RADAR AND CMR IN THE ED

W. Frank Peacock, MD, FACEP, FACC, FESC

Professor, Emergency Medicine

Vice Chair for Research

Baylor College of Medicine

DISCLOSURES

• I wish

SHORTNESS OF BREATH IN THE ED

-Estimated 141.7 million annual ED presentations

-2.4% (3.4 million) present for acute shortness of breath.

-If stratified by diagnosis:

-Diseases of the respiratory system = 14.7 million

-Congestive HF = 1.4 million

Getting the

dx right

would be nice…

THE PIE OF DYSPNEA

Heart Failure?????

MeaslesLupus

H1N1

Salmonella

Pneumonia

URI

Mondor’s

SyndromeTietze’s

Disease

Herpes

Zoster

Coxsackie

Breast

Cancer

Breast Abcess

Contact

Dermatitis

ITP

Hemolytic

Uremic Syndrome

Reiter’s

Syndrome

Mediastinitis

Lung

Cancer

West Nile SARS

DVT

Potts

Disease

Subdiaphragm

Abcess

Empyema

TTP

Pulmonary embolus

PID

Influenza

It would be REALLY convenient if patients had the diagnosis tattooed on their forehead

Erectile

Dysfunction

COPD

PREHOSPITAL EFFECTS

• 8,315 EMS runs

• 499 HF

• Overall Mortality = 10.9%

• Excluded BP < 100

• Tx= ntg, ms, lasix

• Linear rln btwn high BP & Tx

• Treated n=241

• Untx’d n=252

• If EMS Tx: 36 min sooner

• Scene time: 1.9 mins longer

Wuerz R et al. Ann Emerg Med. 1992;21:669-74.

If treated,

OR of survival 2.51 (1.37-4.55) p<0.01

Early treatment works

• 106 non-HF final dx…..BUT tx’d for HF by EMS

• Asthma, COPD, pneumonia, bronchitis

• Represented 15% of dyspneic patients

Non-HF treated for HF 13.6%

No treatment 8.2%

Treated with bronchodilators 3.8%

Prehospital Effects

Wuerz R et al. Ann Emerg Med.1992;21:669-74.

Mortality (p<0.05)

10

Which one of

these people

gets to die??

PHYSIOLOGICAL MARKERS OF DECOMPENSATION

Adapted from Adamson PB. Curr Heart Fail Rep. 2009;6(4):287-292

BACKGROUND

ReDS (Remote Dielectric Sensing):

- non-invasive, transcutaneous measurement of

lung fluid

• Reads in 90 seconds

• Physiologic lung fluid range:

20 to 35%.

• Point-of-Care Lung Fluid Management

• Non-invasive

• Over the clothes

• Portable

• Easy and Efficient

• Absolute reading in 45 seconds

• Normal ReDS reading is between 20-35%

REDS VS. CT – ACCURACY DATA

CCT – Chest Computed Tomography1 Amir O et al. Int J Cardiol. 2016;221:841-8462 Data on file

ReDS vs. CT Comparison

2

2

ReDS has a high

correlation to CCT for

lung fluid content

Interclass Correlation

Coefficient (ICC) 0.90

[0.8-0.95]1

CT Fluid quantification with

commercially available syngo.CT

Pulmo3D™ tool (Siemens)1

RELATIONSHIP WITH WEDGE PRESSURE STUDY

ROC – Receiver Operating Characteristics;; AUC – area under the curve; PAWP – Pulmonary Arterial Wedge PressureUriel N et al . J Am Heart Assoc. 2018;7(22):e009175

ROC Curve

94.9% of the time a ReDS reading of < 34% suggests that a PAWP

is below 18 mm Hg

Endpoint

Cutoff

Negative Predictive Value

PAWP ≥18

ReDS >34

94.9%

N = 139

Weight

Monitoring

Electrical

Bioimpedance

Implantable

Sensors (e.g.

CardioMEMSTM)

Swan-Ganz

CatheterCT-Scan

Accurate &

Useful Output X1,2 X3,4 ✔ ✔ ✔✔

0.9 correlation with CT5

95% NPV with PAWP6

87% HF re-admission reduction7

Easy-to-Use &

Non-invasive ✔ ✔ X X X✔

Portable, Non-invasive, Over-the-

clothes

Appropriate for

In-Hospital Lung

Fluid Monitoring✔ ✔ X

✔CCL X

✔ED, HF Floor, Predischarge, Clinic,

SNFs etc.

COMPARISON TO OTHER METHODS OF LUNG FLUID MONITORING

CT – computed tomography; NPV – negative predictive value; PAWP – pulmonary arterial wedge pressure; HF – heart failure; ED – emergency department; SNF – skilled nursing facilities; CCL – Cardiac Catheterization Lab;

1 Chaudhry SI et al. N Engl J Med. 2010;363:2301-23092 Koehler F et al. Circulation 2011;123(17):1873-803 van Veldhuisen DJ et al. Circulation. 2011;124(16):1719-264 Brachmann J et al. Eur J Heart Fail. 2011;13(7):796-8045 Amir O et al. Int J Cardiol. 2016;221: 841–8466 Uriel N et al. J Am Heart Assoc. 2018;7(22):e0091757 Amir O et al. Int J Cardiol. 2017;240:279-284

RADAR

BACKGROUND

AIM

• Evaluate the accuracy of ReDS to detect

lung fluid in ED patients with

undifferentiated shortness of breath.

INCLUSION CRITERIA

• - Chief complaint of ”shortness of breath”

• - ≥ 21 years of age & provided informed

consent

• - Non-pregnant

METHODSDemographics, vital signs, and medical history were collected from medical records.

The ReDS vest was applied and data was recorded.

Volume status was then adjudicated by 2 EM physicians post-discharge

RESULTS

11

64 2 2 2 2 2 1

13

Differential Diagnosis: Prevalence

Physiological

ReDS Cutoff:

35%

Sn = 0.85

Sp = 0.78

NPV = 0.91

PPV = 0.68

N=45

Impact of BNP Assay on Accuracy

Maisel AS, NEJM, 347(3), 161-7, 2002.

26 %

wrong18.5%

wrong

RESULTSOptimal ReDS

Cutoff: 37%

Sn = 0.89

Sp = 0.83

NPV = 0.93

PPV = 0.74

AUC = 0.920

0.2

0.4

0.6

0.8

1

0 0.2 0.4 0.6 0.8 1

Sensi

tivi

ty

1-Specificity

ROC for lung fluid evaluation of ReDS

Device vs. Expert Diagnosis

TPF Lower CI Upper CI

CONCLUSION

Adjudicated diagnosis: of 35% of patients with

volume overload, ReDS detected 85%

At a cut point of 37%, the ReDS device has

excellent sensitivity (0.85) and negative predictive

value (0.91) in detecting pathological lung fluid.

Assessing readiness for dischargeafter AHF hospitalization

• Prospective RCT

• ReDs guided vs SoC

• At d/c, randomized to ReDs or not

– If ReDs = wet, received HF specialty consultation

Bensimhon D. Heart Lung 2020 (1-6)

Assessing readiness for dischargeafter AHF hospitalization

Bensimhon D. Heart Lung 2020 (1-6)

• N=108 HF patients• 50% male• Age 73.6 ± 12.6 years• BMI 29.3 ± 4.3 kg/m2• EF 38.5 ± 15.1%• BNP = 1138 ± 987 pg/mL)

• 32% had residual lung congestion at the time of proposed hospital discharge.

Assessing readiness for dischargeafter AHF hospitalization

• ReDS guided therapy

– Tx arm: additional diuresis in 30% (18/60)

– Mean weight loss = 5.6 pounds (p = 0.02)

– 30-day HF readmit rates: • similar in Tx and SoC (0.2% vs 4.2%; p = 0.44)

– If d/c’d “as planned” with residual lung congestion (ReDS >39%)• Higher 30-day readmit rates vs. adequately decongested pts (ReDS <39%)

• 11.8% vs. 0.2%, p = 0.03

Bensimhon D. Heart Lung 2020 (1-6)

for CAD

for obstructive CADGold standard =invasive angiography

Outcomes: Primary: CV death or nonfatal MISecondary: CV death, nonfatal MI, USA

hospitalization, CHF, unplanned CABG

SENC-MRIStrain–encoded magnetic resonance imaging

• Imaging strain of deforming tissue.

• An improvement on MR elastography

– faster imaging time

– less post-processing time

• Single beat acquisition

Summary

• Radar

– Improved volume assessment for diagnosis

– May be useful for guided treatment

• CMR: SENC-MRI

– High sensitivity and speed may be ED solution for suspected ACS