Heart Failure - Diagnosis

11/03/2005

Question:  What are the best methods for diagnosing heart failure?

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16234501.ui or 16181821.ui or 15477431.ui or 15312852.ui or 14960741.ui or 12683700.ui or 12658254.ui or 12748317.ui or 11420761.ui or 10029125.ui or 8409071.ui or 2913385.ui

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16234501[PMID] OR 16181821[PMID] OR 15477431[PMID] OR 15312852[PMID] OR 14960741[PMID] OR 12683700[PMID] OR 12658254[PMID] OR 12748317[PMID] OR 11420761[PMID] OR 10029125[PMID] OR 8409071[PMID] OR 2913385[PMID]

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<1>

Unique Identifier [PMID]: 16234501

Authors: Wang CS. FitzGerald JM. Schulzer M. Mak E. Ayas NT.

Institution: Department of Medicine, University of British Columbia, Canada.

Title: Does this dyspneic patient in the emergency department have congestive heart failure?. [Review] [70 refs]

Source: JAMA. 294(15):1944-56, 2005 Oct 19.

Abstract: CONTEXT: Dyspnea is a common complaint in the emergency department where physicians must accurately make a rapid diagnosis. OBJECTIVE: To assess the usefulness of history, symptoms, and signs along with routine diagnostic studies (chest radiograph, electrocardiogram, and serum B-type natriuretic peptide [BNP]) that differentiate heart failure from other causes of dyspnea in the emergency department. DATA SOURCES: We searched MEDLINE (1966-July 2005) and the reference lists from retrieved articles, previous reviews, and physical examination textbooks. STUDY SELECTION: We retained 22 studies of various findings for diagnosing heart failure in adult patients presenting with dyspnea to the emergency department. DATA EXTRACTION: Two authors independently abstracted data (sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality. DATA SYNTHESIS: Many features increased the probability of heart failure, with the best feature for each category being the presence of (1) past history of heart failure (positive LR = 5.8; 95% confidence interval [CI], 4.1-8.0); (2) the symptom of paroxysmal nocturnal dyspnea (positive LR = 2.6; 95% CI, 1.5-4.5); (3) the sign of the third heart sound (S(3)) gallop (positive LR = 11; 95% CI, 4.9-25.0); (4) the chest radiograph showing pulmonary venous congestion (positive LR = 12.0; 95% CI, 6.8-21.0); and (5) electrocardiogram showing atrial fibrillation (positive LR = 3.8; 95% CI, 1.7-8.8). The features that best decreased the probability of heart failure were the absence of (1) past history of heart failure (negative LR = 0.45; 95% CI, 0.38-0.53); (2) the symptom of dyspnea on exertion (negative LR = 0.48; 95% CI, 0.35-0.67); (3) rales (negative LR = 0.51; 95% CI, 0.37-0.70); (4) the chest radiograph showing cardiomegaly (negative LR = 0.33; 95% CI, 0.23-0.48); and (5) any electrocardiogram abnormality (negative LR = 0.64; 95% CI, 0.47-0.88). A low serum BNP proved to be the most useful test (serum B-type natriuretic peptide <100 pg/mL; negative LR = 0.11; 95% CI, 0.07-0.16). CONCLUSIONS: For dyspneic adult emergency department patients, a directed history, physical examination, chest radiograph, and electrocardiography should be performed. If the suspicion of heart failure remains, obtaining a serum BNP level may be helpful, especially for excluding heart failure. [References: 70]

Publication Type: Journal Article. Review.

<2>

Unique Identifier [PMID]: 16181821

Authors: Nohria A. Mielniczuk LM. Stevenson LW.

Institution: Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. anohria@partners.org

Title: Evaluation and monitoring of patients with acute heart failure syndromes. [Review] [44 refs]

Source: American Journal of Cardiology. 96(6A):32G-40G, 2005 Sep 19.

Abstract: Advanced heart failure (HF) is associated with frequent hospitalizations, poor quality of life, and increased mortality. Despite optimal medical management, readmission rates remain high and account for approximately two thirds of all costs related to HF management. Evaluation of patients with HF is critical for the appropriate selection and monitoring of therapy as well as for the prevention of recurrent hospitalizations. This evaluation can be complex and relies on integration of the bedside evaluation and information available from invasive and other noninvasive diagnostic techniques. The clinical examination remains the cornerstone of HF evaluation. Key features of the history and physical examination can be used to assign hemodynamic profiles based on the absence or presence of congestion and adequacy of perfusion. These hemodynamic profiles provide prognostic information and may be used to guide therapy. Direct measurement of hemodynamics may be helpful in patients in whom the physical examination is limited or discordant with symptoms. Although the pulmonary artery catheter (PAC) is not recommended during routine therapy of patients hospitalized with HF, it is reasonable to consider the use of PAC monitoring to adjust therapy in patients who demonstrate recurrent or refractory symptoms despite ongoing standard therapy adjusted according to clinical assessment. This is particularly relevant in centers with experience in hemodynamic monitoring for HF. B-type natriuretic peptide (BNP) testing has been shown to facilitate diagnosis of the etiology of dyspnea in the urgent setting for patients without a prior diagnosis of HF. Furthermore, BNP levels provide important prognostic information in patients with chronic HF, but serial BNP testing has not been validated as a guide to inpatient or outpatient management. Echocardiographic assessment can provide prognostic information about ventricular function and size as well as information about hemodynamic status. Development of validated and reproducible noninvasive techniques to monitor patients with acute HF will be an important step in maximizing interventions to improve outcomes in this patient population. [References: 44]

Publication Type: Journal Article. Review. Review, Tutorial.

<3>

Unique Identifier [PMID]: 15477431

Authors: Doust JA. Glasziou PP. Pietrzak E. Dobson AJ.

Institution: Centre for General Practice, School of Population Health, University of Queensland, Herston, Australia. j.doust@uq.edu.au

Title: A systematic review of the diagnostic accuracy of natriuretic peptides for heart failure.[see comment]. [Review] [41 refs]

Comments Comment in: Arch Intern Med. 2005 Mar 28;165(6):704; PMID: 15795355

Source: Archives of Internal Medicine. 164(18):1978-84, 2004 Oct 11.

Abstract: BACKGROUND: The diagnosis of heart failure is difficult, with both overdiagnosis and underdiagnosis occurring commonly in practice. Natriuretic peptides have been proposed as a possible test for assisting diagnosis. We assessed the diagnostic accuracy of brain natriuretic peptide (BNP), including a comparison with atrial natriuretic peptide (ANP). METHODS: Electronic searches were conducted of MEDLINE and EMBASE from January 1994 to December 2002 and handsearches of reference lists of included studies. We included studies that assessed the diagnostic accuracy of BNP against echocardiographic or clinical criteria or that compared the diagnostic accuracy of BNP with ANP. Two reviewers assessed studies for inclusion and quality and extracted the relevant data. A meta-analysis was performed by pooling the diagnostic odds ratios for studies that used a common reference standard. RESULTS: Twenty studies were included. For the 8 studies (n = 4086) that measured BNP against the criterion of left ventricular ejection fraction of 40% or less (or equivalent), the pooled diagnostic odds ratio was 11.6 (95% confidence interval, 8.4-16.1). The pooled diagnostic odds ratio was greater, 30.9 (95% confidence interval, 27.0-35.4), in the 7 studies (n = 2374) that measured BNP against clinical criteria (generally a consensus view using all other clinical information). The diagnostic odds ratio was similar in studies conducted in general practice and in hospital settings. Three studies compared BNP with N-terminal-ANP, a precursor form of ANP, and pooling of the results of these studies showed BNP to be a more accurate marker of heart failure than NT-ANP. CONCLUSIONS: Brain natriuretic peptide is an accurate marker of heart failure. Use of a cutoff value of 15 pmol/L achieves high sensitivity, and BNP values below this exclude heart failure in patients in whom disease is suspected. As the diagnostic odds ratio for BNP is greater when assessed against clinical criteria than against left ejection fraction alone, BNP may also be detecting patients with "diastolic" heart failure. [References: 41]

Publication Type: Journal Article. Meta-Analysis. Review.

<4>

Unique Identifier [PMID]: 15312852

Authors: Rodeheffer RJ.

Institution: Division of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA. rodeheffer.richard@mayo.edu

Title: Measuring plasma B-type natriuretic peptide in heart failure: good to go in 2004?. [Review] [78 refs]

Source: Journal of the American College of Cardiology. 44(4):740-9, 2004 Aug 18.

Abstract: Elevated plasma brain natriuretic (BNP) concentrations correlate with increased cardiac filling pressures. Therefore, increased BNP has been proposed as a marker for asymptomatic ventricular dysfunction, as an aid in the diagnosis of cardiac dyspnea, as an end point to assess the efficacy of heart failure therapy, and as a prognostic marker in heart failure. An understanding of the utility of BNP requires an appreciation of the sensitivity, specificity, and diagnostic accuracy of BNP in each of these clinical situations. At this time, there is strong evidence for the value of BNP in the evaluation of dyspnea of uncertain cause. Further population studies will need to be performed to refine the application of BNP to community cohorts and to determine its clinical value and cost-effectiveness as a screening tool in the early diagnosis of ventricular dysfunction. To make optimal use of BNP for the assessment of heart failure therapy and prognosis in individual patients, physicians will require additional information on the biological variability of BNP. Studies comparing the sensitivity, specificity, and predictive value of the available BNP and N-terminal pro-BNP assays need to be conducted in each of these clinical settings. [References: 78]

Publication Type: Journal Article. Review. Review, Tutorial.

<5>

Unique Identifier [PMID]: 14960741

Authors: Mueller C. Scholer A. Laule-Kilian K. Martina B. Schindler C. Buser P. Pfisterer M. Perruchoud AP.

Institution: Department of Internal Medicine, Medical Division A, University of Basel, University Hospital, Basel, Switzerland. chmueller@uhbs.ch

Title: Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea.[see comment].

Comments Comment in: ACP J Club. 2004 Sep-Oct;141(2):35; PMID: 15341455, Comment in: N Engl J Med. 2004 Feb 12;350(7):718-20; PMID: 14960748, Comment in: N Engl J Med. 2004 Jun 3;350(23):2416-7; author reply 2416-7; PMID: 15175447

Source: New England Journal of Medicine. 350(7):647-54, 2004 Feb 12.

Abstract: BACKGROUND: B-type natriuretic peptide levels are higher in patients with congestive heart failure than in patients with dyspnea from other causes. METHODS: We conducted a prospective, randomized, controlled study of 452 patients who presented to the emergency department with acute dyspnea: 225 patients were randomly assigned to a diagnostic strategy involving the measurement of B-type natriuretic peptide levels with the use of a rapid bedside assay, and 227 were assessed in a standard manner. The time to discharge and the total cost of treatment were the primary end points. RESULTS: Base-line demographic and clinical characteristics were well matched between the two groups. The use of B-type natriuretic peptide levels reduced the need for hospitalization and intensive care; 75 percent of patients in the B-type natriuretic peptide group were hospitalized, as compared with 85 percent of patients in the control group (P=0.008), and 15 percent of those in the B-type natriuretic peptide group required intensive care, as compared with 24 percent of those in the control group (P=0.01). The median time to discharge was 8.0 days in the B-type natriuretic peptide group and 11.0 days in the control group (P=0.001). The mean total cost of treatment was 5,410 dollars (95 percent confidence interval, 4,516 dollars to 6,304 dollars) in the B-type natriuretic peptide group, as compared with 7,264 dollars (95 percent confidence interval, 6,301 dollars to 8,227 dollars) in the control group (P=0.006). The respective 30-day mortality rates were 10 percent and 12 percent (P=0.45). CONCLUSIONS: Used in conjunction with other clinical information, rapid measurement of B-type natriuretic peptide in the emergency department improved the evaluation and treatment of patients with acute dyspnea and thereby reduced the time to discharge and the total cost of treatment. Copyright 2004 Massachusetts Medical Society

Publication Type: Clinical Trial. Journal Article. Randomized Controlled Trial.

<6>

Unique Identifier [PMID]: 12683700

Authors: Shapiro BP. Chen HH. Burnett JC Jr. Redfield MM.

Institution: Department of Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA.

Title: Use of plasma brain natriuretic peptide concentration to aid in the diagnosis of heart failure. [Review] [16 refs]

Source: Mayo Clinic Proceedings. 78(4):481-6, 2003 Apr.

Abstract: Plasma concentration of brain natriuretic peptide (BNP), as measured by the Triage BNP Test, is approved by the Food and Drug Administration to aid in the diagnosis of heart failure. This diagnostic test is available in many institutions. The purpose of this article is to help the physician know the appropriate time to order this test and to aid in interpreting results. To achieve this goal, we review the physiology of BNP, clinical studies that support its use for diagnosing heart failure, and confounding variables to consider when BNP is being used clinically. We show that the BNP test can be extremely helpful when used in the correct clinical setting. [References: 16]

Publication Type: Journal Article. Review. Review, Tutorial.

<7>

Unique Identifier [PMID]: 12658254

Authors: Collins SP. Ronan-Bentle S. Storrow AB.

Institution: Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA. sean.collins@uc.edu

Title: Diagnostic and prognostic usefulness of natriuretic peptides in emergency department patients with dyspnea. [Review] [66 refs]

Source: Annals of Emergency Medicine. 41(4):532-45, 2003 Apr.

Abstract: More than 4.5 million Americans have congestive heart failure (CHF), close to 550,000 new cases are diagnosed each year, and one third of known patients with CHF are annually admitted to the hospital. Emergency department diagnosis of CHF is often based on history and physical examination findings along with results of ancillary tests, such as chest radiography and ECG. Although signs and symptoms of fluid overload, such as lower extremity edema and dyspnea, raise the suspicion of CHF, their lack of sensitivity makes them poor screening tools. The natriuretic peptides are promising markers of myocardial dysfunction and heart failure. Because of their relationship to myocardial pressure and stretching, natriuretic peptides have been investigated over the past 5 decades as both diagnostic and prognostic markers in acute coronary syndromes and CHF. This article discusses each of the natriuretic peptides and attempts to delineate their potential diagnostic and prognostic roles in the ED. [References: 66]

Publication Type: Journal Article. Review. Review, Tutorial.

<8>

Unique Identifier [PMID]: 12748317

Authors: Jessup M. Brozena S.

Institution: Heart Failure-Cardiac Transplantation Program, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104, USA. jessupm@uphs.upenn.edu

Title: Heart failure.[see comment]. [Review] [89 refs]

Comments Comment in: N Engl J Med. 2003 Sep 4;349(10):1002-4; author reply 1002-4; PMID: 12954753, Comment in: N Engl J Med. 2003 Sep 4;349(10):1002-4; author reply 1002-4; PMID: 12959100, Comment in: N Engl J Med. 2003 Sep 4;349(10):1002-4; author reply 1002-4; PMID: 12959101, Comment in: N Engl J Med. 2003 Sep 4;349(10):1002-4; author reply 1002-4; PMID: 12959102

Source: New England Journal of Medicine. 348(20):2007-18, 2003 May 15.

Publication Type: Journal Article. Review. Review, Tutorial.

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Unique Identifier [PMID]: 11420761

Authors: Shah MR. Hasselblad V. Stinnett SS. Gheorghiade M. Swedberg K. Califf RM. O'Connor CM.

Institution: Duke Clinical Research Institute, Durham, North Carolina 27715, USA.

Title: Hemodynamic profiles of advanced heart failure: association with clinical characteristics and long-term outcomes.

Source: Journal of Cardiac Failure. 7(2):105-13, 2001 Jun.

Abstract: BACKGROUND: Classifying patients with advanced congestive heart failure (CHF) by baseline measures of congestion and perfusion has been used to estimate hemodynamic status and to select and titrate therapy. We describe clinical characteristics of 4 hemodynamic profiles-wet/cold, wet/warm, dry/cold, and dry/warm-in patients with advanced CHF and assess relations between symptoms, physical signs, and outcomes with each profile. METHODS AND RESULTS: We retrospectively assessed baseline symptoms, physical-examination variables, and 1-year outcomes of 440 patients in a randomized trial. With univariable and multivariable logistic regression, we examined relations of physical-examination variables to hemodynamic profiles. We also assessed the rates of death and death or readmission by profile. Severity of CHF symptoms did not predict the wet-versus-dry profile or cold-versus-warm status, despite significant differences in hemodynamics among groups. Of the physical-examination variables, only a lower proportional pulse pressure was a significant multivariable predictor of the wet category. Among wet patients (n = 348), this same variable was the only significant multivariable predictor of the cold category. For dry patients (n = 92), the cold category was predicted in multivariable analysis by supine heart rate and hepatomegaly. Survival was similar among profiles: wet/cold, 54.2% (n = 91); wet/warm, 58.3% (n = 105); dry/cold, 78.9% (n = 15); and dry/warm, 67.1%, P =.13 (n = 49). Event-free survival also was similar among profiles: wet/cold, 22.0% (n = 37); wet/warm, 29.4% (n = 53); dry/cold, 42.1% (n = 8); and dry/warm, 31.5%, P =.44 (n = 23). CONCLUSIONS: The patient's history and physical examination alone may lead to inaccurate estimation of hemodynamic status and thus suboptimal management for patients with advanced CHF.

Publication Type: Clinical Trial. Journal Article. Randomized Controlled Trial.

<10>

Unique Identifier [PMID]: 10029125

Authors: Chae CU. Pfeffer MA. Glynn RJ. Mitchell GF. Taylor JO. Hennekens CH.

Institution: Department of Medicine, Brigham and Women's Hospital, Boston, MA 02215-1204, USA. chae.claudia@mgh.harvard.edu

Title: Increased pulse pressure and risk of heart failure in the elderly.[see comment].

Comments Comment in: JAMA. 1999 Sep 8;282(10):943; PMID: 10485678

Source: JAMA. 281(7):634-9, 1999 Feb 17.

Abstract: CONTEXT: Arterial stiffness increases with age. Thus, pulse pressure, an index of arterial stiffening, may predict congestive heart failure (CHF) in the elderly. OBJECTIVE: To study prospectively the association between pulse pressure and risk of CHF. DESIGN: Prospective cohort study. SETTING: The community-based East Boston Senior Health Project, East Boston, Mass. PATIENTS: A total of 1621 men and women (mean [SD] age, 77.9 [5.0] years) free of CHF who had blood pressure measurements taken in 1988-1989 and were followed up for 3.8 years. MAIN OUTCOME MEASURE: Incidence of CHF as ascertained by hospital discharge diagnosis (n = 208) and death certificates (n = 13). RESULTS: After controlling for age, sex, mean arterial pressure, history of coronary heart disease, diabetes mellitus, atrial fibrillation, valvular heart disease, and antihypertensive medication use, pulse pressure was an independent predictor of CHF. For each 10-mm Hg elevation in pulse pressure, there was a 14% increase in risk of CHF (95% confidence interval, 1.05-1.24; P = .003). Those in the highest tertile of pulse pressure (>67 mm Hg) had a 55% increased risk of CHF (P=.02) compared with those in the lowest (<54 mm Hg). Pulse pressure was more predictive than systolic blood pressure alone and was independent of diastolic blood pressure. CONCLUSION: Pulse pressure, an easily measurable correlate of pulsatile hemodynamic load, is an independent predictor of risk of CHF in this elderly cohort.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 8409071

Authors: Butman SM. Ewy GA. Standen JR. Kern KB. Hahn E.

Institution: Department of Internal Medicine, University of Arizona College of Medicine, Tucson.

Title: Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension.

Source: Journal of the American College of Cardiology. 22(4):968-74, 1993 Oct.

Abstract: OBJECTIVES. The aim of this study was to determine the sensitivity, specificity and utility of the cardiovascular examination in predicting cardiac hemodynamics in patients with advanced chronic congestive heart failure. BACKGROUND. Although the physical signs of acute left heart failure have been shown to correlate relatively well with cardiac hemodynamics, their reliability in estimating hemodynamics in patients with chronic heart failure has recently been questioned. METHODS. We prospectively recorded the history, cardiovascular physical signs present at bedside examination and the hemodynamic measurements obtained at right heart catheterization in 52 patients with chronic congestive heart failure undergoing in-hospital evaluation for possible heart transplantation. In addition, we obtained chest radiographs and multigated nuclear scans for the evaluation of left ventricular function. RESULTS. Pulmonary rales, a left ventricular third heart sound, jugular venous distension and the abdominojugular test, when positive, indicated higher right heart pressures and lower measures of cardiac performance. The presence of jugular venous distension, at rest or inducible, had the best combination of sensitivity (81%), specificity (80%) and predictive accuracy (81%) for elevation of the pulmonary capillary wedge pressure (> or = 18 mm Hg). Furthermore, in this population sample, the probability of an elevated wedge pressure was 0.86 when either variable was present. CONCLUSIONS. The bedside cardiovascular examination in the patient with chronic heart failure is extremely useful in identifying patients with elevation of right and left heart pressures. Examination for jugular venous distension at rest or by the abdominojugular test is simple and highly sensitive and specific in assessing left heart pressures in these patients.

Publication Type: Journal Article.

<12>

Unique Identifier [PMID]: 2913385

Authors: Stevenson LW. Perloff JK.

Institution: Department of Medicine, UCLA Medical Center 90024.

Title: The limited reliability of physical signs for estimating hemodynamics in chronic heart failure.

Source: JAMA. 261(6):884-8, 1989 Feb 10.

Abstract: The cardiovascular physical examination is used commonly as a basis for diagnosis and therapy in chronic heart failure, although the relationship between physical signs, increased ventricular filling pressure, and decreased cardiac output has not been established for this population. We prospectively compared physical signs with hemodynamic measurements in 50 patients with known chronic heart failure (ejection fraction, .18 +/- .06). Rales, edema, and elevated mean jugular venous pressure were absent in 18 of 43 patients with pulmonary capillary wedge pressures greater than or equal to 22 mm Hg, for which the combination of these signs had 58% sensitivity and 100% specificity. Proportional pulse pressure correlated well with cardiac index (r = .82), and when less than 25% pulse pressure had 91% sensitivity and 83% specificity for a cardiac index less than 2.2 L/min/m2. In chronic heart failure, reliance on physical signs for elevated ventricular filling pressure might result in inadequate therapy. Conversely, the adequacy of cardiac output is assessed reliably by pulse pressure. Our results facilitate decisions regarding treatment in chronic heart failure.

Publication Type: Journal Article.