Table 3.

Proposed initial focused cardiac and lung ultrasonography assessment for patients with suspected AHF in acute care setting

Clinical question	Structural and functional assessment	Views (2D imaging)	Comments	Evidence
Focused echocardiography131,132
Alternative diagnoses for patient’s signs and symptoms?	Pericardial effusion RV dilatation/systolic function	Subxiphoid, parasternal long-axis and short-axis views, apical four-chamber view	Absence of RV dilatation/dysfunction cannot exclude the presence of pulmonary emboli	Pericardial effusion: sensitivity up to 100%, specificity 95% for detection of pericardial effusion133,134 RV dysfunction (various criteria): sensitivity 74%, specificity 54% for diagnosis of acute PE19
Evidence of impaired systolic function?	Global LV systolic function	Subxiphoid, parasternal long-axis and short-axis views, apical four-chamber view	Might be useful in new-onset HF for identification of reduced EF	Sensitivity and specificity for diagnosis of AHF depending on prevalence of HFrEF38,135
Is there (additional) evidence of volume overload?	IVC assessment	IVC (subxiphoid)	IVC collapsibility <50%	Sensitivity 83%, specificity 81% for diagnosis of AHF in patients with dyspnoea in the ED135
Gross structural abnormality as AHF aetiology?	Gross valvular abnormality* Intracardiac mass‡	Subxiphoid, parasternal long-axis and short-axis views, apical four-chamber view	AHF aetiology might be identified in rare cases	NA
Lung and pleural ultrasonography37,38
Alternative diagnoses for patient’s signs and symptoms?	Pneumothorax assessment	Anterior, upper chest on each hemithorax	Presence of lung sliding along pleural line rules out pneumothorax in the scanned chest zones	Sensitivity 91%, specificity 98% for detection of pneumothorax136
Evidence of pulmonary oedema?	Pulmonary oedema detection	Three or four anterior/lateral chest zones on each hemithorax	Three or more B-lines in two or more zones on each hemithorax considered diagnostic for AHF	Sensitivity 94%, specificity 92% for diagnosis of AHF in patients with dyspnoea in the ED33,38
Evidence of pleural effusions?	Pleural effusion detection	Posterior axillary line on both hemithoraces	Echo-free space above the diaphragm	Sensitivity 79–84%, specificity 83–98% for diagnosis of AHF in patients with dyspnoea in the ED44,45

^*Valvular abnormalities recognizable with focused echocardiography (without the use of Doppler-based techniques) entail leaflet or cusp massive disruption or marked thickening, flail, or anatomical gaps.

^‡Refers to large valve vegetations or visible intracardiac or IVC thrombi. AHF, acute heart failure; Echo, echocardiography; ED, emergency department; EF, ejection fraction; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; IVC, inferior vena cava; LV, left ventricular; NA, not available; PE, pulmonary embolism; RV, right ventricular.