Uporaba obposteljne ultrasonografije pri vodenju bolnikov s srčnim popuščanjem v domu starejših občanov«

Homar, Vesna (author), Švab, Igor (mentor), Lainščak, Matija (comentor)

Ozadje: Med stanovalci domov starejših občanov (DSO) je srčno popuščanje pogosto ter predstavlja pomemben diagnostičen in terapevtski izziv. Obposteljna ultrasonografija je nova metoda, ki omogoča zanesljivejšo oceno volumskega stanja bolnika kot klinični pregled. Raziskave so se doslej osredotočale na uporabnost obposteljne ultrasonografije za prilagajanje diuretične terapije pri akutnem poslabšanju srčnega popuščanja. Namen naše raziskave pa je bil ugotoviti, ali uporaba obposteljne ultrasonografije v daljšem časovnem obdobju izboljša obravnavo srčnega popuščanja. Cilji: Cilji raziskave so bili ugotoviti razširjenost srčnega popuščanja v DSO in preizkusiti, ali obravnava srčnega popuščanja s pomočjo obposteljne ultrasonografije izboljša izide zdravljenja srčnega popuščanja. V tem primeru potrebujejo bolniki s srčnim opuščanjem v DSO drugačen algoritem zdravljenja. Metode: V multicentrični, prospektivni, randomizirani kontrolirani raziskavi smo med stanovalci DSO izvedli presejanje glede srčnega popuščanja. Presejanje smo izvedli po diagnostičnem algoritmu Evropskega kardiološkega združenja (ECS 2016). Vse faze presejanja so potekale v DSO. Bolnike s srčnim popuščanjem smo vključili v interventno fazo študije. Naključno smo jih razdelili v dve enakovredni skupini. Primerjali smo obravnavo srčnega popuščanja s pomočjo obposteljne ultrasonografije (skupina POCUS) ter ustaljeno klinično obravnavo srčnega popuščanja (kontrolna skupina). V kontrolni skupini smo volumski status bolnika vrednotili klinično. V skupini POCUS smo volumski status dodatno vrednotili s pomočjo B-linij in z oceno premera ter kolapsibilnosti spodnje vene kave. Obe skupini smo spremljali 6 mesecev in na podlagi ocene volumskega statusa prilagajali terapijo z diuretiki. Primarni izid je bil skupek dogodkov, povezanih s poslabšanjem srčnega popuščanja: potreba po intravenski diuretični terapiji, potreba po intervenciji nujne medicinske pomoči, nenačrtovana hospitalizacija zaradi nepoškodbenega vzroka ali smrt zaradi kateregakoli vzroka. Sekundarni izidi so bili vsak opazovani dogodek posebej, sprememba kakovosti življenja, sprememba funkcionalnega stanja, število dni v bolnišnici, povezanih s poslabšanjem srčnega popuščanja in število dni, ki so jih bolniki preživeli izven bolnišnice. Rezultati: Maja 2018 smo povabili 532 stanovalcev dveh DSO na presejanje za srčno popuščanje. Od 203 stanovalcev, ki so se odzvali, jih je 198 zaključilo diagnostiko srčnega popuščanja. Srčno popuščanje smo dokazali pri 90 (46%) stanovalcih. Pri 61 (68%) stanovalcih je bila diagnoza srčnega popuščanja postavljena na novo, medtem ko je imelo 14 (33%) stanovalcev zabeleženo diagnozo srčnega popuščanja v zdravstveni dokumentaciji, vendar srčnega popuščanja niso imeli. Stanovalci s srčnim popuščanjem so bili v povprečju stari 86 ± 5 let, večina je bila žensk (71%) in imeli so več pridruženih bolezni s povprečno 10 zdravili v redni terapiji. V povprečju so imeli iztisni delež levega prekata (LVEF) 60 ± 12%. Le 7% stanovalcev je imelo srčno popuščanje z zmanjšanim iztisnim deležem (HFrEF <40%). Srednja vrednost NT-proBNP je bila pri stanovalcih s srčnim popuščanjem 1670 pg/mL in pri stanovalcih brez srčnega popuščanja 348 pg/mL. Na podlagi naših podatkov smo določili višjo mejno vrednost NT-proBNP, kot jo predlagajo ESC smernice: namesto 125 pg/mL predlagamo za izključitev srčnega popuščanja pri stanovalcih DSO mejno vrednost 455 pg/mL. Primarni izid smo ugotovili pri 8 (18%) bolnikih v skupini POCUS in pri 10 (22%) bolnikih v kontrolni skupini (p = 0,793). Čeprav so imeli bolniki skupine POCUS manj dogodkov kot bolniki v kontrolni skupini (18 proti 22, p = 0,525), med skupinama ni bilo statistično značilne razlike. Najpogostejši dogodek je bila nenačrtovana hospitalizacija iz nepoškodbenega vzroka (5 v skupini POCUS in 10 v kontrolni skupini, p = 0,258). Prav tako ni bilo statistično pomembnih razlik v kakovosti življenja stanovalcev ali pri obremenitvah zdravnikov v DSO zaradi uporabe obposteljne ultrasonografije. To dokazuje, da je obravnava srčnega popuščanja s pomočjo obposteljne ultrasonografije primerljiva z ustaljeno obravnavo. Razprava: V raziskavi smo ugotovili visoko razširjenost srčnega popuščanja v DSO. Srčno popuščanje je večinoma nediagnosticirano ali napačno diagnosticirano. Glede na rezultate naše študije bi bilo za presejanje srčnega popuščanja v DSO potrebno prilagoditi mejne vrednosti NT-proBNP glede na starost. Obravnava srčnega popuščanja s pomočjo obposteljne ultrasonografije ni statistično značilno izboljšala obravnave srčnega popuščanja, vendar je bilo dogodkov, povezanih s srčnim popuščanjem, precej manj, kot smo pričakovali (20% v primerjavi s 50%). Možno je, da razlika med skupinama obstaja, vendar je nismo uspeli dokazati. Zaključek: Srčno popuščanje je zelo pogosto pri stanovalcih DSO in je v veliki meri nediagnosticirano ali napačno diagnosticirano. Raziskava je pokazala, da je obravnava srčnega popuščanja s pomočjo obpostljne ultrasonografije v DSO izvedljiva in je glede na vse opazovane vidike vsaj enakovredna standardni oskrbi. Na podlagi rezultatov študije je mogoče prilagoditi pristop ugotavljanja in vodenja srčnega popuščanja pri stanovalcih DSO.

• Language: Slovenian
• Keywords: prevalenca srčnega popuščanja, zdravljenje srčnega popuščanja, domovi starejših občanov, starejši, obposteljna ultrasonografija, obposteljni ultrazvok
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2020
• PID: 20.500.12556/RUL-121229
• COBISS.SI-ID: 35170563
• Publication date in RUL: 02.10.2020

Secondary language

• Language: English
• Title: Point-of-care ultrasonography for management of heart failure in nursing home residents

Abstract

Background: Heart failure is common in the nursing-home population, with many diagnostic and therapeutic challenges. Point-of-care ultrasonography (POCUS) is a bedside method that can be used to assess volume status more reliably than clinical examination. To date, POCUS has mostly been researched for dichotomous decision-making in acute heart failure to promptly adjust heart failure diuretic therapy. This trial was conceived to test whether POCUS-guided heart failure management improves a long-term outcome. Aims: We aimed to determine the prevalence of heart failure in nursing homes and to test whether POCUS-guided heart failure management improves outcome in nursing-home residents. We also aimed to develop a novel algorithm for the management of heart failure patients in the nursing-home population. Methods: This multicentre, prospective, randomized controlled trial enrolled nursing home residents that were screened for heart failure. Screening followed the 2016 European Cardiology Society diagnostic algorithm for diagnosis of heart failure of non-acute onset. All diagnostic steps were performed in the nursing-home facilities. Patients with heart failure were randomized in 1:1 fashion into the clinical management of heart failure (control) group versus POCUS-guided management of heart failure (POCUS) group. In the control group, the volume status was evaluated clinically. In the POCUS group, the volume status was additionally evaluated by the presence of B-lines, and vena cava diameter and collapsibility. During a 6-months follow-up of both groups, the diuretic therapy was optimised at regular intervals based on volume evaluation. The primary endpoint was a composite of the need for an intravenous diuretic therapy, emergency service intervention, unplanned hospitalization for a non-traumatic cause or all-cause death. Secondary endpoints were individual components of primary endpoint, a change in the quality of life, a change of the functional state, the number of days in hospital related to HF deterioration, and the number of days alive and out of hospital. Results: In May 2018, a total of 532 residents from two nursing-home facilities were invited to heart failure screening. Of those, 203 responded and 198 completed the heart failure diagnostic procedure. Heart failure was diagnosed in 90 (46%) residents. In 61 (68%) residents the diagnosis of heart failure was previously unknown, while 14 (33%) had a previous diagnosis of HF in medical records which was not confirmed in our study. Nursing-home residents with heart failure were elderly (86±5 years), predominantly female (71%), with several comorbidities and with an average of 10 regular medications. The average left ventricular ejection fraction was 60±12% and 7% had heart failure with reduced ejection fraction (LVEF <40%). The median NT-proBNP value in residents with HF was significantly higher than in those without HF (1670 pg/mL vs. 348 pg/mL, p<0.001). Based on our data, a cut-off value of NT-proBNP at 455 pg/mL was proposed to rule out heart failure in the nursing-home population as opposed to currently the recommended value of 125 pg/mL. The primary endpoint occurred in 8 (18%) POCUS and 10 (22%) control group patients (p=0.793). Although the POCUS group patients had fewer events than control group patients (18 vs. 22, p=0.525), there was no statistically significant difference between the groups. The most frequent event was an unplanned hospitalization for a non-injury cause (5 in the POCUS group and 10 in the control group, p=0.258). There were also no statistically significant differences in quality of life outcomes or in the outcomes related to the workload of the nursing-home physicians due to the use of POCUS. Discussion: This study found a high heart failure prevalence among nursing home residents, which was largely undiagnosed. We suggest to adjust the NT-proBNP cut-off for heart failure screening in nursing homes. POCUS-guided management of heart failure was feasible but did not improve clinical outcome in nursing home residents, likely due to low incidence of clinical events. Conclusion: Heart failure is highly prevalent but often unrecognized in nursing home population. POCUS in addition to clinical examination was not superior to clinical examination only guided heart failure management. The findings of this study justify a modified approach to heart failure diagnostic process and management in the nursing-home population.

• Keywords: heart failure prevalence, heart failure management, nursing home, elderly, aged, point-of-care ultrasonography, bedside ultrasonography