Clinical Investigation
Application of Ultrasound-Enhancing Agents
Routine Use of Contrast on Admission Transthoracic Echocardiography for Heart Failure Reduces the Rate of Repeat Echocardiography during Index Admission

https://doi.org/10.1016/j.echo.2021.07.008Get rights and content

Highlights

  • UEA on initial TTE for HF is associated with a fivefold decrease in unjustified TTE.

  • Optimal baseline image quality was associated with only a twofold decrease.

  • There may be reduced LOS and cost savings with this strategy.

Background

The authors retrospectively evaluated the impact of ultrasound enhancing agent (UEA) use in the first transthoracic echocardiographic (TTE) examination, regardless of baseline image quality, on the number of repeat TTEs and length of stay (LOS) during a heart failure (HF) admission.

Methods

There were 9,115 HF admissions associated with admission TTE examinations over a 4-year period (5,337 men; mean age, 67.6 ± 15.0 years). Patients were grouped into those who received UEAs (contrast group) in the first TTE study and those who did not (noncontrast group). Repeat TTE examinations were classified as justified if performed for concrete clinical indications during hospitalization.

Results

In the 9,115 admissions for HF (5,600 in the contrast group, 3,515 in the noncontrast group), 927 patients underwent repeat TTE studies (505 in the contrast group, 422 in the noncontrast group), which were considered justified in 823 patients. Of the 104 patients who underwent unjustified repeat TTE studies, 80 (76.7%) belonged to the noncontrast group and 24 to the contrast group. Also, UEA use increased from 50.4% in 2014 to 74.3%, and the rate of unjustified repeat studies decreased from 1.3% to 0.9%. The rates of unjustified repeat TTE imaging were 2.3% and 0.4% (in the noncontrast and contrast groups, respectively), and patients in the contrast group were less likely to undergo unjustified repeat examinations (odds ratio, 0.18; 95% CI, 0.12–0.29; P < .0001). The mean LOS was significantly lower in the contrast group (9.5 ± 10.5 vs 11.1 ± 13.7 days). The use of UEA in the first TTE study was also associated with reduced LOS (linear regression, β1 = −0.47, P = .036), with 20% lower odds for odds of prolonged (>6 days) LOS.

Conclusions

The routine use of UEA in the first TTE examination for HF irrespective of image quality is associated with reduced unjustified repeat TTE testing and may reduce LOS during an index HF admission.

Section snippets

Study Population

Between January 2014 and December 2017, there were 9,115 admissions to Piedmont Atlanta Hospital (5,067 men; mean age, 68.4 ± 15.0 years; average LV ejection fraction [LVEF], 43 ± 17%) for HF or HF-related symptoms that were associated with at least one TTE examination during the admission (eligible HF admissions for this study). Admissions were identified from the Piedmont electronic medical record system on the basis of HF symptoms (e.g., dyspnea, shortness of breath, chest pain) and

HF Admission Demographics and UEA Echocardiography

Eligible HF admissions to Piedmont Atlanta Hospital increased from 1,867 in 2014 to 2,655 in 2017, totaling 9,115 admissions over the 4-year period (Table 1). Of these, 5,600 patients received UEAs in the first TTE examination (contrast group) and 3,515 patients did not receive UEAs in the first TTE examination (noncontrast group). The noncontrast group consisted of patients not receiving contrast because of known contraindications or hypersensitivity to microbubble contrast (n = 26 [0.7%]),

Discussion

Data from this observational study demonstrate that among patients who were admitted with suspected or confirmed HF, both suboptimal image quality and lack of UEA use in the first TTE examination was associated with an increased likelihood of repeat echocardiographic testing. Whereas poor image quality is a previously validated, clinically understood justification for repeat testing, the potential merits of UEA use regardless of image quality have not previously been elucidated. Our data

Conclusion

The use of UEA in the first TTE examination at HF admission irrespective of image quality was associated with a nearly fivefold decrease in unjustified repeat TTE imaging during an index hospitalization. In comparison, optimal baseline image quality was also correlated with only a twofold decrease in the likelihood of repeat TTE testing. The use of UEA in the first TTE study for HF admission regardless of image quality was also associated with significant reduction in LOS and 20% reduced odds

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  • Cited by (0)

    Dr. Vannan is a speakers bureau member and has received research grants and speaking honoraria (all payments and grant support to Piedmont Heart Institute). Dr. Green has received consulting payments.

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