To assess the accuracy in diagnosing heart failure of clinical features and potential primary care investigations, and to perform a decision analysis to test the impact of plausible diagnostic strategies on costs and diagnostic yield in the UK health-care setting. MEDLINE and CINAHL were searched from inception to 7 July 2006. 'Grey literature' databases and conference proceedings were searched and authors of relevant studies contacted for data that could not be extracted from the published papers. A systematic review of the clinical evidence was carried out according to standard methods. Individual patient data (IPD) analysis was performed on nine studies, and a logistic regression model to predict heart failure was developed on one of the data sets and validated on the other data sets. Cost-effectiveness modelling was based on a decision tree that compared different plausible investigation strategies. Dyspnoea was the only symptom or sign with high sensitivity (89%), but it had poor specificity (51%). Clinical features with relatively high specificity included history of myocardial infarction (89%), orthopnoea (89%), oedema (72%), elevated jugular venous pressure (70%), cardiomegaly (85%), added heart sounds (99%), lung crepitations (81%) and hepatomegaly (97%). However, the sensitivity of these features was low, ranging from 11% (added heart sounds) to 53% (oedema). Electrocardiography (ECG), B-type natriuretic peptides (BNP) and N-terminal pro-B-type natriuretic peptides (NT-proBNP) all had high sensitivities (89%, 93% and 93% respectively). Chest X-ray was moderately specific (76-83%) but insensitive (67-68%). BNP was more accurate than ECG, with a relative diagnostic odds ratio of ECG/BNP of 0.32 (95% CI 0.12-0.87). There was no difference between the diagnostic accuracy of BNP and NT-proBNP. A model based upon simple clinical features and BNP derived from one data set was found to have good validity when applied to other data sets. A model substituting ECG for BNP was less predictive. From this a simple clinical rule was developed: in a patient presenting with symptoms such as breathlessness in whom heart failure is suspected, refer directly to echocardiography if the patient has a history of myocardial infarction or basal crepitations or is a male with ankle oedema; otherwise, carry out a BNP test and refer for echocardiography depending on the results of the test. On the basis of the cost-effectiveness analysis carried out, such a decision rule is likely to be considered cost-effective to the NHS in terms of cost per additional case detected. The cost-effectiveness analysis further suggested that, if likely benefit to the patient in terms of improved life expectancy is taken into account, the optimum strategy would be to refer all patients with symptoms suggestive of heart failure directly for echocardiography. The analysis suggests the need for important changes to the NICE recommendations. First, BNP (or NT-proBNP) should be recommended over ECG and, second, some patients should be referred straight for echocardiography without undergoing any preliminary investigation. Future work should include evaluation of the clinical rule described above in clinical practice.

https://espace.library.uq.edu.au/view/UQ:216901/UQ216901_OA.pdf

Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care

Background: Most patients suspected of having heart failure (HF) will get a 12-lead electrocardiogram (ECG) but its utility for excluding HF or assisting in its management has rarely been investigated.Methods: The EuroHeart Failure survey identified 11,327 patients hospitalised with a suspected diagnosis of HF from 115 hospitals in 24 countries. ECGs were obtained from 9315 patients, of whom 5934 had cardiac imaging tests. The utility of the ECG was assessed for excluding or diagnosing major structural heart disease (MSHD) or major left ventricular systolic dysfunction (MLVSD) and for therapeutic decision making.Findings: MSHD was present in 70% and MLVSD in 54% of patients overall but in only 21% and 5%, respectively, if the ECG was entirely normal. However, = 120 ms or anterior pathological Q-waves had a probability >80% of MSHD and >70% of MLVSD. Diagnostic models suggested that electrocardiographic criteria alone were not accurate for the diagnosis or exclusion of important heart disease in this population. However, 2468 patients (42%) had an electrocardiographic finding that should be used to guide the choice of therapy.Conclusions: A normal ECG is rare in patients with suspected HF but has limited diagnostic value in this setting. The ECG has an important role in guiding therapy. (C) 2006 European Society of Cardiology. Published by Elsevier B.V All rights reserved.

https://onlinelibrary.wiley.com/doi/pdf/10.1016/j.ejheart.2006.11.003

Prevalence of ECG abnormalities in an international survey of patients with suspected or confirmed heart failure at death or discharge

Background In 2003 the National Institute of Clinical Excellence published guidelines recommending the use of brain natriuretic peptide (BNP) and the electrocardiogram (ECG) as part of the diagnostic work up of individuals with heart failure. However, the guideline did not address whether one test was superior to the other or whether performing both tests was superior to performing single tests. Aim To investigate the relative test accuracy of the ECG, BNP, N terminal-pro brain natriuretic peptide (NT-proBNP) and combinations of two or more tests in the diagnosis of left ventricular systolic dysfunction (LVSD) in the primary care setting. Design of study Cohort studies making within-subject comparisons of intervention diagnostic test(s) with reference standard results. Method Standard systematic review methodology was followed. Results Thirty-two primary studies met the review inclusion criteria. Studies were of variable quality and highly clinically heterogeneous, therefore restricting the use of meta-analysis. Within these limitations BNP, NT-proBNP and the ECG all had similar test sensitivity (>80% in the majority of studies). Specificity of the three tests was not as good. Three studies directly comparing BNP and the ECG found no difference in sensitivity and limited support for improved specificity of BNP. Two studies found no difference in sensitivity and limited evidence for an improvement in specificity for the combination of the ECG and BNP compared to single tests. Conclusion On the basis of existing evidence, the ECG, BNP and NT-proBNP are useful in excluding a diagnosis of LVSD (good sensitivity). However, use of abnormal test results to select individuals for echocardiography may overwhelm services. There is currently no evidence to justify the use of one test over another or the use of tests in combination. The additional cost of BNP is not self-evidently justified by improved test accuracy. Further research is needed to directly compare the diagnostic performance of these tests in homogeneous, representative primary care populations.

Assessing the diagnostic test accuracy of natriuretic peptides and ECG in the diagnosis of left ventricular systolic dysfunction: a systematic review and meta-analysis

Noninvasive Detection of Left Ventricular Systolic Dysfunction by Acoustic Cardiography in Cardiac Failure Patients

Discrimination of systolic and diastolic dysfunctions using multi-layer perceptron in heart rate variability analysis

.


Objective. To determine whether the combination of prolonged QRS duration and brain natriuretic peptide (BNP) levels predicts left ventricular systolic dysfunction (LVSD) with a higher accuracy compared with QRS duration or BNP alone.



Setting.  University hospital.



Methods.  We studied 128 consecutive patients with suspected cardiac disease. At rest the QRS duration on 12-lead ECG and BNP levels were determined. A left ventricular ejection fraction (LVEF) <50% at echocardiography was defined as LVSD.



Results.  QRS duration in the LVSD group (n = 66, LVEF 30 ± 8%) was longer than in the group without LVSD (n = 62, LVEF 60 ± 5%; QRS 129 ± 34 vs. 96 ± 20 ms, P  0.1, >0.11 or >0.12 s was highly specific (63, 90 and 98%) but less sensitive (84, 81 and 75%) for the prediction of LVSD. A QRS cut-off value of 106 ms was moderately sensitive (65%) but very specific (87%) for the prediction of LVSD, whereas a BNP cut-off value of >84 pg mL−1 was highly sensitive (89%) but only modestly specific (58%). The positive likelihood ratio for LVSD of abnormal BNP (2.0) and QRS prolongation >0.1 s (2.3) was improved by the combination of both criteria (5.1). In multivariate analysis, BNP and QRS duration were independent predictors of LVSD.



Conclusions.  The combination of abnormal BNP and QRS prolongation yields a higher positive likelihood ratio for the detection of LVSD compared with the two criteria alone.

https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1365-2796.2003.01265.x

QRS prolongation on surface ECG and brain natriuretic peptide as indicators of left ventricular systolic dysfunction

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QRS prolongation on surface ECG and brain natriuretic peptide as indicators of left ventricular systolic dysfunction