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

Abstract

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.