Detection Of Chronic Heart Failure Research Articles

Features of chronic heart failure on the background of thrombocytopenia in persons infected with the human immunodeficiency virus

The general context of the study is to review the characteristics of the course of chronic heart failure (CHF) in persons infected with the human immunodeficiency virus (HIV) as a part of a single-stage screening clinical trial.Aim: To determine the features of the CHF course in HIV-infected patients, depending on the presence of thrombocytopenia (TP).Material and Methods. In a multidisciplinary hospital, 240 patients with HIV infection were examined for four years, where a cohort of patients with CHF (160 people) was identified, further divided into groups of patients with TP (107 people) and without TP (53 people). Patients underwent the same amount of research, including echocardiography, non-invasive arteriography, and a detailed laboratory examination.Results. TP in patients with CHF and HIV infection is more common in smokers and people with alcohol dependence and is associated with hemodynamic disorders in the form of higher systolic and diastolic blood pressure, left atrium increase. With TP, the values of NT-proBNP in blood plasma are higher, and in the blood serum – tissue inhibitor of metalloproteinases-1, urea, bilirubin, while the concentration of sodium and potassium ions in the blood serum is lower. Anemia and leukopenia were more common in the group of patients with thrombocytopenia. Patients with TP are more adherent to taking protease inhibitors and non-steroidal anti-inflammatory drugs.Conclusion. The frequency of CHF detection in patients with HIV infection against the background of TP is almost 2 times higher and is more often accompanied by dilatation of the left atrium, higher blood pressure, an increase in TIMP-1 and a decrease in the concentration of potassium ions in the blood serum. The concentration of NT-proBNP in blood plasma has a close inverse correlation with the number of platelets in patients with CHF and TP, and the presence of severe TP ≤ 30 × 109 cells/l increases the chances of developing CHF with low left ventricular ejection fraction by 10.8 times. Smoking, possible alcohol dependence and adherence to taking protease inhibitors and NSAIDs are significant factors associated with the development of thrombocytopenia in HIV-infected patients with CHF.

Diagnostic performance of microRNAs in the detection of heart failure with reduced or preserved ejection fraction: a systematic review and meta-analysis.

Chronic heart failure (CHF) can be classified as heart failure with preserved ejection fraction (HFpEF) or with reduced ejection fraction (HFrEF). Currently, there is an unmet need for a minimally invasive diagnostic tool for different forms of CHF. We aimed to investigate the diagnostic potential of circulating microRNAs (miRNAs) for the detection of different CHF forms via a systematic review and meta-analysis approach. Comprehensive search on Medline, Web of Science, Scopus, and EMBASE identified 45 relevant studies which were used for qualitative assessment. Out of these, 29 studies were used for qualitative and quantitative assessment and allowed to identify a miRNA panel able to detect HFrEF and HFpEF with areas under the curve (AUC) of 0.86 and 0.79, respectively. A panel of eight miRNAs (hsa-miR-18b-3p, hsa-miR-21-5p, hsa-miR-22-3p, hsa-miR-92b-3p, hsa-miR-129-5p, hsa-miR-320a-5p, hsa-miR-423-5p, and hsa-miR-675-5p) detected HFrEF cases with a sensitivity of 0.85, specificity of 0.88 and AUC of 0.91. A panel of seven miRNAs (hsa-miR-19b-3p, hsa-miR-30c-5p, hsa-miR-206, hsa-miR-221-3p, hsa-miR-328-5p, hsa-miR-375-3p, and hsa-miR-424-5p) identified HFpEF cases with a sensitivity of 0.82 and a specificity of 0.61. Although conventional biomarkers (N-terminal pro-B-type natriuretic peptide and B-type natriuretic peptide) presented a better performance in detecting CHF patients, the results presented here pointed towards specific miRNA panels with potential additive values to circulating natriuretic peptides in the diagnosis of different classes of CHF. Equally important, miRNAs alone showed a reasonable capacity for 'ruling out' patients with HFrEF or HFpEF. Additional studies with large populations are required to confirm the diagnostic potential of miRNAs for sub-classes of CHF.

Soluble ST2 proteins in male cachectic patients with chronic heart failure

Background and aimsUntil now, there are lack of established clinical factors allowing management of chronic heart failure (CHF) patients being at risk of cardiac cachexia (CC). The changes in soluble protein ST2 (sST2) concentrations suggest a valuable and prognostic usefulness of this biomarker in monitoring patients with CHF, especially those who potentially are prompt to develop CC. The aim of this study was to assess the potential role of sST2 in male patients with CHF under cachexia condition. Methods and result91 male patients were selected to the study group and underwent meticulous screening according to recent clinical guidelines in order to CHF and CC detection. Additionally all patients underwent assessment of body composition and sST2 testing. Patients were followed-up for 60 months. Plasma sST2 concentration was significantly increased in cachectic compared with non-cachectic patients (median: 27.40 ng/mL and 20.62 ng/mL; p < 0.001), however, in this group the EF% was reduced (mean: 34 ± 13.5% and 41 ± 14.5%; p = 0.029). Correlations between sST2 and CRP (R = 0.524; p < 0.001) and phase angle (PA) (R = −0.513; p < 0.001) were observed. CHF patients in whose the PA value ranged in Q1 (<3.06°) and sST2 concentration ranged in Q3 (>33.15 ng/mL) had higher risk of death (HR = 9.62 and 8.60, respectively). The death rate was the highest in cachectic group with the simultaneous presence of sST2-Q3 and PA-Q1 (87.5% of this group). They had almost 7-fold higher risk of death during follow-up period (HR = 6.89, p < 0.001). ConclusionssST2 demonstrates potential utility in male patients with CHF under cachexia condition in prediction death rate.

Features of hemodynamics in the comorbid course of essential hypertension and type 2 diabetes in men, residents of Podillia, carriers of polymorphic variants of the brain natriuretic peptide gene

Essential hypertension (EH) and type 2 diabetes (T2D) are important risk factors for the development of chronic heart failure (CHF). The early detection of CHF, especially under comorbidity, remains a challenge. To solve it in today’s conditions are used not only instrumental diagnostic methods (Echo-CG), but also the assessment of plasma levels of biomarker – brain natriuretic peptide (BNP), the expression of which is determined by the corresponding gene (locus T-381C) and may depend on its structural organization. It is proved that deregulation of the natriuretic peptide system (NP) is an important factor in the initiation and progression of myocardial dysfunction and energy imbalance, but the role of genetic preconditions for these disorders, including the peculiarities of polymorphic variants of the most physiologically significant gene is still not enough clear. The aim of the work was to investigate the presence of associations between indicators of systemic and intracardiac hemodynamic and the carrier of polymorphic variants of the BNP gene (T-381C) in men, residents of Podillia with the comorbid course of EH 2 and type 2 diabetes mellitus. We examined 132 middle-age men: 62 patients with EH 2 and chronic heart failure (CHF) 0-I functional classes (FC) according to NYHA Classification and 70 - with EH 2 combined with T2D and CHF FC I-II. Patients with EH 2 included in the first group and patients with EH 2 and T2D included in the second group of comparison. Parameters of intracardiac hemodynamics were determined on the basis of pulsed Doppler echocardiography. The genomic DNA of the BNP gene (T-381C) for the determination of its alleles was isolated by PCR. The mathematical processing was performed using the standard statistical package Statistica 10. We calculated the primary statistical indicators, identified differences between groups on statistical signs, performed correlation and discriminant analysis. The calculation of the relative risk with a 95% confidence interval was performed using an online calculator (https://medstatistic.ru/calculators/calcrisk.html). Among men living in Podillya with EH, both in the presence and absence of diabetes mellitus 2, the T381C genotype of the BNP gene (p&gt;0.05) dominates. In the group of comorbid patients diastolic dysfunction of the left ventricle (DD LV) was diagnosed in 90% of people (n=63), while in the isolated course of EH it was found only in 43.55% (n=28). Although among homozygotes T381T BNP gene its symptoms were 100% (n=24), and among carriers of the C allele – in 84.78% (n=39) of patients. Carriers of the T381T genotype of the BNP gene dominated among persons with DD grade II: 41.66% against 10.87% of carriers of the C allele (p&lt;0.05), while among persons with DD LV grade I there were more carriers of the C allele. Homozygous T381T genotype with EH 2 and T2D had a higher level of pulse blood pressure (p&lt;0,01), a higher probability of developing eccentric left ventricular hypertrophy (p≤0.05) and more pronounced diastolic changes in the myocardium, as compared with carriers of the C allele and can be allocated to the priority group of observation for the organization of targeted measures aimed at preventing the development and progression of CHF.

Electrical and Hormonal Biomarkers in Cachectic Elderly Women with Chronic Heart Failure.

Background: Cachexia is an unfavorable metabolic syndrome causing involuntary weight loss followed by muscle wasting, which can lead to the exacerbation of chronic heart failure (CHF), and considerably increases mortality rate among CHF patients. Unfortunately, until now it has not been possible to determine factors that could improve clinical options for cachexia management or enable the identification of patients at risk of its development. We assessed how cachexia conditions in CHF reflect cardiac and laboratory parameters in comparison with non-cachectic patients. Methods: 66 women were enrolled to the study group and underwent meticulous screening, according to recent clinical guidelines, in order to enable CHF and cachexia detection. Body composition was evaluated by bioelectrical impedance analysis (BIA) and laboratory tests were supplemented by analysis of plasma circulating irisin. Results: A negative correlation between irisin concentration and both CRP and TNF-α was recorded (R = −0.362 and R = −0.243; p < 0.05). Irisin concentration positively correlated with EF% (R = 0.253; p = 0.046) and negatively with LVESd, LVEDd and NT-proBNP (R = −0.326, −0.272, and −0.320; p < 0.05). Both low levels of circulating irisin and Capacitance of membrane (Cm) were selected as unfavorable factors affecting cachexia in CHF patients (OR = 1.39 and 34.49; p < 0.05). Combination of Cm, irisin, CRP and albumin demonstrated sensitivity of 93.3% and specificity of 85.3% (AUC = 0.949) for distinguishing between cachectic and non-cachectic CHF patients. Conclusions: Selected parameters reliably reflect cachectic conditions in CHF, and the proposed approach for cachexia based on the combined analysis of at least a few non-invasive markers could offer new opportunities for improving clinical outcomes in CHF patients.

Machine Learning and End-to-End Deep Learning for the Detection of Chronic Heart Failure From Heart Sounds

Chronic heart failure (CHF) affects over 26 million of people worldwide, and its incidence is increasing by 2% annually. Despite the significant burden that CHF poses and despite the ubiquity of sensors in our lives, methods for automatically detecting CHF are surprisingly scarce, even in the research community. We present a method for CHF detection based on heart sounds. The method combines classic Machine-Learning (ML) and end-to-end Deep Learning (DL). The classic ML learns from expert features, and the DL learns from a spectro-temporal representation of the signal. The method was evaluated on recordings from 947 subjects from six publicly available datasets and one CHF dataset that was collected for this study. Using the same evaluation method as a recent PhysoNet challenge, the proposed method achieved a score of 89.3, which is 9.1 higher than the challenge’s baseline method. The method’s aggregated accuracy is 92.9% (error of 7.1%); while the experimental results are not directly comparable, this error rate is relatively close to the percentage of recordings labeled as “unknown” by experts (9.7%). Finally, we identified 15 expert features that are useful for building ML models to differentiate between CHF phases (i.e., in the decompensated phase during hospitalization and in the recompensated phase) with an accuracy of 93.2%. The proposed method shows promising results both for the distinction of recordings between healthy subjects and patients and for the detection of different CHF phases. This may lead to the easier identification of new CHF patients and the development of home-based CHF monitors for avoiding hospitalizations.

The use of recurrence plots and beat recordings in chronic heart failure detection

Abstract Chronic heart failure is a syndrome consisting in clinical symptoms that arise as a result of complications of many disease entities. According to the definition it is a condition in which, as a consequence of permanent heart dysfunction, cardiac output is reduced in relation to tissues’ metabolic demand. This results in subjective symptoms or proper cardiac output is sustained over higher filling pressure of the left heart ventricle. The occurrence of disease among adults in Europe and North America is 0.4-2%. Heart dysfunction detected by echocardiography appears with the frequency of 3%, and in people over 60 years of age it doubles with each decade of life, reaching 10% after 80 years of age. The aim of the study is to make an acquisition of fremitus in apex beat place and quantitative evaluation of some of their features which are correlated with the advanced syndrome. We have built the apparatus for the heart signal recording and proposed the original method of its analysis based on the theory of chaos and recurrence plots. It gave us, on the group of 85 patients, sensitivity equal to 0.896 specificity equal to 0.676 and the accuracy of diagnostics of the chronic heart failure equal up to 80%.

SCReening Evaluation of the Evolution of New Heart Failure Study (SCREEN-HF): early detection of chronic heart failure in the workplace.

Objective The aim of the present study was to determine whether asymptomatic heart failure (HF) in the workplace is subject to the health worker effect, making screening using conventional risk factors combined with a cardiac biomarker, namely N-terminal pro B-type natriuretic peptide (NT-proBNP), as useful as in the general population. Methods Between June 2007 and December 2009 a 'well' population deemed at high risk for development of HF was identified through health insurance records. Blood was collected from volunteer participants for analysis of urea, electrolytes and creatinine, a full blood count and NT-proBNP. An echocardiogram was performed on selected participants based on high NT-proBNP concentrations. Results The mean left ventricular ejection fraction (LVEF) was significantly reduced in participants with the highest compared with the lowest NT-proBNP quintile. In multivariate analysis, log-transformed NT-proBNP was independently associated with impaired LVEF and with moderate to severe diastolic dysfunction after adjustment for age, sex, coronary artery disease, diabetes, hypertension and obesity. Conclusions A large burden of asymptomatic left ventricular dysfunction (AVLD) was observed in subjects aged 60 and over with plasma NT-proBNP in the top quintile that was independent of conventional risk factors and work status. HWE does not appear to operate in AVLD. NT-proBNP testing in a population with HF risk factors may cost-effectively identify those at greatest risk of developing HF in a working population and facilitate early diagnosis, treatment and maintenance of work capacity. What is known about the topic? Chronic heart failure (CHF) has several causes, the most common being hypertension and coronary ischaemia. CHF is a major health problem of increasing prevalence that severely impacts quality of life, shortens lives and reduces worker productivity. It is often not diagnosed early enough to take full advantage of ameliorating medication. What does this paper add? Population screening for CHF is not currently advocated. This may be because conventional risk factors must be used in combination and there is no useful biomarker available. Yet evidence (SOLVD (Studies of Left Ventricular Dysfunction trials) recommends early diagnosis. We believe the work place is an area of potential screening where there is little supporting evidence. This paper provides evidence that the biomarker NT-proBNP is a useful new tool that improves cost-effectiveness of screening in a selected population. Specifically, the paper recommends CHF screening in the population with the highest potential health gain (i.e. the working population) by the sector with the highest economic gain (i.e. employers). What are the implications for practitioners? The paper presents important health screening recommendations for medical and health and safety practitioners within a selected population of workers. We feel practitioners should consider screening for incipient heart failure, particularly within Australia's working population, to save lives, provide economic benefit and extend working longevity.

N-terminal pro-brain natriuretic peptide levels and diastolic dysfunction in patients with early rheumatoid arthritis before the administration of disease-modifying antirheumatic drugs

To determine N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in patients with early rheumatoid arthritis (RA) before the use of disease-modifying antirheumatic drugs (DMARDs); to compare NT-proBNP values with traditional risk factors (TRF), cardiovascular diseases (CVD), inflammatory markers, and left ventricular (LV) diastolic dysfunction (DD). The investigation enrolled 74 patients with a valid RA diagnosis (the 2010 ACR/EULAR criteria), 56 (74%) women, median (Me) age, 54 years; disease duration, 7 months; seropositive for IgM rheumatoid factor (87%) and/or anti-cyclic citrullinated peptide antibodies (100%) with no history of the use of DMARDs and glucocorticosteroids. Duplex scanning and echographic findings were used to assess TRF for CVD and carotid artery atherosclerosis (CAA) in all the patients with early RA prior to therapy. An E/A ratio was used as a criterion for LVDD. NT-proBNP concentrations in patients with early RA proved to be higher than those in the control group (p<0.0001). Higher-than-normal NT-proBNP levels were seen in 36 (49%) patients. The patients with early RA and elevated NT-proBNP values were older and had a higher body mass index (BMI) than those with normal NT-proBNP levels. Those with elevated NT-proBNP concentrations were more frequently found to have CAA, coronary calcification, and coronary heart disease; their intima-media thickness was also larger and C-reactive protein (CRP) levels higher than in those with normal NT-proBNP values. There were correlations between NT-proBNP levels and erythrocyte sedimentation rate, CRP, simplified disease activity index, and clinical disease activity index. Multivariate analysis revealed that chronic heart failure (CHF), CAA, CRP and low-density lipoprotein (LDL) levels, and BMI correlated with NT-proBNP concentrations. LVDD was detected in 35 (48%) patients with early RA. The level of NT-proBNP in patients with DD was higher than in those without DD. Higher-than-normal NT-proBNP values were observed in 23 (65%) and 12 (32%) patients with and without LVDD, respectively. The optimal NT-proBNP level for CHF detection was equal to 237.4 pg/ml (86% sensitivity and 85% specificity); the area under the ROC curve was 0.879. Just at the early disease stage, the patients are noted to have a high NT-proBNP level that is influenced by higher BMI, low LDL levels, CAA, CHF, and high CRP values. In the patients with early RA, the diagnostically significant NT-proBNP concentration for CHF detection was higher (237 pg/ml) than in those without RA (125 pg/ml). The patients with early RA should undergo NT-proBNP determination, LVDD screening, correction of TRF for CVD, atherosclerosis treatment, and remission achievement.

Computer-assisted diagnosis for chronic heart failure by the analysis of their cardiac reserve and heart sound characteristics

An innovative computer-assisted diagnosis system for chronic heart failure (CHF) was proposed in this study, based on cardiac reserve (CR) indexes extraction, heart sound hybrid characteristics extraction and intelligent diagnosis model definition. Firstly, the modified wavelet packet-based denoising method was applied to data pre-processing. Then, the CR indexes such as the ratio of diastolic to systolic duration (D/S) and the amplitude ratio of the first to second heart sound (S1/S2) were extracted. The feature set consisting of the heart sound characteristics such as multifractal spectrum parameters, the frequency corresponding to the maximum peak of the normalized PSD curve (fPSDmax) and adaptive sub-band energy fraction (sub_EF) were calculated based on multifractal detrended fluctuation analysis (MF-DFA), maximum entropy spectra estimation (MESE) and empirical mode decomposition (EMD). Statistical methods such as t-test and receiver operating characteristic (ROC) curve analysis were performed to analyze the difference of each parameter between the healthy and CHF patients. Finally, least square support vector machine (LS-SVM) was employed for the implementation of intelligent diagnosis. The result indicates the achieved diagnostic accuracy, sensitivity and specificity of the proposed system are 95.39%, 96.59% and 93.75% for the detection of CHF, respectively. The selected cutoff values of the diagnosis features are D/S=1.59, S1/S2=1.31, Δα=1.34 and fPSDmax=22.49, determined by ROC curve analysis. This study suggests the proposed methodology could provide a technical clue for the CHF point-of-care system design and be a supplement for CHF diagnosis.

Excretion of urinary orosomucoid 1 protein is elevated in patients with chronic heart failure.

Easily screening markers for early detection of chronic heart failure (CHF) are lacking. We identified twenty differently expressed proteins including orosomucoid 1(ORM1) in urine between patients with CHF and normal controls by proteomic methods. Bioinformatics analyses suggested ORM1 could be used for further analysis. After verification by western blotting, the urinary levels of ORM1 were quantified with enzyme-linked immunosorbent assay (ELISA) by correcting for creatinine expression. The ORM1-Cr was significantly elevated in CHF patients than normal controls (6498.83±4300.21 versus 2102.26±1069.24 ng/mg). Furthermore, a Spearman analysis indicated that the urinary ORM1 levels had a high positive correlation with the classification of CHF, and the multivariate analysis suggested that the urinary ORM1 content was associated with the plasma amino-terminal pro- brain natriuretic peptide (NT-proBNP) (OR: 2.106, 95% CI: 1.213–3.524, P = 0.002) and the New York Heart Association (NYHA) classification (OR: 3.019, 95% CI: 1.329–4.721, P<0.001). In addition, receiving operating curve (ROC) analyses suggested that an optimum cut-off value of 2484.98 ng/mg with 90.91% sensitivity and 85.48% specificity, respectively, could be used for the diagnosis of CHF. To sum up, our findings indicate that ORM1 could be a potential novel urinary biomarker for the early detection of CHF.

Pharmacist educational interventions program for outpatients with chronic heart failure

BackgroundPatients with chronic heart failure (CHF) take several medicines and frequently manage their medicines inappropriately. In our hospital, a postdischarge pharmacist educational interventions program (PEIP) has been introduced as a...

Chronic Heart Failure and Ischemic Stroke

Chronic heart failure (CHF) is one of the leading causes of hospitalization, morbidity, and mortality worldwide. This review summarizes current knowledge with regard to CHF as a risk factor for ischemic stroke. CHF is associated with an increased risk of thrombus formation and is accompanied by a 2- to 3-fold increased risk of stroke. Moreover, stroke in CHF patients is associated with poor outcome and higher mortality. Available evidence for additional "vascular" stroke risk factors in heart failure patients is inconsistent and is mostly derived from cohort studies or retrospective analyses. Current guidelines recommend anticoagulation for CHF patients with concomitant atrial fibrillation but not for those in sinus rhythm. Prospective studies are needed to test whether early detection and optimal treatment of CHF reduces the burden of stroke-associated neurologic and neuropsychological sequelae.

Top-Down Quantitative Proteomics Identified Phosphorylation of Cardiac Troponin I as a Candidate Biomarker for Chronic Heart Failure

The rapid increase in the prevalence of chronic heart failure (CHF) worldwide underscores an urgent need to identify biomarkers for the early detection of CHF. Post-translational modifications (PTMs) are associated with many critical signaling events during disease progression and thus offer a plethora of candidate biomarkers. We have employed a top-down quantitative proteomics methodology for comprehensive assessment of PTMs in whole proteins extracted from normal and diseased tissues. We systematically analyzed 36 clinical human heart tissue samples and identified phosphorylation of cardiac troponin I (cTnI) as a candidate biomarker for CHF. The relative percentages of the total phosphorylated cTnI forms over the entire cTnI populations (%P(total)) were 56.4 ± 3.5%, 36.9 ± 1.6%, 6.1 ± 2.4%, and 1.0 ± 0.6% for postmortem hearts with normal cardiac function (n = 7), early stage of mild hypertrophy (n = 5), severe hypertrophy/dilation (n = 4), and end-stage CHF (n = 6), respectively. In fresh transplant samples, the %P(total) of cTnI from nonfailing donor (n = 4), and end-stage failing hearts (n = 10) were 49.5 ± 5.9% and 18.8 ± 2.9%, respectively. Top-down MS with electron capture dissociation unequivocally localized the altered phosphorylation sites to Ser22/23 and determined the order of phosphorylation/dephosphorylation. This study represents the first clinical application of top-down MS-based quantitative proteomics for biomarker discovery from tissues, highlighting the potential of PTMs as disease biomarkers.

2011 Update to National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006

Chronic heart failure (CHF) is a complex and lethal clinical syndrome accounting for an increasing number of Australian hospital separations and more than 2700 Australian deaths in 2008. In 2006, the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand published Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006. Results from recently published clinical trials provide additional information to be considered in the prevention, detection and management of CHF. In some cases, this new evidence strengthens recommendations previously made in the 2006 guidelines; in others, it provides new approaches to current recommended practice. Areas in which there have been significant new developments include: Use of B-type natriuretic peptide (BNP) or N-terminal proBNP plasma level measurement in guiding treatment of CHF; New pharmacological approaches to the treatment of systolic heart failure; Drugs to avoid or use with caution in CHF; Treatment of cardiac arrhythmias in patients with CHF; Multidisciplinary care and post-discharge management programs. While patient circumstances and clinical judgement should guide the interpretation of these findings in the clinical context, this update, together with the 2006 guidelines, provides current clinical guidance on CHF.

Should All Heart Failure Patients Undergo Echocardiographic Examination?

The recent advances in the management of chronic heart failure (CHF) have the potentials to delay the onset or slow down its progression, improve symptoms and quality of life with better clinical outcome. Early detection of CHF is very crucial for effective intervention but the diagnosis of mild cases is known to be difficult as there may be few clinical features at this stage. Although, some societies’ guidelines require both symptoms and objective evidence of cardiac dysfunction for diagnosis, the role of echocardiography in the assessment of CHF in the presence of overt symptoms has been controversial. The concern bothers mainly on the cost-effectiveness of the procedure and whether or not it adds value to patient care. A test useful to a patient is one that leads to better understanding and choice of treatment associated with improved clinical outcome. Echocardiography provides a rapid, non-invasive assessment of cardiac function which is relatively cheaper compared with competing technologies. It often provides morphologic and hemodynamic information which may guide the management of patients with CHF. Brain natriuretic peptide (BNP) is useful for screening for heart failure due to systolic dysfunction but it is not a substitute for echocardiography in the diagnosis of heart failure. We suggest that all patients with CHF should have echocardiographic examination (if possible) for adequate diagnosis and accurate risk quantification. This is crucial for drug choice and monitoring of therapy.

Heart failure diagnosis in primary health care: clinical characteristics of problematic patients. A clinical judgement analysis study.

BackgroundEarly detection of chronic heart failure has become increasingly important since the introduction of effective treatment. However, clinical diagnosis of heart failure is known to be difficult, especially in mild cases or early in the course of the disease. The purpose of this study is to analyse how patient characteristics contribute to difficulties in diagnosing systolic heart failure.MethodsDesign: A Clinical Judgement Analysis study of 40 case vignettes based on authentic patients, including relevant clinical data except echocardiography. Setting: Primary health care and two cardiology outpatient clinics in Stockholm. Subjects: 70 participants with different types of clinical experience; 27 specialists in general practice, 22 cardiologists, and 21 medical students. Main outcome measures: The assessed probability of heart failure for each case vignette, and the disagreement between the participants. The number of clinical variables (cues) indicative of heart failure in the case vignettes.ResultsThe ten case vignettes with the least diverging assessments more often had increased relative cardiac volume and atrial fibrillation. No further specific clinical patterns could be found in subgroups of the case vignettes. The ten case vignettes with the most diverging assessments were those with an intermediate number of clinical variables. The case vignettes with the least diverging assessments more often represented patients with cardiac enlargement and atrial fibrillation.ConclusionDiagnosing mild heart failure is difficult, as these patients are not easy to characterise. In our study, a larger number of positive cues resulted in more diagnostic conformity among the participants, and the most important information was cardiac enlargement. The importance of more objective diagnostic methods in diagnosing suspected cases of heart failure should be emphasised.