Which method is best for an early accurate diagnosis of acute heart failure? Comparison between lung ultrasound, chest X-ray and NT pro-BNP performance: a prospective study
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Acute heart failure is a common condition among adults presenting with dyspnea in the Emergency Department (ED), still the diagnosis is challenging as objective standardized criteria are lacking. First line work-up, other then clinical findings, is nowadays made with lung ultrasound imaging study, chest X-ray study and brain natriuretic peptide (BNP) level determination; however, it is not clear which is the best diagnostic test to be used and whether there is any real benefit for clinical judgement. We set up this study to compare the performances of these three diagnostic tools; furthermore, we combined them to find the best possible approach to dyspneic patients. This is a prospective observational study based in the ED. We enrolled adults presenting with dyspnea not trauma-related, they underwent lung ultrasound, and chest X-ray studies, and NT pro-BNP level determination. Then we compared the results with the diagnosis of acute heart failure established by an independent panel of experts. 236 patients were enrolled in the study. We find sensitivity and specificity for lung ultrasound of 57.73 and 87.97 %, for chest X-ray 74.49 and 86.26 %, for NT pro-BNP 97.59 and 27.56 %, respectively. Combining together the chest X-ray and lung ultrasound, we find the best overall performance with 84.69 % sensitivity, 77.69 % specificity and 87.07 % negative predictive value. From our results, we could not identify the “best test” to diagnose acute heart failure in an emergency setting, although we could suggest that a stepwise workup combining chest X-ray and lung ultrasound at first, then for those negative, a determination of NT pro-BNP assay would be a reasonable approach to the dyspneic patient.
KeywordsDiagnosis Heart failure Natriuretic peptides Ultrasound Dyspnea Chest X-ray
Compliance with ethical standards
Conflict of interest
There are no conflict of interest for all authors.
Statement of human and animal rights
The study was performed in accordance to the Declaration of Helsinki and approved by our local ethics committee. The study was registered by the Local Ethics Committee of the University Hospital of Siena and also registered in clinicaltrial.gov (Identifier NCT02122640).
Written informed consent was obtained from all subjects.
- 1.American Heart Association (2007) Heart disease and stroke statistics—2007 update. American Heart Association, DallasGoogle Scholar
- 4.Collins S, Storrow AB, Albert NM et al (2015) Early management of patients with acute heart failure: state of the art and future directions. A consensus document from the Society for Academic Emergency Medicine/Heart Failure Society of America Acute Heart Failure Working Group. J Cardiac Fail 21:27–43CrossRefGoogle Scholar
- 8.Luchner A, Möckel M, Spanuth E, Möcks J, Peetz D, Baum H, Spes C, Wrede CE, Vollert J, Müller R, Katus H, Giannitsis E (2012) N-terminal pro brain natriuretic peptide in the management of patients in the medical emergency department (PROMPT): correlation with disease severity, utilization of hospital resources, and prognosis in a large, prospective, randomized multicentre trial. Eur J Heart Fail 14:259–267CrossRefPubMedGoogle Scholar
- 17.Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G, Dean A, Tsung JW, Soldati G, Copetti R, Bouhemad B, Reissig A, Agricola E, Rouby J, Arbelot C, Liteplo A, Sargsyan A, Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti E, Petrovic T (2012) International Liaison Committee on Lung Ultrasound (ILC-LUS) for the International, Consensus Conference on Lung Ultrasound (ICC-LUS), International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38:577–591CrossRefPubMedGoogle Scholar
- 19.Prosen G, Klemen P, Strnad M, Grmec Š (2011) Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care 15:R114CrossRefPubMedPubMedCentralGoogle Scholar
- 20.Mebazaa A, Yilmaz MB, Levy P et al (2015) Recommendations on pre-hospital and early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine. Eur J Heart Fail 17:544–558CrossRefPubMedGoogle Scholar
- 23.Tang WHW, Tsai EJ, Wilkoff McMurray BL, Mitchell LE, Peterson PN, Riegel B, Sam F, Stevenson LW, Kasper EK, Levy WC, Masoudi FA, McBride PE, Drazner JJV, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Clyde MR, Yancy W, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Mark H (2013) Guidelines College of Cardiology Foundation/American Heart Association Task Force on Practice 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American. Circulation 128:e240–e327CrossRefPubMedGoogle Scholar
- 24.McMurray JJV, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, Falk V, Filippatos G, Fonseca C, Gomez-Sanchez MA, Jaarsma T, Køber L, Lip GYH, Maggioni AP, Parkhomenko A, Pieske BM, Popescu BA, Rønnevik PK, Rutten FH, Schwitter J, Seferovic P, Stepinska J, Trindade PT, Voors AA, Zannad F, Zeiher A (2012) ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur Heart J 33:1787–1847CrossRefPubMedGoogle Scholar
- 38.Pivetta E, Goffi A, Lupia E, Tizzani M, Porrino G, Ferreri E, Volpicelli G, Balzaretti P, Banderali A, Iacobucci A, Locatelli S, Casoli G, Stone B, Maule MM, Baldi I, Merletti F, Cibinel GA (2015) Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the ED. Chest 148(1):202–210CrossRefPubMedGoogle Scholar
- 39.Neskovic AN, Hagendorff A, Lancellotti P, Guarracino F, Varga A, Cosyns B, Flachskampf FA, Popescu BA, Gargani L, Zamorano JL, Badano LP (2013) Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations. Eur Heart J 14:1–11Google Scholar
- 41.Lancellotti P, Price S, Edvardsen T, Cosyns B, Neskovic AN, Dulgheru R, Flachskampf FA, Hassager C, Pasquet A, Gargani L, Galderisi M, Cardim M, Haugaa KH, Ancion A, Zamorano JL, Donal E, Bueno H, Habib G (2015) The use of echocardiography in acute cardiovascular care: Recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association. Eur Heart J Acute Cardiovasc Care 16:119–146Google Scholar
- 43.Baggish AL, Siebert U, Lainchbury JG, Cameron R, Anwaruddin S, Chen A, Krauser DG, Tung R, Brown DF, Richards AM, Januzzi JL Jr (2006) A validated clinical and biochemical score for the diagnosis of acute heart failure: the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Acute Heart Failure Score. Am Heart J 151:48–54CrossRefPubMedGoogle Scholar
- 45.Hill SA, Booth RA, Santaguida PL, Don-Wauchope A, Brown JA, Oremus M, Ali U, Bustamam A, Sohel N, McKelvie R, Balion C, Raina P (2014) Use of BNP and NT-proBNP for the diagnosis of heart failure in the emergency department: a systematic review of the evidence. Heart Fail Rev 19:421–438CrossRefPubMedGoogle Scholar
- 46.Schartum-Hansen H, Løland KH, Svingen GFT, Seifert R, Pedersen ER, Nordrehaug JE, Bleie Ø, Ebbing M, Berge C, Nilsen DWT, Nygård O (2015) Use of loop diuretics is associated with increased mortality in patients with suspected coronary artery disease, but without systolic heart failure or renal impairment: an observational study using propensity score matching. PLoS One. doi: 10.1371/journal.pone.0124611 PubMedPubMedCentralGoogle Scholar