Point-of-care ultrasound modalities in terms of diagnosing acute decompensated heart failure in emergency department; a diagnostic accuracy study

  • Shervin Farahmand
  • Ali Abdolhoseini
  • Ehsan Aliniagerdroudbari
  • Sepideh Babaniamansour
  • Alireza Baratloo
  • Shahram Bagheri-HaririEmail author


This study aimed to compare the diagnostic accuracy of heart, lung and inferior vena cava (IVC) ultrasonography modalities, alone and combined, for possible added accuracy in diagnosing acute decompensated heart failure (ADHF), in a group of patients with the final diagnosis of ADHF based on plasma level of B-type natriuretic peptide (BNP) as the standard. The present study is a diagnostic accuracy study, which was carried out in the emergency department of Imam Khomeini hospital, affiliated to Tehran University of Medical Sciences, in 2014–2015. All patients over 18 years old, who were referred to emergency department with complaint of acute dyspnea were regarded as eligible and no exclusion criteria were considered. All ultrasounds were performed by a trained emergency medicine resident and then saved and classified for each patient, separately, and reviewed by the attending emergency medicine physician. In this study, patients with BNP levels higher than 500 pg/ml were considered positive for dyspnea caused by heart failure. A total of 120 patients with an average age of 60.83 ± 16.528 years were studied, 64 (53%) of which were male. In total, 47.5% of patients had a BNP level over 500 pg/ml. Among patients with positive ultrasound, 94.7% were true positive and among those with a negative ultrasound, 61.4% were true negative. Based on the findings, B-line ≥ 10 has the highest specificity and left ventricular ejection fraction (LVEF) < 45% has the highest sensitivity. The combination of LVEF and IVC collapsibility index (IVC-CI), LVEF and BLC, IVC-CI and BLC, and IVC-CI and BBPC had a higher specificity rate and combination of LVEF and BBPC and BLC and BBPC had the highest sensitivity. Sensitivity, specificity, positive predictive value and negative predictive value of all three ultrasounds combined were 31.6%, 98.4%, 94.7% and 61.4%, respectively. In this study, the diagnostic accuracy of double and triple ultrasonography of heart, lung and IVC in the diagnosis of ADHF was very high, among which triple ultrasonography was more preferable.


Heart failure Natriuretic peptide Brain Ultrasonography Dyspnea 



We would like to express our gratitude to Prehospital and Hospital Emergency Research Center affiliated to Tehran University of Medical Sciences.


This study has not been funded.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Human and animal rights statement

This study did not impose any additional cost or risk on patients or the healthcare system.

Informed consent

All participants were included in the study after obtaining informed consent from them or their legally authorized relatives.


  1. 1.
    Jobs A, Brunjes K, Katalinic A, Babaev V, Desch S, Reppel M et al (2017) Inferior vena cava diameter in acute decompensated heart failure as predictor of all-cause mortality. Heart Vessel 32(7):856–864CrossRefGoogle Scholar
  2. 2.
    Krishnan DK, Pawlaczyk B, McCullough PA, Enright S, Kunadi A, Vanhecke TE (2016) Point-of-care, ultraportable echocardiography predicts diuretic response in patients admitted with acute decompensated heart failure. Clin Med Insights Cardiol 10:201–208CrossRefGoogle Scholar
  3. 3.
    Pivetta E, Goffi A, Nazerian P, Castagno D, Tozzetti C, Tizzani P et al (2019) Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial. Eur J Heart Fail 21:754–766CrossRefGoogle Scholar
  4. 4.
    Pivetta E, Goffi A, Lupia E, Tizzani M, Porrino G, Ferreri E et al (2015) Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the ed: a SIMEU multicenter study. Chest 148(1):202–210CrossRefGoogle Scholar
  5. 5.
    Soares FLJ, Oliveira JMG, Freire G, Andrade LC, Noya-Rabelo MM, Correia LCL (2017) incremental prognostic value of conventional echocardiography in patients with acutely decompensated heart failure. Arq Bras Cardiol 109(6):560–568PubMedPubMedCentralGoogle Scholar
  6. 6.
    Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K et al (2009) Heart disease and stroke statistics–2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 119(3):e21–181PubMedGoogle Scholar
  7. 7.
    Maw AM, Hassanin A, Ho PM, McInnes MDF, Moss A, Juarez-Colunga E et al (2019) Diagnostic accuracy of point-of-care lung ultrasonography and chest radiography in adults with symptoms suggestive of acute decompensated heart failure: a systematic review and meta-analysis. JAMA Netw Open 2(3):e190703CrossRefGoogle Scholar
  8. 8.
    Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P et al (2002) Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 347(3):161–167CrossRefGoogle Scholar
  9. 9.
    Mantuani D, Frazee BW, Fahimi J, Nagdev A (2016) Point-of-care multi-organ ultrasound improves diagnostic accuracy in adults presenting to the emergency department with acute dyspnea. West J Emerg Med 17(1):46–53CrossRefGoogle Scholar
  10. 10.
    Anderson KL, Jenq KY, Fields JM, Panebianco NL, Dean AJ (2013) Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and lung ultrasonography. Am J Emerg Med 31(8):1208–1214CrossRefGoogle Scholar
  11. 11.
    Cibinel GA, Casoli G, Elia F, Padoan M, Pivetta E, Lupia E et al (2012) Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the emergency department. Intern Emerg Med 7(1):65–70CrossRefGoogle Scholar
  12. 12.
    Liteplo AS, Marill KA, Villen T, Miller RM, Murray AF, Croft PE et al (2009) Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med 16(3):201–210CrossRefGoogle Scholar
  13. 13.
    Dehbozorgi A, Eslami Nejad S, Mousavi-Roknabadi RS, Sharifi M, Tafakori A, Jalli R (2019) Lung and cardiac ultrasound (LuCUS) protocol in diagnosing acute heart failure in patients with acute dyspnea. Am J Emerg Med. CrossRefPubMedGoogle Scholar
  14. 14.
    Lokuge A, Lam L, Cameron P, Krum H, de Villiers S, Bystrzycki A et al (2010) B-type natriuretic peptide testing and the accuracy of heart failure diagnosis in the emergency department. Circ Heart Fail 3(1):104–110CrossRefGoogle Scholar
  15. 15.
    Collins SP, Lindsell CJ, Storrow AB, Abraham WT (2006) Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure. Ann Emerg Med 47(1):13–18CrossRefGoogle Scholar
  16. 16.
    Rubio-Gracia J, Demissei BG, Ter Maaten JM, Cleland JG, O'Connor CM, Metra M et al (2018) Prevalence, predictors and clinical outcome of residual congestion in acute decompensated heart failure. Int J Cardiol 258:185–191CrossRefGoogle Scholar
  17. 17.
    Kadri AN, Kaw R, Al-Khadra Y, Abuamsha H, Ravakhah K, Hernandez AV et al (2018) The role of B-type natriuretic peptide in diagnosing acute decompensated heart failure in chronic kidney disease patients. Arch Med Sci 14(5):1003–1009CrossRefGoogle Scholar
  18. 18.
    De Vecchis R, Ariano C, Giandomenico G, Di Maio M, Baldi C (2016) Change of serum BNP between admission and discharge after acute decompensated heart failure is a better predictor of 6-month all-cause mortality than the single bnp value determined at admission. J Clin Med Res 8(10):737–742CrossRefGoogle Scholar
  19. 19.
    Chen LJ, Hung CL, Yeh HI, Jeng MJ, Su CH, Wu TY et al (2016) The utilization and prognostic impact of B-type natriuretic peptide in hospitalized acute decompensated heart failure in an Asian population. BMC Cardiovasc Disord 16(1):178CrossRefGoogle Scholar
  20. 20.
    Di Somma S, De Berardinis B, Bongiovanni C, Marino R, Ferri E, Alfei B (2010) Use of BNP and bioimpedance to drive therapy in heart failure patients. Congest Heart Fail 16(Suppl 1):S56–61CrossRefGoogle Scholar
  21. 21.
    Stolfo D, Stenner E, Merlo M, Porto AG, Moras C, Barbati G et al (2017) Prognostic impact of bnp variations in patients admitted for acute decompensated heart failure with in-Hospital worsening renal function. Heart Lung Circ 26(3):226–234CrossRefGoogle Scholar
  22. 22.
    Disomma S, Magrini L, Pittoni V, Marino R, Peacock WF, Maisel A (2008) Usefulness of serial assessment of natriuretic peptides in the emergency department for patients with acute decompensated heart failure. Congest Heart Fail 14(4 Suppl 1):21–24CrossRefGoogle Scholar
  23. 23.
    Khalid U, Wruck LM, Quibrera PM, Bozkurt B, Nambi V, Virani SS et al (2017) BNP and obesity in acute decompensated heart failure with preserved vs. reduced ejection fraction: The Atherosclerosis Risk in Communities Surveillance Study. Int J Cardiol 233:61–66CrossRefGoogle Scholar
  24. 24.
    Yang F, Wang Q, Zhi G, Zhang L, Huang D, Shen D et al (2017) The application of lung ultrasound in acute decompensated heart failure in heart failure with preserved and reduced ejection fraction. Echocardiography (Mount Kisco, NY) 34(10):1462–1469CrossRefGoogle Scholar
  25. 25.
    Ruddox V, Norum IB, Stokke TM, Edvardsen T, Otterstad JE (2017) Focused cardiac ultrasound by unselected residents-the challenges. BMC Med Imaging 17(1):22CrossRefGoogle Scholar
  26. 26.
    McGivery K, Atkinson P, Lewis D, Taylor L, Harris T, Gadd K et al (2018) Emergency department ultrasound for the detection of B-lines in the early diagnosis of acute decompensated heart failure: a systematic review and meta-analysis. Cjem 20(3):343–352CrossRefGoogle Scholar
  27. 27.
    Zanatta M, Benato P, De Battisti S, Pirozzi C, Ippolito R, Cianci V (2018) Pre-hospital lung ultrasound for cardiac heart failure and COPD: is it worthwhile? Crit Ultrasound J 10(1):22CrossRefGoogle Scholar
  28. 28.
    Tzadok B, Shapira S, Tal-Or E (2018) Ultrasound of jugular veins for assessment of acute dyspnea in emergency departments and for the assessment of acute heart failure. Isr Med Assoc J 5(20):308–310PubMedGoogle Scholar
  29. 29.
    Laffin LJ, Patel AV, Saha N, Barbat J, Hall JK, Cain M et al (2018) Focused cardiac ultrasound as a predictor of readmission in acute decompensated heart failure. Int J Cardiovasc Imaging 34(7):1075–1079CrossRefGoogle Scholar
  30. 30.
    Mantuani D, Nagdev A (2013) Three-view bedside ultrasound to differentiate acute decompensated heart failure from chronic obstructive pulmonary disease. Am J Emerg Med 31(4):759.e3–5CrossRefGoogle Scholar
  31. 31.
    Kajimoto K, Madeen K, Nakayama T, Tsudo H, Kuroda T, Abe T (2012) Rapid evaluation by lung-cardiac-inferior vena cava (LCI) integrated ultrasound for differentiating heart failure from pulmonary disease as the cause of acute dyspnea in the emergency setting. Cardiovasc Ultrasound 10(1):49CrossRefGoogle Scholar
  32. 32.
    Nakada Y, Kawakami R, Nakano T, Takitsume A, Nakagawa H, Ueda T et al (2016) Sex differences in clinical characteristics and long-term outcome in acute decompensated heart failure patients with preserved and reduced ejection fraction. Am J Physiol Heart Circ Physiol 310(7):H813–H820CrossRefGoogle Scholar
  33. 33.
    Chengode S (2016) Left ventricular global systolic function assessment by echocardiography. Ann Card Anaesth 19(Supplement):S26–s34CrossRefGoogle Scholar
  34. 34.
    Shahgaldi K, Gudmundsson P, Manouras A, Brodin LA, Winter R (2009) Visually estimated ejection fraction by two dimensional and triplane echocardiography is closely correlated with quantitative ejection fraction by real-time three dimensional echocardiography. Cardiovasc Ultrasound 7:41CrossRefGoogle Scholar
  35. 35.
    Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW et al (2012) International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38(4):577–591CrossRefGoogle Scholar
  36. 36.
    Aggarwal M, Gupta M, Vijan V, Vupputuri A, Chintamani S, Rajendran B et al (2016) Use of lung ultrasound for diagnosing acute heart failure in emergency Department of Southern India. J Clin Diagn Res 10(11):TC05–TC8PubMedPubMedCentralGoogle Scholar
  37. 37.
    Miyamoto K, Takeuchi D, Inai K, Shinohara T, Nakanishi T (2016) Prognostic value of multiple biomarkers for cardiovascular mortality in adult congenital heart disease: comparisons of single-/two-ventricle physiology, and systemic morphologically right/left ventricles. Heart Vessel 31(11):1834–1847CrossRefGoogle Scholar
  38. 38.
    Baker K, Mitchell G, Thompson AG, Stieler G (2013) Comparison of a basic lung scanning protocol against formally reported chest x-ray in the diagnosis of pulmonary oedema. Australas J Ultrasound Med 16(4):183–189CrossRefGoogle Scholar
  39. 39.
    Sartini S, Frizzi J, Borselli M, Sarcoli E, Granai C, Gialli V et al (2017) Which method is best for an early accurate diagnosis of acute heart failure? comparison between lung ultrasound, chest X-ray and NT pro-BNP performance: a prospective study. Intern Emerg Med 12(6):861–869CrossRefGoogle Scholar
  40. 40.
    Russell FM, Ehrman RR, Cosby K, Ansari A, Tseeng S, Christain E et al (2015) Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) protocol. Acad Emerg Med 22(2):182–191CrossRefGoogle Scholar
  41. 41.
    Russell FM, Ehrman RR (2017) A Modified lung and cardiac ultrasound protocol saves time and rules in the diagnosis of acute heart failure. J Emerg Med 52(6):839–845CrossRefGoogle Scholar

Copyright information

© Società Italiana di Medicina Interna (SIMI) 2019

Authors and Affiliations

  • Shervin Farahmand
    • 1
    • 2
  • Ali Abdolhoseini
    • 2
  • Ehsan Aliniagerdroudbari
    • 3
  • Sepideh Babaniamansour
    • 4
  • Alireza Baratloo
    • 1
    • 5
  • Shahram Bagheri-Hariri
    • 1
    • 2
    Email author
  1. 1.Prehospital and Hospital Emergency Research CenterTehran University of Medical SciencesTehranIran
  2. 2.Department of Emergency Medicine, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
  3. 3.School of MedicineShahid Beheshti University of Medical SciencesTehranIran
  4. 4.School of MedicineIslamic Azad University of Medical SciencesTehranIran
  5. 5.Department of Emergency Medicine, Sina HospitalTehran University of Medical SciencesTehranIran

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