Does this dyspneic patient in the emergency department have congestive heart failure?

@article{citeulike:479197, abstract = {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.}, address = {Department of Medicine, University of British Columbia, Canada.}, author = {Wang, C. S. and FitzGerald, J. M. and Schulzer, M. and Mak, E. and Ayas, N. T. }, citeulike-article-id = {479197}, doi = {10.1001/jama.294.15.1944}, issn = {1538-3598}, journal = {JAMA}, keywords = {cardiology, diagnostics, epidemiology}, month = {October}, number = {15}, pages = {1944--1956}, posted-at = {2006-01-27 18:11:22}, priority = {4}, title = {Does this dyspneic patient in the emergency department have congestive heart failure?}, url = {http://dx.doi.org/10.1001/jama.294.15.1944}, volume = {294}, year = {2005} }

TY - JOUR ID - citeulike:479197 L3 - citeulike-article-id:479197 TI - Does this dyspneic patient in the emergency department have congestive heart failure? JF - JAMA VL - 294 IS - 15 SP - 1944 EP - 1956 AD - Department of Medicine, University of British Columbia, Canada. SN - 1538-3598 N2 - 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. KW - cardiology KW - diagnostics KW - epidemiology AU - Wang, CS AU - FitzGerald, JM AU - Schulzer, M AU - Mak, E AU - Ayas, NT PY - 2005/10/19/ UR - http://dx.doi.org/10.1001/jama.294.15.1944 ER -