Dyspnea Due to Acute Heart Failure Syndrome

Ian S. deSouza; Jennifer L. Martindale

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Feb 1, 2019 Issue

Medicine by the Numbers

A Collaboration of TheNNT.com and AFP

Dyspnea Due to Acute Heart Failure Syndrome

IAN S. DESOUZA, MD, and JENNIFER L. MARTINDALE, MD, MSc

Am Fam Physician. 2019 Feb 1;99(3):online.

Narrative: Dyspnea is a common acute symptom in patients presenting to the emergency department and who are ultimately diagnosed with acute heart failure syndrome (AHFS).1 However, in patients with undifferentiated dyspnea, an accurate diagnosis of AHFS may be difficult with the standard initial evaluation that includes patient history, physical examination, electrocardiography (ECG), chest radiography, and natriuretic peptide testing. This systematic review and meta-analysis comprehensively evaluated the diagnostic accuracy of the clinical assessment and index tests that physicians may use to distinguish AHFS from other clinical conditions in patients presenting to the emergency department with dyspnea.2

This review included 57 mostly prospective or cross-sectional studies, 52 unique cohorts, and a total of 17,893 patients.2 There was no single historical variable, symptom, or physical examination finding that could significantly reduce the likelihood of AHFS. An S3 gallop marginally increased the likelihood of AHFS (positive likelihood ratio [LR+] = 4.0; 95% confidence interval [CI], 2.7 to 5.9) but was an insensitive finding. None of the abnormal ECG findings substantially increased or decreased the probability of AHFS. The presence of radiographic findings that represented edema moderately increased the likelihood of AHFS (LR+ = 4.8 to 6.5; Table 1), but a negative chest radiograph was unhelpful. Serum B-type natriuretic peptide (BNP) testing increased the probability of AHFS (LR+ > 5.0) but only at markedly elevated concentrations (more than 800 pg per mL [800 ng per L]; Table 2); both BNP and serum N-terminal proB-type natriuretic peptide (NT-proBNP) testing were useful at excluding AHFS at very low concentrations (less than 100 pg per mL [100 ng per L]). Bedside lung ultrasonography of three or more B-line artifacts in two bilateral lung zones had the greatest discriminatory value among index tests (LR+ = 7.4; 95% CI, 4.2 to 12.8; negative likelihood ratio [LR–] = 0.16; 95% CI, 0.05 to 0.51). Bedside echocardiography of visually estimated reduced ejection fraction was somewhat helpful (LR+ = 4.1; 95% CI, 2.4 to 7.2), and the finding of restrictive mitral pattern was highly predictive of AHFS (LR+ = 8.3; 95% CI, 4.0 to 16.9).

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TABLE 1.

Notable Pooled Test Performance Characteristics

	N	n	% AHFS (95% CI)	Sensitivity % (95% CI)	Specificity % (95% CI)	Positive LR (95% CI)	Negative LR (95% CI)
Chest radiography
Kerley B lines	2	814	46.8 (43.4 to 50.2)	9.2 (6.5 to 12.5)	98.8 (97.3 to 99.6)	6.5 (2.6 to 16.2)	0.88 (0.69 to 1.13)
Interstitial edema	3	2,001	48.3 (46.2 to 50.5)	31.1 (28.2 to 34.2)	95.1 (93.6 to 96.3)	6.4 (3.4 to 12.2)	0.73 (0.68 to 0.78)
Cephalization	5	1,338	54.0 (51.3 to 56.6)	44.7 (41.1 to 48.4)	94.6 (92.6 to 96.3)	5.6 (2.9 to 10.4)	0.53 (0.39 to 0.72)
Alveolar edema	3	2,001	48.3 (46.2 to 50.5)	5.7 (4.7 to 6.9)	98.9 (98.4 to 99.3)	5.3 (3.3 to 8.5)	0.95 (0.94 to 0.97)
Lung ultrasonography
Positive B-line scan*	8	1,914	48.2 (46.0 to 50.5)	85.3 (82.8 to 87.5)	92.7 (90.9 to 94.3)	7.4 (4.2 to 12.8)	0.16 (0.05 to 0.51)
Bedside echocardiography
Restrictive mitral pattern†	1	125	43.2 (34.9 to 52.0)	81.5 (68.6 tp 90.7)	90.1 (80.7 to 95.9)	8.3 (4.0 to 16.9)	0.21 (0.12 to 0.36)

AHFS = acute heart failure syndrome; CI = confidence interval; LR = likelihood ratio.

*—Defined as ≥ 2 bilateral lung zones with ≥ 3 B lines per intercostal space.

†—Defined as E/A ratio > 2 or E/A ratio between 1 and 2 and deceleration time (DT) < 130 msec; DT < 130 msec alone if atrial fibrillation.

TABLE 1.

Notable Pooled Test Performance Characteristics

	N	n	% AHFS (95% CI)	Sensitivity % (95% CI)	Specificity % (95% CI)	Positive LR (95% CI)	Negative LR (95% CI)
Chest radiography
Kerley B lines	2	814	46.8 (43.4 to 50.2)	9.2 (6.5 to 12.5)	98.8 (97.3 to 99.6)	6.5 (2.6 to 16.2)	0.88 (0.69 to 1.13)
Interstitial edema	3	2,001	48.3 (46.2 to 50.5)	31.1 (28.2 to 34.2)	95.1 (93.6 to 96.3)	6.4 (3.4 to 12.2)	0.73 (0.68 to 0.78)
Cephalization	5	1,338	54.0 (51.3 to 56.6)	44.7 (41.1 to 48.4)	94.6 (92.6 to 96.3)	5.6 (2.9 to 10.4)	0.53 (0.39 to 0.72)
Alveolar edema	3	2,001	48.3 (46.2 to 50.5)	5.7 (4.7 to 6.9)	98.9 (98.4 to 99.3)	5.3 (3.3 to 8.5)	0.95 (0.94 to 0.97)
Lung ultrasonography
Positive B-line scan*	8	1,914	48.2 (46.0 to 50.5)	85.3 (82.8 to 87.5)	92.7 (90.9 to 94.3)	7.4 (4.2 to 12.8)	0.16 (0.05 to 0.51)
Bedside echocardiography
Restrictive mitral pattern†	1	125	43.2 (34.9 to 52.0)	81.5 (68.6 tp 90.7)	90.1 (80.7 to 95.9)	8.3 (4.0 to 16.9)	0.21 (0.12 to 0.36)

AHFS = acute heart failure syndrome; CI = confidence interval; LR = likelihood ratio.

*—Defined as ≥ 2 bilateral lung zones with ≥ 3 B lines per intercostal space.

†—Defined as E/A ratio > 2 or E/A ratio between 1 and 2 and deceleration time (DT) < 130 msec; DT < 130 msec alone if atrial fibrillation.

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TABLE 2.

Notable Interval Likelihood Ratios of BNP and NT-proBNP Values

Author disclosure: No relevant financial affiliations.

This series is coordinated by Dean A. Seehusen, MD, MPH, AFP Assistant Medical Editor, and Daniel Runde, MD, from the NNT Group.

A collection of Medicine by the Numbers published in AFP is available at https://www.aafp.org/afp/mbtn.

References

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3. Januzzi JL Jr, Chen-Tournoux AA, Christenson RH, et al.; ICON-RELOADED Investigators. N-Terminal pro-B-type natriuretic peptide in the emergency department: the ICON-RELOADED study. J Am Coll Cardiol. 2018;71(11):1191–1200.

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6. Martindale JL, Secko M, Kilpatrick JF, et al. Serial sonographic assessment of pulmonary edema in patients with hypertensive acute heart failure. J Ultrasound Med. 2018;37(2):337–345.

7. Noble VE, Murray AF, Capp R, Sylvia-Reardon MH, Steele DJ, Litepol A. Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution. Chest. 2009;135(6):1433–1439.

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