Physical examination findings in patients who present to the emergency department with congestive heart failure

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Study objectives: The diagnosis of congestive heart failure (CHF) is difficult because physical examination and chest radiograph findings are not reliably identified. We describe the frequency of specific physical examination findings and chest radiograph evidence of CHF in an emergency department (ED) population and determine whether traditional heart failure risk factors affect the presence of these findings. Methods: Patients were identified from a convenience sample of patients with an ED or inpatient diagnosis of CHF according to medical record review who initially presented with a chief complaint of chest discomfort, dyspnea, or leg edema from October 2000 to December 2003. The presence of the physical examination findings of rales, S3, and jugular venous distention (JVD) was based on physician documentation in the ED. The presence of chest radiograph evidence of CHF was based on the radiologist interpretation, which was not collected until January 2002. Traditional risk factors for CHF analyzed were age older than 60 years, sex, history of diabetes, hypertension, coronary artery disease, CHF, and renal insufficiency (creatinine >1.7 mg/dL). In some instances, these risk factors were based on patient self-report. A univariate analysis was performed to determine whether any of the traditional risk factors were significant predictors of physical examination findings or evidence of CHF on chest radiograph. Any significant variables were entered into a multivariate analysis for each endpoint. Descriptive statistics were used, including χ² testing; odds ratios (ORs) and 95% confidence intervals (CIs) are given. Results: CHF was diagnosed in 537 patients who met study criteria. Of these patients, the presence of rales was documented in 67% (176/537), S3 2% (10/537), JVD 11% (61/537), and CHF on chest radiograph in 51% (165/321). History of hypertension was a significant multivariate predictor of CHF on chest radiograph. There were no predictors of the presence of an S3. History of CHF and renal insufficiency were predictors of JVD on physical examination. Only age was predictive of the presence of rales (Table). Conclusion: The presence of physical examination and chest radiograph findings of CHF are unreliable in identifying these patients in the ED. In addition, traditional risk factors for CHF have limited influence on predicting the occurrence of such findings.Table, abstract 325Univariate Analysis, OR (95% CI)Multivariate Analysis, OR (95% CI)CHF on chest radiographHypertension1.8 (1.3–2.9)1.7 (1.1–2.7)Renal insufficiency1.6 (1.0–2.6)1.5 (0.9–3.6)JVDHistory of CHF2.2 (1.2–4.1)2.1 (1.2–4.1)Renal insufficiency1.9 (1.1–3.2)1.9 (1.1–3.2)RalesAge >60 y2.5 (2.7–2.7)2.4 (1.7–3.6)Renal insufficiency1.5 (1.0–2.1)1.4 (0.9–2.0)