European Heart Journal (2016) 37, 1252–1254
doi:10.1093/eurheartj/ehw094
Lung ultrasound: a ‘B-line’ to the prediction
of decompensated heart failure
Mandar A. Aras 1 and John R. Teerlink 1,2*
1
School of Medicine, University of California San Francisco, San Francisco, CA, USA; and 2Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
This editorial refers to ‘Detection and prognostic value of
pulmonary congestion by lung ultrasound in ambulatory
heart failure patients’†, by E. Platz et al. on page 1244.
Despite advances in medical and device-based therapy for the
management of ambulatory patients with heart failure (HF), the
post-discharge mortality and readmission rates have continued
to be unacceptably high,1,2 while chronic mortality has actually
increased recently.3 Central to frequent hospitalizations and high
mortality among patients with HF is cardiogenic pulmonary oedema,
characterized by the accumulation of fluid in the lung’s interstitial
and alveolar spaces at least partially due to elevated cardiac filling
pressures. Early accurate diagnosis and subsequent treatment of
pulmonary congestion may prevent hospitalizations. Furthermore,
reliable quantitative assessment of the pulmonary interstitial fluid
may also aid the provider in determining the most appropriate
discharge date, preventing hospital readmission.
Lung ultrasound (LUS) has emerged as a readily available, effi-
cient, semi-quantitative method for assessing pulmonary conges-
tion. Previous work has shown that LUS is effective as a diagnostic
tool, with a higher sensitivity and specificity than the clinical exam
and chest X-ray.4 Platz and colleagues now report the prognostic
significance of LUS in ambulatory patients with New York Heart As-
sociation (NYHA) class II –IV HF and a previous HF hospitalization
in the past 12 months. Two-second ultrasound clips were recorded
in eight LUS zones by trained investigators using a pocket ultrasound
device. The number of B-lines visualized is an estimate of the degree
of pulmonary congestion. B-lines are sound artefacts created from
an acoustic impedance mismatch that occurs when a sound beam
crosses two interfaces (e.g. fluid between lung and chest wall).
The highest number of B-lines visualized in any single intercostal
space was recorded for each zone. The sum of B-lines in all eight
zones was used for primary analysis.
Ambulatory outpatients who had adequate LUS data in all eight
zones (n ¼ 185/195 evaluated or 95%) were followed for 6
months. The baseline characteristics, stratified by B-line tertiles,
revealed that patients with the highest number of B-lines had
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
†
doi:10.1093/eurheartj/ehv745.
* Corresponding author. Section of Cardiology, San Francisco Veterans Affairs Medical Center, 111C Building 203, Room 2A-49, 4150 Clement Street, San Francisco, CA 94121, USA.
Tel: +1 415 750 2112, Fax: +1 415 750 6950, Email: john.teerlink@ucsf.edu
Published by Oxford University Press on behalf of the European Society of Cardiology 2016. This work is written by (a) US Government employee(s) and is in the public domain in the US.
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EDITORIAL
higher risk features (higher NYHA class, worse renal function,
higher NT-proBNP, and lower sodium and haematocrit). Patients
with the highest B-line number were also more likely to have ele-
vated jugular venous pulsations, crackles on pulmonary ausculta-
tion, and peripheral oedema. In another report, higher B-lines
were associated with echocardiographic evidence of elevated
filling pressures (E/e’), lower 6-min walk distance, and clinical con-
gestion on a standard clinical congestion scale.6 Thus, B-lines may
be a reliable maker for lung congestion in HF patients, and may
serve as a risk stratification tool when other indicators are difficult
to interpret.
Next, the investigators found that patients with the highest tertile
of B-line quantity had a four-fold higher risk of the primary outcome
[adjusted hazard ratio (HR) 4.08, 95% confidence interval (CI)
1.95–8.54, P , 0.001] compared with those patients in the first ter-
tile. This finding was primarily driven by the higher number of hos-
pitalizations in patients in the highest tertile. Patients in the lowest
tertile spent a significantly lower number of days alive and out of
the hospital (125 days vs. 165 days, adjusted P , 0.001) compared
with those in the third tertile. Finally, using the incremental discrim-
ination improvement (IDI) and the area under the receiver operat-
ing characteristic (ROC) curve (AUC), the authors suggested that
LUS provides incremental prognostic value compared with physical
exam findings (crackles on auscultation; congestion score). Unfortu-
nately, only a subset of patients had NT-proBNP drawn at a time
close to their clinic visits, and so the incremental value of LUS
over biomarkers was not assessed.
The work of Platz and colleagues should be applauded, as it pro-
vides an important step forward for the implementation of LUS in
the clinical evaluation of HF patients. When compared with most
of the established clinical tools for detecting decompensation,
LUS has performed similarly.6 In a recent prospective study in which
emergency physicians were asked to categorize the diagnosis for pa-
tients presenting with acute dyspnoea, LUS had a significantly higher
accuracy (sensitivity 97%, specificity 97%) in differentiating acute de-
compensated HF from non-cardiac causes than the initial clinical
work-up, chest X-ray alone, and natriuretic peptides.4 In the present
study, the authors found that only 19% of patients in the highest
 Editorial
Figure 1 A potential conceptual approach for the integration of lung ultrasound (LUS) in the risk stratification and management of patients with
heart failure is presented. This algorithm is dependent upon the future demonstration that the information provided by LUS can meaningfully
impact clinical outcomes.
tertile had crackles on auscultation, suggesting that LUS may be
able to identify subclinical congestion and improve risk stratification.
However, the lack of a true gold standard for pulmonary congestion
and acute decompensated HF is an important limitation that
prevents the understanding of the true accuracy of LUS.
While LUS certainly has the benefits of being more accessible
and faster than echocardiography, there is no standard technique
established to examine the lungs with ultrasound. Both the
28-scanning-site technique and the 8-region technique have been
recommended as useful in the evaluation of pulmonary interstitial
oedema.7 In the study of Platz et al., eight LUS zones (four on
each hemithorax) were scanned, and the sum of B-lines in all eight
zones was used for analysis. Previous studies have included a varied
number of chest sites scanned, various patient positions (supine,
orthopnic, sitting), and have used a varied number of B-lines as cut-
off values for risk stratification. Furthermore, while all studies claim
that the LUS exam can be performed within 10 min, and often with-
in ,5 min, all investigations have utilized experienced sonogra-
phers. Real-world experience with emergency department staff,
primary care providers, and cardiology clinic providers may not
achieve such rapid exam times, calling into question the incremental
utility of LUS in a patient with elevated neck veins, peripheral
oedema, and an elevated NT-proBNP.
Perhaps the most exciting application of LUS may be in the prog-
nostic value of B-lines at discharge to predict rehospitalization. Two
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1253
small prospective studies have recently shown that residual pulmon-
ary congestion before discharge, as assessed by LUS, predicts rehos-
pitalization and all-cause death in patients admitted with HF. 8,9 In
this context, LUS may be a very useful tool in identifying patients
that need continued hospitalization for therapy optimization vs.
those that are safe for discharge. Continued investigations utilizing
LUS must be pursued in the future.
The present work advances the field of LUS in HF by correlating
the number of B-lines to HF mortality and future hospitalizations.
Early recognition of patients with impending decompensation by
LUS when other variables are equivocal may aid the clinician in
risk stratification (Figure 1). However, previous work has found
that non-invasive biomarkers as well as implantable monitoring de-
vices that detect persistent or developing congestion are very good
at predicting risk in HF patients, but are equivocal in guiding therapy
and improving outcomes.10,11 Thus, the most clinically relevant un-
answered question remains: are B-lines on LUS a therapeutic target?
In a different patient population, this question is being addressed in
the Lung Water by Ultrasound Guided Treatment in Hemodialysis
Patients (LUST; clinicaltrials.gov NCT02310061) study. It is impera-
tive to test the hypothesis of whether LUS-guided therapy of HF
patients could improve outcomes. Therefore, additional work is
necessary to demonstrate that routine LUS assessment is a non-
invasive method that not only predicts, but can also prevent HF
morbidity and mortality.
 1254
Conflict of interest: none declared.
References
1. Ambrosy AP, Fonarow GC, Butler J, Chioncel O, Greene SJ, Vaduganathan M,
Nodari S, Lam CS, Sato N, Shah AN, Gheorghiade M. The global health and eco-
nomic burden of hospitalizations for heart failure: lessons learned from hospita-
lized heart failure registries. J Am Coll Cardiol 2014;63:1123 – 1133.
2. Gheorghiade M, Vaduganathan M, Fonarow GC, Bonow RO. Rehospitalization for
heart failure: problems and perspectives. J Am Coll Cardiol 2013;61:391 – 403.
3. Ni H, Xu J. Recent trends in heart failure-related mortality: United States, 2000 –
2014. NCHS Data Brief 2015 (231):1–8.
4. Pivetta E, Goffi A, Lupia E, Tizzani M, Porrino G, Ferreri E, Volpicelli G, Balzaretti P,
Banderali A, Iacobucci A, Locatelli S, Casoli G, Stone MB, Maule MM, Baldi I,
Merletti F, Cibinel GA, SIMEU Group for Lung Ultrasound in the Emergency Depart-
ment in Piedmont. Lung ultrasound-implemented diagnosis of acute decompensated
heart failure in the ED: a SIMEU multicenter study. Chest 2015;148:202–210.
5. Platz E, Lewis EF, Uno H, Peck J, Pivetta E, Merz AA, Hempel D, Wilson C,
Frasure SE, Jhund PS, Cheng S, Solomon SD. Detection and prognostic value of
pulmonary congestion by lung ultrasound in ambulatory heart failure patients.
Eur Heart J 2016;37:1244 – 1251.
6. Miglioranza MH, Gargani L, Sant’Anna RT, Rover MM, Martins VM, Mantovani A,
Weber C, Moraes MA, Feldman CJ, Kalil RA, Sicari R, Picano E, Leiria TL. Lung ultra-
sound for the evaluation of pulmonary congestion in outpatients: a comparison
with clinical assessment, natriuretic peptides, and echocardiography. JACC Cardio-
vasc Imaging 2013;6:1141 – 1151.
Downloaded from https://academic.oup.com/eurheartj/article-abstract/37/15/1252/1748872
by Pontificia Universidad Cat�lica de Chile user
on 01 July 2018
Editorial
7. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW,
Melniker L, Gargani L, Noble VE, Via G, Dean A, Tsung JW, Soldati G,
Copetti R, Bouhemad B, Reissig A, Agricola E, Rouby JJ, Arbelot C, Liteplo A,
Sargsyan A, Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti E,
Petrovic T, International Liaison Committee on Lung Ultrasound (ILC-LUS) for
International Consensus Conference on Lung Ultrasound (ICC-LUS). International
evidence-based recommendations for point-of-care lung ultrasound. Intensive Care
Med 2012;38:577 –91.
8. Gargani L, Pang PS, Frassi F, Miglioranza MH, Dini FL, Landi P, Picano E. Persistent
pulmonary congestion before discharge predicts rehospitalization in heart failure: a
lung ultrasound study. Cardiovasc Ultrasound 2015;13:40.
9. Coiro S, Rossignol P, Ambrosio G, Carluccio E, Alunni G, Murrone A, Tritto I,
Zannad F, Girerd N. Prognostic value of residual pulmonary congestion at dis-
charge assessed by lung ultrasound imaging in heart failure. Eur J Heart Fail 2015;
17:1172 –1181.
10. Abraham WT, Adamson PB, Bourge RC, Aaron MF, Costanzo MR,
Stevenson LW, Strickland W, Neelagaru S, Raval N, Krueger S, Weiner S,
Shavelle D, Jeffries B, Yadav JS. Wireless pulmonary artery haemodynamic mon-
itoring in chronic heart failure: a randomised controlled trial. Lancet 2011;377:
658 – 666.
11. Böhm M, Drexler H, Oswald H, Rybak K, Bosch R, Butter C, Klein G, Gerritse B,
Brachmann J, for the OptiLink HF Study Investigators. Effect of implanted device-
based impedance monitoring with telemedicine alerts on mortality and morbidity
in heart failure (OptiLink HF). August 29, 2015, European Society of Cardiology
Congress, London 2015.