Skip to main content
SpringerLink
Log in

Why, when, and how to assess pulmonary congestion in heart failure: pathophysiological, clinical, and methodological implications

  • Published:
Heart Failure Reviews Aims and scope Submit manuscript

Abstract

Acute heart failure syndrome (AHFS) is a major public health problem. It is defined as gradual or rapid change in heart failure (HF) signs and symptoms, which often results in an unplanned hospitalization and a need for urgent therapy. Many evidence-based pharmacologic, device, and surgical treatment for HF are available or under development. Despite these new treatments and improvement in survival, hospitalizations in HF have steadily increased over the last 30 years, and the post-discharge prognosis of patients hospitalized with AHFS remains poor (Gheorghiade et al. Circulation 112:3958–3968, 2005; Fonarow et al. Rev Cardiovasc Med 4:S21–30, 2003). Most hospitalizations for AHFS are related to “congestion” rather than to low cardiac output. The definition, identification, quantification, and monitoring of congestion are therefore essential in AHFS. The purpose of this article is: (1) to characterize the different types of hemodynamic, clinical, and pulmonary congestion in AHFS; (2) to focus on the different possible ways to assess pulmonary congestion (probably the most important, and up to now the most diagnostically elusive of the three types of congestions); (3) to propose new possible ways to implement objective and user-friendly measures of pulmonary congestion in clinical and scientific decision-making in AHFS in the near future.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Gheorghiade M, Zannad F, Sopko G, Klein L, Piña IL, Konstam MA, Massie BM, Roland E, Targum S, Collins SP, Filippatos G, Tavazzi L, International Working Group on Acute Heart Failure Syndromes (2005) Acute heart failure syndromes: current state and framework for future research. Circulation 112:3958–3968

    Article  PubMed  Google Scholar 

  2. Fonarow GC, ADHERE Scientific Advisory Committee (2003) The Acute Decompensated Heart Failure National Registry (ADHERE): opportunities to improve care of patients hospitalized with acute decompensated heart failure. Rev Cardiovasc Med 4(Suppl 7):S21–S30

    PubMed  Google Scholar 

  3. Gheorghiade M, Filippatos G, De Luca L, Burnett J (2006) Congestion in acute heart failure syndromes: an essential target of evaluation and treatment. Am J Med 119(Suppl 1):S3–S10

    Article  PubMed  Google Scholar 

  4. Gheorghiade M, Shin DD, Thomas TO, Brandimarte F, Fonarow GC, Abraham WT (2006) Congestion is an important diagnostic and therapeutic target in heart failure. Rev Cardiovasc Med 7(Suppl 1):S12–S24

    PubMed  Google Scholar 

  5. Chaudhry SI, Wang Y, Concato J, Gill TM, Krumholz HM (2007) Patterns of weight change preceding hospitalization for heart failure. Circulation 116:1549–1554

    Article  PubMed  Google Scholar 

  6. Adamson PB, Magalski A, Braunschweig F et al (2003) Ongoing right ventricular hemodynamics in heart failure: clinical value of measurements derived from an implantable monitoring system. J Am Coll Cardiol 41:565–571

    Article  PubMed  Google Scholar 

  7. Yu CM, Wang L, Chau E, Chan RH, Kong SL, Tang MO, Christensen J, Stadler RW, Lau CP (2005) Intrathoracic impedance monitoring in patients with heart failure: correlation with fluid status and feasibility of early warning preceding hospitalization. Circulation 112:841–848

    Article  PubMed  Google Scholar 

  8. Nieminen MS, Böhm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, Hasin Y, Lopez-Sendon J, Mebazaa A, Metra M, Rhodes A, Swedberg K, Priori SG, Garcia MA, Blanc JJ, Budaj A, Cowie MR, Dean V, Deckers J, Burgos EF, Lekakis J, Lindahl B, Mazzotta G, Morais J, Oto A, Smiseth OA, Garcia MA, Dickstein K, Albuquerque A, Conthe P, Crespo-Leiro M, Ferrari R, Follath F, Gavazzi A, Janssens U, Komajda M, Morais J, Moreno R, Singer M, Singh S, Tendera M, Thygesen K, ESC Committe for Practice Guideline (CPG) (2005) Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology. Eur Heart J 26:384–416

    Article  PubMed  Google Scholar 

  9. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B, American College of Cardiology, American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians, International Society for Heart and Lung Transplantation, Heart Rhythm Society (2005) ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 112:e154–235

    Google Scholar 

  10. Gattis WA, O’Connor CM (2004) Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure. Am J Cardiol 93(Suppl):74B–76B

    Article  CAS  PubMed  Google Scholar 

  11. Gheorghiade M, Orlandi C, Burnett JC, Demets D, Grinfeld L, Maggioni A, Swedberg K, Udelson JE, Zannad F, Zimmer C, Konstam MA (2005) Rationale and design of the multicenter, randomized, double-blind, placebo-controlled study to evaluate the Efficacy of Vasopressin antagonism in Heart Failure: outcome study with Tolvaptan (EVEREST). J Card Fail 11:260–269

    Article  CAS  PubMed  Google Scholar 

  12. Binanay C, Califf RM, Hasselblad V, O’Connor CM, Shah MR, Sopko G, Stevenson LW, Francis GS, Leier CV, Miller LW, ESCAPE Investigators and ESCAPE Study Coordinators (2005) Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA 294:1625–1633

    Article  PubMed  Google Scholar 

  13. Stevenson LW (2003) Clinical use of inotropic therapy for heart failure: looking backward or forward? Part I: inotropic infusions during hospitalization. Circulation 108:367–372

    Article  PubMed  Google Scholar 

  14. Shah MR, Hasselblad V, Stevenson LW, Binanay C, O’Connor CM, Sopko G, Califf RM (2005) Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials. JAMA 294:1664–1670

    Article  CAS  PubMed  Google Scholar 

  15. Remes J, Miettinen H, Reunanen A, Pyörälä K (1991) Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J 12:315–321

    CAS  PubMed  Google Scholar 

  16. Dao Q, Krishnaswamy P, Kazanegra R, Harrison A, Amirnovin R, Lenert L, Clopton P, Alberto J, Hlavin P, Maisel AS (2001) Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent-care setting. J Am Coll Cardiol 37:379–385

    Article  CAS  PubMed  Google Scholar 

  17. Bourge RC, Abraham WT, Adamson PB, Aaron MF, Aranda JM Jr, Magalski A, Zile MR, Smith AL, Smart FW, O’Shaughnessy MA, Jessup ML, Sparks B, Naftel DL, Stevenson LW, COMPASS-HF Study Group (2008) Randomized controlled trial of an implantable continuous hemodynamic monitor in patients with advanced heart failure: the COMPASS-HF study. J Am Coll Cardiol 51:1073–1079

    Article  PubMed  Google Scholar 

  18. Adamson PB, Conti JB, Smith AL, Abraham WT, Aaron MF, Aranda JM Jr, Baker J, Bourge RC, Warner-Stevenson L, Sparks B (2007) Reducing events in patients with chronic heart failure (REDUCEhf) study design: continuous hemodynamic monitoring with an implantable defibrillator. Clin Cardiol 30:567–575

    Article  PubMed  Google Scholar 

  19. Komajda M, Lapuerta P, Hermans N, Gonzalez-Juanatey JR, van Veldhuisen DJ, Erdmann E, Tavazzi L, Poole-Wilson P, Le Pen C (2005) Adherence to guidelines is a predictor of outcome in chronic heart failure: the MAHLER survey. Eur Heart J 26:1653–1659

    Article  PubMed  Google Scholar 

  20. Adams KF Jr, Fonarow GC, Emerman CL et al (2005) Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100, 000 cases in the Acute Decompensated Failure National Registry (ADHERE). Am Heart J 149:209–216

    Article  PubMed  Google Scholar 

  21. Fonarow GC, Abraham WT, Albert NM et al (2004) Organized program to initiate lifesaving treatment in hospitalized patients with heart failure (OPTIMIZE-HF): rationale and design. Am Heart J 148:43–51

    Article  PubMed  Google Scholar 

  22. Tavazzi L, Maggioni AP, Lucci D et al (2006) Nationwide survey on acute heart failure in cardiology ward services in Italy. Eur Heart J 27:1207–1215

    Article  PubMed  Google Scholar 

  23. Lange NR, Schuster DP (1999) The measurement of lung water. Crit Care 3:R19–R24

    Article  PubMed  Google Scholar 

  24. Gheorghiade M, Abraham WT, Albert NM, Greenberg BH, O’Connor CM, She L, Stough WG, Yancy CW, Young JB, Fonarow GC, OPTIMIZE-HF Investigators and Coordinators (2006) Systolic blood pressure at admission, clinical characteristics, and outcomes in patients hospitalized with acute heart failure. JAMA 296:2217–2226

    Article  CAS  PubMed  Google Scholar 

  25. Chakko S, Woska D, Martinez H, de Marchena E, Futterman L, Kessler KM, Myerberg RJ (1991) Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care. Am J Med 90:353–359

    CAS  PubMed  Google Scholar 

  26. Butman SM, Ewy GA, Standen JR, Kern KB, Hahn E (1993) Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension. J Am Coll Cardiol 22:968–974

    Article  CAS  PubMed  Google Scholar 

  27. Mahdyoon H, Klein R, Eyler W, Lakier JB, Chakko SC, Gheorghiade M (1989) Radiographic pulmonary congestion in end-stage congestive heart failure. Am J Cardiol 63:625-627

    Article  CAS  PubMed  Google Scholar 

  28. Goldberg LR, Piette JD, Walsh MN, Frank TA, Jaski BE, Smith AL, Rodriguez R, Mancini DM, Hopton LA, Orav EJ, Loh E, WHARF Investigators (2003) Randomized trial of a daily electronic home monitoring system in patients with advanced heart failure: the Weight Monitoring in Heart Failure (WHARF) trial. Am Heart J 146:705–712

    Article  PubMed  Google Scholar 

  29. Bedetti G, Gargani L, Corbisiero A, Frassi F, Poggianti E, Mottola G (2006) Evaluation of ultrasound lung comets by hand-held echocardiography. Cardiovasc Ultrasound 4:34

    Article  CAS  PubMed  Google Scholar 

  30. Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampf FA, Pellikka PA, Evangelista A (2009) Recommendations for the evaluation or left ventricular diastolic function by echocardiography. Eur J Echocardiogr 10:165–193

    Article  PubMed  Google Scholar 

  31. Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quinones MA (1997) Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 30:1527–1533

    Article  CAS  PubMed  Google Scholar 

  32. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ, Chamber Quantification Writing Group (2005) American Society of Echocardiography’s Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 18:1440–1463

    Article  PubMed  Google Scholar 

  33. Fauci A, Braunwald E, Kasper D, Hauser J, Longo D (2008) Harrison’s principles of internal medicine, 17th edn. McGraw-Hill, New York

  34. Picano E, Frassi F, Agricola E, Gligorova S, Gargani L, Mottola G (2006) Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr 19:356–363

    Article  PubMed  Google Scholar 

  35. Jambrik Z, Monti S, Coppola V, Agricola E, Mottola G, Miniati M, Picano E (2004) Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water. Am J Cardiol 93:1265–1270

    Article  PubMed  Google Scholar 

  36. Agricola E, Bove T, Oppizzi M, Marino G, Zangrillo A, Margonato A, Picano E (2005) “Ultrasound comet-tail images”: a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water. Chest 127:1690–1695

    Article  PubMed  Google Scholar 

  37. Gargani L, Lionetti V, Di Cristofano C, Bevilacqua G, Recchia FA, Picano E (2007) Early detection of acute lung injury uncoupled to hypoxemia in pigs using ultrasound lung comets. Crit Care Med 35:2769–2774

    Article  PubMed  Google Scholar 

  38. Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Thomas SH, Harris NS (2007) Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema. Chest 131:1013–1018

    Article  PubMed  Google Scholar 

  39. Frassi F, Pingitore A, Cialoni D, Picano E (2008) Chest sonography detects lung water accumulation in healthy elite apnea divers. J Am Soc Echocardiogr 21:1150–1155

    Article  PubMed  Google Scholar 

  40. Gargani L, Frassi F, Soldati G, Tesorio P, Gheorghiade M, Picano E (2008) Ultrasound lung comets for the differential diagnosis of acute cardiogenic dyspnoea: a comparison with natriuretic peptides. Eur J Heart Fail 10:70–77

    Article  CAS  PubMed  Google Scholar 

  41. Frassi F, Gargani L, Tesorio P, Raciti M, Mottola G, Picano E (2007) Prognostic value of extravascular lung water assessed with ultrasound lung comets by chest sonography in patients with dyspnea and/or chest pain. J Cardiac Fail 13:830–835

    Article  Google Scholar 

  42. Biomarkers Definitions Working Group (2001) Biomarkers and surrogate endpoints: preferred definitions and conceptual framework. Clin Pharmacol Ther 69:89–95

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Institute of Clinical Physiology, National Research Council, Pisa, Italy

    Eugenio Picano & Luna Gargani

  2. Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Mihai Gheorghiade

Authors
  1. Eugenio Picano
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Luna Gargani
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mihai Gheorghiade
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Luna Gargani.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Picano, E., Gargani, L. & Gheorghiade, M. Why, when, and how to assess pulmonary congestion in heart failure: pathophysiological, clinical, and methodological implications. Heart Fail Rev 15, 63–72 (2010). https://doi.org/10.1007/s10741-009-9148-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10741-009-9148-8

Keywords

Search

Navigation