role of ultrasound and biomarkers
TRANSCRIPT
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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
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CONGESTION MECHANISMRight Left
Increase afterload
Decrease capacitance
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CONGESTION MARKERSRight Left
Increase afterload
Decrease capacitance
Pulmonary artery wedge pressure increase
Pulmonary edema
Inferior Vena Cava dilatation
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RECOGNIZE CONGESTION
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation
ULTRASONOGRAPHY
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RECOGNIZE CONGESTION
ULTRASONOGRAPHY
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation
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E/E’
NormalPAWP increase
E’A’
E’ A’
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E/E’ and PAWP
Sherif FN J Am Coll Cardiol 1997
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Septal E/E′
○ patients with EF <50%
• patients with EF >50%.
Ommen SR Circulation 2000
Copyright © American Heart Association, Inc. All rights reserved.
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• 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
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INTRODUCTION Types of congestion in AHF
Picano E. Heart Fail Rev (2010)
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RECOGNIZE CONGESTION
ULTRASONOGRAPHY
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation
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Picano E. Heart Fail Rev 2010
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Picano E . Heart Fail Rev 2010
Miglioranza MH J Am Coll Cardiol Imag 2013Jambrik ZN Ultrasound Med. & Biol. 2010
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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
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Trovato GM. Am J Resp Crit Care Med 2013
LIMITS OF LUNG ULTRASOUND
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RECOGNIZE CONGESTION
ULTRASONOGRAPHY
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation
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IVC diameter and collapsibility
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IVC diameter and collapsibility Limits
Zengin S Am J Emerg Med 2012
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RECOGNIZE CONGESTION
BIOMARKERS ?
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BIOMARKERS AND CONGESTION
Gaggin HK Biochimica Biophysica Acta 2013
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BIOMARKERS AND CONGESTION
Miglioranza MH J Am Coll Cardiol Imag 2013
Forfia PR J Am Coll Card 2005
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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
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CONCLUSION Congestion
Hemodynamic Pulmonary
US+++
E/E’
B-lines
IVC Ø collaps
Biomarkers
BNPMR-ANPMR-ADM
Others ?
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ThankThank youyou
Greetings From Tunisia
2nd Global network conference 2013 Pr. Semir NOUIRA Tunisia