ABC | Volume 110, Nº6, June 2018

Review Article Muniz et al Pulmonary ultrasound in patients with heart failure Arq Bras Cardiol. 2018; 110(6):577-584 0 0 0 1 1 1 1 3 3 3 13 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Figure 4 – Distribution of specific publications about pulmonary ultrasound in heart failure in the 2006-2016 period. patients had no compatible alteration in lung auscultation. Gustafsson et al., 37 studying 104 patients, have identified that the presence of B-lines or pleural effusion or both correlated with the increased risk of death or hospitalization (HR: 3-4; p < 0.05). In 2015, Gargani et al. 9 and Corio et al. 10 found prognostic value on hospital discharge for the number of B-lines ≥ 30 and ≥ 15, respectively, for all-cause death or event-free hospitalization in 3 and 6 months (p < 0.001 for both). We found a mean number of B-lines of 12.2 ± 7.3 on hospital discharge. Five patients were hospitalized again in 90 days, with an event-free mean of 63.6 ± 25.7 days and a mean BNP value of 450.10 ± 409.96 pg/mL. Pulmonary ultrasound and therapeutic assessment Volpicelli et al. 8 have concluded that B-line pattern mostly clears after medical treatment and correlates with other parameters, such as radiologic (p < 0.05) and clinical (p < 0.05) scores of congestion and BNP levels (p < 0.05). Discussion This systematic review was aimed at identifying scientific evidence about PU in HF. The results showed it increases the HF diagnosis accuracy in the prehospital and hospital settings with incremental prognostic value on the discharge of patients with decompensated HF and might play a role in guiding the treatment of patients with HF. Figure 4 shows the progressive increase in the number of publications on PU in HF over the past 10 years; however, several studies were clinical reviews, 7,38,39 others were editorials, and there was a methodological description. 40 There are several scenarios for the applicability of PU in assessing dyspneic patients with decompensated or presumed HF. As shown in Figure 5, the emergency application of PU was the most studied. It is believed that one of the reasons for that would be the low accuracy of physical examination and of chest X-ray 6 for a rapid and more accurate diagnosis. 23,24 A review study with 100 patients in the emergency department and using a pocket-sized cardiac ultrasound device has shown that PU can rapidly aid the diagnosis of HF, providing a more adequate and early treatment. 38 In that context of emergency assessment, Miglioranza et al. 34 and Facchini et al. 41 have reported positive correlations between PU data and neuropeptide levels. That information can be useful, mainly when the measurement of natriuretic peptides is not available for the initial assessment. Another author, 42 using PU in the emergency setting, has reported that the identification of multiple B-lines bilaterally was a sensitive, but not specific, predictor of BNP elevation>500 pg/mL. That was the first study correlating B-lines with BNP. 42 In addition, it was confirmed that the presence of alveolar‑interstitial syndrome, identified by the presence of B-lines, can represent a precise and reproducible test to discriminate between cardiac and noncardiac dyspnea in the emergency setting, with sensitivity of 93.6%, specificity of 84%, positive predictive value of 87.9% and negative predictive value of 91.3%. 43 Those findings also correlate with the NYHA functional class, left ventricular ejection fraction and grade of diastolic dysfunction. 44 Several studies 5,18,23,24 have correlated the presence of B-lines on PU with a sensitive marker for the diagnosis of decompensated HF; however, B-lines are not an exclusivity of decompensated HF. They can appear in adult respiratory distress syndrome and pulmonary interstitial fibrosis. 12 Another review study of patients with HF followed up on an outpatient basis has concluded that PU has great diagnostic potential for identifying pulmonary congestion signs at the bedside, can become a state-of-the-art marker of interstitial fluid, and that the B-line pattern usually disappears after proper treatment of acute HF, revealing itself as an alternative diagnostic tool of easy use and therapeutic 581