Use of hand carried ultrasound, B-type natriuretic peptide, and clinical assessment in identifying abnormal left ventricular filling pressures in patients referred for right heart catheterization.

BACKGROUND: The estimation of left ventricular filling pressure (LVFP) remains a critical component in the management of patients with known or suspected acute heart failure syndromes. Although right heart catheterization (RHC) remains the gold standard, several noninvasive parameters, including clinical assessment, B-type natriuretic peptides (BNP), and echocardiography can approximate LVFP. We sought to use a combination of these measures to noninvasively predict high or low LVFP in a population referred for RHC. METHODS AND RESULTS: The study consisted of validation of hand-carried ultrasound (HCU)-derived measurement of mitral E/E' against standard echocardiograms in 50 patients, as well as direct comparison of jugular venous pressure (JVP), a clinical congestion score, HCU-derived E/E' and maximum inferior vena cava diameter (IVCmax), and BNP with pulmonary capillary wedge pressure (PCWP) in another 50 patients. The mean age was 61 years, ejection fraction 40%, JVP 9 cm, BNP 948 pg/mL, IVCmax 2.1 cm, E/E' 13, and PCWP 21. All parameters performed well in determining PCWP >or=15 mm Hg, with clinical score performing the worst (area under the receiver-operator characteristic curve [AUC] 0.74), and IVCmax performing the best (AUC 0.89). JVP, in combination with HCU-derived parameters and BNP performed better than any of the individual tests alone (AUC 0.97 for combination of all 3). CONCLUSIONS: Clinical score, JVP, HCU indices, and BNP perform well at identifying patients with a PCWP >or=15 mm Hg. Use of these indices alone or in combination can be used to identify and potentially monitor patients with high LVFP in the inpatient and outpatient settings.

Duke Scholars

Author J. Matthew Brennan Medicine, Cardiology