Brief ReportInferior vena cava assessment in the bedside diagnosis of acute heart failure☆
Introduction
Emergency physicians in the United States annually care for more than 650 000 patient visits for acute heart failure (AHF) [1]. To provide optimal care to these patients, rapid differentiation of AHF from other causes of dyspnea is desired. Recent data have indicated that bedside assessment of the inferior vena cava (IVC) could be a rapid, noninvasive means for clinicians to determine a patient's volume status, and thus aid in differentiating AHF from other common etiologies of dyspnea [2].
The objective of this study was to determine the test characteristics of IVC ultrasonography for diagnosing AHF in the evaluation of patients with acute dyspnea. Specifically, this study evaluated the test characteristics of the caval index, defined by the percentage change in the IVC diameter through a respiratory cycle, and the caval-aortic ratio, defined by the ratio of the static IVC and aortic diameters.
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Study design and setting
This was a prospective observational study of adult ED patients presenting with the chief complaint of acute dyspnea. Informed written consent was obtained from patients, and the study was approved by the institutional review board of the participating hospital.
This study was conducted at an urban, academic ED with an annual patient volume of 94 000 patients. Patients were enrolled between September 1, 2008, and April 30, 2009, as a convenience sample. Inclusion criteria were adults 50 years
Results
A total of 92 patients were enrolled, of whom 89 were included in the final analysis. Three patients (3%) were excluded because of inability to visualize the IVC. Investigators reported image acquisition to require 5 minutes or less in 78% of the patients. The mean age of the cohort was 68 years. There were 52 men (58%) and 37 women (42%); 80 were black (90%), 6 white (7%), and 3 Hispanic (3%). The admission rate for the cohort was 80%, and the survival to discharge was 99%. A comparison of
Discussion
Dyspnea is a common condition for which clinicians seek a noninvasive assessment of a patient's volume status. This study aimed to determine whether measurements of IVC respirophasic change can contribute to this assessment. This study also analyzed whether static measurements of the maximum IVC diameter compared with the aortic diameter have diagnostic value in this assessment.
The data reveal that in patients presenting with acute dyspnea, smaller caval indices increase the likelihood that a
Limitations
This study was performed at a single center, and enrollment occurred primarily during daytime hours as a convenience sample. Unintended factors in enrolling this sample may have influenced the results. The study also limited enrollment to patients older than 50 years so as to include a higher proportion of patients with heart failure. By chance, no patient with cardiac tamponade or right ventricular failure was enrolled in this study. A low caval index should be applied with caution if there is
Conclusions
We propose that bedside assessment of the caval index or caval-aortic ratio has potential for complementing the clinical assessment of patients with acute dyspnea. Further studies may confirm how clinicians may incorporate such measurements into clinical decision making in the ED.
References (15)
- et al.
Identification of congestive heart failure via respiratory variation of inferior vena cava diameter
Am J Emerg Med
(2009) - et al.
Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava
Am J Cardiol
(1990) - et al.
Reappraisal of the use of inferior vena cava for estimating right atrial pressure
J Am Soc Echocardiogr
(2007) - et al.
Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure
Ann Emerg Med
(2010) - et al.
Usefulness of hand-carried ultrasound to predict elevated left ventricular filling pressure
Am J Cardiol
(2009) - et al.
Diagnostic value of B-type natriuretic peptide and chest radiographic findings in patients with acute dyspnea
Am J Med
(2004) - et al.
Ambulatory medical care utilization estimates for 2006
Natl Health Stat Report
(2008)
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2021, Advances in Chronic Kidney DiseaseCitation Excerpt :For example, in a convenience sample of 658 encounters with 267 ICU patients with nephrology consults, of which a subset who received dialysis was formally analyzed and published,15 we found that 47% of encounters had IVC CI ≤ 20%, 18% had IVC CI > 50%, and 35% had IVC CI 20 to 50%. IVC collapsibility may also predict ability to remove volume by ultrafiltration or to increase cardiac output with net volume removal in patients with intravascular volume overload.15,34,66,67 Especially when at one extreme or the other, IVC ultrasound findings may influence the prediction of whether a patient would benefit from administration of volume, diuretics or ultrafiltration, or neither.
The Association of CT-measured Cardiac Indices with Lung Involvement and Clinical Outcome in Patients with COVID-19
2021, Academic RadiologyCitation Excerpt :For example, an elevated cardiothoracic ratio (CTR) or increased pulmonary artery-to-aorta (PA/A) ratio is linked with unfavorable prognosis in patients with respiratory diseases (7,8); these indices might also be indicative of increased risk of cardiovascular diseases (CVD) (9,10). Other cardiac parameters such as increased epicardial adipose tissue (EAT) thickness, lower EAT density and dilated inferior vena cava (IVC) also convey prognostic information regarding major CVD and respiratory events (11–15). Since COVID-19 is also associated with lung injury and cardiac events (16,17), these findings raise the question of whether meaningful differences also exist among survivors and non-survivors of COVID-19 in terms of cardiac parameters and pulmonary vasculature.
Evaluation of volume status in a prehospital setting by ultrasonographic measurement of inferior vena cava and aorta diameters
2018, Turkish Journal of Emergency Medicine
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Prior presentations: Preliminary data presented at the Society for Academic Emergency Medicine Annual Meeting, New Orleans, LA, 2009.