Make the Diagnosis: Heart Failure
A broad range of prior probabilities (10%-40%) is required for clinical decisions, with outpatients who have suggestive symptoms at the lower end of the range and inpatients toward the upper end. The patient with dyspnea who presents to the emergency department without an obvious cause for dyspnea has about a 50% probability of left ventricular dysfunction (range, 34%-83%).
Population for Whom Left Ventricular Dysfunction Should Be Considered
Any patient with compatible symptoms, especially orthopnea and paroxysmal nocturnal dyspnea
Coronary artery disease, especially patients who have had a myocardial infarction
Patient receiving cardiotoxic medications
Family history of cardiomyopathy
Detecting the Likelihood of Left Ventricular Dysfunction
Patients with symptoms of heart failure and those with risk factors should be examined for pulmonary rales, jugular venous distention, a third heart sound, and peripheral edema and should have an ECG and chest radiograph (see Table 16-12).
Table 16-12Likelihood Ratios for Diagnosis of Left Ventricular Dysfunction |Favorite Table|Download (.pdf) Table 16-12 Likelihood Ratios for Diagnosis of Left Ventricular Dysfunction
|Medical Inpatients, Including Postmyocardial Infarction ||LR+ or Range (95% CI) ||LR– or Range (95% CI) |
|Clinical diagnosisa ||2.0-3.1 ||0.41-0.62 |
|ECG abnormalb ||2.8 (2.3-3.4) ||0.03 (0.01-0.10) |
|Clinical scorec with a BNP > 37 pg/mL || |
|Score ≥ 1 + elevated BNP ||3.9 (3.0-5.0) |
|Score ≥ 1 + normal BNP ||1.1 (0.61-2.0) |
|Score < 1 + elevated BNP ||0.23 (0.06-0.92) |
|Score < 1 + normal BNP ||0.04 (0.01-0.30) |
|The Breathless Emergency Patient || ||LR – (95% CI) |
|Patient History |
|Heart failure ||5.8 (4.1-8.0) ||0.45 (0.38-0.53) |
|Myocardial infarction ||3.1 (2.0-4.9) ||0.69 (0.58-0.82) |
|Physical Examination |
|Third heart sound ||11 (4.9-25) ||0.88 (0.83-0.94) |
|Abdominojugular reflux ||6.4 (0.81-51) ||0.79 (0.62-1.0) |
|Jugular venous distention ||5.1 (3.2-7.9) ||0.66 (0.57-0.77) |
|Rales ||2.8 (1.9-4.1) ||0.51 (0.37-0.70) |
|Chest Radiograph |
|Pulmonary venous congestion ||12 (6.8-21) ||0.48 (0.28-0.83) |
|Interstitial edema ||12 (5.2-27) ||0.68 (0.54-0.85) |
|Alveolar edema ||6.0 (2.2-16) ||0.95 (0.93-0.97) |
|Cardiomegaly ||3.3 (2.4-4.7) ||0.33 (0.23-0.48) |
|Pleural effusion(s) ||3.2 (2.4-4.3) ||0.81 (0.77-0.85) |
|Atrial fibrillation ||3.8 (1.7-8.8) ||0.79 (0.65-0.96) |
|New T-wave changes ||3.0 (1.7-5.3) ||0.83 (0.74-0.92) |
|Any abnormal finding ||2.2 (1.6-3.1) ||0.64 (0.47-0.88) |
|B-Type Natriuretic Peptide, pg/mLd |
|≥250 ||4.6 (2.6-8.0) || |
|≥100 ||2.7 (2.0-3.9) || |
|≥50 ||1.7 (1.2-2.6) || |
|<50 ||0.06 (0.03-0.12) || |
|Overall Clinical Impression |
|Initial clinical judgment that the patient is in heart failure ||4.4 (1.8-10) ||0.45 (0.28-0.73) |
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