Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure?

Abstract

A 70-year-old woman with a history of a previous myocardial infarction and heart failure presents to the emergency department (ED) with a 2-day history of dyspnea at rest, orthopnea, and paroxysmal nocturnal dyspnea. Physical examination reveals an elevated jugular venous pressure, a third heart sound (ventricular filling gallop), bibasilar rales and wheezing, and bilateral lower extremity edema. The chest radiograph reveals cardiomegaly. An electrocardiogram (ECG) shows atrial fibrillation. Case 2A 65-year-old previously healthy man with a 30 pack-year smoking history presents to the ED with a 3-week history of dyspnea on exertion and at rest, associated with productive cough and sputum. Physical examination reveals bilateral rales and wheezing. The chest radiograph reveals pulmonary venous congestion and a pattern of interstitial edema. An ECG shows lateral STsegment depression. Case 3A 60-year-old man with a history of chronic obstructive pulmonary dis-ease (COPD) and previous myocardial infarction presents to the ED with a 2-week history of worsening dyspnea on exertion and cough. Physical examination reveals an elevated jugular venous pressure, bilateral wheezing, and bilateral lower extremity edema. The chest radiograph shows CME available online at www.jama.com

Comparison of a basic lung scanning protocol against formally reported chest x‐ray in the diagnosis of pulmonary oedema

“…In a systematic review, Wang calculated the accuracy of clinical acumen (‘gestalt’‐including clinician x‐ray review) as having a positive likelihood ratio of 4.4 and a negative likelihood ratio of 0.45 5 . These figures are supported by the findings of the Breathing Not Properly multinational study, where bedside clinician judgement ‘80% certain’ using chest x‐ray, had a sensitivity of 49%, a specificity of 96% and an overall diagnostic accuracy of 74% for identifying the presence or absence of heart failure 9 .…”

“…, 2 For this reason, many people who present with breathlessness require more complex investigation to determine its cause. Specific clinical and radiographic signs of heart failure are rare 1 – 5 so patients undergo a barrage of tests with mediocre precision. This is an expensive business.…”

“…, 7 , 8 When used to investigate breathless patients, it may be interpreted as negative in up to 20% of patients with heart failure 7 9 Alternatively, when non‐radiologist x‐ray interpretation is added to clinical assessment, the diagnostic formulation is incorrect in up to 25% of breathlessness presentations 5 9 , 10 …”

Bedside Evaluation of Critical Dyspnea. Proposal of a Diagnostic Score for Acute Heart Failure in Emergency Setting

“…The score model supplies high accuracy (AUC=91.7%) and, by choosing a decision threshold again equal to 18, it minimizes the number of false negative patients who would be mistakenly be considered not at risk of AHF (SE=93.4%, 95% CI=87.0%-97.2%; NPV=94.1%, 95% CI=88.3%-97.5%). The score model, so called 18-LUNG (Lung Ultrasound-NT pro-BNP-radiology), which combines two instrumental exams and one laboratory biomarker, has a superior diagnostic accuracy compared to each one of these taken alone [39,40].…”

Diagnostic accuracy of basic lung ultrasound in breathless patients over 60 years of age; stressing the protocol

“…– 10 One in four elderly patients who present with breathlessness may be misdiagnosed 11 , 12 and possibly mismanaged in the emergency department. Rapid reliable tests evoke interest as pressure grows from increased geriatric presentations, while National Emergency Access Targets reduce time available for investigation.…”