Visualizing congestion with ultrasound : diagnostic and therapeutic implications

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http://urn.fi/URN:ISBN:978-951-51-4822-3
Title: Visualizing congestion with ultrasound : diagnostic and therapeutic implications
Author: Öhman, Jonas
Contributor organization: University of Helsinki, Faculty of Medicine
Doctoral Program in Clinical Research
Helsingin yliopisto, lääketieteellinen tiedekunta
Kliininen tohtoriohjelma
Helsingfors universitet, medicinska fakulteten
Doktorandprogrammet i klinisk forskning
Publisher: Helsingin yliopisto
Date: 2019-01-25
Language: eng
Belongs to series: pdf
URI: http://urn.fi/URN:ISBN:978-951-51-4822-3
http://hdl.handle.net/10138/278321
Thesis level: Doctoral dissertation (article-based)
Abstract: Background The syndrome of Acute Heart Failure (AHF) is a very common cause for hospitalization, and carries a poor prognosis both in hospital and after discharge. The syndrome is caused by a various disease of the cardiovascular system and the heart. Congestion due to elevated cardiac filling pressures is the key physiological feature in AHF. There is to date very little evidence-based therapy existing for AHF and hospitalizations are lengthy and expensive. The aim of this thesis is to investigate a cardiothoracic rapid ultrasound protocol (CaTUS) in allowing an individual approach to be taken considering diagnosis, treatment monitoring and treatment guidance in AHF. Methods We enrolled 4 partly overlapping populations for this thesis. In our first study, we enrolled a total of 100 dyspneic ED patients in whom we tested CaTUS for diagnosing AHF, with the protocol done immediately upon arrival in the ED. Except for diagnosing AHF, CaTUS was also tested for diagnosing other conditions causing dyspnea in this study. In our second study on early monitoring of AHF, we enrolled 60 hospitalized AHF patients who had CaTUS done 3 times during the first 24 hours, thereafter 24 hours later and finally once more prior to discharge. In our third study evaluating the prognostic impact of CaTUS among other congestion parameters, we enrolled a sample of 100 hospitalized AHF patients, to whom CaTUS was done at baseline, at 24 and 48 hours and finally at the day of discharge. In our fourth study, we enrolled a small 20-patient AHF population, who had their treatment guided by the CaTUS protocol. The treatment results in this population were compared with treatment results in the previously enrolled 100-patient population enrolled before, who had received conventional in-hospital treatment for AHF. Results The CaTUS protocol performed very well for diagnosing AHF, as well as for differential diagnostics in dyspneic patients. Sensitivity was 100 % and specificity 95.8 % for diagnosing AHF as compared to a golden standard consisting of a brain natriuretic peptide-value of > 400 ng/l or > 100 ng/l in combination on chest x-ray as evaluated by an independent radiologist on the radiology ward . During early treatment, CaTUS was able to identify early treatment responders and disgtinguish them from non-responders, which seemed to be relevant since early responders often expressed a favorable treatment response throughout hospitalization and a significantly better post-discharge prognosis. For determining post-discharge prognosis, inferior vena cava index at discharge seemed to be the most relevant congestion parameter, indicating whether an AHF patient is sufficiently decongested. Finally, CaTUS-guided decongestive therapy seemed safe, was associated with greater decongestion by all parameters, and seems to have been associated with fewer re-hospitalizations due to AHF. Conclusion CaTUS seems useful for diagnosing, monitoring and guiding decongestive therapy in AHF.Tiivistelmä Tutkimme kohdennetun rintakehän alueen ultraäänitutkimuksen käyttöä akuutin sydämen vajaatoiminnan diagnosoimiseen, hoidon seuraamiseen sekä hoidon ohjaamiseen. Pienissä aineistoissamme protokollan tarkkuus akuutin sydämen vajaatoiminnan diagnosoimiseen oli 95.8 % ja herkkyys 100 %. Lisäksi se kykeni löytämään hoitoon vastaavat potilaat jo sairaalahoidon ensimmäisten 12 tunnin aikana, ja näillä potilailla hoitovaste usein jatkui hyvänä hoitojakson loppuun, ja kuolleisuus kotiutumisen jälkeen oli pieni. Lisäksi protokollamme osoittautui lupaavaksi kotikelpoisuuden arvioimisessa, sillä kotiutumisen jälkeinen ennuste riippui kotiutumispäivänä mitatuista kongestio-suureista. Viimeisessä työssämme protokolla osoittautui lupaavaksi myös hoidon ohjauksessa. Jatkossa tarvitaan lisätutkimuksia protokollan käytettävyydestä eri tilanteissa, etenkin hoidon ohjauksessa, mutta näyttäisi siltä, että kohdennetusta sydämen- ja keuhkojen ultraäänitutkimuksesta saattaisi olla hyötyä hoitojakson aikana.
Subject: Lääketiede
Rights: Julkaisu on tekijänoikeussäännösten alainen. Teosta voi lukea ja tulostaa henkilökohtaista käyttöä varten. Käyttö kaupallisiin tarkoituksiin on kielletty.


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