This document discusses congestion in acute heart failure and methods for recognizing and evaluating congestion. It covers: 1. Congestion mechanisms that increase afterload and decrease capacitance on the right and left sides of the heart. 2. Methods for recognizing congestion including increased pulmonary artery wedge pressure, pulmonary edema seen on ultrasound imaging, and inferior vena cava dilatation on ultrasound. 3. The use of ultrasound to evaluate E/E' ratio, pulmonary edema via B-lines, and inferior vena cava diameter and collapsibility. Biomarkers like BNP, MR-ANP, and MR-ADM are also elevated in fluid overloaded patients. 4.

1. Congestion
The key target in acute heart failure
Role of ultrasound and biomarkers
Pr Semir Nouira
Emergency Department
Fattouma Bourguiba University Hospital
Monastir Tunisia

5. CONGESTION MECHANISM
Right Left
Increase afterload
Decrease capacitance

6. CONGESTION MARKERS
Right Left
Increase afterload
Decrease capacitance



 Pulmonary artery wedge pressure increase
 Pulmonary edema
 Inferior Vena Cava dilatation

7. RECOGNIZE CONGESTION
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation
ULTRASONOGRAPHY

8. RECOGNIZE CONGESTION
ULTRASONOGRAPHY
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation

9. E/E’
Normal
PAWP increase
E’
A’
E’ A’

10. E/E’ and PAWP
Sherif FN J Am Coll Cardiol 1997

11. Septal E/E′
○ patients with EF <50%
•patients with EF >50%.
Ommen SR Circulation 2000

12. • Situations where the use of E/e' may be unreliable
– Tachycardia
– Mitral regurgitation or replacement
– LBBB
èSurrogate indices
─ PFV
─ LA Ø
─ LV Ø
• Hemodynamic and pulmonary congestion discrepancy
E/E’ Limits

13. INTRODUCTION
Types of congestion in AHF
Picano E. Heart Fail Rev (2010)

14. RECOGNIZE CONGESTION
ULTRASONOGRAPHY
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation

16. Picano E. Heart Fail Rev 2010

17. Picano E . Heart Fail Rev 2010
Miglioranza MH J Am Coll Cardiol Imag
2013Jambrik ZN Ultrasound Med. & Biol. 2010

18. q Sensitive but not specific
üARDS
ü Pulmonary fibrosis…
q Methodological biais
üPosition of the patient
üEquipment (probe type…)
LIMITS OF LUNG ULTRASOUND

19. Trovato GM. Am J Resp Crit Care Med 2013
LIMITS OF LUNG ULTRASOUND

20. RECOGNIZE CONGESTION
ULTRASONOGRAPHY
1. Pulmonary artery wedge pressure increase
2. Pulmonary edema
3. Inferior Vena Cava dilatation

21. IVC diameter and collapsibility

22. IVC diameter and collapsibility Limits
Zengin S Am J Emerg Med 2012

23. RECOGNIZE CONGESTION
BIOMARKERS ?

24. BIOMARKERS AND CONGESTION
Gaggin HK Biochimica Biophysica Acta 2013

25. BIOMARKERS AND CONGESTION
Miglioranza MH J Am Coll Cardiol Imag
2013
Forfia PR J Am Coll Card 2005

26. BIOMARKERS AND CONGESTION
q Mid-region pro-atrial natriuretic peptide (MR-
proANP)
q Mid-regional adrenomedullin (MR-proADM)
as BNP are elevated in fluid overloaded patients
who have elevated filling pressures

27. CONCLUSION
Congestion
Hemodynamic Pulmonary
US+++
E/E’
B-lines
IVC Ø
collaps
Biomarkers
BNP
MR-ANP
MR-ADM
Others ?

28. ThankThank youyou
Greetings
From Tunisia
2nd Global network conference 2013 Pr. Semir NOUIRA Tunisia