Pre-discharge lung and inferior vena cava (IVC) assessment (LUICA) performed by heart failure (HF) nurses can provide crucial diagnostic support that is predictive of acute decompensated heart failure (ADHF) outcomes, a new trial suggests.
The study, published online Monday and in the Aug. 2 issue of the Journal of the American College of Cardiology, noted that despite major treatment advances, HF remains a major health care and economic problem – with high readmission and mortality rates.
“These rates are driven by the presence of residual congestion at discharge. It is estimated that about one-half of all patients admitted for HF are discharged with residual congestion,” said the authors, led by Georgios Zisis, RN, MSc, from the Baker Heart and Diabetes Institute, Western Health, and he University of Melbourne, Australia.
“Effective diuretic protocols are needed to achieve euvolemia during hospitalization,” they said, noting that predischarge congestion assessments by healthcare professionals are currently based only on clinical and laboratory congestion markers.
They noted that, in particular, lung ultrasound (LUS) is an emerging non-invasive assessment that has been proven to be safe to guide fluid management and to identify residual congestion, while ultrasound assessment of the IVC is established for the estimation of right atrial pressure.
However, Zisis and colleagues noted that little is known about the value of combining the assessment of both LUS and IVC – adding that while previous studies have shown that healthcare professionals can be trained to deliver LUS assessment in inpatients and outpatients, the ability of a HF nurse to deliver established pre-discharge LUS and IVC imaging is undefined.
The multisite, prospective, observational study was set up to assess the ability of HF nurses to deliver a predischarge LUICA to predict 90-day outcomes.
HF nurses scanned 240 patients with ADHF (median age: 77 years [IQR: 67-83 years]; 56% men) using a nine-zone LUICA protocol. Obtained images were reviewed by independent nurses who were blinded to clinical characteristics and outcomes.
Based on a B-line cutoff of 10, patients were dichotomized as congested (n = 115) or not congested (n = 125). The 115 (48%) patients (73 [63%] men; median age: 75 years [IQR: 68-82 years]) were more likely to have had previous cardiac operations, long-standing HF (>6-month history), and renal impairment.
At 90-day follow-up, the team reported that HF readmission or mortality occurred in 42 (37%) congested patients compared with 18 (14%) non-congested patients (odds ratio [OR] 3.42; 95% confidence interval [CI] 1.82-6.40; p < 0.001).
Three (2%) non-congested patients died post-discharge, compared with 13 (10%) congested patients (OR: 5.18; 95% CI: 1.44-18.69; P < 0.01).
Furthermore, 30-day follow-up shows an increase in HF readmission or mortality (OR: 3.86; 95% CI: 1.65-8.99; P < 0.01).
Over 90 days, days alive out of hospital were fewer (78.3 days vs 85.5 days; P < 0.01) in congested patients, said Zisis and colleagues.
The team concluded that the non-invasive assessment of congestion is easy to implement and provides a path to guided volume management during the hospital course.
“Incorporation of LUICA in nursing care can detect residual congestion and reduce readmissions,” they said. “Further efforts are needed to expand training in and implementation of nursing ultrasound protocols in HF management programs.”
A vision for the future?
Writing in an accompanying editorial, Brandon M. Wiley, MD; Barry A. Borlaug, MD; and Garvan C. Kane, MD, PhD, all from the Mayo Clinic, Rochester, Minnesota, noted that interest in point-of-care ultrasound (POCUS) has “exploded” in recent years, with more widespread integration into the bedside examination as devices have become smaller and more affordable.
“Within the practice of cardiovascular medicine, LUS has clear applications. LUS is unique in that it is highly feasible, simple to perform using even the most unsophisticated HHU [handheld ultrasound] device, and clinically impactful,” said the editorialists.
They added that IVC evaluation has previously been shown to predict the risk of HF hospitalization and noted that while it was not found to be predictive in the current study, it was only interrogated in a minority of the participants.
“We should not be quick to exclude its importance in POCUS assessment of HF patients,” they said, adding that the study reinforces the effectiveness of LUS for risk-stratifying patients with HF.
“Zisis et al have provided a vision of how expanding the use of handheld ultrasound could strengthen health care delivery,” the expert commenters noted.
“The potential of these devices to elevate the physical examination and change the delivery of health care can only be realized by placing them in the hands of a broad array of health care providers,” they said, adding that next-generation devices will support less-experienced operators with advanced artificial intelligence software and machine learning algorithms that optimize diagnostic efficacy and provide meaningful clinical feedback at the point of care.
Zisis G, Yang Y, Huynh Q, et al. Nurse-Provided Lung and Inferior Vena Cava Assessment in Patients With Heart Failure. J Am Coll Cardiol 2022;80:513-523.
Wiley BM, Borlaug BA, Kane GC. Lung Ultrasound in Heart Failure: Envisioning Handheld Ultrasound to Empower Nurses and Transform Health Care. J Am Coll Cardiol 2022;80:524-526.
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