Categories: Cardiology

JAMA: Does this patient have Heart Failure? Likelihood Ratios

Two systematic reviews have assessed the diagnostic accuracy of elements of the medical history, physical examination, or readily available tests in diagnosing HF in adults with undifferentiated dyspnea:
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Many features increased the probability of heart failure, with the best feature for each category being the presence of:
(1) the chest radiograph showing pulmonary venous congestion (positive LR = 12.0; 95% CI, 6.8-21.0);
(2) the sign of the third heart sound (S3) gallop (positive LR = 11; 95% CI, 4.9-25.0);
(3) past history of heart failure (positive LR = 5.8; 95% confidence interval [CI], 4.1-8.0);
(4) electrocardiogram showing atrial fibrillation (positive LR = 3.8; 95% CI, 1.7-8.8).
(5) the symptom of paroxysmal nocturnal dyspnea (positive LR = 2.6; 95% CI, 1.5-4.5);
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Conversely, findings useful in excluding HF include, in decreasing order:
  1. 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).
  2. The chest radiograph not showing cardiomegaly (negative LR = 0.33; 95% CI, 0.23-0.48);
  3. The absence of a past history of heart failure (negative LR = 0.45; 95% CI, 0.38-0.53);
  4. The absence of symptom of dyspnea on exertion (negative LR = 0.48; 95% CI, 0.35-0.67);
  5. No Rales (negative LR = 0.51; 95% CI, 0.37-0.70)
  6. Lack of Any electrocardiogram abnormality (negative LR = 0.64; 95% CI, 0.47-0.88).

REFERENCES:

  1. Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? JAMA. 2005;294(15):1944–1956.
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Dr. C Humphreys

Internal Medicine

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