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Abstract：
OBJECTIVE: Diagnosing and classifying heart failure (HF) in the oldest-old patients has technical and interpretation issues, especially in the acute setting. We assessed the usefulness of both N-terminal pro-brain natriuretic peptide (NT-proBNP) and lung ultrasound (LUS) for confirming HF diagnosis and predicting, among hospitalized HF patients, those with reduced ejection fraction (HFrEF).
METHODS: We performed a cross-sectional study on 148 consecutive patients aged ≥ 80 years admitted to our Internal Medicine and Geriatrics ward with at least one symptom/sign compatible with HF and NT-proBNP ≥ 125 pg/mL. We measured serum NT-proBNP levels and performed LUS and transthoracic echocardiography (TTE) on admission before diuretic therapy. We divided our cohort into three subgroups according to the left ventricular ejection fraction (LVEF): reduced (LVEF ≤ 40%), mildly-reduced (LVEF = 41-49%) and preserved (LVEF ≥ 50%).
RESULTS: The mean age was 88±5 years. Male prevalence was 42%. Patients with HFrEF were 19%. Clinical features and laboratory parameters did not differ between the three subgroups, except for higher NT-proBNP in HFrEF patients, which also had a higher number of total B-lines and intercostal spaces of pleural effusion at LUS. Overall, NT-proBNP showed an inverse correlation with LVEF (r = -0.22, p = 0.007) and a direct correlation with age, total pulmonary B-lines, and intercostal spaces of pleural effusion. According to the ROCs, NT-proBNP levels, pulmonary B-lines and pleural effusion extension were poorly predictive for HFrEF. The best-performing cut-offs were 9531 pg/mL for NT-proBNP (SP 0.70, SE 0.50), 13 for total B-lines (SP 0.69, SE 0.85) and one intercostal space for pleural effusion (SP 0.55, SE 0.89). Patients with admission NT-proBNP ≥ 9531 pg/mL had a 2-fold higher risk for HFrEF (OR 2.5, 95% CI 1.3-4.9), while we did not find any association for total B-lines ≥ 13 or pleural effusion ≥ 1 intercostal space with HFrEF. A significant association with HFrEF emerged for the combination of NT-proBNP ≥ 9531 pg/mL, total B-lines ≥ 13 and intercostal spaces of pleural effusion ≥ 1 (adjusted OR 4.3, 95% CI 1.5-12.9).
CONCLUSIONS: Although NT-proBNP and LUS help diagnose HF, their accuracy in discriminating HFrEF from non-HFrEF was poor in our real-life clinical study on oldest-old hospitalized patients, making the use of TTE still necessary to distinguish HF phenotypes in this peculiar setting. These data require confirmation in more extensive and longer prospective studies.
METHODS: We performed a cross-sectional study on 148 consecutive patients aged ≥ 80 years admitted to our Internal Medicine and Geriatrics ward with at least one symptom/sign compatible with HF and NT-proBNP ≥ 125 pg/mL. We measured serum NT-proBNP levels and performed LUS and transthoracic echocardiography (TTE) on admission before diuretic therapy. We divided our cohort into three subgroups according to the left ventricular ejection fraction (LVEF): reduced (LVEF ≤ 40%), mildly-reduced (LVEF = 41-49%) and preserved (LVEF ≥ 50%).
RESULTS: The mean age was 88±5 years. Male prevalence was 42%. Patients with HFrEF were 19%. Clinical features and laboratory parameters did not differ between the three subgroups, except for higher NT-proBNP in HFrEF patients, which also had a higher number of total B-lines and intercostal spaces of pleural effusion at LUS. Overall, NT-proBNP showed an inverse correlation with LVEF (r = -0.22, p = 0.007) and a direct correlation with age, total pulmonary B-lines, and intercostal spaces of pleural effusion. According to the ROCs, NT-proBNP levels, pulmonary B-lines and pleural effusion extension were poorly predictive for HFrEF. The best-performing cut-offs were 9531 pg/mL for NT-proBNP (SP 0.70, SE 0.50), 13 for total B-lines (SP 0.69, SE 0.85) and one intercostal space for pleural effusion (SP 0.55, SE 0.89). Patients with admission NT-proBNP ≥ 9531 pg/mL had a 2-fold higher risk for HFrEF (OR 2.5, 95% CI 1.3-4.9), while we did not find any association for total B-lines ≥ 13 or pleural effusion ≥ 1 intercostal space with HFrEF. A significant association with HFrEF emerged for the combination of NT-proBNP ≥ 9531 pg/mL, total B-lines ≥ 13 and intercostal spaces of pleural effusion ≥ 1 (adjusted OR 4.3, 95% CI 1.5-12.9).
CONCLUSIONS: Although NT-proBNP and LUS help diagnose HF, their accuracy in discriminating HFrEF from non-HFrEF was poor in our real-life clinical study on oldest-old hospitalized patients, making the use of TTE still necessary to distinguish HF phenotypes in this peculiar setting. These data require confirmation in more extensive and longer prospective studies.
摘要：
目的：老年患者心力衰竭（HF）的诊断和分类存在技术和解释问题，尤其是在急性环境中。我们评估了N末端脑钠肽前体（NT-proBNP）和肺超声（LUS）对确认HF诊断和预测的有用性，在住院的HF患者中，那些降低射血分数（HFrEF）。
方法：我们对我们内科和老年病科病房收治的148名年龄≥80岁的连续患者进行了横断面研究，这些患者至少有一种症状/体征与HF和NT-proBNP≥125pg/mL相符。我们测量了血清NT-proBNP水平，并在利尿剂治疗前进行了LUS和经胸超声心动图（TTE）。我们根据左心室射血分数（LVEF）将我们的队列分为三个亚组：降低（LVEF≤40％），轻度降低（LVEF=41-49％）和保留（LVEF≥50％）。
结果：平均年龄为88±5岁。男性患病率为42%。HFrEF患者占19%。三个亚组之间的临床特征和实验室参数没有差异，除了HFrEF患者NT-proBNP较高，在LUS处，胸腔积液的总B线和肋间空间的数量也较高。总的来说,NT-proBNP与LVEF呈负相关(r=-0.22,p=0.007),与年龄呈直接相关,总肺B线，和胸腔积液的肋间空间。根据ROC,NT-proBNP水平,肺B线和胸腔积液扩展对HFrEF的预测能力较差。NT-proBNP（SP0.70，SE0.50）的最佳截止值为9531pg/mL，13为总B线（SP0.69，SE0.85），一个肋间间隙为胸腔积液（SP0.55，SE0.89）。NT-proBNP≥9531pg/mL的患者发生HFrEF的风险高2倍（OR2.5，95％CI1.3-4.9），而我们没有发现总B线≥13或胸腔积液≥1与HFrEF的任何关联。NT-proBNP≥9531pg/mL的组合出现与HFrEF的显着关联，总B线≥13，胸腔积液的肋间空间≥1（校正OR4.3，95％CI1.5-12.9）。
结论：尽管NT-proBNP和LUS有助于诊断HF，在我们对年龄最大的住院患者进行的现实生活临床研究中，他们区分HFrEF和非HFrEF的准确性很差，仍然需要使用TTE来区分这种特殊环境中的HF表型。这些数据需要在更广泛和更长期的前瞻性研究中得到证实。
方法：我们对我们内科和老年病科病房收治的148名年龄≥80岁的连续患者进行了横断面研究，这些患者至少有一种症状/体征与HF和NT-proBNP≥125pg/mL相符。我们测量了血清NT-proBNP水平，并在利尿剂治疗前进行了LUS和经胸超声心动图（TTE）。我们根据左心室射血分数（LVEF）将我们的队列分为三个亚组：降低（LVEF≤40％），轻度降低（LVEF=41-49％）和保留（LVEF≥50％）。
结果：平均年龄为88±5岁。男性患病率为42%。HFrEF患者占19%。三个亚组之间的临床特征和实验室参数没有差异，除了HFrEF患者NT-proBNP较高，在LUS处，胸腔积液的总B线和肋间空间的数量也较高。总的来说,NT-proBNP与LVEF呈负相关(r=-0.22,p=0.007),与年龄呈直接相关,总肺B线，和胸腔积液的肋间空间。根据ROC,NT-proBNP水平,肺B线和胸腔积液扩展对HFrEF的预测能力较差。NT-proBNP（SP0.70，SE0.50）的最佳截止值为9531pg/mL，13为总B线（SP0.69，SE0.85），一个肋间间隙为胸腔积液（SP0.55，SE0.89）。NT-proBNP≥9531pg/mL的患者发生HFrEF的风险高2倍（OR2.5，95％CI1.3-4.9），而我们没有发现总B线≥13或胸腔积液≥1与HFrEF的任何关联。NT-proBNP≥9531pg/mL的组合出现与HFrEF的显着关联，总B线≥13，胸腔积液的肋间空间≥1（校正OR4.3，95％CI1.5-12.9）。
结论：尽管NT-proBNP和LUS有助于诊断HF，在我们对年龄最大的住院患者进行的现实生活临床研究中，他们区分HFrEF和非HFrEF的准确性很差，仍然需要使用TTE来区分这种特殊环境中的HF表型。这些数据需要在更广泛和更长期的前瞻性研究中得到证实。
