Acute decompensated heart failure (ADHF) is the primary cause in up to 40% of older adults presenting with dyspnea and one of the leading reasons for emergency department visits in the world.1 ADCHF is the most common cause of hospitalization in patients more than 65 years of age and is associated with high in-hospital mortality and rehospitalization rates.2,3 The diagnosis of Acute Heart failure is often challenging as the

clinical symptoms and signs have limited sensitivity and specificity, especially in elderly population with frequent comorbidities that can mimic or mask the clinical picture of heart failure. Furthermore, the insensitivity of guideline-recommended tools for diagnosing ADHF, such as chest radiography (CXR), physical examination, and brain-type natriuretic peptide (BNP) is known to delay treatment, which is associated with an increase in mortality.4 In particular, the sensitivity of CXR in detecting pulmonary edema is limited, with 20% being a false-negative.5

Lung ultrasonography (LUS) has been gaining increasing attention over the past decade as a noninvasive tool in the detection and quantification of pulmonary congestion in both ambulatory and hospitalized patients with heart failure (HF).6 LUS could potentially play an important role in the monitoring of pulmonary congestion during an ADHF hospitalization and improve risk assessment. The analysis of B-lines (ultrasound lung comets) allows the detection of alveolar-interstitial syndrome and the access to extravascular lung water. The B-lines are laser-like vertical hyperechoic reverberation artifacts that arise from the pleural line, extend to the bottom of the screen without fading and move synchronously with lung sliding.7 Several B-lines are present in pulmonary congestion and can aid the detection, semi-quantification and monitoring of extravascular lung water, the differential diagnosis of dyspnea and the prognostic stratification of chronic and acute HF.8 When three or more B-lines are identified, the zone or field is considered positive. Lung ultrasound (LUS) evaluation of B-lines has been proposed as a simple, non-invasive and semi-quantitative tool to assess pulmonary congestion (PC). B-lines have been related to extravascular lung water, pulmonary Capillary wedge pressure and NT-proBNP levels in heart failure patients. LUS can also identify clinically silent pulmonary edema, suggesting its additional value to improve hemodynamic profiling and treatment optimization.9 However, comprehensive data for the prevalence, dynamic changes, and prognostic importance of pulmonary congestion on LUS in ADHF are sparse. Prior studies have predominantly used time-intensive 28-zone imaging protocols and have lacked central, off-line ultrasonography image analysis.6,8,10 Furthermore, the data on the diagnostic accuracy of LUS for cardiogenic pulmonary edema are conflicting, with reported sensitivity ranging from 57% to higher than 95%.11,12 Given its potential advantages over CXR, including its ease of acquisition, immediate availability of results, and evidence of comparable accuracy, LUS could have important implications for standard of care in the evaluation of patients with dyspnea at risk for ADHF. This study aimed to evaluate the utility of lung ultrasound in detecting pulmonary congestion and assessing the response to therapy in acute decompensated heart failure. Additionally, it sought to compare the diagnostic accuracy of lung ultrasound with chest X-ray in this condition. Furthermore, the study investigated the correlation between B-lines on lung ultrasound and plasma BNP levels in patients with acute decompensated heart failure.

This prospective, observational study was conducted in the Department of General Medicine and Department of Cardiology, Government Medical College, Srinagar, Jammu and Kashmir which is a tertiary care institute and receives patients from the Urban and Rural areas of Kashmir valley as well as from surrounding subdivisions of J&K. The study was done over a period of 18 months. The patients presenting in Emergency Department (ED) with acute dyspnea who fulfilled the following inclusion and exclusion criteria were enrolled in the study.

Inclusion Criteria:

1. Patients aged ≥18years
2. Patients admitted with suspected clinical diagnosis of Acute Decompensated Heart Failure.
3. Patients who gave informed consent for the study.
4. Patient with known history of cardiac disease.

Exclusion Criteria:

1. Patients aged less than 18 years
2. Patients who did not give consent for the study.
3. Patients in Cardiogenic shock.
4. Patients with End Stage Renal Disease on hemodialysis.
5. Pregnant patients.

Institutional Ethical Committee clearance was sought before initiating the study and proper informed consent was obtained from all patients before their inclusion in the study. In all the subjects enrolled for the study, a detailed clinical history was taken, complete relevant clinical examination, baselines investigations including biochemical markers (BNP levels), ECG, Chest X-ray (CXR), and Echocardiography was done and recorded on the study proforma. Patients subsequently underwent Lung Ultrasound (LUS1) at admission.

Lung Ultrasound Protocol and Image Analysis:

Lung ultrasonography (LUS) examination was performed by a trained radiologist using GE Logic Tech in all the patients with patients in a semi recumbent position. Patients were assessed by using a simplified 4-zone imaging protocol (2 zones on each hemithorax), in addition to an examination of pleural effusions laterally at the level of the diaphragm. Patients with LUS finding of 3 or more B lines in two or more zones were considered as positive for pulmonary congestion in acute decompensated heart failure (ADHF). Chest X-Ray was done in all patients. Typical features suggestive of vascular congestion and interstitial edema were taken as positive for pulmonary congestion in ADHF.

Diagnosis of ADHF was made by an expert physician on the basis of clinical signs and symptoms of heart failure along with Echocardiographic findings and BNP levels in accordance with the Universal Definition of Heart failure from Heart Failure Society if America (HFSA), Heart Failure Association of European Society of Cardiology (HFA/ESC) and the Japanese Heart Failure Society (JHFS). Patients meeting the eligibility criteria were labelled as positive for ADHF and those not meeting the criteria were labelled as negative for heart failure. Patients admitted with ADHF requiring diuretic therapy underwent repeat LUS2 at discharge. LUS1 findings and LUS2 findings (Number of B lines) were compared. Association between baseline LUS1 and post-therapeutic LUS2 (number of B lines) and BNP levels was also studied. Elevated BNP levels cut off was >100pg/dL according to American College of Cardiology Guidelines 2021.

Statistical Analysis

Statistical analysis was performed using SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA). Data were initially compiled in Microsoft Excel and subsequently exported to SPSS for analysis. Continuous variables were expressed as mean ± standard deviation (SD) while categorical variables were presented as frequencies and percentages and analysed for inter group comparison using the chi-square test. The paired t-test was employed to compare mean number of B-lines on lung ultrasound and BNP levels before and after diuretic therapy. Diagnostic accuracy measures, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated for chest X-ray and lung ultrasound in predicting acute decompensated heart failure (ADCHF). A p-value of <0.05 was considered statistically significant.

In this section, the results of the study are described

The study population consisted of 200 patients with a mean age of 62.3 ± 10.64 years (range: 35–80 years). The majority of patients were between 51 and 80 years of age, with 30.0% in the 51–60 age group, 27.5% in the 61–70 age group, and 26.0% in the 71–80 age group. Males comprised 60.5% of the study population, while females accounted for 39.5%. All patients (100%) presented with breathlessness, followed by palpitations (78.5%), fatigue (70.5%), cough (64.5%), and pedal edema (39.0%). Hypertension was the most common comorbidity (94.5%), followed by atrial fibrillation (62.5%), coronary artery disease (56.0%), diabetes mellitus (42.0%), COPD (34.0%), hypothyroidism (13.5%), and other conditions (11.5%). Based on the NYHA classification, 20.5% of patients were in Class II, 53.5% in Class III, and 26.0% in Class IV. In terms of Ejection Fraction, 32.0% had heart failure with reduced ejection fraction (HFrEF <40%), 22.0% had mildly reduced EF (41–49%), and 46.0% had preserved EF (>50%). Out of 200 patients enrolled in the study, 168 (84%) fulfilled the diagnostic criteria of ADCHF as per Universal definition of Heart Failure.

Table 2: Comparison of Diagnostic Modalities for ADCH

Table 3: Diagnostic Performance of Chest X-Ray, BNP Levels, and Lung Ultrasound in Detecting Acute Heart Failure

The study included 200 patients, of whom 168 (84.0%) were diagnosed with acute decompensated heart failure (HF), while 32 (16.0%) did not have HF. The diagnostic efficacy of chest X-ray, B-type natriuretic peptide (BNP) levels, and lung ultrasound was assessed, with all three modalities showing a statistically significant association with the presence of ADCHF (p < 0.0001). Chest X-ray findings of pulmonary congestion were present in 128 of 168 ADCHF patients (76.2%), while 40 patients (23.8%) with ADCHF had no radiographic signs of congestion. Among non-ADCHF patients, 6 (18.8%) were misclassified as having congestion, whereas 26 (81.3%) had no abnormalities. The association between chest X-ray findings and ADCHF was statistically significant (χ² = 40.11, df = 1, p < 0.0001), though its diagnostic accuracy was lower than other modalities.

BNP levels demonstrated a strong correlation with ADCHF, with a chi-square value of 44.7 (df = 2, p < 0.0001). BNP levels below 500 pg/ml were found in 30 ADCHF patients (17.9%) and 24 non-ADCHF patients (75.0%), indicating that lower BNP values were more common in non-ADCHF cases. BNP levels between 500–1000 pg/ml were observed in 130 HF patients (77.4%) and 8 non-ADCHF patients (25.0%), while BNP levels exceeding 1000 pg/ml were present in 8 ADCHF patients (4.8%), with no cases in the non-ADCHF group.

Lung ultrasound features of ADCHF, such as the presence of multiple B-lines, were detected in 152 of 168 HF patients (90.5%), whereas 16 patients (9.5%) with ADCHF had negative lung ultrasound findings. Among non-ADCHF patients, 4 (12.5%) were misclassified as positive, while 28 (87.5%) had no signs of ADCHF on ultrasound. The association between lung ultrasound findings and ADCHF was the strongest, with a chi-square value of 95.24 (df = 1, p < 0.0001). These results suggest that lung ultrasound and BNP levels demonstrated the highest diagnostic accuracy in identifying ADCHF, with lung ultrasound exhibiting 90.5% sensitivity and 87.5% specificity, while BNP showed 91.1% sensitivity and 85.0% specificity. Chest X-ray had comparatively lower sensitivity (76.2%) and specificity (81.3%). These findings highlight the superiority of lung ultrasound and BNP as diagnostic tools for ADCHF, emphasizing their role in improving early and accurate detection.

Table 4: Association between BNP Levels and Lung Ultrasound B-Lines in Acute Heart Failure

The relationship between B-type natriuretic peptide (BNP) levels and lung ultrasound B-line patterns was analysed in patients with suspected acute heart failure. Among patients with BNP levels <500 pg/ml, 50 (89.3%) had <5 B-lines, 20 (35.7%) had 5–10 B-lines, and 6 (6.3%) had >10 B-lines. In contrast, those with BNP levels between 500–1000 pg/ml predominantly exhibited higher B-line counts, with 10 (16.7%) having <5 B-lines, 40 (61.5%) having 5–10 B-lines, and 88 (89.8%) showing >10 B-lines. Similarly, in the >1000 pg/ml BNP category, most patients exhibited extensive pulmonary congestion, with 5 (62.5%) presenting 5–10 B-lines and 3 (37.5%) having >10 B-lines. A strong positive correlation (ρ = 0.85, p < 0.0001) was observed between BNP levels and the extent of B-lines on lung ultrasound, indicating a significant concordance between these diagnostic modalities in assessing pulmonary congestion in acute heart failure.

           Table 5: Comparison of B-lines and BNP Levels Before and After Diuretic Therapy

 Before diuretic therapy, the mean B-lines count was 15.2 ± 1.12, reflecting significant pulmonary congestion. Following treatment, this value decreased to 6.2 ± 1.07 (95% CI: 5.2–6.23), indicating a notable reduction in extravascular lung water (p < 0.0001). Similarly, the mean BNP level was 682.8 ± 229.1 pg/ml before treatment, consistent with volume overload and cardiac stress. After diuretic therapy, BNP levels significantly declined to 101.1 ± 12.3 pg/ml (95% CI: 95.34–102.3), suggesting effective decongestion and reduced cardiac strain (p < 0.0001). These findings highlight a statistically significant improvement in both pulmonary congestion and cardiac stress markers following diuretic therapy, supporting its role in optimizing volume status in affected patients.

The present study provides valuable insights into the diagnostic utility of lung ultrasound (LUS) in patients with acute decompensated heart failure (ADCHF) and its role in assessing the therapeutic response to decongestive therapy. The key findings of this study include:

1. Superior Diagnostic Accuracy of LUS: LUS demonstrated higher diagnostic accuracy (89.0%) in detecting pulmonary congestion in ADCHF patients compared to chest X-ray (77%). It exhibited greater sensitivity (90.5% vs. 76.2%), specificity (87.5% vs. 81.3%), positive predictive value (PPV: 97.5% vs. 95.5%), and negative predictive value (NPV: 65.1% vs. 39.4%), underscoring its superiority over chest X-ray in this clinical setting.
2. Correlation between LUS Findings and BNP Levels: A strong positive correlation was observed between LUS-detected pulmonary congestion and plasma BNP levels (r = 0.85, p < 0.0001), reinforcing the role of LUS as a non-invasive marker of volume overload in ADCHF patients.
3. Therapeutic Monitoring Using LUS: Following diuretic therapy, there was a statistically significant reduction in both B-lines on LUS (15.2 vs. 6.2, p < 0.001) and BNP levels (682 vs. 101, p < 0.0001), indicating effective pulmonary decongestion. This finding highlights the potential role of LUS in guiding and monitoring the response to decongestive therapy in ADCHF patients.

Lung ultrasound is an emerging tool in the comprehensive management of ADCHF, offering advantages in diagnosis, therapy monitoring, and prognostication. Several studies have explored its role, yielding variable results. The present study, conducted in one of the largest tertiary care referral institutions in the Union Territory of Jammu & Kashmir, aimed to evaluate the diagnostic accuracy of LUS, compare its efficacy with chest X-ray, assess its correlation with BNP levels, and examine its effectiveness in monitoring pulmonary decongestion post-diuretic therapy. In this study, the age of patients ranged from 35 to 80 years, with a mean age of 62.3 ± 10.64 years. The most commonly affected age group was 51–60 years (30%), followed by 61–70 years (27.5%), 71–80 years (26%), 41–50 years (14.5%), and <40 years (2%). Males constituted the majority of the study population, with 121 (60.5%) patients, compared to 79 (39.5%) females, and the mean ejection fraction was 41%. These findings are consistent with previous studies. Platz E et al. (2016) reported a mean age of 66 years, with 61% male patients.⁶ Similarly, Aggarwal M et al. (2016) observed a mean age of 64.4 years among 42 patients (26 males, 16 females).¹³ Gargani L et al. (2008) studied patients with cardiogenic dyspnea (Group 1, n=122) and non-cardiogenic dyspnea (Group 2, n=22), reporting mean ages of 72 ± 11 years and 66 ± 9 years, respectively, with a male predominance (74%) in Group 1, these results are asking to our study.⁸

In this study, all patients (100%) presented with breathlessness, followed by palpitations in 157 (78.5%) patients, fatigue in 141 (70.5%), cough in 129 (64.5%), and pedal edema in 78 (39%). These findings are consistent with the study by Cipollini F et al., 2018, which reported dyspnea in 89% of patients, cough in 79.7%, and fever in 87.5%.¹⁴ The clinical presentation of acute decompensated heart failure (ADHF) often overlaps with other conditions, particularly chronic obstructive pulmonary disease (COPD), making diagnosis challenging. Due to the heterogeneous nature of ADHF, no single clinical finding is definitive, and a broad spectrum of signs and symptoms must be considered.¹⁵ Among these, dyspnea on exertion is the most sensitive (negative likelihood ratio: 0.45; 95% CI: 0.35–0.67), while paroxysmal nocturnal dyspnea is the most specific (positive likelihood ratio: 2.6; 95% CI: 1.5–4.5).¹⁶

Regarding comorbidities, the most frequently observed conditions in this study included hypertension (94.5%), chronic atrial fibrillation (62.5%), coronary artery disease (56%), diabetes mellitus (42%), hypothyroidism (13.5%), and other diseases (11.5%). Similarly, Gargani L et al. (2008) reported hypertension in 54% of patients with cardiogenic dyspnea (Group 1) and 48% in non-cardiogenic dyspnea (Group 2).8 In their study, diabetes mellitus was the second most common comorbidity (43%), followed by a history of congestive heart failure (37%) and COPD (18%). Furthermore, Hammond DA et al. (2018) identified common precipitating factors for ADHF, including poor dietary and medication adherence, arrhythmias, renal function deterioration, uncontrolled hypertension, myocardial infarction, and infections, emphasizing the multifactorial nature of the disease.¹⁷

In this study, we assessed the diagnostic efficacy of chest X-ray, B-type natriuretic peptide (BNP) levels, and lung ultrasound in identifying acute decompensated heart failure (ADCHF). Our findings demonstrated that all three modalities were significantly associated with ADCHF diagnosis (p < 0.0001); however, lung ultrasound and BNP exhibited superior diagnostic accuracy compared to chest X-ray. Chest X-ray findings indicative of pulmonary congestion were present in 76.2% of ADCHF patients, yet 23.8% of cases showed no radiographic abnormalities. Additionally, 18.8% of non-ADCHF patients were misclassified as having congestion. These results align with prior studies highlighting the limitations of chest X-ray in ADCHF diagnosis. Cardinale L et al. (2014) reported that while chest radiography remains a common initial investigation, its sensitivity for detecting ADCHF-related congestion is limited due to variability in radiographic interpretation and the presence of confounding lung pathologies.⁵ Furthermore, studies by Mant J et al. (2009) and Mueller-Lenke N et al. (2006) have shown that radiographic evidence of pulmonary congestion often lags behind the onset of clinical symptoms, reducing its reliability for early diagnosis.^18,19

BNP levels were significantly associated with ADCHF diagnosis, with higher BNP values correlating with heart failure cases. Our findings revealed that BNP levels exceeding 500 pg/ml were observed in 82.2% of ADCHF patients, while 75% of non-ADCHF cases had BNP levels below 500 pg/ml. These results are consistent with previous studies demonstrating BNP as a valuable biomarker for differentiating ADCHF from other causes of dyspnea. Yoo BS et al. (2014) and Lee D et al. (2023) reported that BNP levels exhibit high sensitivity and specificity in ADCHF diagnosis, particularly when used in conjunction with clinical assessment.^20,21 However, BNP levels can be influenced by factors such as chronic kidney disease, obesity, and atrial fibrillation, potentially leading to false-positive or false-negative results. This may explain the presence of ADCHF patients with BNP levels below 500 pg/ml (17.9%) in our study.

Lung ultrasound demonstrated the highest diagnostic accuracy in our study, with a sensitivity of 90.5% and specificity of 87.5%. The presence of multiple B-lines strongly correlated with ADCHF, reinforcing its role as a rapid and reliable diagnostic tool. These findings align with those of Campora A et al. (2024) and Ott C et al. (2021), who reported that lung ultrasound surpasses traditional imaging methods in detecting pulmonary congestion, even in its early stages.^22,23 The ability of lung ultrasound to detect extravascular lung water non-invasively and in real-time makes it particularly advantageous in emergency settings. Additionally, studies by Ang S et al. (2012) and Gargani L et al. (2023) have emphasized its utility in monitoring disease progression and guiding therapeutic interventions.^8,24 Our study demonstrated a strong positive correlation (ρ = 0.85, p < 0.0001) between B-type natriuretic peptide (BNP) levels and lung ultrasound B-line patterns, reinforcing their complementary role in assessing pulmonary congestion in acute heart failure. Patients with higher BNP levels exhibited a greater number of B-lines, with those exceeding 1000 pg/ml predominantly showing extensive congestion. These findings align with previous studies, such as Dolgun H et al. (2021) and Muniz R et al. (2018), which reported a direct association between BNP levels and lung ultrasound findings in heart failure patients.^25,26 The concordance between BNP and lung ultrasound can be attributed to their shared pathophysiological basis—BNP reflects myocardial stretch and volume overload, while B-lines indicate interstitial edema. Given its high sensitivity, lung ultrasound serves as a valuable adjunct to BNP, particularly in differentiating cardiac from non-cardiac dyspnea. Moreover, our study demonstrated a significant reduction in both B-line count and BNP levels following diuretic therapy, indicating effective decongestion in acute heart failure. Before treatment, the mean B-line count (15.2 ± 1.12) and BNP level (682.8 ± 229.1 pg/ml) reflected substantial pulmonary congestion and volume overload. Post-treatment, these values declined significantly (p < 0.0001), with B-lines decreasing to 6.2 ± 1.07 and BNP levels dropping to 101.1 ± 12.3 pg/ml, highlighting the therapeutic impact of diuretics in reducing extravascular lung water and cardiac strain. These findings are consistent with previous studies by Imanishi J et al., (2023); Rastogi T et al. (2024), Campora A et al (2024) and Platz et al. (2016), which reported a strong association between lung ultrasound B-lines, BNP reduction, and clinical improvement in heart failure patients.^6,22,27,28 The decline in BNP levels aligns with its role as a biomarker of myocardial stress, further validating lung ultrasound as a dynamic tool for monitoring treatment response.  These results collectively suggest that lung ultrasound and BNP demonstrated superior diagnostic accuracy for ADCHF compared to chest X-ray. Although BNP is a reliable biochemical marker with high sensitivity and specificity, its delayed response to acute hemodynamic changes limits its real-time clinical utility. In contrast, lung ultrasound offers immediate assessment of pulmonary congestion, making it the most effective diagnostic tool in an emergency setting. These findings highlight the importance of an integrated approach combining lung ultrasound and BNP measurement to enhance the accuracy and timeliness of ADCHF diagnosis, ultimately improving patient outcomes.

The present study underscores the clinical utility of lung ultrasound (LUS) as a superior diagnostic and monitoring tool in acute decompensated heart failure (ADCHF). LUS demonstrated higher diagnostic accuracy, sensitivity, and specificity compared to chest X-ray, reinforcing its role in accurately detecting pulmonary congestion. The strong correlation between LUS findings and B-type natriuretic peptide (BNP) levels further highlights its reliability as a non-invasive marker of volume overload. Additionally, LUS proved to be an effective modality for assessing therapeutic response, with significant reductions in B-lines and BNP levels post-diuretic therapy. These findings align with existing literature, supporting the integration of LUS into routine heart failure management for early diagnosis, treatment monitoring, and prognostication. Given its rapid bedside applicability, LUS offers a valuable adjunct to traditional imaging and biomarker assessments, particularly in settings where immediate clinical decisions are required. Future research with larger cohorts and multi-center validation is warranted to further establish standardized protocols and optimize its clinical application in heart failure management.

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