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The Role of Hand Carried Ultrasound in Guiding Management of Challenging Heart Failure Patients
Abstracts
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959 The Role of Hand Carried Ultrasound in Guiding Management of Challenging Heart Failure Patients W. Khalife, A. Albaeni, V.R. Mukku and M. Almahmoud Cardiology, University of Texas Medical Branch, Galveston, TX. Purpose: Accurate assessment of volume status and estimation of central venous pressure is critical in directing management of acute heart failure (HF) patients . We evaluated the impact of hand carried ultrasound (US) in guiding therapy for HF patients with uncertain volume status on physical examination (PE) or with worsening serum creatinine (Cr). Methods: We prospectively included patients admitted to the hospital with acute HF exacerbation and had uncertain volume status or worsening Cr to undergo US-guided management between January 2017 to October 2018. HF team provided initial management plan based on standard of care (PE, symptoms and lab results), then they were provided with US estimation of intravascular volume (by assessing inferior vena cava size and respiratory variation, right and left jugular veins size, respiratory variation and compressibility). Primary outcome was percent change of initial plan after providing US results. Logistic regression was used to compare the percent change in plan by HF type. Results: A total of 151 (Age 64§15,46% females, 78% white) patients were included during study duration. 47(31%) patients had HF with preserved ejection fraction (HFpEF), and 104 (69%) patients had HF with reduced ejection fraction (HFrEF). A change in plan was observed in 77.5% of the patients after using ultrasound. No difference in percent change of plan between HFrEF (81%) and HFpEF patients (70%), (OR 1.7, 95% CI: 0.73, 3.9, p= 0.2). Conclusion: Ultrasound management of patients with HF and uncertain volume status or worsening Cr may significantly impact management decisions regardless of HF type, Further studies are needed to explore whether these changes improve outcomes of this population.
960 Hand Carried Ultrasound Utilization in Acute Heart Failure Patients, Does It Correlate with Physical Examination? W. Khalife, A. Albaeni, V. Mukku and M. Almahmoud Cardiology, University of Texas Medical Branch, Galveston, TX. Purpose: Evaluation of intravascular volume is an essential component of clinical management of acute heart failure (HF) patients. Correlation between physical examination and ultrasound measurements has not been well studies and was the focus of this investigation. Methods: We prospectively studied patients admitted to the medical floor with acute heart failure exacerbation between January 2017 to October 2018. Assessment of volume status by physical examination (PE) was performed by heart failure team, and classified patient’s volume status into (0euvolemic, 1- Mildly overloaded, 2- Moderately overloaded, 3- Severely overloaded), then central venous pressure (CVP) was measured using hand carried US (assessment of inferior vena cava size and respiratory variation, right and left jugular veins size, respiratory variation and compressibility). Spearman’s correlation was used to correlate between PE findings and USestimated CVP. Finally, the distribution of CVP for each PE category was provided (Figure). Results: A total of 186 (Age 64§15,42% females) patients were included during study duration. (34%) patients had HF with preserved ejection fraction (HFpEF), and 104 (66%) patients had HF with reduced ejection fraction (HFrEF). The correlation between PE and US-estimated CVP was moderate at best (rho=0.41, p<0.001). In many instances PE was unreliable to determine intravascular volume status. (Figure) Conclusion: Physical exam is moderately correlated with US-estimated CVP and is unreliable in directing therapy for acute HF exacerbation. Further investigations are needed to integrate hand carried US in the daily management of heart failure patients.
961 Physician Prediction versus Model Predicted Prognosis in Ambulatory Patients with Heart Failure T.A. Buchan,1 H.J. Ross,1 M. McDonald,1 F. Billia,1 D. Delgado,1 J.G. Duero Posada,1 A. Luk,1 G.H. Guyatt,2 and A.C. Alba.1 1Cardiology, Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada; and the 2Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada. Purpose: Previous evidence suggests that both cardiologists and family doctors have limited accuracy in predicting patient prognosis. Predictive models with satisfactory accuracy for estimating mortality in heart failure (HF) patients exist; physicians, however, seldom use these models. We evaluated the relative accuracy of physician versus model prediction to estimate 1-year survival in ambulatory HF patients. Methods: We conducted a single centre prospective cohort study involving 150 consecutive ambulatory HF patients >18 years of age with a left ventricular ejection fraction ≤40%. Each patient’s cardiologist and family doctor provided their predicted 1-year survival. Using clinical and laboratory data at the time of enrolment we calculated predicted survival using three models: the HF Meta-Score, the Seattle Heart Failure Model (SHFM) and the Meta-Analysis Global Group in Chronic HF (MAGGIC) score. We compared accuracy between physician and model predictions using intraclass correlation (ICC). Results: Median predicted survival by HF cardiologists was lower (median 80%, IQR 61-90%) than that predicted by family doctors (median 90%, IQR 70-99%, p=0.08). The 1-year median predicted survivals calculated by the HF Meta-Score (94.6%), SHFM (95.4%) and MAGGIC (88.9%,) proved as high or higher than physician estimates. Agreement among both HF cardiologists (ICC 0.28-0.41) and family doctors (ICC 0.43-0.47) when compared to 1-year model-predicted survival scores proved limited, while the 3 models agreed well with one another (ICC >0.65). Conclusion: We found that median survival estimates are lower among HF cardiologists in comparison to family doctors, while both physician estimates are lower than calculated model estimates. Considering previous evidence that model’s accuracy is acceptable and physicians’ is limited, our results provide additional evidence of the superior accuracy of predictive models 1-year survival in ambulatory HF patients. These results should be validated in longitudinal studies collecting actual survival. 962 Outpatient Weaning of Inotropes is Achievable in Patients with Advanced Heart Failure A. Afzal, A.Y. Lee, A.S. Bindra and P. Kale. Baylor University Medical Center, Dallas, TX. Purpose: Patients admitted with advanced decompensated systolic heart failure (ADHF) typically require inotropes. Those who cannot be bridged to advanced heart failure therapies are discharged home on inotropes (as a
S381
959 The Role of Hand Carried Ultrasound in Guiding Management of Challenging Heart Failure Patients W. Khalife, A. Albaeni, V.R. Mukku and M. Almahmoud Cardiology, University of Texas Medical Branch, Galveston, TX. Purpose: Accurate assessment of volume status and estimation of central venous pressure is critical in directing management of acute heart failure (HF) patients . We evaluated the impact of hand carried ultrasound (US) in guiding therapy for HF patients with uncertain volume status on physical examination (PE) or with worsening serum creatinine (Cr). Methods: We prospectively included patients admitted to the hospital with acute HF exacerbation and had uncertain volume status or worsening Cr to undergo US-guided management between January 2017 to October 2018. HF team provided initial management plan based on standard of care (PE, symptoms and lab results), then they were provided with US estimation of intravascular volume (by assessing inferior vena cava size and respiratory variation, right and left jugular veins size, respiratory variation and compressibility). Primary outcome was percent change of initial plan after providing US results. Logistic regression was used to compare the percent change in plan by HF type. Results: A total of 151 (Age 64§15,46% females, 78% white) patients were included during study duration. 47(31%) patients had HF with preserved ejection fraction (HFpEF), and 104 (69%) patients had HF with reduced ejection fraction (HFrEF). A change in plan was observed in 77.5% of the patients after using ultrasound. No difference in percent change of plan between HFrEF (81%) and HFpEF patients (70%), (OR 1.7, 95% CI: 0.73, 3.9, p= 0.2). Conclusion: Ultrasound management of patients with HF and uncertain volume status or worsening Cr may significantly impact management decisions regardless of HF type, Further studies are needed to explore whether these changes improve outcomes of this population.
960 Hand Carried Ultrasound Utilization in Acute Heart Failure Patients, Does It Correlate with Physical Examination? W. Khalife, A. Albaeni, V. Mukku and M. Almahmoud Cardiology, University of Texas Medical Branch, Galveston, TX. Purpose: Evaluation of intravascular volume is an essential component of clinical management of acute heart failure (HF) patients. Correlation between physical examination and ultrasound measurements has not been well studies and was the focus of this investigation. Methods: We prospectively studied patients admitted to the medical floor with acute heart failure exacerbation between January 2017 to October 2018. Assessment of volume status by physical examination (PE) was performed by heart failure team, and classified patient’s volume status into (0euvolemic, 1- Mildly overloaded, 2- Moderately overloaded, 3- Severely overloaded), then central venous pressure (CVP) was measured using hand carried US (assessment of inferior vena cava size and respiratory variation, right and left jugular veins size, respiratory variation and compressibility). Spearman’s correlation was used to correlate between PE findings and USestimated CVP. Finally, the distribution of CVP for each PE category was provided (Figure). Results: A total of 186 (Age 64§15,42% females) patients were included during study duration. (34%) patients had HF with preserved ejection fraction (HFpEF), and 104 (66%) patients had HF with reduced ejection fraction (HFrEF). The correlation between PE and US-estimated CVP was moderate at best (rho=0.41, p<0.001). In many instances PE was unreliable to determine intravascular volume status. (Figure) Conclusion: Physical exam is moderately correlated with US-estimated CVP and is unreliable in directing therapy for acute HF exacerbation. Further investigations are needed to integrate hand carried US in the daily management of heart failure patients.
961 Physician Prediction versus Model Predicted Prognosis in Ambulatory Patients with Heart Failure T.A. Buchan,1 H.J. Ross,1 M. McDonald,1 F. Billia,1 D. Delgado,1 J.G. Duero Posada,1 A. Luk,1 G.H. Guyatt,2 and A.C. Alba.1 1Cardiology, Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada; and the 2Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada. Purpose: Previous evidence suggests that both cardiologists and family doctors have limited accuracy in predicting patient prognosis. Predictive models with satisfactory accuracy for estimating mortality in heart failure (HF) patients exist; physicians, however, seldom use these models. We evaluated the relative accuracy of physician versus model prediction to estimate 1-year survival in ambulatory HF patients. Methods: We conducted a single centre prospective cohort study involving 150 consecutive ambulatory HF patients >18 years of age with a left ventricular ejection fraction ≤40%. Each patient’s cardiologist and family doctor provided their predicted 1-year survival. Using clinical and laboratory data at the time of enrolment we calculated predicted survival using three models: the HF Meta-Score, the Seattle Heart Failure Model (SHFM) and the Meta-Analysis Global Group in Chronic HF (MAGGIC) score. We compared accuracy between physician and model predictions using intraclass correlation (ICC). Results: Median predicted survival by HF cardiologists was lower (median 80%, IQR 61-90%) than that predicted by family doctors (median 90%, IQR 70-99%, p=0.08). The 1-year median predicted survivals calculated by the HF Meta-Score (94.6%), SHFM (95.4%) and MAGGIC (88.9%,) proved as high or higher than physician estimates. Agreement among both HF cardiologists (ICC 0.28-0.41) and family doctors (ICC 0.43-0.47) when compared to 1-year model-predicted survival scores proved limited, while the 3 models agreed well with one another (ICC >0.65). Conclusion: We found that median survival estimates are lower among HF cardiologists in comparison to family doctors, while both physician estimates are lower than calculated model estimates. Considering previous evidence that model’s accuracy is acceptable and physicians’ is limited, our results provide additional evidence of the superior accuracy of predictive models 1-year survival in ambulatory HF patients. These results should be validated in longitudinal studies collecting actual survival. 962 Outpatient Weaning of Inotropes is Achievable in Patients with Advanced Heart Failure A. Afzal, A.Y. Lee, A.S. Bindra and P. Kale. Baylor University Medical Center, Dallas, TX. Purpose: Patients admitted with advanced decompensated systolic heart failure (ADHF) typically require inotropes. Those who cannot be bridged to advanced heart failure therapies are discharged home on inotropes (as a