Utility of History, Physical Examination, Electrocardiogram, and ...

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Table 3. Characteristics of Patients with a Left Ventricular Ejection Fraction 30% Compared with 30% Characteristic Ejection Fraction 30% (n 136) Ejection Fraction 30% (n 89) P Value Number (%) or Mean SD Age (years) 58 14 53 13 0.008 Age 60 years 67 (50) 34 (39) 0.10 Male sex Risk factors 65 (49) 60 (67) 0.004 Hypertension 108 (81) 61 (69) 0.04 Diabetes mellitus 55 (41) 27 (30) 0.10 Hyperlipidemia 8 (6) 5 (6) 0.91 Smoking 54 (41) 40 (45) 0.52 Obesity (body mass index 30 kg/m 2 ) Other conditions 75 (61) 36 (44) 0.01 History of coronary disease 32 (24) 27 (30) 0.29 Chronic renal failure 20 (15) 7 (8) 0.11 Alcohol use Medications 29 (22) 36 (40) 0.003 ACE inhibitors 88 (67) 76 (85) 0.002 Diuretics 124 (94) 84 (94) 0.89 Beta-blockers 25 (19) 6 (7) 0.01 Digoxin 39 (30) 56 (63) 0.001 Calcium antagonists 41 (32) 10 (11) 0.001 Hydralazine Symptoms 21 (16) 8 (9) 0.14 Dyspnea at rest 52 (39) 40 (45) 0.39 Dyspnea on exertion 132 (98) 87 (99) 0.55 Orthopnea 114 (85) 76 (87) 0.64 Paroxysmal nocturnal dyspnea 98 (75) 65 (76) 0.86 Angina 11 (8) 6 (7) 0.71 Nonanginal chest pain Physical examination 49 (36) 21 (24) 0.05 Heart rate (beats per minute) 92 20 102 20 0.001 Heart rate 100 beats per minute 46 (35) 47 (53) 0.005 Systolic blood pressure (mm Hg) 162 39 139 27 0.001 Systolic blood pressure 160 mm Hg 67 (50) 17 (19) 0.001 Diastolic blood pressure (mm Hg) 92 26 88 16 0.15 Diastolic blood pressure 110 mm Hg 32 (24) 9 (10) 0.01 Pulse pressure (mm Hg) 70 26 51 19 0.001 Pulse pressure 60 mm Hg 89 (66) 27 (31) 0.001 Jugular venous distention 91 (69) 69 (79) 0.09 Pedal edema 113 (84) 63 (71) 0.02 Rales 111 (82) 80 (90) 0.09 S3 gallop 33 (29) 34 (45) 0.02 S4 gallop Electrocardiogram Rhythm 14 (12) 2 (3) 0.02 Sinus rhythm 108 (82) 72 (83) 0.91 Atrial fibrillation 21 (16) 10 (11) 0.46 Other rhythm 2 (2) 5 (6) 0.18 Abnormal Q waves 26 (20) 17 (20) 0.98 Left ventricular hypertrophy 36 (27) 35 (41) 0.04 Left atrial abnormality Chest radiograph 34 (30) 43 (52) 0.001 Cardiomegaly 114 (86) 83 (97) 0.01 Cephalization 107 (80) 80 (93) 0.01 Pulmonary edema 17 (13) 14 (16) 0.47 Pleural effusion 34 (26) 15 (17) 0.16 ACE angiotensin-converting enzyme. Clinical Findings in Heart Failure/Thomas et al 442 April 15, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 112
Table 4. Sensitivity, Specificity, and Positive and Negative Predictive Values of Clinical Findings for Markedly Decreased Systolic Function (Ejection Fraction 30%) Sensitivity Specificity was more common in patients with decreased systolic function, even though it is commonly considered to be a characteristic of diastolic heart failure. This result is a reminder that concentric or eccentric hypertrophy is common in heart failure regardless of the etiology. A limitation of this study is that some of the history and physical examinations were performed by an internist rather than by a cardiologist, and the clinical skills of the examining physicians were not assessed. Our results might have been different if all patients had been interviewed and examined by a cardiologist. However, this study does represent the real-world situation, in which Clinical Findings in Heart Failure/Thomas et al Positive Predictive Value Negative Predictive Value Percentage Historical factors Age 60 years 39 50 34 55 Male sex 67 52 48 71 Hypertension 69 19 36 48 Diabetes mellitus 30 59 33 56 Hyperlipidemia 6 94 38 60 Smoking 45 59 43 62 History of coronary disease 30 76 46 62 Chronic renal failure 8 85 26 58 Alcohol use Symptoms 40 78 55 66 Dyspnea at rest 45 61 43 62 Dyspnea on exertion 99 2 40 75 Orthopnea 87 15 40 65 Paroxysmal nocturnal dyspnea 76 25 40 62 Angina 7 92 35 60 Nonanginal chest pain Physical examination 24 64 30 56 Body mass index 30 kg/m 2 44 39 32 51 Heart rate 100 beats per minute 53 65 51 68 Systolic blood pressure 160 mm Hg 19 50 20 49 Diastolic blood pressure 110 mm Hg 10 76 22 56 Pulse pressure 60 mm Hg 31 34 23 42 Jugular venous distention 79 31 43 69 Pedal edema 71 16 36 46 Rales 90 18 42 74 S3 gallop 45 71 51 66 S4 gallop Electrocardiogram 3 88 12 58 Atrial fibrillation 11 84 32 59 Abnormal Q waves 20 80 40 61 Left ventricular hypertrophy 41 73 49 65 Left atrial abnormality Chest radiograph 52 70 56 67 Cardiomegaly 97 14 42 86 Cephalization 93 20 43 81 Pleural effusion 17 74 31 58 Pulmonary edema 16 87 45 62 many patients with heart failure are managed by primary care physicians. A related limitation is that the study included all patients with an admitting diagnosis of heart failure; no other definition of heart failure was applied. However, all but 2 of the 225 patients met the Framingham criteria for congestive heart failure (17). Another limitation is that we included only patients admitted to the hospital. Outpatients have fewer symptoms and physical findings of heart failure, and it is possible that differences between patients with normal and decreased systolic function might be more apparent. Furthermore, only the findings at the time of admission were April 15, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 112 443
Page 1 and 2: CLINICAL STUDIES Utility of History
Page 3 and 4: Table 1. Characteristics of Patient
Page 5: ating characteristic curves for the
Page 9: 26. Kitzman DW, Higginbotham MB, Co

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