Editorial
Ultrasound assessment of the inferior vena cava in heart failure
Valoración ecográfica de la vena cava inferior en insuficiencia cardiaca
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Such admissions are often associated with the patient's functional deterioration, exacerbation of other comorbidities and lead to a 3-month mortality of around 15%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Virtually all patients admitted for this reason will require intravenous diuretic treatment and therefore assessment of blood volume is critical. We have several tools to individualise treatment for these patients, including assessment of the inferior vena cava (IVC).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The IVC is a relatively simple vessel to visualise and measure by ultrasound and is one of the aspects that can be assessed by non-cardiologists using echocardioscopy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is therefore accessible information in pre-hospital and hospital emergency departments, hospital wards or outpatient clinics, and is an easy parameter to obtain at the patient's bedside, quickly, cheaply, reproducibly and without complications.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physiologically, the diameter of the IVC varies with respiratory movements in such a way that, during inspiration, due to the negative thoracic pressure, cardiac filling is favoured and thus its diameter is reduced. The diameter and distensibility of the IVC, measured 2 cm from its orifice at the entrance to the right atrium, has been described as an indirect, non-invasive measurement of right atrial pressure and therefore of central venous pressure and blood volume, although it should be remembered that the relationship between blood volume, venous pressure and distensibility is much more complex. Central venous pressure is determined by multiple factors in addition to intravascular volume such as venous reservoir compliance and tone, ventricular interaction, pericardial constraint or ventricular function.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Other factors that modulate it include the presence of pulmonary hypertension, dilatation and dysfunction of the right ventricle, pulmonary hyperinflation in patients with acute asthma or COPD, increased intra-abdominal pressure or inspiratory effort, as may occur in cases of respiratory distress, among others. Therefore, the assessment of IVC must be interpreted in the clinical and pathophysiological context of the individual patient.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">International consensus documents recommend a maximum IVC diameter greater than 20 mm or an IVC collapsibility index of less than 50% as the cut-off value (which correlates with a right atrial pressure of at least 3 mmHg).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The different studies that have tried to confirm this correlation show contradictory results with some evidence confirming a close correlation and others showing a lower precision.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In the field of HF, the usefulness of ultrasound assessment of the IVC has been extensively investigated in three areas: diagnosis, prognostic estimation and its potential use as a guide to diuretic therapy in patients with systemic congestion.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding the diagnosis of HF in the patient with dyspnoea of uncertain origin, studies have mainly been conducted in hospital emergency departments. The presence of an IVC greater than 2 cm and a collapsibility of less than 30% have been reported to have a sensitivity and specificity of 80% for the diagnosis of HF. The authors of this editorial consider this to be a reasonable cut-off value to confirm or exclude the presence of this disease.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In fact, other authors have proposed different diagnostic algorithms with IVC as a key variable.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However, different systematic reviews consider their diagnostic ability in isolation to be suboptimal.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> A recent meta-analysis evaluating different tests for the diagnosis of the cause of dyspnoea in emergency department patients indicates that echocardiography and lung ultrasound are the most useful tools for the diagnosis of HF, while natriuretic peptides are of value in ruling it out.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Another example showing that there are situations in which ICV is not an adequate parameter to diagnose HF are patients with acute pulmonary oedema associated with hypertension, as they may have a normal or decreased ICV in a state of euvolemia and even hypovolemia, since the pathophysiological mechanism is redistribution of fluid to the lungs.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Regarding the use of the IVC as a prognostic marker, perhaps the most extensive and robust evidence shows that the presence of a dilated IVC without inspiratory collapse is associated with a worse prognosis, with higher mortality and risk of hospitalisation, both in patients admitted to hospital with acute HF and in stable patients who receive outpatient or day hospital follow-up.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–15</span></a> The contribution of pulmonary hypertension and right ventricular dysfunction as prognostic markers associated with dilatation and non-collapsibility of the IVC is likely to play a major role in this scenario.</p><p id="par0040" class="elsevierStylePara elsevierViewall">It seems logical to suggest that ICV could guide diuretic therapy in patients with acute or chronic acute HF. Although there is some evidence to suggest that it may be sensitive to acute changes in blood volume, as seen in patients treated with ultrafiltration, and that such changes after diuretic treatment are evident within hours,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> other studies have not confirmed this correlation between change in IVC-related ultrasound parameters and other measurements of congestion. In addition, published studies on this topic have important biases, such as limited sample size or lack of blinding of clinical data to the investigators performing the ultrasound, and therefore the level of evidence is weak.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The results of two randomised clinical trials analysing the impact of guiding diuretic therapy using ultrasound parameters of congestion, including IVC, are awaiting publication: CAVAL_US, which included 58 patients with AHF who were randomised to receive lung and IVC ultrasound-guided congestion management versus the usual clinical approach. The primary objective will be to assess changes in ultrasound parameters of congestion, but other outcomes such as readmission for HF, emergency department visits, natriuretic peptides or hospital stay will also be assessed.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The CAVA-ADHF-DZHK10 study is also a randomised multicentre clinical trial that will enrol 388 HF patients in which treatment for congestion will be conducted in two groups: one guided by daily IVC assessment and the other by routine clinical assessment. The primary endpoint is the change in NT-proBNP levels.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In recent years, the Vexus protocol <span class="elsevierStyleItalic">(Venous Excess Ultrasound)</span> has been proposed as a tool for the assessment of systemic congestion in patients with IVC greater than 2 cm. This protocol is based on the analysis of portal, hepatic and renal vein flows to gain a more precise understanding of the level of systemic congestion. Although this protocol has not yet generated sufficient evidence in patients with HF, intensive research is underway and is demonstrating its role as a source of prognostic information.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, measurement of IVC diameter and collapsibility is useful as a prognostic marker in patients with HF but should not be used in isolation as an ultrasound parameter for diagnosis or adjustment of diuretic therapy in these patients. It should be combined with clinical information, lung ultrasound, biomarkers such as natriuretic peptides, and with new parameters currently under investigation such as those obtained by the Vexus protocol, moving towards a multimodal congestion assessment model.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0065" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "RICA Investigators. 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