App10 Et1

Heart Failure Guideline: Evidence tables
Section 6: Diagnosing Heart Failure
Chronic heart failure: management of chronic heart failure in

adults in primary and secondary care
A clinical guideline for the NHS in England and Wales
APPENDIX J: EVIDENCE TABLES
Section 6: Diagnosing heart failure
Contents:
Symptoms, signs and non-cardiac investigation 2
Symptoms 11
Echocardiography 15
Electrocardiogram 19
Natiuretic peptides 21
Other diagnostic procedures 28
Page 1
Symptoms, signs and non-cardiac investigation
Experimental Studies
Paper Davie, A. P., Francis, C. M., Caruana, L., Sutherland, G. R., & McMurray, J. J. 1997, "Assessing diagnosis in heart failure: which features are
any use?", QJM, vol. 90, no. 5, pp. 335-339.
Description Diagnostic study
N= n=259
Intervention History; symptoms; signs; medication or any combination of these
Outcomes Comparison with reference standard - the assessment of LV function by echocardiograph – impaired if fractional shortening <25% or qualitative
judgement of impairment
Results History of MI – sensitivity 59%; specificity 86%

Oedema – sensitivity 20%; specificity 86%
Displaced apex – sensitivity 66%; specificity 96%
Combination MI, dyspnoea on exertion and diuretic medication not much more sensitive than MI alone.
MI and displaced apex more specific, but less sensitive than either of them alone
Comments Reference blind after clinical examination and history
All tests/ histories taken for all patients by same examiner
No asymptomatic patients with LV systolic dysfunction found
Lack of replicability of assessment of LV systolic function if quantitative test not possible
Reference 18
Page 2
Paper Chakko, S., Woska, D., Martinez, H., de, M., Futterman, L., Kessler, K. M., & Myerberg, R. J. 1991, "Clinical, radiographic, and hemodynamic
correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care", American Journal of Medicine, vol. 90, no. 3,
pp. 353-359.
N= n=55
Intervention Clinical examination; chest x-ray
Outcomes Comparison with the standard diagnostic test of haemodynamic function
Results Good correlation between right arterial pressure and pulmonary capillary wedge pressure (r=0.64; p<0.001).
Chest x-ray: Venous redistribution and interstitial pulmonary oedema more common in patients with increased pulmonary capillary wedge
pressure.
Selective clinical and radiographic findings had poor negative predictive value.
Significant number of patients with marked elevation of wedge pressure do not have congestion on radiograph
Comments All tests carried out blind.
Probability of less than 0.01 taken as significant
Reference 22
Page 3
Paper Ghali, J. K., Kadakia, S., Cooper, R. S., & Liao, Y. L. 1991, "Bedside diagnosis of preserved versus impaired left ventricular systolic function in
heart failure.", American Journal of Cardiology, vol. 67, no. 11, pp. 1002-1006.
N= n=82
Mean age =60 years, Male =60%, Hypertension =70%, Coronary artery disease =17%
Intervention Range of clinical tests
Outcomes Echocardiography-tested LV dysfunction and hypertension
Results No significance of S3 gallop, oedema, natriuretic, pulmonary congestion, ECG hypertrophy to predict impaired systolic function
Jugular venous distension and diastolic blood pressure (>105mm Hg) are significantly predictive (p<0.05)
Diastolic BP >105mm Hg: sensitivity 61%, specificity 70%
Absence of jugular venous distension: sensitivity 52%, specificity 71%
Together these provide 30% sensitivity, 100% specificity
Comments One blinded observer.
All tests performed on all patients
Reference 24
Page 4
Non-experimental studies
Paper Shamsham, F. & Mitchell, J. 2000, "Essentials of the diagnosis of heart failure.", American Family Physician, vol. 61, no. 5, pp. 1319-1328.
Description Review
N=
Intervention
Outcomes
Results History
Dyspnoea from on exertion to at rest with increased severity
Nocturia frequent sign, peripheral oedema a common complaint
Confusion and altered mental status by decreased cerebral perfusion or cardiac cirrhosis
Previous MI has a better sensitivity and specificity for heart failure compared with other symptoms and histories
nd
History of hypertension 2 most frequent cause
Tests
Blood pressure and Heart rate should be monitored as tachycardia a compensatory mechanism to maintain cardiac output
Jugular venous distention has a low replicability
Point of maximal impulse specificity 66% and sensitivity 96% for evaluation heart size
rd
3 heart sound has specificity on 24% and sensitivity of 99%
Rales and plural effusion possible on pulmonary examination
Lower extremity oedema when extra cellular volume >5I
Valsalva manoeuvre – abnormal responses have a specificity of 91% and sensitivity of 69% for detecting left ventricular systolic and diastolic
dysfunction
Ageing can produce the symptoms of Anorexia, generalised weakness, and fatigue when are often predominant symptoms
Systolic dysfunction often described by:- history of MI, younger patient, displaced point of maximal impulse, S3 gallop, Q waves of ECG,
cardiomegaly on X-ray
All diagnostic tests
Total assessment by Boston Criteria, A maximum 12-point scale over 3 categories of history, exam, radiography. Having a total sensitivity of
50%, and specificity of 78%
Comments 36 references, including national guidelines

Efficacy rates given
Linked to wider scope of treatment, and differentiation of diastolic dysfunction
Reference 20
Page 5
Paper Khunti, K., Baker, R., & Grimshaw, G. 2000, "Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination,
and investigations.", British Journal of General Practice, vol. 50, no. 450, pp. 50-54.
Description Review
N=
Intervention
Outcomes
Results Symptoms:
breathlessness, fatigue, ankle swelling – suggest possibility of HF. Hard to interpret in elderly and obese patients.
History:
Most common cause is IHD, in particular MI. Past hypertension may also predispose to HF.
Clinical examination:
Initial assessment up to 70% accurate in determining the cause: Abnormal apical impulse, pulse >90-100 bpm, systolic BP <90mm Hg,
crepitations, S3 . Some are found infrequently but have high specificity. Raised jugular venous pressure and oedema only helpful when present.
Investigations:
Electrocardiogram sensitivity =89%, specificity =46%; should not be relied on to confirm a diagnosis but indicates further investigation. Chest X-
ray recommended by guidelines, but alone cannot adequately exclude or confirm LV dysfunction. Added to clinical assessment, can improve
specificity to 92%. Echocardiogram (current “gold standard”) has no economic evaluation for open access.
Research is needed of signs and symptoms in primary care, as most studies conducted in secondary care setting.
Comments Modern review of 75 articles; Medline 1993 onwards, and Cochrane with a check of references
No mention of natriuretic peptides
Thorough search strategy
Well cited
Good simple algorithm
Many studies carried out without using explicit diagnostic criteria
Symptoms often subjective and do not relate closely to outcome
Clinical diagnosis is difficult early in the disease
False positive diagnosis of HF common in papers
Framingham and Boston criteria are based on similar clinical elements, with similar incidence rules
Reference 20
Page 6
Paper Ikram, H. 1995, "Identifying the patient with heart failure.", Journal of International Medical Research, vol. 23, no. 3, pp. 139-153.
Description Guidelines
N=
Intervention
Outcomes
Results GP central to providing diagnosis from early clinical indications

NYHA – simple and correlates with prognosis, but no differentiation of patho-physiological conditions
Boston criteria shown to give false positives
Need combination of history, signs and routine tests
Predisposed by history of MI, ischaemic heart disease, hypertension, LV hypertrophy, congestive cardiomyopathy and excessive alcohol,
water and/or salt
Symptoms and signs
Weakness and tiredness - low output

Weight gain, oedema, cough – pulmonary and systemic venous congestion

Dyspnoea – congestive heart failure (also due to other factors)

40% of all HF diagnoses based purely on oedema are wrong

Lung rales – non-specific

Cardiovascular exam
Low blood pressure and other factor

Tachycardia and low volume pulse

Third heart sound at cardiac apex abnormal in patients 40 years +

Elevation of jugular vein >1cm above normal at rest

Page 7
Results Precipitory factors

Anaemia, infection, thyrotoxicosis, beriberi arrhythmias
cont’d When GP can read a preliminary diagnosis of HF
Blood tests
To confirm that renal, liver and typhoid malfunction or anaemia is not underlying factor
Electrocardiography
To determine whether LV hypertrophy is present
Duel conduction abnormalities, tachy-arrhythmia, ischaemia by Q-waves
Atrial fibrillation found in 70% patients with congestive HF
MUGA
Important for research, but expensive and time consuming in routine diagnostic work
Chest x-ray
Measures cardiothoracic ratio (at end diastole)
Relatively insensitive and normal x-ray cannot rule out HF
Echocardiography
When underlying cause cannot be established
Simple and non-invasive from which diastolic and systolic dimensions can be measured
Reveals LV dysfunction and dilation, if present
Information on wall thickness, systolic function, valve disease to assess severity of HF
Distinguish systolic or diastolic dysfunction
Doppler echocardiography enables assessment of the extent of overall impairment of the circulatory system
Comments 22 references
Good figures and algorithms
Links to treatment
Discusses harm of delayed diagnosis
Considers large trials
Refernce 15
Page 8
Paper Johnstone, D. E., Abdulla, A., Arnold, J. M., Bernstein, V., Bourassa, M., Brophy, J., Davies, R., Gardner, M., Hoeschen, R., & Mickleborough, L.
1994, "Diagnosis and management of heart failure. Canadian Cardiovascular Society.", Canadian Journal of Cardiology, vol. 10, no. 6, pp. 613-
631.
Description Guideline
N=
Intervention
Outcomes
Results Symptoms
In severe failure:
Obvious fatigue

Dyspnoea

Peripheral oedema

Cough

Weight gain

Abdominal discomfort

Cool extremities

NYHA widely used as classification

Physical findings
Low or normal blood pressure
Tachycardia (80-100 BPM)
Varying degrees of oedema
Cyanotic appearance
Rales, wheezing, plural effusions and auscultation of lungs
Gallop rhythms (S3 and S4)
Mitral regurgitation
In severe right sided failure:
Tricuspid regurgitation
Increased jugular venous pressure
Hepato-jugular reflux sportive
Page 9
Results Tests
Thorough medical history and physical exam should be preformed in all patients including:
cont’d Chest x-ray

ECG

Complete blood count

Electrolytes, creatinine, urea
Cardiac testing
Not necessary to perform both echocardiography and Radionuclide ventriculography where one has been performed recently, but one or other
strongly recommended in all patients with known or suspected HF
Selection of technique depends on expertise
Routine use of sequential tests for monitoring not recommended
Echocardiography recommended in patients with HF to provide a comprehensive non-invasive diagnostic and prognostic assessment
Radionuclide angiography recommended in HF patients for measurement of ventricular function and LV ejection fraction
Exercise test not routinely recommended in heart failure patients – maybe useful to confirm a diagnosis of limited functional capacity and to
assess major limiting symptoms
Routine ambulatory monitoring not recommended
Electrophysiological studies are recommended where an evaluation of sustained ventricular arrhythmias is required
Coronary angiography is not routinely required in patients with congestive HF. Exceptions are:
Those with anginal symptoms and documented myocardial ischaemia

When non-chemical defect suspected post MI

In some patients to help diagnose cardiomyopathy

Endomyocardial biopsies not recommended in either dilated cardiomyopathies or myocarditis

Refernce 19
Page 10
Symptoms
Experimental Studies
Paper Badgett, R. G., Mulrow, C. D., Otto, P. M., & Ramirez, G. 1996, "How well can the chest radiograph diagnose left ventricular dysfunction?",
Journal of General Internal Medicine, vol. 11, no. 10, pp. 625-634.
Description Systematic review
N= n=? (27 studies)
Intervention Diagnostic accuracy of chest x-ray (various signs) against baseline LV function
Outcomes Sensitivity and specificity to diagnose were tested and predictive value calculated given normal frequency within population
Results Cardiac redistribution most sensitive to increased preload (65%) but low specificity (67%). Can exclude if negative (<5%), but cannot confirm
(>95%) if present.
Cardiomegaly tended to be most sensitive in diagnosing reduced ejection fraction (sensitivity, 51%; specificity 79%) again, can exclude if
negative findings but alone cannot confirm diagnosis.
Chest x-ray unlikely to help distinguish systolic from diastolic dysfunction
Comments Non-blinding of half of studies
Good spread of populations
Transplant patients excluded from analyses as all had systolic dysfunction
A random effects model used to pool data as no homogeneity present
Reference 14
Page 11
Paper Badgett, R. G., Lucey, C. R., & Mulrow, C. D. 1997, "Can the clinical examination diagnose left-sided heart failure in adults?", JAMA, vol. 277,
no. 21, pp. 1712-1719.
Description Systematic review
N= n=? (28 diagnostic studies)
Intervention An assessment of the following investigations to assess cardiac function:

Clinical history
Pulse rate
Chest radiograph
Electrocardiography
Outcomes Sensitivity/specificity of diagnosis graded to 3 levels of usefulness of findings in 3 diagnostic areas:
Filling pressure
Ejection fraction <40%
Diastolic dysfunction
Results Distinguishing diastolic from systolic dysfunction: hypertension - sensitivity =65%; specificity =65%
Detecting increased left ventricular filling: radiographic redistribution = probability of 85-100% - but absence can’t rule out.
Ejection fraction <40%: radiographic megaly / redistribution – sensitivity = 50% (insufficient in most clinical settings); specificity = 79%.
Also useful - anterior Q waves; left bundle branch block and abnormal apical impulse.
Less useful – pulse >90/100 BPM; rales and dyspnoea.
Comments Inclusion criteria were tight
Limited search
Large studies
Reference 21
Page 12
Paper Ries, A. L., Gregoratos, G., Friedman, P. J., & Clausen, J. L. 1986, "Pulmonary function tests in the detection of left heart failure: correlation
with pulmonary artery wedge pressure", Respiration, vol. 49, no. 4, pp. 241-250.
N= n=40
Intervention Pulmonary function tests
Outcomes Comparison with cardiac catheterisation
Results Radiographic review accuracy of predicting LHF mean – sensitivity 93%; specificity 64%.
Good correlation between total lung capacity and pulmonary wedge pressure p<0.01 (except when assessed by x-ray)
Restriction shown in group with HF likely to be caused by retained lung water or blood, which is not detected by x-ray
Correlation between clinical class on NYHA and pulmonary wedge pressure p<0.01
Comments Restrictive lung disease patients excluded
All tests blinded
Different examiners for each test
Low levels of co-morbidity (1/40 had COPD)
Young study population (mean age 47)

Page 13
Paper Geltman, E. M. 1989, "Mild heart failure: diagnosis and treatment.", American Heart Journal, vol. 118, no. 6, pp. 1277-1291.
N=
Intervention
Outcomes
Results Patient history
1. Establish diagnosis
2. Determine the degree of cardiovascular limitation
3. Determine baseline status
4. Assess therapeutic benefits
5. Compare patients with one another
Dyspnoea, orthopnoea and paroxysmal nocturnal dyspnoea – classic respiratory complications
Classification of cardiac status and treatment plan on symptoms alone maybe deceptive
Lab tests
Bloods and urinalysis. Complete blood count, electrolytes, blood urea nitrogen, serum creatinine/ kinase/kinaseKB, liver function tests –
although non-specific for HF abnormal findings may suggest precipitory cause, indicate severity and provide prognostic information
ECG
ECG (12 lead) and chest x-ray when correlated with other findings are helpful in establishing underlying cause. ECG can provide baseline data
for future comparisons
Echocardiogram
Echocardiography and Radionuclide ventriculography important adjuncts early in evaluation of suspected cases.
Impairment of LV function may precede enlargement of the heart as found on examination or x-ray
Radionuclide useful where echo difficult (COPD/obesity) but not as detailed an assessment
Others – where the cause of HF is unclear, further testing with tolerance testing, stress thallium scintigraphy, ventilation perfusion, lung
scanning, cardiac catheterisation, angiography
Comments Review
Little referencing
10 years and older
Part of a paper on the management of HF
Reference 17
Page 14
Echocardiography
Experimental studies
Paper Senni, M., Rodeheffer, R. J., Tribouilloy, C. M., Evans, J. M., Jacobsen, S. J., Bailey, K. R., & Redfield, M. M. 1999, "Use of echocardiography in
the management of congestive heart failure in the community", Journal of the American College of Cardiology, vol. 33, no. 1, pp. 164-170.
Description Cohort study
N= n=216
Intervention Echocardiography or not
Outcomes Whether the investigation was carried out according to the following criteria.
Age 80 years or lower
Lower NYHA class
Absence of valvular disease
Negative X-ray
Absence of fourth heart sound
Results Age 80 years or lower OR=2.22 (1.14–4.29), p 0.0177
Absence of positron X-ray OR 0.04 (0.11–1.01) p 0.0521
Comments Prognostic test of outcome and also pharmaceutical issues

Time limitation of 3 weeks
Reference 36
Page 15
Paper Arnold, J. M., Cheung, P., & Burton, G. L. 1994, "Continuous wave Doppler measurements of aortic blood flow during exercise in patients with
chronic heart failure", Canadian Journal of Cardiology, vol. 10, no. 2, pp. 185-192.
N= n=68
Intervention Heart failure patients or not heart failure patients
Outcomes Exercise capacity by Doppler recording at rest and post exercise
Results No difference in exercise capacity between ischaemic heart disease and dilated cardiomyopathy.
No difference in capacity of class 2 or 3.
2
Suggest peak velocity of 70.8mb or an acceleration 73 dms are unlikely to be consistent with clinical diagnosis of heart failure.
Comments Good discrimination of Doppler technique – positive ratio 0.8
Reference 35
Page 16
Paper Roelandt, J. & Lubsen, J. (1983) Usefulness of qualitative echocardiography on congestive heart failure
Description Review
N=
Intervention
Outcomes
Results Advantages of echocardiogram, harmless effects of sound waves, so can be repeated

Limitations: restricted to one dimensional echo so that it is necessary to extrapolate to 3D. Errors are worse when the heart enlarges
Good against own control
Two dimensional echocardiography has correlation coefficient of 0.76–0.96 with left ventricle angiocardiography
Underestimation due to: Cardiac apex non tangental to sections of left ventricle
Margins being tips of trabeculae
Echo ejection fraction has better agreement with angiocardiography and radionuclide ventriculography
Major limits are: % patients with unsatisfactory electrocardiography (10–40%)
Time consuming data analysis
Difficulty on exercise testing
Limited for test
Limited clinical use
Comparison of Echocardiogram result reproducibility against other test
Conclusions suitably limited
Reference 37
Page 17
Paper Hanrath, P. & Schlüter, M. (1983) Is echocardiography a reliable tool?
Description Review
N=
Intervention
Outcomes
Results Variation of test of left ventricle dimension (end systolic and diastolic) ˜ ±3.5mm
Variation reduced by following international recommendations or a number of precautions:
(1) all records performed from same intercostal space
(2) taken during normal respiration at end respiration
(3) performance of ‘T’ scan mandatory for measuring maximum dimension
(4) at least three to five consecutive cycles and mean value
(5) analysed by independent unbiased observers
Stroke volume cannot be measured by valve echocardiograms where aortic regurgitation is present
Many patients with significant coronary artery disease show left ventricle dysfunction only under stress such as exercise
Can be used to detect the underlying cause of heart failure particularly in differentiating cardiomegalies due to plural effusion,
congenital/acquired valve disease, or cardiomyopathy
M-mode echocardiographic parameters from left ventricle dimensional changes can be helpful in the quantitative assessment of left ventricle
performance
Technical limits on performance during exercise may be overcome with new approaches such as oesophageal imaging
Comments Short review of effectiveness of echocardiography to detect underlying cause in congestive heart failure
Old review (20 years) may not be relevant with new technologies
Comparison of 10 previous studies for reproducibility of tests
Reference 38
Page 18
Electrocardiogram
Paper Houghton, A. R., Sparrow, N. J., Toms, E., & Cowley, A. J. 1997, "Should general practitioners use the electrocardiogram to select patients with
suspected heart failure for echocardiography?", International Journal of Cardiology, vol. 62, no. 1, pp. 31-36.
N= n=200
Intervention LV dysfunction by echocardiogram test.
Outcomes ECG assessment of LV

Dysfunction
Results No significant difference between sub-survey (2 GPs, 1 specialist).

ECG sensitivity 89.1%, speciality 45.7 %.
20% of referrals to echo positive, this relates to 43% drop in workload but 10% of positive patients would not be assessed.
ECG quick and effective, but not recommended for solution alone due to low speciality, so combine with x-rays or natriuretic peptide
examination
Comments Very strong study
Reference 26
Page 19
Paper Remes, J., Miettinen, H., Reunanen, A., & Pyorala, K. 1991, "Validity of clinical diagnosis of heart failure in primary health care. [see
comments]", European Heart Journal, vol. 12, no. 3, pp. 315-321.
N= n=68
Intervention Fractional shortening, previous MI, abnormalities from ECG. All tests performed on all patients
Outcomes Boston criteria for HF and own clinical criteria with 6 month review as baseline
Results One-third of primary care diagnoses were correct – more often so in men (p=0.0001).
Fractional shortening found more often in definite HF group (p<0.01).
Previous MI found more often in definite HF group (p<0.05).
Abnormalities from ECG found more often in definite HF group (p<0.05).
Comments Not clearly stated if blinded trial
Did not identify false negative primary care diagnoses.
False positive diagnoses caused unnecessary drug treatment in more than half of the patients
Reference 27
Page 20
Natriuretic Peptides
Paper Davis, K. M., Fish, L. C., Elahi, D., Clark, B. A., & Minaker, K. L. 1992, "Atrial natriuretic peptide levels in the prediction of congestive heart
failure risk in frail elderly. [erratum appears in JAMA 1993 Feb 24;269(8):991]", JAMA, vol. 267, no. 19, pp. 2625-2629.
N= N=310
Intervention Blood plasma ANP levels
Outcomes Presence of congestive heart failure, no congestive heart failure, death
Results Non congestive heart failure group had lower ANP level (207+/- 15 pmol/l) Vs (493 +/- 55 pmol/l) (p<0.001)
ANP >200 pmol/l has sensitivity of 85% and specificity of 66% as a predictor of coronary heart failure
Comments Specialist care setting may detect more coronary heart failure cases, or may treat patients better
Reference 32
Page 21
Paper Hunt, P. J., Richards, A. M., Nicholls, M. G., Yandle, T. G., Doughty, R. N., & Espiner, E. A. 1997, "Immunoreactive amino-terminal pro-brain
natriuretic peptide (NT- PROBNP): a new marker of cardiac impairment", Clin.Endocrinol.(Oxf), vol. 47, no. 3, pp. 287-296.
Description Case control study
N= n=157
Intervention Hypertension and cardiac impairment Vs control
Outcomes Levels of BNP in blood plasma. NT-proBNP, and BNP-32
Results No significant difference in hypertension to control

Cardiac impairment tests both BNP tests higher than for controls
Both tests inversely correlated with left ventricular ejection fraction (p<0.001), and exercise test time (particularly NT-proBNP)
Results higher in NYHA class I than controls, and higher in classes II-III than class I
Comments New Zealand study
Source of IR NT-proBNP appears to be the heart as shown by significant gradients in levels sampled from femoral artery and coronary sinus
Reference 33
Page 22
Paper Cowie, M. R., Struthers, A. D., Wood, D. A., Coats, A. J., Thompson, S. G., Poole-Wilson, P. A., & Sutton, G. C. 1997, "Value of natriuretic
peptides in assessment of patients with possible new heart failure in primary care", Lancet, vol. 350, no. 9088, pp. 1349-1353.
N= n=122
Intervention Diagnostic value of natriuretic peptides (ANP and BNP)
Outcomes Against clinical diagnosis of HF by physical assessment, Chest X-ray and echocardiography
Results Peptide levels higher in HF diagnosed than not HF diagnosed for all test types
ANP 29.2 Vs 12.4
BNP 63.9 Vs 13.9
NT-ANP 1187.0 Vs 410.6
(pmol/l) (p<0.001)
No significant association with age and sex
At negative predictive value of 98% (BNP =22.2 pmol/l) a sensitivity of 97% and specificity of 84%
BNP only independently predictive value for HF with other peptides and chest X-ray, by logistic regression
Comments Possible systematic loss of assays due to high or low concentrations
Patients from referral of 81 GPs
Possibly more HF aware population of GPs from participation in Hillingdon study
Reference 28
Page 23
Paper Maisel, A. S., Krishnaswamy, P., Nowak, R. M., McCord, J., Hollander, J. E., Duc, P., Omland, T., Storrow, A. B., Abraham, W. T., Wu, A. H.,
Clopton, P., Steg, P. G., Westheim, A., Knudsen, C. W., Perez, A., Kazanegra, R., Herrmann, H. C., McCullough, P. A., & Breathing, N. 2002,
"Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure.", New England Journal of Medicine., vol. 347, no.
3, pp. 161-167.
N= n=1586
Age =64yrs, Male =56%, History of HF =33%, MI =27%, COPD =41%, diabetes =25%
USA, France, Norway
Intervention A multinational trial to assess the utility of B-type natriuretic peptide levels in the diagnosis of congestive HF within a broad population of
patients presenting with dyspnoea.
Outcomes The reference standard used was clinical assessment of HF cause by two independent cardiologists (agreement not stated) using patient
records, chest roentgenograms, and cardiac function test results. The reference standard was measured in all patients regardless of the test
result
Results Final diagnosis was of HF in 774 patients (47%), non cardiac causes inpatients with history of LV dysfunction 72 patients (5%) , and no finding
of HF in 770 patients (49%).
In 97% of patients with HF the final diagnosis was confirmed by the use of other tests
Patients with final diagnosis of HF had a natriuretic peptide level of 675 pg/ml, those without HF had a level of 110 pg/ml, and those who had
baseline LV dysfunction and had Dyspnoea without an exacerbation of HF had a peptide level of 346 pg/ml. The difference between each of
these groups was significant at p<0.001for each comparison
A B-type natriuretuc cut-off value of 100 pg/ml had a sensitivity of 90% a sensitivity of 76% and an accuracy of 83% fro differentiating
congestive HF from other causes of dyspnoea
B-type natriueretic values varied significantly with patient NYHA class as determined by cardiologists, with the level in class I averaging 144
pg/ml, in class II it was 389 pg/ml. In class III the reading was 640 pg/ml, and in class IV the level was 817 pg/ml (p<0.0010 for comparison of
groups
In a multiple logistic regression analysis the addition of B=type natriuretic peptide added to the combined explanatory power of history,
symptoms, signs, radiological studies, and laboratory findings. A value of 100pg/ml or higher was the strongest independent predictor of
congestive HF with an OR 29.60 (95% CI 17.75 to 49.37)
Comments Test of B-type natriuretic peptide using a fluorescence immunoassay kit
All patients were classified as to whether dyspnoea due to HF or otherwise blind to test result, other tests of cardiac function such as
echocardiogram were strongly encouraged but not undertaken in all patients
Multivariate analysis of diagnostic use of natriuretic assay using historical, clinical , and roentgenographic parameters in a stepwise logistic
regression using factors that had a significance at p=0.05 in bivariate analysis
This test may be useful where echocardiography is difficult or where there is a co-existing condition such as obesity or Lung disease
Reference 29
Page 24
Paper Selvais, P. L., Donckier, J. E., Robert, A., Laloux, O., van, L., Ahn, S., Ketelslegers, J. M., & Rousseau, M. F. 1998, "Cardiac natriuretic peptides
for diagnosis and risk stratification in heart failure: influences of left ventricular dysfunction and coronary artery disease on cardiac hormonal
activation", European Journal of Clinical Investigation, vol. 28, no. 8, pp. 636-642.
N= n=147
Intervention Diagnostic value of natriuretic peptides (ANF and BNP
Outcomes Against Left ventricular ejection fraction by echocardiography and NYHA class
Results Significant correlatio nof the three peptide measures and left ventricular dysfunction
BNP r=-0.59
N-proANF r=-0.53
ANF r=-0.30
(p<0.001)
BNP performed better than others at grading severity of congestive heart failure (p<0.05)
Comments Larger proportion of women in control group
Used NYHA class rather than ejection fraction for receiver-operating analysis
Reference 30
Page 25
Paper Yamamoto, K., Burnett, J. C. J., Jougasaki, M., Nishimura, R. A., Bailey, K. R., Saito, Y., Nakao, K., & Redfield, M. M. 1996, "Superiority of brain
natriuretic peptide as a hormonal marker of ventricular systolic and diastolic dysfunction and ventricular hypertrophy.", Hypertension, vol. 28, no.
6, pp. 988-994.
N= n=94
Intervention Diagnostic ability of BNP, C-ANP, and N-ANP
Outcomes Against Left ventricular ejection fraction and mass by echocardiography, and end diastolic pressure , and time constant of left ventricular
relaxation by catheterisation
Results For each physiological variable BNP showed the strongest correlation (ejection fraction, left ventricular mass, relaxation time) and was
significantly better than C-ANP or N-ANP, no significant difference in Left ventricular end diastolic pressure
Sensitivity 73% and specificity 83% to detect any abnormality of left ventricular structure or function at BNP= 14.7 pmol/l
Significant structural and functional abnormalities in patients without clinical evidence of heart failure
Comments All test interpreted blind
Minnesota study
Age ˜ 62 yrs, 57% male
Used control patients to define baseline peptide levels and the elevated level set at this plus 3 Standard deviations
Reference 31
Page 26
Paper Morrison, L. K., Harrison, A., Krishnaswamy, P., Kazanegra, R., Clopton, P., & Maisel, A. 1916, "Utility of a rapid B-natriuretic peptide assay in
differentiating congestive heart failure from lung disease in patients presenting with dyspnea", Journal of the American College of Cardiology.,
vol. 39, no. 2, pp. 202-209
N= n=321
USA
Intervention Test compared with duplicated cardiologist defined evaluation as to whether the patients presented with HF or other causes of dyspnoea
Outcomes A multivariate model was used to find the assess the additive predictive value of BNP over clinical findings
Results 42% of patients presenting with dyspnoea had HF as their final diagnosis, and 26% had a final diagnosis of pulmonary disease
Of the patients with the final diagnosis of HF the mean BNP level was 759 pg/ml compared to 61 pg/ml in the pulmonary patients (p<0.001)
A BNP level of 94 pg/ml had a sensitivity of 86%, a specificity of 98%, and an accuracy of 91%
The best clinical predictors of final diagnosis for dyspnoea were history of HF, and heart size and venous hypertension on chest X-ray
The addition of BNP levels to the multivariate regression substantially increased the explanatory power of the model and was a significant
independent variable (p<0.001)
Comments All tests were conducted on all patients, with two independent cardiologists determining whether dyspnoea was relating to HF (according to
Framingham criteria), or to other conditions (Pulmonary disease, baseline LV dysfunction without acute HF, other cardiac problems, non cardiac
or pulmonary causes)
Blood samples from patients were taken and kept at room temperature and analysed within 4 hours.
Analysis was done in triplicate with a BNP immunoassay.
The coefficient of variation at 28.8ng/l is 9.5% for intra-assay precision and 10% for inter-assay precision.
The lowest concentration of BNP distinguishable is <5.0 ng/l
Dyspnoea is reported to be relevant in 2.7% of emergency department visits, in which echocardiography has limited availability.
BNP was able to distinguish whether dyspnoea was due to an exacerbation of COPD or worsening HF in patient with comorbid conditions as the
levels were 47 pg/ml in the former and 731 pg/ml in the later (in 65 patients with both conditions)
In cases where both cardiac and pulmonary diseases are occurring concurrently as when pneumonia triggers HF, both a high BNP and
consolidation on chest X-ray would be likely
Patients who are on dialysis or have end-stage renal failure may have elevated BNP levels and would need standard diagnostic criteria to be
assessed
Page 27
Other diagnostic procedures
Experimental studies
Paper Houghton, A. R., Sparrow, N. J., Toms, E., & Cowley, A. J. 1997, "Should general practitioners use the electrocardiogram to select patients with
suspected heart failure for echocardiography?", International Journal of Cardiology, vol. 62, no. 1, pp. 31-36.
N= n=200
Intervention LV dysfunction by echocardiogram test.
Outcomes ECG assessment of LV

Dysfunction
Results No significant difference between sub-survey (2 GPs, 1 specialist).

ECG sensitivity 89.1%, speciality 45.7 %.
20% of referrals to echo positive, this relates to 43% drop in workload but 10% of positive patients would not be assessed.
ECG quick and effective, but not recommended for solution alone due to low speciality, so combine with x-rays or natriuretic peptide
examination
Comments Very strong study.
Reference 26
Page 28
Paper Henriksson, L., Sundin, A., Smedby, O., & Albrektsson, P. 1990, "Assessment of congestive heart failure in chest radiographs. Observer
performance with two common film-screen systems", Acta Radiologica, vol. 31, no. 5, pp. 469-471.
N= n=27
Intervention Two systems and films
Outcomes Comparing inter-rater reliability between 3 observers
Results No difference in film type

No systematic difference between systems (p>0.05)
Poor concordance between observers – k=0.02 (-0.14-o.25)
Pressures of oedema difficult to assess unless comparison to a pre-failure film
Comments 54 (2 x 27) radiographers assessed blindly through coding.
No description of inclusion criteria of patients
Reference 143
Page 29
Paper La Vecchia, L., Mezzena, G., Zanolla, L., Paccanaro, M., Varotto, L., Bonanno, C., & Ometto, R. 2000, "Cardiac troponin I as diagnostic and
prognostic marker in severe heart failure", Journal of Heart & Lung Transplantation, vol. 19, no. 7, pp. 644-652.
N= n=34
Intervention Cardiac troponin I concentration, in blood
Outcomes Effectiveness against standard assessment and heart function by echocardiography
Results No significant relationship with clinical variables

Left ventricular function lower in positive troponin group (p=0.023)
Correlation of troponin levels and left ventricular dysfunction (r=0.53) (p-0.11)
May be detected in 25-33% of all patients admitted with HF
Comments Authors state that value remains to be established
Conventional assays do not detect troponin in stable Heart failure patients
Page 30
Paper Butman, S. M., Ewy, G. A., Standen, J. R., Kern, K. B., & Hahn, E. 1993, "Bedside cardiovascular examination in patients with severe chronic
heart failure: importance of rest or inducible jugular venous distension", Journal of the American College of Cardiology, vol. 22, no. 4, pp. 968-
974.
N= n=52
Intervention Various clinical diagnostic tests
Outcomes Pulmonary capillary wedge pressure by catheterisation within 24 hours
rd
Results Assessment of 3 heart sound: good agreement ( =0.6)

Abdomino-jugular test: good agreement ( =0.92).

Chest X-ray: reasonably good agreement, especially in intestinal oedema ( =0.86).

Pulmonary wedge pressure predicted by:
rd
3 heart sound (sensitivity 68%, specificity 73%)
Jugular venous distension (sensitivity 57%, specificity 93%)
Combined with abdomino-jugular test (sensitivity 81%, specificity 80%)
Chest X-ray can be used to detect clinically unrecognised HF.
Comments Mean age 53 years
Study confined to severe cardiac dysfunction
Sensitivity and specificity of any test are confined to the study sample.
Moderate sample size.
Page 31
Paper Binkley, P. F., Lewe, R. F., Unverferth, D. V., & Leier, C. V. 1988, "Late systolic indices of ventricular function: noninvasive derivation in
congestive heart failure", American Heart Journal, vol. 116, no. 5 Pt 1, pp. 1276-1282.
N= n=10
Intervention Blood pressure recordings
Outcomes LV contractility by echocardiogram and electrocardiogram – uncommon in practice
Results End-systolic pressure and dimension: good correlation (0.95 0.04)

End-systolic pressure and volume: good correlation (0.95 0.04)

Peak systolic pressure and dimension: good correlation (0.94 0.05)

Mean slopes of relationships well below the magnitude in normal subjects
Incremental increase in dimension at larger levels (>6cm) produces larger volume increases
Comments All tests carried out on all patients.
One blind observer
Small study sample
Ohio study
Page 32
Paper Zema, M. J., Restivo, B., Sos, T., Sniderman, K. W., & Kline, S. 1980, "Left ventricular dysfunction--bedside Valsalva manoeuvre", British Heart
Journal, vol. 44, no. 5, pp. 560-569.
N= n=37
Intervention Left ventricular dysfunction by Valsava Manoeuvre, with diagnostic signs and chest X-ray
Outcomes Cardiac catheterisation
Results LV ejection fraction means were significantly different for:

- square wave versus absent overshoot response (p<0.001)
- square wave versus sinusoidal response (p<0.001)
- absent overshoot versus sinusoidal response (p<0.005)
Height of pressure overshoot correlates with magnitude of LV ejection fraction (r=0.72) and inversely to end diastolic pressure (r= -0.79)
For patients not on propranolol, the clinical value for determining LV dysfunction was better than all other clinical tests.
Comments Mean age =60 years
Male =60%
Hypertension =70%
Coronary artery disease =17%
One blinded observer.
All tests performed on all patients
Page 33
Non experimental studies
Paper Smith, H., Pickering, R. M., Struthers, A., Simpson, I., & Mant, D. 2000, "Biochemical diagnosis of ventricular dysfunction in elderly patients in
general practice: observational study.", BMJ, vol. 320, no. 7239, pp. 906-908.
Description Observational study
N=
Intervention
Outcomes
Results Concentration of B type natriuretic peptides 39.3 poml/l in patients with ventricular dysfunction and 15.8 pmol/l in those with normal function
At lowest cut off point (18.7 pmol/l) a sensitivity of 92% and specificity of 65%
Test may not perform so well in elderly as in young with increases for other no HF reasons
Could be used as effective screening programme in community.
Using a low cut off point can be used as a rule out test of left ventricular dysfunction
Implications for NHS that even if done access to echocardiography remains essential
Comments n=817 (77.4% take up rate) random sample
Dorset setting
Diagnosis of LV ejection fraction by echocardiograph
No details of blinding
Sample large but not big enough to determine concentration cut off point at which an effective rule out test can be established
Reference 34
Page 34
Paper Pavia, S. V. & Galbraith, A. J. 1999, "Therapy for cardiac failure: Treatments old and new", Medical Journal of Australia, vol. 171, no. 5, pp. 265-
271.
N=
Intervention
Outcomes
Results Clinical signs and symptoms

Split into those of reduced cardiac output, congestion, arrhythmia:
o Lack of diagnostic specificity, individually
o Combined presence improves diagnostic confidence
Chest X ray
Cardiac enlargement and pulmonary venous congestion
o Cardiac silhouette should not exceed 50% of interthoracic diameter
ECG
Useful to show previous MI; arrhythmia or LV hypertrophy
Echocardiogram
Useful to assess systolic and diastolic dysfunction, valve function and cardiovascular physiology – including degree of pulmonary hypertension
Blood tests
Useful in patients with dilated cardiomyopathy to exclude other factors
Cardiac catheterisation
Used to guide management. Particularly in patients with coronary artery disease expected to cause reversible ischaemia
Comments Evidence-based but not systematic assessment or review
Page 35
Paper Tresch, D. D. 1997, "The clinical diagnosis of heart failure in older patients. ", Journal of the American Geriatrics Society, vol. 45, no. 9, pp.
1128-1133.
Description Review
N=
Intervention
Outcomes
Results Symptoms
o Older patients will not experience exertional dyspnoea – as sedentary and compensatory pulmonary vascular changes
o When pulmonary/peripheral oedema occur the disease is far advanced
Non-specificity and co-morbidity lead to frequent misdiagnosis
Physical findings
Age related arteriosclerotic changes lead to stiff walls and can obscure pulse contour
Cardiovascular testing
o Electrocardiogram – diagnosis of coronary artery disease/ventricular hypertrophy
o Chest x-ray – information on heart size and presence of pulmonary disease (co-morbidity)
o Echocardiography – most useful when evaluating older patients, structural abnormalities and ventricular function and pulmonary artery
pressure
o Doppler echo can differentiate between systolic and diastolic dysfunction
o Radionuclide ventriculography is necessary in all patients
o Cardiac catheterisation not necessary
Systolic Vs diastolic HF
o Diastolic dysfunction – little clinical effect when mild. When severe, ventricular filling damaged/incomplete and pressure increased
o In HF patients, normal systolic function 6% <60 years to 41% >75 years

Comments Review paper

Most tests not referenced
Part diagnosis, part treatment
No description of ‘older patient’
Reference 43
Page 36
Paper Hobbs, F. D. R., Jones, M. I., Allan, T. F., Wilson, S., & Tobias, R. 2000, "European survey of primary care physician perceptions on heart
failure diagnosis and management (Euro-HF)", European Heart Journal, vol. 21, no. 22, pp. 1877-1887.
Description
N=
Intervention
Outcomes
Results Signs quoted as most suggestive of heart failure: Oedema 75%, Short of breath on exertion 19%
Diagnosed on symptoms alone 26.4% (SD 25.2)
Symptoms + signs 41.2% (SD 26.0)
Only after specialist referral 11.6% (SD 13.4)
Chest X-rays (80%) and electrocardiography (70%) most commonly ordered tests in all countries (% routinely used for diagnosis)
No limit to use by non open access i.e. as 22% of physicians have access to echocardiography but 38% routinely use it
Comments n=294/1250
Pan European survey into heart failure management and attitudes
Structured questionnaire by cardiologists including how diagnosed and access to investigations
Questionnaire piloted y 16 GPs for reliability and validity checks
Questionnaire translated checked
Lists of GPs are not always available so a commercial source used
Multiple mailing to non-responders—low rate may indicate keener interest in heart failure by the responders and therefore may artificially inflate
results
Up to date survey
Reference 247
Page 37
Paper Goldberger, A. L. 1981, "Congestive heart failure in adults. Six considerations in systematic diagnosis", Postgraduate Medicine, vol. 69, no. 3,
pp. 151-160.
Description Review
N=
Intervention
Outcomes
Results No single ECG pattern in congestive heart failure, pathologic Q waves suggest ischaemic heart disease
Chest X-rays are useful in initial assessment, normal sized cardiac silhouette commonly seen with ischaemic heart disease
With congestive cardiomyopathies of multiple causes, echocardiography characteristically shows a dilated left ventricle
Comments Literature review of heart failure diagnosis in six key areas. Three of relevance
Short reference list (15 items)
Defined by tests rather than structured by heart function
No data on efficacy of diagnostic tests or event comparability
Page 38
Paper Schmidt, D. D., Delany, D. J., & McLaurin, L. P. 1977, "The clinical recognition of congestive heart failure", Journal of Family Practice, vol. 5, no.
2, pp. 193-197.
Description Review
N=
Intervention
Outcomes
Results Congestive heart failure defined as a ‘constellation’ of symptoms and physical findings
Symptoms relative to chronic heart failure:
Cough—i.e. respiratory infection abnormally severe/prolonged Nocturia with changes in normal renal plasma flows
Exercise dyspnoea
Orthopnoea
Paroxysmal Nocturnal dyspnoea—minutes to hours increase venous return as peripheral oedema fluid re-enters vascular system
Wheezy
Physical findings:
Rales frequently heard
Elevated neck vein pulsations
Ventricular gallop / 3rd heart sound—very suggestive of heart failure (seldom heard in those over 30)
X-ray—erect a selective increase in vascular resistance in lower lobe and increased blood flow through upper lobes
Care must be taken not to make a false positive diagnosis in patients with diminished ventilation of the lung bases
Comments Old review (25+ years)
Looking at mild congestive heart failure in terms of symptoms, signs and X-rays
Page 39
Paper Schocken, D. D. 1984, "Congestive heart failure: Dx and Rx in the elderly", Geriatrics, vol. 39, no. 11, pp. 77-80.
Description Review
N=
Intervention
Outcomes
Results Important symptoms in heart failure in the elderly include confusion, somnolence or other altered behaviour— low cardiac output should not be
excluded
Oedema may confound clinical picture as this might be from co-morbidity
Medication with negative cardiac inotropes: beta-blockers, disopyramide, veramipril
Physical exam: Inappropriate tachycardia/bradycardia
Increased blood pressure relating to hypertensive vascular disease
Widened pulse pressure suggests aortic regurgitation
Neck— Jugular venous distension a valid sign of right arterial pressure
Chest— Can show pulmonary disease
Increased amounts of inter-bronchial fluid can mimic bronchitis
Heart— Atypical palpitation can reveal ventricular S3 gallop (S4 gallop is of little use in the elderly)
Odemea— A poor predictor without other ventricular dysfunction
X-ray— Plural effusion may be the only manifestation of left ventricle heart failure
ECG— May indicate longstanding ischaemic heart disease or chamber enlargement
Comments Paper copy not complete
Sub set of elderly patients not wholly relevant
Not referenced to citations
Does not include all tests
Page 40
Paper Semelka, R. C., Tomei, E., Wagner, S., Mayo, J., Caputo, G., O’Sullivan, M., Parmley, W. W., Chatterjee, K., Wolfe, C., & Higgins, C. B. 1990,
"Interstudy reproducibility of dimensional and functional measurements between cine magnetic resonance studies in the morphologically
abnormal left ventricle", American Heart Journal, vol. 119, no. 6, pp. 1367-1373.
Description Case series – reproducibility study
N=
Intervention
Outcomes
Results Little variation in LV end-diastolic mass measurements for either observer in either group of patients: 5%

End-systolic wall stress measurement showed greatest variability: 16% in dilated cardiomyopathy group, 14% in LV hypertrophy group

Good reproducibility in all function tests
More variability in measurements of end-systolic wall stress in both HF groups compared with normal patients (p<0.05)
Comments Low study numbers. n = 11 and 8
Based in California
Low ages: Means 45 and 64 years.
2 observers, repeating observations within 1 day to 3 weeks at same time of day.
1 dropout due to change in functional class between measurements
No studies excluded due to poor image quality
Reference 39
Page 41
Paper Buser, P. T., Auffermann, W., Holt, W. W., Wagner, S., Kircher, B., Wolfe, C., & Higgins, C. B. 1989, "Noninvasive evaluation of global left
ventricular function with use of cine nuclear magnetic resonance", Journal of the American College of Cardiology, vol. 13, no. 6, pp. 1294-1300.
Description Case series
N=
Intervention
Outcomes
Results LV values (both end-systolic and end-diastolic) significantly lower in cardiomyopathy group than in normal volunteers (p<0.005), and LV
ejection fraction significantly less (p<0.001)
Correlation of LV volumes obtained by cine NMR and echocardiography was similar as in other results, but with echo giving systematically
larger measurements
In cardiomyopathy patients, dilated LV systolic wall thickening was diminished at the mid-ventricular and apical levels
LV volumes by transverse or short-axis imaging plane are nearly identical.
Comments Studied test of repeatability of cine NMR in 10 patients with dilated cardiomyopathy and 10 normal volunteers (diagnosis based on clinical
information and echocardiography)
Small number of cases
Inter-observer variability also tested
Conducted in California and Switzerland
5% significance level for hypothesis tests
Reference 40
Page 42
Paper Wagner, S., Buser, P., Auffermann, W., Holt, W. W., Wolfe, C. L., & Higgins, C. B. 1989, "Cine magnetic resonance imaging: tomographic
analysis of left ventricular function. ", Cardiology Clinics, vol. 7, no. 3, pp. 651-659.
Description Review
N=
Intervention
Outcomes
Results Cine MRI does not depend upon reproduction of imaging in relation to internal or external co-ordinates.
Comments Ejection fraction calculated as the stroke volume of a ventricle divided by the lipid dyastatic volume.
Measurements of stroke volume by the cine MRI correlate well with measurements from angiography.
In patients with previous infarction the region LV wall thickening is shown to be <2mm, while normal myocardial regions show >2mm.
Can provide non-invasive 3D
Reference 41
Page 43
Paper Clerico, A., Del Ry, S., & Giannessi, D. 2000, "Measurement of cardiac natriuretic hormones (atrial natriuretic peptide, brain natriuretic peptide,
and related peptides) in clinical practice: the need for a new generation of immunoassay methods", Clin.Chem., vol. 46, no. 10, pp. 1529-1534.
Description Review
N=
Intervention
Outcomes
Results Problems with current assay

- only the biologically active substances of the system should be studied
- peptides have different metabolisms and biological activity and secretion may be regulated differently in humans
- N-terminal hormones have different biological properties with respect to ANP/BNP system
- Use of protease inhibitors may not be necessary for BNP and proANP tests
Non competitive assays generally 5 – 20 times more precise and sensitive than competitive assays and not significantly affected by
interference
Recent non-competitive immunoluminometric assays for N-terminal BNP are highly sensitive and specific and can be modified for an
automated system
Because cardiac natriuretic hormones are raised in a variety of clinical conditions a normal value has only negative predictive value
Studies comparing the clinical usefulness of different cardiac natriuretic hormone assays have produces conflicting results
Comments Overview of the present available peptide assays and future development
40 references well linked to text
Not directly relevant to diagnostic accuracy
Italian authors reviewing international papers
Page 44
Paper Cowie, M. R. 2000, "BNP: soon to become a routine measure in the care of patients with heart failure?", Heart, vol. 83, no. 6, pp. 617-618.
Description Review
N=
Intervention
Outcomes
Results Resource implications for all 120,000 new suspected heart failure patients each year to have echocardiography, need to target patients
Diagnosis in heart failure where patient has milder symptoms more difficult than with severe cases
Limit of positive BNP test to suggest the presence of some form of cardiac abnormality, requires further investigation to confirm
Can identify patients with significant left ventricular systolic dysfunction who present asymptomatically
Can identify patients that are likely to have significant left ventricular dysfunction
Comments Brief editorial article
12 references
Diagnosis is only one theme of the piece
Attempt to predict future trends
Page 45
Paper Ishmail AA et al (1987). Inter-observer agreement by auscultation in the presence of a third heart sound in patients with congestive heart failure
Description Case series
N=
Intervention
Outcomes
Results 57% total agreement

68% partial agreement (i.e. not yes/no)
cumulative kappa of 4 observers was 0.4 (fair)
Worse correlation in all HF or non-HF patients
Factors for poor concordance, gender, training effect, time interval all not significant (p>0.1)
S3 recorded at 24dB are almost always heard
Poor agreement attributed to difficulty in discriminating S3 from background noise
Comments n = 81
Paired test for detection of S3 sound, blind to history and reason for admission
60% male
40% CHF
Background noise reduced where possible
Percentage agreement, weighted percentage agreement, and kappa score were calculated
Page 46
Paper Haas, G. J. & Leier, C. V. 1990, "Invasive cardiovascular testing in chronic congestive heart failure.", Critical Care Medicine, vol. 18, no. 1 Pt 2,
p. S1-S4.
Description Review
N=
Intervention
Outcomes
Results Coronary angiography: Most useful method for detecting the presence and assessing obstructive coronary artery disease in congestive heart
failure provides a basis for therapeutic decisions.
Unless patient has a history of myocardial infarction, coronary angiography is usually required to unequivocally categorise as ischaemic or non-
ischaemic cardiomyopathy
Cardiac catheterisation: To diagnose previously undiagnosed conditions such as pulmonary hypertension silent aortic stenosis
Often results in patient stress and this makes a true assessment of baseline function difficult
Poor correlation between catheterisation data and clinical status or exercise capacity (4 references)
Pulmonary artery catheter: Can be used to assess status pf ventricular preload and after load if not available from clinical examination or other
lab data
To record patients haemodynamic response to exercise
Comments Review of 39 papers
Focussing on diagnosis and prognosis
Assessing a range of invasive cardiovascular testing devices
No quantitative grading of test types
No assessment of comfort / side effects
Reference 44
Page 47
Paper Massie, B. 1986, "Updated diagnosis and management of congestive heart failure", Geriatrics, vol. 41, no. 3, pp. 30-35.
Description Review
N=
Intervention
Outcomes
Results Often essential to make objective measurements of left ventricle function to confirm or exclude the presence of congestive heart failure
If left ventricle ejection fraction is normal or less than 40% the patient is unlikely to be very symptomatic from systolic myocardial dysfunction
of the left ventricle— in these patients and alternative explanation should be sought. Echocardiography, exercise testing, ambulatory ECG
monitoring, and cardiac catheterisation are useful
Cardiac catheterisation is rarely helpful in the absence of abnormal findings on non invasive tests
Comments No reforming to test
Diagnosis only one part of fuller management review
Focused at elderly subset of patients
Reference 42
Page 48

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Heart Failure Guideline: Evidence tables

Section 6: Diagnosing Heart Failure

Chronic heart failure: management of chronic heart failure in

APPENDIX J: EVIDENCE TABLES

Section 6: Diagnosing heart failure

Symptoms, signs and non-cardiac investigation

Description Diagnostic study

Intervention History; symptoms; signs; medication or any combination of these

Results History of MI – sensitivity 59%; specificity 86%

Intervention Clinical examination; chest x-ray

Outcomes Comparison with the standard diagnostic test of haemodynamic function

Description Diagnostic study

Intervention Range of clinical tests

Outcomes Echocardiography-tested LV dysfunction and hypertension

Comments 36 references, including national guidelines

Results GP central to providing diagnosis from early clinical indications

Weight gain, oedema, cough – pulmonary and systemic venous congestion

Dyspnoea – congestive heart failure (also due to other factors)

40% of all HF diagnoses based purely on oedema are wrong

Lung rales – non-specific

Tachycardia and low volume pulse

Third heart sound at cardiac apex abnormal in patients 40 years +

Elevation of jugular vein >1cm above normal at rest

Results Precipitory factors

NYHA widely used as classification

When non-chemical defect suspected post MI

In some patients to help diagnose cardiomyopathy

Endomyocardial biopsies not recommended in either dilated cardiomyopathies or myocarditis

Description Systematic review

N= n=? (27 studies)

Description Systematic review

N= n=? (28 diagnostic studies)

Intervention An assessment of the following investigations to assess cardiac function:

Description Diagnostic study

Intervention Pulmonary function tests

Outcomes Comparison with cardiac catheterisation

Description Cohort study

Intervention Echocardiography or not

Comments Prognostic test of outcome and also pharmaceutical issues

Description Cohort study

Intervention Heart failure patients or not heart failure patients

Outcomes Exercise capacity by Doppler recording at rest and post exercise

Results Advantages of echocardiogram, harmless effects of sound waves, so can be repeated

Paper Hanrath, P. & Schlüter, M. (1983) Is echocardiography a reliable tool?

Description Diagnostic study

Intervention LV dysfunction by echocardiogram test.

Outcomes ECG assessment of LV

Results No significant difference between sub-survey (2 GPs, 1 specialist).

Description Diagnostic study

Description Cohort study

Intervention Blood plasma ANP levels

Outcomes Presence of congestive heart failure, no congestive heart failure, death

Description Case control study

Intervention Hypertension and cardiac impairment Vs control

Outcomes Levels of BNP in blood plasma. NT-proBNP, and BNP-32

Results No significant difference in hypertension to control

Description Diagnostic study

Intervention Diagnostic value of natriuretic peptides (ANP and BNP)