) 100 (92) 0.553
Hydrothorax, n (%) 23 (43.4) 54 (50) 0.253
Table 5. Cox proportional-hazards regression one-variative model for lung congestion parameters, estimated by different methods for all-cause mortality in patients with HF
Prognostic value of lung congestion according to lung ultrasound and LVEF in patients with decompensated heart failure The median follow-up was 293 days. During this pe- riod, 30 (18.5 %) patients died and 56 (35 %) patients were readmitted due to DHF.
We used one-variative Cox regression analysis to assess the prognostic value and severity of pulmonary congestion and LVEF (Table 5, 6). We found that swollen jugular veins and pulmonary stasis detected using lung ultrasound are another signs of congestion during discharge associated with the risk of death.
According to multivariate Cox regression analysis (including gender, age, EF, functional class of HF and jugular vein distention during discharge), > 5 B-lines during discharge were independently associated with a higher probability of 12-month all-cause mortality (RR 2.86 95 % CI 1.15-7.13, p = 0.024).
According to similar to Cox multivariate regression analysis, >15 B-lines were independently associated with higher probability of readmission due to heart failure during one-year follow-up (RR 2.83, 95 % CI 1.41-5.67, p = 0.003) after the adjustment by age, gender, functional class of HF and the presence of jugular vein distention during discharge. We did not find any reliable associations of readmission and all-cause mortality with LVEF regardless of its level (Fig. 2-4).
Parameter RR 95 % CI P
Admission
Dyspnea at rest 0.63 0.30-1.30 0.218
Orthopnea 0.55 0.19-1.58 0.268
Rales 0.44 0.10-1.87 0.271
Jugular vein distension 0.61 0.28-1.30 0.206
Congestion on X-Ray 0.89 0.39-2.01 0.785
Hydrothorax 0.59 0.28-1.26 0.177
The summary of B-lines during admission 1.72 0.75-3.94 0.172
>30 B-lines during admission 1.70 0.73-3.98 0.215
EF <40 % 1.1 0.58-2.43 0.638
EF 40-49 % 0.7 0.30-2.04 0.633
EF > 50 % 0.8 0.38-2.00 0.757
Discharge
Dyspnea on exertion 0.60 0.29-1.24 0.172
Orthopnea 0.57 0.25-1.28 0.173
Rales 0.88 0.30-2.52 0.814
Jugular vein distension 3.00 1.36-6.58 0.006
The summary of B-lines during discharge 1.05 1.02-1.09 0.001
>5 B-lines during discharge 3.94 1.68-9.21 0.002
>15 B-lines during discharge 2.44 1.11-5.36 0.026
Table 6. Cox proportional-hazards regression model for lung congestion parameters, estimated by different methods for the risk of readmission in patients with HF
Parameter RR CI P
Admissio n
Dyspnea at rest 0,60 0,35-1,02 0,061
Orthopnea 0,61 0,29-1,30 0,205
Rales 0,69 0,29-1,62 0,405
Jugular vein distension 0,73 0,41-1,31 0,300
Congestion on X-Ray 0,81 0,41-1,58 0,539
Hydrothorax 0,47 0,47-1,41 0,473
The summary of B-lines during admission 0,85 0,51-1,42 0,546
>30 B-lines during admission 0,88 0,49-1,58 0,678
EF <40 % 1,5 0,93-2,68 0,087
EF 40-49 % 0,5 0,24-1,09 0,086
EF > 50 % 0,7 0,39-1,30 0,276
Discharge
Dyspnea on exertion 0,93 0,55-1,58 0,806
Orthopnea 0,75 0,35-1,58 0,451
rales 0,68 0,33-1,40 0,304
Jugular vein distension 0,54 0,28-1,03 0,065
The summary of B-lines during discharge 0,79 0,46-1,34 0,387
>5 B-lines during discharge 1,44 1,07-1,94 0,015
>15 B-lines during discharge 0,74 0,44-1,26 0,276
Dyspnea at rest 2,67 1,47-4,83 <0,001
0,002
_n s 5 B-lines during discharge _n >5 B-lines during discharge -t- Censored Censored
0 100 200 300 «0
Duration of follow-up, days
Figure 2. Kaplan Meier curves for cumulative probability of survival (without all-cause mortality) depending on the presence and severity of
lung congestion according to lung ultrasound during discharge.
Figure 3. Kaplan Meier curves for cumulative probability of survival without readmissions due to HF depending on the presence and severity of lung congestion according to lung ultrasound during discharge.
Discussion
Chronic heart failure (CHF) is still one of the most common outcomes with poor prognosis of many cardiovascular diseases (CVD). According to epidemiological studies over 37.7 million people are affected by CHF in the world [12]. This chronic progressive
disease is characterized by high mortality, high risk of complications and hospital admissions [13]. HF is classified by LVEF level that also defines the effectiveness of evidence-based therapy. According to the MAGGIC study, patients with HFmrEF have lower mor- tality rates compared with patients with HFrEF [14]. Even though some studies have shown that patients
Figure 4. Kaplan Meier curves for cumulative probability of survival (without all-cause mortality) and without readmissions due to HF
depending on the LVEF during discharge.
with HFmrEF have a significantly better prognosis compared with patients with HFrEF, other investigations established similar mortality and hospital admission rates [15-20].
Recently published data from GWTG-HF (Get with The Guidelines — HF) showed that patients with HFrEF and HFpEF have equally low survival rates during 1-month and 1-year follow-up after admission compared with patients with HFrEF. In addition, patients with HF, regardless of LVEF, have high 5-year mortality rate compared with admission index (75.4 %) [12].
In our study, 30.2 % of patients admitted due to DHF had LVEF >50 %; 23.5 % — LVEF 40-49 %, 46.3 %
of patients — LVEF <40 %. During the follow-up (median follow-up—293 days) 18.5 % of patients died, 35 % were readmitted. However, we did not find the association between the level of LVEF and all-cause mortality level (RR 0.72, 95 % CI) 0.61-1.41, p = 0.880) during 1-year follow-up and with the probability of re- admission due to HF (RR 0.52, CI 0.24-1.09, p = 0.169). In the presented study, patients with DHF, were in- vestigated with standard laboratory, clinical and in- strumental methods, and underwent lung ultrasound to assess the frequency and dynamics of pulmonary congestion during admission and prognostic signifi- cance of residual pulmonary stasis. We found signs of pulmonary congestion according to clinical data and lung ultrasound in all patients during admission and in 87.7 % of cases, it was confirmed by lung radiogra- phy. We established the association between initially severe pulmonary congestion according to lung ultra-
sound with jugular vein distention, radiological signs of stasis, and significantly higher level of NT-proBNP. We also demonstrated high frequency of residual pulmonary stasis during discharge.
Randomized two-center study included 518 patients with acute respiratory failure (ARF) and demonstrated that lung ultrasound as part of routine screening examination during the diagnosis of DHF is superior to traditional physical examination, chest radiography, and NTproBNP laboratory test [21]. The accuracy of the HF diagnosis using lung ultrasound was significantly higher compared with physical examination (area un- der the curve [AUC] 0.95 versus 0.88, p <0.01) or its combination with X-ray examination and NTproBNP determination (AUC 0 95 versus 0.87, p <0.01). In con- trast, lung radiography and NTproBNP determina- tion was not superior to physical examination alone (AUC 0.87 and 0.85, respectively, p> 0.05). In addition, lung ultrasound was associated with decreased num- ber of diagnostic errors by 7.98 cases compared with 2.24 cases per 100 patients using x-ray and NTproBNP [21]. The results of meta-analysis, which included 1827 patients with shortness of breath also showed higher sensitivity of lung ultrasound (88 %) compared with chest x-ray (73 %, p <0.001) with comparable specificity of the methods (90 %) [22].
Multivariate analysis showed that > 5 B-lines was independently associated with all-cause mortality. Patients with > 15 B-lines had higher risk of readmission due to CHF during 12-months follow-up.
The results of published studies also showed that B-lines allows to identify the risk group of adverse
long-term outcomes in patients with HF at outpatient and inpatient levels. In outpatient study >3 B-lines during ultrasound of 5 and 8 zones was associated with 4-fold risk of all-cause mortality and readmission due to HF during 6 months follow-up [23]. Other studies also showed that preservation of B-lines during discharge in patients admitted due to DHF is associated with the risk of readmission due to DHF during the next 3 and 6 months [24, 25, 26]. Thus, high frequency of pulmonary congestion detected by lung ultrasound and the possibility to monitor its dynamics, combined with prognostic significance, emphasize the need to include this method into the algorithm of investigation of patients with DHF during admission along with clinical, laboratory and other instrumental methods.
Conclusion
Heart failure hospitalization is associated with poor long-term prognosis and an increased cardiovascular risk, regardless of LVEF. Lung ultrasound may be a simple, available non-invasive method for assessing the severity of pulmonary congestion, control its progression and may have prognostic value in patients with DHF.
Conflict of interest: None declared. References
1. Palazzuoli A., Ruocco G., Beltrami M., et al. Combined use of lung ultrasound, B-type natriuretic peptide, and echocardiog-raphy for outcome prediction in patients with acute HFrEF and HFpEF. Clin Res Cardiol. 2018 Jul;107 (7): 586-596. 2 Ponikowski P., Voors A.A., Anker S.D., Bueno H., Cleland J.G., Coats A.J., et al.; Authors/Task Force Members; Document Reviewers. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diag- nosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the spe- cial contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016;18 (8): 891 -975.
3. Palazzuoli A, Beltrami M, Ruocco G, Franci B, Campagna MS, Nuti R (2016) Diagnostic utility of contemporary echo and BNP assessment in patients with acute heart failure during early hospitalization. Eur J Intern Med 30:43-48
4. Ricci F., Aquilani R., Radico F., Bianco F., Dipace G., Miniero E., et al., Role and importance of ultrasound lung comets in acute cardiac care. Eur Heart J Acute Cardiovasc Care. 2015 Apr;4 (2): 103-12.
5. Gargani L, Frassi F, Soldati G, Tesorio P, Gheorghiade M, Picano E (2008) Ultrasound lung comets for the differential diagnosis
of acute cardiogenic dyspnoea: a comparison with natriuretic peptides. Eur J Heart Fail 10:70-77
6. Altaie S., Khalife W. The prognosis of mid-range ejection fraction heart failure: a systematic review and meta-analysis. ESC Heart Fail. 2018 Dec;5 (6): 1008-1016.
7. Miglioranza MH., Picano E., Badano LP. Pulmonary congestion evaluated by lung ultrasound predicts decompensation in heart failure outpatients. Int J Cardiol. 2017 Aug 1 ;240:271-278.
8. Bekgoz B., Kilicaslan I., Bildik F., Keles A., Demircan A., Hakoglu O., Coskun G., Demir HA.. BLUE protocol ultraso-nography in Emergency Department patients presenting with acute dyspnea Am J Emerg Med. 2019 Feb 20. pii: S0735-6757 (19) 30112-3.
9. Mareev V.Y., Fomin I.V., Ageev F.T., Begrambekova Y.L., Vasyuk Y.A., Garganeeva A.A., Gendlin G.E., Glezer M.G., Gautier S.V., Dovzhenko T.V., Kobalava Z.D., Koziolova N.A., Koroteev A.V., Mareev Y.V., Ovchinnikov A.G., Perepech N.B., Tarlovskaya E.I., Chesnikova A.I., Shevchenko A.O., Arutyunov G.P., Belenkov Y.N., Galyavich A.S., Gilyarevsky S.R., Drapkina O.M., Duplyakov D.V., Lopatin Y.M., Sitnikova M.Y., Skibitsky V.V., Shlyakhto E.V. Russian Heart Failure Society, Russian Society of Cardiology. Russian Scientific Medical Society of Internal Medicine Guidelines for Heart failure: chronic (CHF) and acute decompensated (ADHF). Diagnosis, prevention and treatment. Kardiologiia. 2018; 58 (6S): 8-158. Russian.
10. Picano E., Pellikka P.A. Ultrasound of extravascular lung water: A new standard for pulmonary congestion. European Heart Journal 2016 Jul 14;37 (27): 2097-104.
11. Alekhin M. N. Lung ultrasonography in the diagnosis of extra-vascular lung water. Creative Cardiology. № 1, 2015; 27-37. Russian (Алехин М.Н. Ультразвуковое исследование легких для диагностики внесосудистой жидкости. Креативная кардиология, № 1, 2015; 27-37)
12. Shah K.S., Xu H., Matsouaka R.A., Bhatt D.L. Heart Failure With Preserved, Borderline, and Reduced Ejection Fraction: 5-Year Outcomes. J Am Coll Cardiol. 2017 Nov 14;70 (20): 2476-2486.
13. Jessup M., AbrahamW.T., CaseyD.E. et al. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults//Circulation.-2009.-Vol.119 (14).-P.1977-2016
14. Salah K., Stienen S., Pinto YM., Eurlings LW., Prognosis and NT- proBNP in heart failure patients with preserved versus reduced ejection fraction. Heart. 2019 Apr 8. pii: heartjnl-2018-314173.
15. Lekavich CL, Barksdale DJ, Neelon V, Wu JR.Heart failure pre- served ejection fraction (HFpEF): an integrated and strategic review. Heart Fail Rev2015;20:643-53.
16. Steinberg BA, Zhao X, Heidenreich PA, et al. Trends in patients hospitalized with heart failureand preserved left ventricular ejection fraction:prevalence, therapies, and outcomes. Circulation 2012;126:65-75.
17. Yancy CW, Jessup M, Bozkurt B, et al. 2013ACCF/AHA guideline for the management of heartfailure: a report of the American College ofCardiology Foundation/American Heart Associa- tion Task Force on Practice Guidelines. J Am CollCardiol 2013;62:e147-239.
18. Bhatia RS, Tu JV, Lee DS, et al. Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med 2006;355:260-9.
19. Owan TE, Hodge DO, Herges RM, Jacobsen SJ,Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejectionfraction. N Engl J Med 2006;355:251-9.
20. Burkhoff D. Mortality in heart failure with preserved ejection fraction: an unacceptably high rate. Eur Heart J 2012;33:1718- 20).
21. Pivetta E., Goffi A., Nazerian P., Castagno D., Tozzetti C., Tizzani
P. et al. Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial. Eur J Heart Fail. 2019
22. Maw A.M., Hassanin A., Ho P.M., McInnes M.D., Moss A., Juarez-Colunga E., et al. Diagnostic Accuracy of Point-of-Care
Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis. JAMA Netw. Open. 2019 Mar 1;2 (3): e190703.
23. Platz E., Lewis E.F., Uno H., Peck J., Pivetta E., Merz A.A., et al. Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients. Eur Heart J. 2016 Apr 14;37 (15): 1244-51.
24. Platz E., Merz A.A., Jhund P.S. et al. Dynamic changes and prognostic value of pulmonary congestion by lung ultrasound in acute and chronic heart failure: a systematic review. European Journal of Heart Failure. 2017 Sep;19 (9): 11541163.
25. Martindale J.L., Secko M., Kilpatrick J.F., et al. Serial sono-graphic assessment of pulmonary edema in patients with hypertensive acute heart failure. J Ultrasound Med 2018;37 (2): 337-45.
26. Donadio C, Bozzoli L, Colombini E, et al. Effective and timely evaluation of pulmonary congestion: qualitative comparison between lung ultrasound and thoracic bioelectrical impedance in maintenance hemodialysis patients. Medicine (Baltimore) 2015;94:e473.
