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CongestionThe key target in acute heart failure
Role of ultrasound and biomarkers
Pr Semir NouiraEmergency Department
Fattouma Bourguiba University Hospital
Monastir Tunisia
CONGESTION MECHANISMRight Left
Increase afterload
Decrease capacitance
CONGESTION MARKERSRight Left
Increase afterload
Decrease capacitance
Pulmonary artery wedge pressure increase
Pulmonary edema
Inferior Vena Cava dilatation
RECOGNIZE CONGESTION
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation
ULTRASONOGRAPHY
RECOGNIZE CONGESTION
ULTRASONOGRAPHY
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation
E/E’
NormalPAWP increase
E’A’
E’ A’
E/E’ and PAWP
Sherif FN J Am Coll Cardiol 1997
Septal E/E′
○ patients with EF <50%
• patients with EF >50%.
Ommen SR Circulation 2000
Copyright © American Heart Association, Inc. All rights reserved.
• Situations where the use of E/e' may be unreliable
– Tachycardia
– Mitral regurgitation or replacement
– LBBBèSurrogate indices
─ PFV ─ LA Ø─ LV Ø
• Hemodynamic and pulmonary congestion discrepancy
E/E’ Limits
INTRODUCTION Types of congestion in AHF
Picano E. Heart Fail Rev (2010)
RECOGNIZE CONGESTION
ULTRASONOGRAPHY
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation
Picano E. Heart Fail Rev 2010
Picano E . Heart Fail Rev 2010
Miglioranza MH J Am Coll Cardiol Imag 2013Jambrik ZN Ultrasound Med. & Biol. 2010
q Sensitive but not specific
üARDS
ü Pulmonary fibrosis…
q Methodological biais
ü Position of the patient
ü Equipment (probe type…)
LIMITS OF LUNG ULTRASOUND
Trovato GM. Am J Resp Crit Care Med 2013
LIMITS OF LUNG ULTRASOUND
RECOGNIZE CONGESTION
ULTRASONOGRAPHY
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation
IVC diameter and collapsibility
IVC diameter and collapsibility Limits
Zengin S Am J Emerg Med 2012
RECOGNIZE CONGESTION
BIOMARKERS ?
BIOMARKERS AND CONGESTION
Gaggin HK Biochimica Biophysica Acta 2013
BIOMARKERS AND CONGESTION
Miglioranza MH J Am Coll Cardiol Imag 2013
Forfia PR J Am Coll Card 2005
BIOMARKERS AND CONGESTION
q Mid-region pro-atrial natriuretic peptide (MR-
proANP)
q Mid-regional adrenomedullin (MR-proADM)
as BNP are elevated in fluid overloaded patients
who have elevated filling pressures
CONCLUSION Congestion
Hemodynamic Pulmonary
US+++
E/E’
B-lines
IVC Ø collaps
Biomarkers
BNPMR-ANPMR-ADM
Others ?
ThankThank youyou
Greetings From Tunisia
2nd Global network conference 2013 Pr. Semir NOUIRA Tunisia
