HF Care in the ED Languishes Despite Congestion-Driven Treatment Strategy

Lung ultrasound (LUS) did not help emergency departments (EDs) manage acute heart failure (HF) patients in their first few hours after presentation, a randomized pilot trial found.

HF treatment targeting LUS B-lines, a marker of pulmonary congestion, left patients no less congested at 6 hours compared to usual care in the ED: B-lines ≤15 was achieved by 25.0% of people randomized to LUS guidance versus 27.5% of peers managed according to clinical assessments alone (P=0.83).

Additionally, the two groups shared similar B-line counts at 6 hours (average 35.4 vs 34.3, P=0.82), as well as the same average 21.3 days alive and out of hospital at 30 days, reported Peter Pang, MD, of Indiana University School of Medicine in Indianapolis, and colleagues. Results of their 130-person study were published online in JACC: Heart Failure.

Thus, doubt and confusion remain in the in-hospital management of HF patients, noted the authors of an accompanying editorial.

“Despite worsening congestion being the driver of most HF hospitalizations and IV loop diuretic agents a near universal part of in-hospital treatment, the routine approach to decongestion remains crude and generally unchanged from decades ago,” wrote Stephen Greene, MD, and Muhammad Shahzeb Khan, MD, MSc, both of Duke University School of Medicine in Durham, North Carolina.

“A core challenge is that the assessment of congestion and grading of response to diuretic therapy remain highly subjective,” they continued. “In the absence of a clearly defined optimal approach, clinicians may routinely rely on any combination of multiple parameters, such as physical examination, laboratory tests, weight change, net fluid loss, and patient symptoms.”

In the study, BLUSHED-AHF, the observed lack of difference in B-lines between groups may be largely explained by the similar total IV doses of furosemide administered to both, Greene and Khan noted, adding that this highlights the problem of testing a LUS-guided strategy when the treatment protocol ends after the first few hours — when “administration of IV diuretic is generally clinician reflex and there is modest use of any other therapy.”

“Rather, variability with in-hospital management is likely heavily concentrated in the middle-to-end phases of the hospital course,” the editorialists wrote, suggesting that these are better opportunities to test guided therapy for acute HF.

BLUSHED-AHF was a single-blind trial conducted at four EDs in the U.S. in 2017-2019. Study participants were randomized to a LUS-guided treatment strategy or usual care for acute HF. All were required to have had at least 15 B-lines at enrollment (average 47.5 vs 49.3, P=0.70).

The two study arms shared similar baseline characteristics (72% were men, average age was approximately 65, and more than half were Black).

Protocol called for the first LUS assessment at baseline, a second one 2-4 hours after randomization, and a third one 2-4 hours after the second or immediately before ED disposition.

LUS B-lines quantify pulmonary congestion via measurement of extravascular lung water signals. B-lines are associated with prognosis and are thought to be a good measure of response to HF therapy given that they decrease as intravascular volume is removed.

The single blinding in BLUSHED-AHF was a major limitation of the study, Pang and co-authors noted. Furthermore, about two dozen participants wound up not receiving all three LUS evaluations. “LUS assessments were missed for the following reasons: to avoid interference with ongoing patient care, patients had left the ED for other diagnostic tests, or patients had left the ED for admission to the hospital. Whether this would have changed the primary outcome is unknown,” the team wrote.

“BLUSHED-AHF demonstrates that such strategy trials with guided-therapy during the HF hospitalization are certainly feasible, while refining the stage for future randomized trials testing LUS approaches for in-hospital decision-making for HF,” Greene and Khan concluded. “Nonetheless, for now, the search continues for a practical, noninvasive, objective, and highly reproducible approach for guiding in-hospital decongestive therapy for HF.”