The epidemiology of pre-clinical congestion in patients at high risk of heart failure - DASH_Prevent' Study
H Khin, D Hunter, A Alsaeed, K Martin, N Greenlaw, M Morsy, P Maffia, J Cleland, P PellicoriAbstract
Background
Congestion is a key contributor to poor outcomes in heart failure (HF). It is treatable, but its early detection is challenging due to reliance on subjective, non-specific symptoms and signs. Objective identification of congestion using ultrasound before overt HF develops may enable timely diagnosis and intervention.
Purpose
To quantify the prevalence of preclinical congestion in patients at high risk for HF.
Methods
This is a single-centre, prospective observational cohort screening of adults (≥18 years) with ≥1 risk factor for HF (including hypertension, type II diabetes mellitus, ischaemic heart disease, chronic kidney or pulmonary disease, atrial fibrillation or taking a loop diuretic in absence of a prior diagnosis of HF) invited from primary care. After consent, participants underwent comprehensive clinical assessment, echocardiography, and congestion ultrasound. Congestion was defined, a priori, as the presence of at least one ultrasound sign of congestion: 1) inferior vena cava (IVC) diameter >20mm; 2) jugular vein distensibility (JVD) ratio <4 (the ratio of the jugular vein diameter during Valsalva to that at rest); 3) ≥15 B-lines from a 28-point lung ultrasound.
Results
Among 501 participants (median age 68 years (IQR 62–75), 62% men), ultrasound-defined pre-clinical congestion was present in 27% (n=137), most commonly IVC dilatation (23%), followed by ≥15 lung B-lines (6%) and JVD ratio <4 (4%). Of those with pre-clinical congestion, most participants (81%, n=111) had a single congestion marker, while 16% (n=22) had two and 3% (n=4) had all three. Compared to non-congested participants, those with pre-clinical congestion were older, had lower estimated glomerular filtration rate, higher prevalence of atrial fibrillation and loop diuretic use (p<0.005). They also had larger left atrial volumes (84ml vs 58ml, p<0.0001) but similar left ventricular ejection fraction (60.0% vs 61.7%) and higher plasma NT pro BNP (283 (IQR 112-577), 603 (IQR 168-1599) and 1533 (IQR 930-2179) ng/L, for participants with one, two and three signs of congestion respectively), compared to those without (115 (IQR 58-226)) ng/L) (p<0.0001).
Conclusion
Pre-clinical congestion is common in patients at high risk of heart failure, is detectable by ultrasound, and is associated with higher plasma concentrations of NT-proBNP. Whether integrating ultrasound of congestion and natriuretic peptides into diagnostic strategies improves earlier detection, intervention, and clinical outcomes in heart failure warrants further evaluation.