Author + information
- Jennifer T. Thibodeau, MD, MSCS and
- Mark H. Drazner, MD, MSc∗ ()
- ↵∗University of Texas Southwestern Medical Center, Department of Internal Medicine, Division of Cardiology, 5323 Harry Hines Boulevard, Dallas, Texas 75390-9047
We greatly appreciate the interest of Drs. Wallace and Weiss and Dr. Zema in our review (1).
We agree with Drs. Wallace and Weiss that lung ultrasound has a high potential to improve upon the clinical examination in estimating volume status in patients with heart failure. We would take an even broader view and note that hand-held echocardiography ultimately may be included in the standard clinical examination (2). When standing at the precipice of a major change in the time-honored clinical examination, it will be important to demonstrate that such a change is warranted by supporting data. Studies that compare hand-held echocardiography with the clinical examination in estimating volume status in patients with heart failure need to ensure that the clinical examination is performed with the same rigor as applied to the echocardiographic protocols (3). Unfortunately, we believe this is often not the case. For example, in the Ohman et al. study (4) cited by Wallace and colleagues, the jugular venous pressure was not reported, which suggested that this vital component of the clinical examination was not assessed. Furthermore, although lung ultrasound was shown to detect elevated left-ventricular filling pressures in patients with acute pulmonary edema, it will also be important to assess its utility in patients with decompensated chronic heart failure, who despite elevated left ventricular filling pressures, might have clear lung spaces due to an increase in lymphatic drainage (1).
We are most appreciative of the comments by Dr. Zema, whose seminal work demonstrated that monitoring blood pressure changes during the Valsalva maneuver has high utility in assessing the pulmonary capillary wedge pressure in patients with heart failure. We chose to limit the discussion to the square-wave response given that the data supporting its association with elevated left-sided filling pressures, rather than detection of a reduced left ventricular ejection fraction, are more robust than that for an absent overshoot response. Furthermore, it was our hope that this simplified approach might increase the chances that the medical community adopts this efficacious test, a goal that until now has been difficult to achieve despite the admirable efforts by Dr. Zema.
Please note: Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- Thibodeau J.T.,
- Drazner M.H.
- Narula J.,
- Chandrashekhar Y.,
- Braunwald E.
- Drazner M.H.
- Ohman J.,
- Harjola V.P.,
- Karjalainen P.,
- Lassus J.