Elisa Merli1, Quirino Ciampi2, Maria Chiara Scali3, Angela Zagatina4, Pablo Martin Merlo5, Rosina Arbucci5, Clarissa Borguezan Daros6, José Luis de Castro E Silva Pretto7, Miguel Amor8, Michael F Salamè8, Hugo Mosto8, Doralisa Morrone9, Antonello D'Andrea10, Barbara Reisenhofer11, Hugo Rodriguez-Zanella12, Karina Wierzbowska-Drabik13, Jaroslaw D Kasprzak13, Gergely Agoston14, Albert Varga14, Jorge Lowenstein5, Claudio Dodi15, Lauro Cortigiani16, Iana Simova17,18, Martina Samardjieva17,18, Rodolfo Citro19, Jelena Celutkiene20, Federica Re21, Ines Monte22, Suzana Gligorova23, Francesco Antonini-Canterin24, Mauro Pepi25, Clara Carpeggiani26, Patricia A Pellikka27, Eugenio Picano26. 1. Department of Cardiology, Ospedale per gli Infermi, Faenza, Italy (E.M.). 2. Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy (Q.C.). 3. Cardiology Division, Campostaggia Hospital, Siena, Italy (M.C.S.). 4. Cardiology Department, Saint Petersburg State University Hospital, Saint Petersburg, Russian Federation (A.Z.). 5. Cardiodiagnosticos, Investigaciones Medicas, Buenos Aires, Argentina (P.M.M., R.A., J.L.). 6. Cardiology Division, Hospital San José, Criciuma, Brasil (B.D.). 7. Hospital Sao Vicente de Paulo e Hospital de Cidade, Passo Fundo, Brasil (J.L.d.C.e.S.P.). 8. Cardiology Department, Ramos Mejia Hospital, Buenos Aires, Argentina (M.A., M.F.S., H.M.). 9. Cardiology Department, Cisanello University Hospital, Pisa, Italy (D.M.). 10. Cardiology, Monaldi Hospital, Second University of Naples, and Nocera Inferiore, Italy (A.D.). 11. Cardiology Division, Pontedera Hospital, Pontedera, Italy (B.R.). 12. Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico (H.R.-Z.). 13. Chair of Cardiology, Bieganski Hospital, Medical University, Lodz, Poland (K.W.-D., J.D.K.). 14. Institute of Family Medicine, University of Szeged, Hungary (G.A., A.V.). 15. Cardiology Department, Ospedale di Cremona, Italy (C.D.). 16. Cardiology Department, San Luca Hospital, Lucca, Italy (L.C.). 17. Cardiology Department, Heart and Brain Center of Excellence, University Hospital, Pleven, Bulgaria (I.S., M.S.). 18. Medical University, Pleven, Bulgaria (I.S., M.S.). 19. Cardio-Thoracic-Vascular-Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy (R.C.). 20. Centre of Cardiology and Angiology, Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.C.). 21. Ospedale San Camillo, Cardiology Division, Rome, Italy (F.R.). 22. Cardio-Thorax-Vascular Department, Echocardiography Lab, "Policlinico Vittorio Emanuele", Catania University, Italy (I.M.). 23. Divisione Cardiologia, Ospedale Casilino, Rome, Italy (S.G.). 24. Highly Specialized Rehabilitation Hospital Motta di Livenza, Cardiac Prevention and Rehabilitation Unit, Treviso, Italy (F.A.-C.). 25. Centro Cardiologico Monzino, IRCCS, Milan, Italy (M.P.). 26. Institute of Clinical Physiology, CNR, Pisa Italy (C.C., E.P.). 27. Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (P.A.P.).
Abstract
BACKGROUND: Lung ultrasound detects pulmonary congestion as B-lines at rest, and more frequently, during exercise stress echocardiography (ESE). METHODS: We performed ESE plus lung ultrasound (4-site simplified scan) in 4392 subjects referred for semi-supine bike ESE in 24 certified centers in 9 countries. B-line score ranged from 0 (normal) to 40 (severely abnormal). Five different populations were evaluated: control subjects (n=103); chronic coronary syndromes (n=3701); heart failure with reduced ejection fraction (n=395); heart failure with preserved ejection fraction (n=70); ischemic mitral regurgitation ≥ moderate at rest (n=123). In a subset of 2478 patients, follow-up information was available. RESULTS: During ESE, B-lines increased in all study groups except controls. Age, hypertension, abnormal ejection fraction, peak wall motion score index, and abnormal heart rate reserve were associated with B-lines in multivariable regression analysis. Stress B lines (hazard ratio, 2.179 [95% CI, 1.015-4.680]; P=0.046) and ejection fraction <50% (hazard ratio, 2.942 [95% CI, 1.268-6.822]; P=0.012) were independent predictors of all-cause death (n=29 after a median follow-up of 29 months). CONCLUSIONS: B-lines identify the pulmonary congestion phenotype at rest, and more frequently, during ESE in ischemic and heart failure patients. Stress B-lines may help to refine risk stratification in these patients. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03049995.
BACKGROUND: Lung ultrasound detects pulmonary congestion as B-lines at rest, and more frequently, during exercise stress echocardiography (ESE). METHODS: We performed ESE plus lung ultrasound (4-site simplified scan) in 4392 subjects referred for semi-supine bike ESE in 24 certified centers in 9 countries. B-line score ranged from 0 (normal) to 40 (severely abnormal). Five different populations were evaluated: control subjects (n=103); chronic coronary syndromes (n=3701); heart failure with reduced ejection fraction (n=395); heart failure with preserved ejection fraction (n=70); ischemic mitral regurgitation ≥ moderate at rest (n=123). In a subset of 2478 patients, follow-up information was available. RESULTS: During ESE, B-lines increased in all study groups except controls. Age, hypertension, abnormal ejection fraction, peak wall motion score index, and abnormal heart rate reserve were associated with B-lines in multivariable regression analysis. Stress B lines (hazard ratio, 2.179 [95% CI, 1.015-4.680]; P=0.046) and ejection fraction <50% (hazard ratio, 2.942 [95% CI, 1.268-6.822]; P=0.012) were independent predictors of all-cause death (n=29 after a median follow-up of 29 months). CONCLUSIONS: B-lines identify the pulmonary congestion phenotype at rest, and more frequently, during ESE in ischemic and heart failure patients. Stress B-lines may help to refine risk stratification in these patients. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03049995.