Diagnosing Heart Failure in the Emergency Department
You don't need to be Editor-In-Chief to add or edit content to WikiDoc. You can begin to add to or edit text on this WikiDoc page by clicking on the edit button at the top of this page. Next enter or edit the information that you would like to appear here. Once you are done editing, scroll down and click the Save page button at the bottom of the page.
September 24, 2007 By Grendel Burrell [1]
Washington, DC: The diagnosis of heart failure (HF) in the Emergency Department (ED) presents challenges and errors are not uncommon (1) (2) (3). Few tests have high specificity in this environment. The S3 is known to be a hallmark of worse outcomes (4) but in busy, noisy EDs, auscultating an S3 is difficult. Auscultation of the S3 can be challenging even outside the setting of the ED (5).
To assess the performance characteristics of the S3 heart sound in the ED evaluation of patients presenting with acute dyspnea, Dr. Frank Peacock et al designed and executed a multicenter prospective study of patients presenting to the ED with a primary complaint of dyspnea, the HEart failure and AUDICOR technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) study. 1077 patients met all entry criteria for the study.
45% of patients were female and 48% were black. There were high rates of concomitant disease: 20% had asthma, 28% emphysema, 34% were diabetic, 43% had a known diagnosis of CHF, 19% had prior MI, and 11% had CVA. 93% underwent chest x-ray and the results were read as “normal” in 22%. 40% of patients had cardiomegaly by x-ray. 26% of patients had an echocardiogram that was read as normal (34%), systolic dysfunction (41%), diastolic dysfunction (11%), both systolic/diastolic dysfunction (6%).
Within 15 minutes of presentation to the ED with acute dyspnea, a blinded S3 was obtained using acoustic cardiography with AUDICOR® (Inovise Medical, Portland, OR). Patients also had BNP assessed by the Biosite point of care device (Triage® BNP). At the time the AUDICOR® reading was obtained, physicians were required to indicate a diagnosis using all available data. The BNP level and S3 by acoustic cardiography were compared to a final diagnosis at the end of hospitalization, adjudicated by 2 cardiologists blinded to the S3 data.
In this large, multicenter study, the sensitivity and specificity of the S3 for heart failure diagnosis were 38% and 90%, respectively. This compared to a BNP level > 100pg/mL, which in this study had a sensitivity and specificity of 98% and 71%, respectively. Commenting on the results of the study presented as a poster at HFSA 2007, Dr. Frank Peacock, HEARD-IT investigator, Department of Emergency Medicine, The Cleveland Clinic, stated, “This technology demonstrated better assessment of an important diagnostic sign that can be missed by many physicians. This sound is a hallmark of heart failure and when present, can change how we treat patients. This approach to rapid diagnosis may improve care for patients with suspected heart failure in the emergency department.”
References:
<biblio>
- ref1 pmid=1590605
</biblio>
<biblio>
- ref2 pmid=11962564
</biblio>
<biblio>
- ref3 pmid=12135939
</biblio>
<biblio>
- ref4 pmid=12727575
</biblio>
<biblio>
- ref5 pmid=9824002
</biblio>
