title: Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure.
abstract: OBJECTIVE
  Sonographic thoracic B-lines and N-terminal pro-brain-type natriuretic peptide (NT-ProBNP) have been shown to help differentiate between congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The authors hypothesized that ultrasound (US) could be used to predict CHF and that it would provide additional predictive information when combined with NT-ProBNP. They also sought to determine optimal two- and eight-zone scanning protocols when different thresholds for a positive scan were used.
  
  
  METHODS
  This was a prospective, observational study of a convenience sample of adult patients presenting to the emergency department (ED) with shortness of breath. Each patient had an eight-zone thoracic US performed by one of five sonographers, and serum NT-ProBNP levels were measured. Chart review by two physicians blinded to the US results served as the criterion standard. The operating characteristics of two- and eight-zone thoracic US alone, compared to, and combined with NT-ProBNP test results for predicting CHF were calculated using both dichotomous and interval likelihood ratios (LRs).
  
  
  RESULTS
  One-hundred patients were enrolled. Six were excluded because of incomplete data. Results of 94 patients were analyzed. A positive eight-zone US, defined as at least two positive zones on each side, had a positive likelihood ratio (LR+) of 3.88 (99% confidence interval [CI] = 1.55 to 9.73) and a negative likelihood ratio (LR-) of 0.5 (95% CI = 0.30 to 0.82), while the NT-ProBNP demonstrated a LR+ of 2.3 (95% CI = 1.41 to 3.76) and LR- of 0.24 (95% CI = 0.09 to 0.66). Using interval LRs for the eight-zone US test alone, the LR for a totally positive test (all eight zones positive) was infinite and for a totally negative test (no zones positive) was 0.22 (95% CI = 0.06 to 0.80). For two-zone US, interval LRs were 4.73 (95% CI = 2.10 to 10.63) when inferior lateral zones were positive bilaterally and 0.3 (95% CI = 0.13 to 0.71) when these were negative. These changed to 8.04 (95% CI = 1.76 to 37.33) and 0.11 (95% CI = 0.02 to 0.69), respectively, when congruent with NT-ProBNP.
  
  
  CONCLUSIONS
  Bedside thoracic US for B-lines can be a useful test for diagnosing CHF. Predictive accuracy is greatly improved when studies are totally positive or totally negative. A two-zone protocol performs similarly to an eight-zone protocol. Thoracic US can be used alone or can provide additional predictive power to NT-ProBNP in the immediate evaluation of dyspneic patients presenting to the ED.
authors.affiliation: Department of Emergency Medicine, Division of Emergency Ultrasound, Massachusetts General Hospital, Boston, MA, USA. aliteplo@partners.org
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Liteplo
authors.forename: Keith A
authors.initials: KA
authors.lastname: Marill
authors.forename: Tomas
authors.initials: T
authors.lastname: Villen
authors.forename: Robert M
authors.initials: RM
authors.lastname: Miller
authors.forename: Alice F
authors.initials: AF
authors.lastname: Murray
authors.forename: Peter E
authors.initials: PE
authors.lastname: Croft
authors.forename: Roberta
authors.initials: R
authors.lastname: Capp
authors.forename: Vicki E
authors.initials: VE
authors.lastname: Noble
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D003937:Diagnosis, Differential; D004417:Dyspnea / Q000097:blood* / Q000000981:diagnostic imaging* / Q000503:physiopathology; D004636:Emergency Service, Hospital; D005260:Female; D006333:Heart Failure / Q000097:blood* / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006801:Humans; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010446:Peptide Fragments / Q000097:blood*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000097:blood / Q000000981:diagnostic imaging / Q000503:physiopathology; D012680:Sensitivity and Specificity; D014463:Ultrasonography
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain