Heart failure: clinical features and atrial peptide can help detect systolic dysfunction in primary care patients

Clinical bottom line (level 2b)

  1. One in eight patients in the community suspected of having heart disease have systolic dysfunction.
  2. Heart rate > diastolic blood pressure (LR + 3.9) and n-atrial peptide > 0.8 nmol/l (LR + 3.7) make systolic dysfunction more likely.
  3. No QRS or ST-T changes on ECG make systolic dysfunction less likely (LR - 0.24) .
Wendelboe Nielsen et al: British Medical Journal 2000; 321 : 220-224
Expires November 2003

The study

Setting: 3 general practices, Denmark

128 patients (aged 49 to 93; mean 71, 56% female) with suspected heart disease (past or present signs or symptoms)

Excluded if
  • lived in a nursing home
  • received inpatient or outpatient treatment for advanced heart failure
  • unable to be examined


    Independent blinded reference standard, applied in all patients from a non-consecutive appropriate spectrum.
    Reference standard:
    • left ventricular ejection fraction < 45% on echocardiography
    Diagnostic test:
    • ECG
    • treatment for congestive heart failure
    • confimed myocardial infarction
    • n-terminal atrial peptide
    • resting heart rate compared with diastolic blood pressure

    The evidence

    pre-test probability of left ventricular systolic dysfunction: 12%, (95% CI: 6.3% to 18%)

    diagnostic test systolic dysfunction no systolic dysfunction LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    QRS or ST-T changes or both on ECG 13 49 2.0
    (1.5 to 2.6)     		21% 0.24
    (0.065 to 0.88)     		3%
    treated for congestive heart failure 9 34 2.0
    (1.2 to 3.2)     		21% 0.58
    (0.31 to 1.1)     		7%
    confirmed myocardial infarction 7 24 2.2
    (1.1 to 4.1)     		23% 0.68
    (0.42 to 1.1)     		8%
    n-terminal atrial peptide > 0.8 nmol/l 6 12 3.7
    (1.6 to 8.4)     		33% 0.67
    (0.44 to 1.0)     		8%
    heart rate > diastolic bp 8 15 3.9
    (2.0 to 7.7)     		35% 0.54
    (0.31 to 0.93)     		7%
    total 15 111

    Comments

    1. A history of heart failure or myocardial infarction was not significantly associated with left ventricular dysfunction
    2. Neither dyspnoea, chest radiography nor the physical examination was associated with systolic dysfunction.

    Citation

    1. Wendelboe Nielsen O, Fischer Hansen J, Hilden J, et al: risk assessment of left ventricular systolic dysfunction in primary care: cross sectional study evaluating a range of diagnostic tests. British Medical Journal 2000; 321 : 220-224
    Search Terms: from ACP Journal Club other articles noted
    Contributor: Chris Ball, November 2001
    Reviewer:

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