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Pulmonary Congestion During Exercise Stress Echocardiography in Ischemic and Heart Failure Patients

Originally published Cardiovascular Imaging. 2022;15


Lung ultrasound detects pulmonary congestion as B-lines at rest, and more frequently, during exercise stress echocardiography (ESE).


We performed ESE plus lung ultrasound (4-site simplified scan) in 4392 subjects referred for semi-supine bike ESE in 24 certified centers in 9 countries. B-line score ranged from 0 (normal) to 40 (severely abnormal). Five different populations were evaluated: control subjects (n=103); chronic coronary syndromes (n=3701); heart failure with reduced ejection fraction (n=395); heart failure with preserved ejection fraction (n=70); ischemic mitral regurgitation ≥ moderate at rest (n=123). In a subset of 2478 patients, follow-up information was available.


During ESE, B-lines increased in all study groups except controls. Age, hypertension, abnormal ejection fraction, peak wall motion score index, and abnormal heart rate reserve were associated with B-lines in multivariable regression analysis. Stress B lines (hazard ratio, 2.179 [95% CI, 1.015–4.680]; P=0.046) and ejection fraction <50% (hazard ratio, 2.942 [95% CI, 1.268–6.822]; P=0.012) were independent predictors of all-cause death (n=29 after a median follow-up of 29 months).


B-lines identify the pulmonary congestion phenotype at rest, and more frequently, during ESE in ischemic and heart failure patients. Stress B-lines may help to refine risk stratification in these patients.


URL:; Unique identifier: NCT 03049995.


Supplemental Material is available at

For Sources of Funding and Disclosures, see page 304.

Correspondence to: Elisa Merli, MD, PhD, UO di Cardiologia, viale stradone 9, 48018, Faenza (RA), Italy. Email


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