Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis

Jennifer L. Martindale, Abel Wakai, Sean P. Collins, Phillip D. Levy, Deborah Diercks, Brian C. Hiestand, Gregory J. Fermann, Ian Desouza, Richard Sinert

Research output: Contribution to journalArticle

75 Citations (Scopus)

Abstract

Background Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging. Objectives The primary objective of this study was to perform a systematic review and meta-analysis of the operating characteristics of diagnostic elements available to the emergency physician for diagnosing AHF. Secondary objectives were to develop a test-treatment threshold model and to calculate interval likelihood ratios (LRs) for natriuretic peptides (NPs) by pooling patient-level results. Methods PubMed, EMBASE, and selected bibliographies were searched from January 1965 to March 2015 using MeSH terms to address the ability of the following index tests to predict AHF as a cause of dyspnea in adult patients in the ED: history and physical examination, electrocardiogram, chest radiograph (CXR), B-type natriuretic peptide (BNP), N-terminal proB-type natriuretic peptide (NT-proBNP), lung ultrasound (US), bedside echocardiography, and bioimpedance. A diagnosis of AHF based on clinical data combined with objective test results served as the criterion standard diagnosis. Data were analyzed using Meta-DiSc software. Authors of all NP studies were contacted to obtain patient-level data. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was utilized to evaluate the quality and applicability of the studies included. Results Based on the included studies, the prevalence of AHF ranged from 29% to 79%. Index tests with pooled positive LRs ≥ 4 were the auscultation of S3 on physical examination (4.0, 95% confidence interval [CI] = 2.7 to 5.9), pulmonary edema on both CXR (4.8, 95% CI = 3.6 to 6.4) and lung US (7.4, 95% CI = 4.2 to 12.8), and reduced ejection fraction observed on bedside echocardiogram (4.1, 95% CI = 2.4 to 7.2). Tests with low negative LRs were BNP < 100 pg/mL (0.11, 95% CI = 0.07 to 0.16), NT-proBNP < 300 pg/mL (0.09, 95% CI = 0.03 to 0.34), and B-line pattern on lung US LR (0.16, 95% CI = 0.05 to 0.51). Interval LRs of BNP concentrations at the low end of "positive" results as defined by a cutoff of 100 pg/mL were substantially lower (100 to 200 pg/mL; 0.29, 95% CI = 0.23 to 0.38) than those associated with higher BNP concentrations (1000 to 1500 pg/mL; 7.12, 95% CI = 4.53 to 11.18). The interval LR of NT-proBNP concentrations even at very high values (30,000 to 200,000 pg/mL) was 3.30 (95% CI = 2.05 to 5.31). Conclusions Bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis.

Original languageEnglish (US)
Pages (from-to)223-242
Number of pages20
JournalAcademic Emergency Medicine
Volume23
Issue number3
DOIs
StatePublished - Mar 1 2016
Externally publishedYes

Fingerprint

Meta-Analysis
Hospital Emergency Service
Heart Failure
Natriuretic Peptides
Confidence Intervals
Brain Natriuretic Peptide
Lung
Dyspnea
Physical Examination
Echocardiography
Emergencies
Auscultation
Bibliography
Pulmonary Edema
PubMed
Electrocardiography
Thorax
Software
Cross-Sectional Studies
History

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Martindale, J. L., Wakai, A., Collins, S. P., Levy, P. D., Diercks, D., Hiestand, B. C., ... Sinert, R. (2016). Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Academic Emergency Medicine, 23(3), 223-242. https://doi.org/10.1111/acem.12878

Diagnosing Acute Heart Failure in the Emergency Department : A Systematic Review and Meta-analysis. / Martindale, Jennifer L.; Wakai, Abel; Collins, Sean P.; Levy, Phillip D.; Diercks, Deborah; Hiestand, Brian C.; Fermann, Gregory J.; Desouza, Ian; Sinert, Richard.

In: Academic Emergency Medicine, Vol. 23, No. 3, 01.03.2016, p. 223-242.

Research output: Contribution to journalArticle

Martindale, JL, Wakai, A, Collins, SP, Levy, PD, Diercks, D, Hiestand, BC, Fermann, GJ, Desouza, I & Sinert, R 2016, 'Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis', Academic Emergency Medicine, vol. 23, no. 3, pp. 223-242. https://doi.org/10.1111/acem.12878
Martindale, Jennifer L. ; Wakai, Abel ; Collins, Sean P. ; Levy, Phillip D. ; Diercks, Deborah ; Hiestand, Brian C. ; Fermann, Gregory J. ; Desouza, Ian ; Sinert, Richard. / Diagnosing Acute Heart Failure in the Emergency Department : A Systematic Review and Meta-analysis. In: Academic Emergency Medicine. 2016 ; Vol. 23, No. 3. pp. 223-242.
@article{c6a5959ed59c4d42ab5b1dea19678cff,
title = "Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis",
abstract = "Background Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging. Objectives The primary objective of this study was to perform a systematic review and meta-analysis of the operating characteristics of diagnostic elements available to the emergency physician for diagnosing AHF. Secondary objectives were to develop a test-treatment threshold model and to calculate interval likelihood ratios (LRs) for natriuretic peptides (NPs) by pooling patient-level results. Methods PubMed, EMBASE, and selected bibliographies were searched from January 1965 to March 2015 using MeSH terms to address the ability of the following index tests to predict AHF as a cause of dyspnea in adult patients in the ED: history and physical examination, electrocardiogram, chest radiograph (CXR), B-type natriuretic peptide (BNP), N-terminal proB-type natriuretic peptide (NT-proBNP), lung ultrasound (US), bedside echocardiography, and bioimpedance. A diagnosis of AHF based on clinical data combined with objective test results served as the criterion standard diagnosis. Data were analyzed using Meta-DiSc software. Authors of all NP studies were contacted to obtain patient-level data. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was utilized to evaluate the quality and applicability of the studies included. Results Based on the included studies, the prevalence of AHF ranged from 29{\%} to 79{\%}. Index tests with pooled positive LRs ≥ 4 were the auscultation of S3 on physical examination (4.0, 95{\%} confidence interval [CI] = 2.7 to 5.9), pulmonary edema on both CXR (4.8, 95{\%} CI = 3.6 to 6.4) and lung US (7.4, 95{\%} CI = 4.2 to 12.8), and reduced ejection fraction observed on bedside echocardiogram (4.1, 95{\%} CI = 2.4 to 7.2). Tests with low negative LRs were BNP < 100 pg/mL (0.11, 95{\%} CI = 0.07 to 0.16), NT-proBNP < 300 pg/mL (0.09, 95{\%} CI = 0.03 to 0.34), and B-line pattern on lung US LR (0.16, 95{\%} CI = 0.05 to 0.51). Interval LRs of BNP concentrations at the low end of {"}positive{"} results as defined by a cutoff of 100 pg/mL were substantially lower (100 to 200 pg/mL; 0.29, 95{\%} CI = 0.23 to 0.38) than those associated with higher BNP concentrations (1000 to 1500 pg/mL; 7.12, 95{\%} CI = 4.53 to 11.18). The interval LR of NT-proBNP concentrations even at very high values (30,000 to 200,000 pg/mL) was 3.30 (95{\%} CI = 2.05 to 5.31). Conclusions Bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis.",
author = "Martindale, {Jennifer L.} and Abel Wakai and Collins, {Sean P.} and Levy, {Phillip D.} and Deborah Diercks and Hiestand, {Brian C.} and Fermann, {Gregory J.} and Ian Desouza and Richard Sinert",
year = "2016",
month = "3",
day = "1",
doi = "10.1111/acem.12878",
language = "English (US)",
volume = "23",
pages = "223--242",
journal = "Academic Emergency Medicine",
issn = "1069-6563",
publisher = "Wiley-Blackwell",
number = "3",

}

TY - JOUR

T1 - Diagnosing Acute Heart Failure in the Emergency Department

T2 - A Systematic Review and Meta-analysis

AU - Martindale, Jennifer L.

AU - Wakai, Abel

AU - Collins, Sean P.

AU - Levy, Phillip D.

AU - Diercks, Deborah

AU - Hiestand, Brian C.

AU - Fermann, Gregory J.

AU - Desouza, Ian

AU - Sinert, Richard

PY - 2016/3/1

Y1 - 2016/3/1

N2 - Background Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging. Objectives The primary objective of this study was to perform a systematic review and meta-analysis of the operating characteristics of diagnostic elements available to the emergency physician for diagnosing AHF. Secondary objectives were to develop a test-treatment threshold model and to calculate interval likelihood ratios (LRs) for natriuretic peptides (NPs) by pooling patient-level results. Methods PubMed, EMBASE, and selected bibliographies were searched from January 1965 to March 2015 using MeSH terms to address the ability of the following index tests to predict AHF as a cause of dyspnea in adult patients in the ED: history and physical examination, electrocardiogram, chest radiograph (CXR), B-type natriuretic peptide (BNP), N-terminal proB-type natriuretic peptide (NT-proBNP), lung ultrasound (US), bedside echocardiography, and bioimpedance. A diagnosis of AHF based on clinical data combined with objective test results served as the criterion standard diagnosis. Data were analyzed using Meta-DiSc software. Authors of all NP studies were contacted to obtain patient-level data. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was utilized to evaluate the quality and applicability of the studies included. Results Based on the included studies, the prevalence of AHF ranged from 29% to 79%. Index tests with pooled positive LRs ≥ 4 were the auscultation of S3 on physical examination (4.0, 95% confidence interval [CI] = 2.7 to 5.9), pulmonary edema on both CXR (4.8, 95% CI = 3.6 to 6.4) and lung US (7.4, 95% CI = 4.2 to 12.8), and reduced ejection fraction observed on bedside echocardiogram (4.1, 95% CI = 2.4 to 7.2). Tests with low negative LRs were BNP < 100 pg/mL (0.11, 95% CI = 0.07 to 0.16), NT-proBNP < 300 pg/mL (0.09, 95% CI = 0.03 to 0.34), and B-line pattern on lung US LR (0.16, 95% CI = 0.05 to 0.51). Interval LRs of BNP concentrations at the low end of "positive" results as defined by a cutoff of 100 pg/mL were substantially lower (100 to 200 pg/mL; 0.29, 95% CI = 0.23 to 0.38) than those associated with higher BNP concentrations (1000 to 1500 pg/mL; 7.12, 95% CI = 4.53 to 11.18). The interval LR of NT-proBNP concentrations even at very high values (30,000 to 200,000 pg/mL) was 3.30 (95% CI = 2.05 to 5.31). Conclusions Bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis.

AB - Background Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging. Objectives The primary objective of this study was to perform a systematic review and meta-analysis of the operating characteristics of diagnostic elements available to the emergency physician for diagnosing AHF. Secondary objectives were to develop a test-treatment threshold model and to calculate interval likelihood ratios (LRs) for natriuretic peptides (NPs) by pooling patient-level results. Methods PubMed, EMBASE, and selected bibliographies were searched from January 1965 to March 2015 using MeSH terms to address the ability of the following index tests to predict AHF as a cause of dyspnea in adult patients in the ED: history and physical examination, electrocardiogram, chest radiograph (CXR), B-type natriuretic peptide (BNP), N-terminal proB-type natriuretic peptide (NT-proBNP), lung ultrasound (US), bedside echocardiography, and bioimpedance. A diagnosis of AHF based on clinical data combined with objective test results served as the criterion standard diagnosis. Data were analyzed using Meta-DiSc software. Authors of all NP studies were contacted to obtain patient-level data. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was utilized to evaluate the quality and applicability of the studies included. Results Based on the included studies, the prevalence of AHF ranged from 29% to 79%. Index tests with pooled positive LRs ≥ 4 were the auscultation of S3 on physical examination (4.0, 95% confidence interval [CI] = 2.7 to 5.9), pulmonary edema on both CXR (4.8, 95% CI = 3.6 to 6.4) and lung US (7.4, 95% CI = 4.2 to 12.8), and reduced ejection fraction observed on bedside echocardiogram (4.1, 95% CI = 2.4 to 7.2). Tests with low negative LRs were BNP < 100 pg/mL (0.11, 95% CI = 0.07 to 0.16), NT-proBNP < 300 pg/mL (0.09, 95% CI = 0.03 to 0.34), and B-line pattern on lung US LR (0.16, 95% CI = 0.05 to 0.51). Interval LRs of BNP concentrations at the low end of "positive" results as defined by a cutoff of 100 pg/mL were substantially lower (100 to 200 pg/mL; 0.29, 95% CI = 0.23 to 0.38) than those associated with higher BNP concentrations (1000 to 1500 pg/mL; 7.12, 95% CI = 4.53 to 11.18). The interval LR of NT-proBNP concentrations even at very high values (30,000 to 200,000 pg/mL) was 3.30 (95% CI = 2.05 to 5.31). Conclusions Bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis.

UR - http://www.scopus.com/inward/record.url?scp=84960411629&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84960411629&partnerID=8YFLogxK

U2 - 10.1111/acem.12878

DO - 10.1111/acem.12878

M3 - Article

AN - SCOPUS:84960411629

VL - 23

SP - 223

EP - 242

JO - Academic Emergency Medicine

JF - Academic Emergency Medicine

SN - 1069-6563

IS - 3

ER -