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Hand-held ultrasound shows promise for predicting outcomes after cardioversion
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At the time of cardioversion, use of hand-held ultrasound to assess inferior vena cava measurements aided in the identification of patients at low risk for early recurrence of atrial fibrillation after successful electrical cardioversion.
A team of researchers used the Vscan hand-held ultrasound (General Electric Healthcare Division) to measure inferior vena cava (IVC) diameter and collapsibility with inspiration in 128 patients (mean age, 68 years; 71% men) with AF or atrial flutter immediately before and after successful cardioversion.
“Assessment of the inferior vena cava by ultrasound is a validated, noninvasive technique to assess central venous pressure and guide management in patients with dyspnea, critical illness and heart failure. Current guidelines published by the American Society of Echocardiography in 2015 support the combined use of maximum IVC diameter (> or < 2.1 cm) and inspiratory IVC collapsibility (> or < 50%) to estimate right atrial pressure as low, intermediate or high. Hand-held ultrasound has emerged as an effective tool to obtain these measurements in a rapid and reproducible fashion at the point of care,” Devin Kehl, MD, cardiologist with Palo Alto Foundation Medical Group and Cedars-Sinai Heart Institute, and colleagues wrote in JMIR Cardio.
Among this patient population, the mean IVC diameter was 2.16 cm before cardioversion and 2.01 cm in sinus rhythm after cardioversion. Inspiratory collapsibility was seen in 49% of patients before cardioversion compared with 73% after cardioversion. Right atrial pressure was estimated as high in 40% of patients before cardioversion compared with 18% after cardioversion.
AF or atrial flutter recurrence occurred in 26.6% of patients within 30 days, 38% within 90 days, 44% within 180 days and 52.5% within 1 year. At 90 days, AF or atrial flutter recurrence was 12.1% among patients with an IVC diameter less than 2.1 cm before cardioversion and with a decrease in IVC diameter after cardioversion, compared with 31.6% among patients with a greater baseline IVC diameter and no decrease in IVC diameter after cardioversion (unadjusted OR = 0.299; 95% CI, 0.096-0.926). This association remained after the researchers adjusted for age, ejection fraction less than 50%, left atrial enlargement and amiodarone use, according to the findings. The combined parameter of IVC diameter less than 2.1 cm before cardioversion and a change in IVC diameter less than 0 was also associated with a lower rate of recurrence at 90 days (unadjusted OR = 0.361; 95% CI, 0.141-0.924).
The researchers also evaluated outcomes among patients with an IVC diameter less than 1.7 cm after cardioversion, in whom the rate of AF or atrial flutter recurrence at 30 days was 13.5% compared with 31.9% among those with a greater IVC diameter (unadjusted OR = 0.334; 95% CI, 0.118-0.946; adjusted OR = 0.185; 95% CI, 0.05-0.691). A similar association was observed at 90 days (unadjusted OR = 0.435; 95% CI, 0.182-1.039; aOR = 0.344; 95% CI, 0.124-0.958).
IVC parameters did not predict AF or atrial flutter recurrence at 180 days or 1 year, according to the researchers.
“These findings not only demonstrate that AF/atrial flutter influences the size and dynamics of the IVC, but also that hand-held ultrasound-derived measurements of the IVC (easily obtained anatomic measurements) are reflective of dynamic changes in physiology,” Kehl and colleagues wrote.
In an interview with Cardiology Today, Kehl noted that “on the small scale, this work identifies a novel biomarker to aid in the risk prediction of AF recurrence, a common clinical problem.”
“On the broader scale, however, it is worth remembering that hand-held ultrasound was originally developed as a tool to enhance bedside diagnosis and accessibility of ultrasound. Now, this work and others are beginning to show that the use of hand-held ultrasound at the point of care may improve risk stratification and assessment of prognosis in select clinical scenarios, beyond established predictors,” he said.
Further research will continue to evaluate use of hand-held ultrasound in this setting, as well as others.
“The use of a hand-held device to acquire anatomic measurements that change with physiologic changes as a predictor of future events is novel. This use of hand-held ultrasound demonstrates the possibility for the use of imaging data as a biomarker of physiologic changes in real time,” Ilan Kedan, MD, MPH, from Cedars-Sinai Medical Group and clinical associate professor of medicine at Cedars-Sinai Smidt Heart Institute, told Cardiology Today. – by Katie Kalvaitis
For more information:
Ilan Kedan, MD, MPH, can be reached at Cedars-Sinai Heart Institute, Suite 403, 250 N. Robertson Blvd., Beverly Hills, CA 90211; email: kedani@cshs.org.
Disclosures: Kedan and Kehl report no relevant financial disclosures.
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