A serum B-type natriuretic peptide level <100 pg/mL was the most useful test for excluding heart failure in dyspneic emergency department patients (negative LR 0.11; 95% CI 0.07-0.16).
Systematic Review
Do history, physical examination, and routine diagnostic tests accurately diagnose congestive heart failure in adult patients presenting with dyspnea to the emergency department?
Clinical features like S3 gallop and radiographic pulmonary congestion strongly increase the probability of heart failure, while a low BNP level is highly effective at excluding it in dyspneic emergency department patients.
Effect estimate: negative LR 0.11 (95% CI 0.07-0.16)
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.
Charlie S. Wang (Tue,) conducted a systematic review in Congestive Heart Failure. Diagnostic evaluation (history, physical exam, chest radiograph, ECG, serum BNP) was evaluated on Probability of heart failure (likelihood ratios) (negative LR 0.11, 95% CI 0.07-0.16). A serum B-type natriuretic peptide level <100 pg/mL was the most useful test for excluding heart failure in dyspneic emergency department patients (negative LR 0.11; 95% CI 0.07-0.16).