Does Your Dyspneic Patient Have CHF?

Author: Michelle Lin, MD
Updated: 8/24/2012

Does a Dyspneic Patient Have Congestive Heart Failure (CHF)?

McCullough et al: ED patients WITH a history of asthma or COPD

Population: Emergency Department patients

Finding (+) LR (-) LR
Initial clinical judgment 4.4 (1.8-10) 0.45 (0.28-0.73)
HISTORY |
• Heart failure 5.8 (4.1-8.0) 0.45 (0.38-0.53)
• Myocardial infarctio 3.1 (1.3-5.8) 0.69 (0.58-0.82)
• Coronary artery disease 1.8 (1.1-2.8) 0.68 (0.48-0.96)
• Dyslipidemia 1.7 (0.43-6.9) 0.89 (0.69-1.1)
• Diabetes mellitus 1.7 (1.0-2.7) 0.86 (0.73-1.0)
• Hypertension 1.4 (1.1-1.7) 0.71 (0.55-0.93)
• Smoking 0.84 (0.58-1.2) 1.4 (0.58-3.6)
• COPD 0.81 (0.60-1.1) 1.1 (0.95-1.4)
SYMPTOMS |
• Paroxysmal noctural dyspnea 2.6 (1.5-4.5) 0.70 (0.54-0.91)
• Orthopnea 2.2 (1.2-3.9) 0.65 (0.45-0.92)
• Edema 2.1 (0.92-5.0) 0.64 (0.39-1.1)
• Dyspnea on exertion 1.3 (1.2-1.4) 0.48 (0.35-0.67)
• Fatigue and weight gain 1.0 (0.74-1.4) 0.99 (0.85-1.1)
• Cough 0.93 (0.70-1.2) 1.0 (0.87-1.3)
PHYSICAL EXAM |
• S3 (ventricular filling gallop) 11 (4.9-25.0) 0.88 (0.83-0.94)
• Abdominal jugular reflex 6.4 (0.81-51.0) 0.79 (0.62-1.0)
• Jugular venous distension 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)
• Any murmur 2.6 (1.7-4.1) 0.81 (0.73--0.90)
• Lower extremity edema 2.3 (1.5-3.7) 0.64 (0.47-0.87)
• Valsalva maneuver 2.1 (1.0-4.2) 0.41 (0.17-1.0)
• SBP <100 mmHg 2.0 (0.60-6.6) 0.97 (0.91-1.0)
• S4 (atrial gallop) 1.6 (0.47-5.5) 0.98 (0.93-1.0)
• SBP ≥150 mmHg 1.0 (0.69-1.6) 0.99 (0.84-1.2)
• Wheezing 0.52 (0.38-0.71) 1.3 (1.1-1.7)
• Ascites 0.33 (0.04-2.9) 1.0 (0.99-1.1)
CHEST RADIOGRAPH |
• Pulmonary venous congestion 12.0 (6.8-21.0) 0.48 (0.28-0.83)
• Interstitial edema 12.0 (5.2-27.0) 0.68 (0.54-0.85)
• Alveolar edema 6.0 (2.2-16.0) 0.95 (0.93-0.97)
• Cardiomegaly 3.3 (2.4-4.7) 0.33 (0.23-0.48)
• Pleural effusion 3.2 (2.4-4.3) 0.81 (0.77-0.85)
• Any edema 3.1 (0.60-16.0) 0.38 (0.11-1.3)
• Pneumonia 0.50 (0.29-0.87) 1.0 (1.0-1.1)
• Hyperinflation 0.38 (0.20-0.69) 1.1 (1.0-1.1)
ECG |
• Atrial fibrillation 3.8 (1.7-8.8) 0.79 (0.66-0.96)
• New T-wave changes 3.0 (1.7-5.3) 0.83 (0.74-0.93)
• Any abnormal finding 2.2 (1.6-3.1) 0.64 (0.47-0.88)
• ST elevation 1.8 (0.80-4.0) 0.98 (0.94-1.0)
• ST depression 1.7 (0.97-2.9) 0.95 (0.90-1.0)

(NS = not significant because LR crosses 1.0)

Subset population: ED patient WITH a history of asthma or COPD

Finding (+) LR (-) LR
Initial clinical judgment 9.5 (5.3-18) 0.65 (0.55-0.77)
HISTORY |
• Atrial fibrillation 4.1 (2.5-6.6) 0.74 (0.63-0.85
• CABG 2.8 (1.3-5.8) 0.92 (0.84-0.99)
• Diabetes mellitus 2.0 (1.3-3.2) 0.85 (0.74-0.97)
• Coronary artery disease 2.0 (1.5-2.6) 0.67 (0.54-0.84)
• Hypertension NS NS
SYMPTOMS |
• Orthopnea 1.3 (1.1-1.5) 0.68 (0.48-0.95)
• Noctural cough NS NS
PHYSICAL EXAM |
• S3 (ventricular filling gallup) 57.0 (7.6-425) 0.83 (0.75-0.91)
• Jugular venous distension 4.3 (2.8-6.5) 0.65 (0.54-0.78)
• Leg edema 2.7 (2.2-3.5) 0.41 (0.30-0.57)
• Rales 2.6 (1.2-4.7) 0.39 (0.28-0.55)
• Hepatic congestion 2.4 (1.2-4.7) 0.91 (0.84-1.0)
• Cardiomegaly NS NS
• Wheezing NS NS
ECG |
• Atrial fibrillation 6.0 (3.4-10.0) 0.74 (0.63-0.84)
• Ischemic ST-T waves 4.6 (2.4-8.7) 0.83 (0.74-0.93)
• Q waves 3.1 (1.8-5.5) 0.84 (0.75-0.94)
Serum BNP ≥100 pg/mL 4.1 (3.5-5.0) 0.09 (0.04-0.19)

BNP test characteristics to predict CHF in ED patients +/- asthma or COPD

Wang et al. (2005)

BNP level (pg/mL) (+) LR (-) LR
≥ 250 4.6 (2.6-8.0) 0.14 (0.06-0.33)
≥ 200 3.7 (2.6-5.4) 0.11 (0.07-0.18)
≥ 150 3.1 (2.1-4.5) 0.15 (0.11-0.21)
≥ 100 2.7 (2.0-3.9) 0.11 (0.07-0.16)
≥ 80 3.3 (1.8-6.3) 0.06 (0.03-0.13)
≥ 50 1.7 (1.2-2.6) 0.06 (0.03-0.12)

References

  • McCullough PA, Hollander JE, Nowak RM, Storrow AB, Duc P, Omland T, McCord J, Herrmann HC, Steg PG, Westheim A, Knudsen CW, Abraham WT, Lamba S, Wu AH, Perez A, Clopton P, Krishnaswamy P, Kazanegra R, Maisel AS; BNP Multinational Study Investigators. Uncovering heart failure in patients with a history of pulmonary disease: rationale for the early use of B-type natriuretic peptide in the emergency department. Acad Emerg Med. 2003 Mar;10(3):198-204. [PubMed]
  • Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005 Oct 19;294(15):1944-56. [PubMed]