Abstract
BackgroundTo assess the accuracy of findings from the clinical history, symptoms, signs and diagnostic tests (ECG, CXR and natriuretic peptides) in relation to the diagnosis of left ventricular systolic dysfunction (LVSD) in a primary care setting.MethodsDiagnostic accuracy systematic review, we searched Medline (1966 to March 2008), EMBASE (1988 to March 2008), Central, Cochrane and ZETOC using a diagnostic accuracy search filter. We included cross-sectional or cohort studies that assess the diagnostic utility of clinical history, symptoms, signs and diagnostic tests, against a reference standard of echocardiography. We calculated pooled positive and negative likelihood ratios and assessed heterogeneity using the I2 index.Results24 studies incorporating 10,710 patients were included. The median prevalence of LVSD was 29.9% (inter-quartile range 14% to 37%). No item from the clinical history or symptoms provided sufficient diagnostic information to "rule in" or "rule out" LVSD. Displaced apex beat shows a convincing diagnostic effect with a pooled positive likelihood ratio of 16.0 (8.2–30.9) but this finding occurs infrequently in patients. ECG was the most widely studied diagnostic test, the negative likelihood ratio ranging from 0.06 to 0.6. Natriuretic peptide results were strongly heterogeneous, with negative likelihood ratios ranging from 0.02 to 0.80.ConclusionFindings from the clinical history and examination are insufficient to "rule in" or "rule out" a diagnosis of LVSD in primary care settings. BNP and ECG measurement appear to have similar diagnostic utility and are most useful in "ruling out" LVSD with a normal test result when the probability of LVSD is in the intermediate range.
Highlights
To assess the accuracy of findings from the clinical history, symptoms, signs and diagnostic tests (ECG, Chest X ray (CXR) and natriuretic peptides) in relation to the diagnosis of left ventricular systolic dysfunction (LVSD) in a primary care setting
The European Society of Cardiology (ESC) state that there is no exclusive definition of Heart Failure it is recognised as a syndrome in which abnormal cardiac function is a cause for the heart being unable to pump blood at the rate required to meet the needs of the metabolizing tissues [2]
Reasons for exclusion of studies (n = 46) included, incorrect study design, population derived from duplicate publication, and population included patients previously diagnosed with LVSD
Summary
To assess the accuracy of findings from the clinical history, symptoms, signs and diagnostic tests (ECG, CXR and natriuretic peptides) in relation to the diagnosis of left ventricular systolic dysfunction (LVSD) in a primary care setting. Left Ventricular Systolic Dysfunction (LVSD) is a major clinical problem worldwide. In the UK alone it has been estimated that 878,000 people have definite or probable LVSD, with 63,000 new cases annually [1]. LVSD is one possible reason for heat failure characterised by compromised ventricular function leading to a variety of symptoms such as fatigue, breathlessness, and oedema. Accurate diagnosis of LVSD with echocardiography is important for two reasons: firstly to determine the underlying cause of heart failurebroadly LVSD, valve disease, or diastolic dysfunction of the left ventricle (heart failure with preserved systolic function); and secondly to initiate treatments to alleviate symptoms, delay progression and improve prognosis [3]
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