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Heart Failure

Make the Diagnosis: Heart Failure

Prior Probability

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

  • Hypertension

  • Diabetes mellitus

  • 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
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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)
Outpatients
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)
Electrocardiogram
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)

Abbreviations: BNP, brain natriuretic peptide; CI, confidence interval; ECG, electrocardiogram; LR+, positive likelihood ratio; LR–, negative likelihood ratio.

aClinical symptoms, physical examination, ECG, and chest radiograph.

bVentricular hypertrophy, ST-segment or T-wave changes, left bundle-branch block, or a paced rhythm. All other findings were considered “normal,” for which the LR– applies.

cScore of 1 or higher when any of the following 5 findings are present: a history of myocardial infarction, previous diagnosis of heart failure, orthopnea or ...

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