Utility of History, Physical Examination, Electrocardiogram, and ...
Utility of History, Physical Examination, Electrocardiogram, and ...
Utility of History, Physical Examination, Electrocardiogram, and ...
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
ecorded, <strong>and</strong> it is possible that the temporal evolution <strong>of</strong><br />
symptoms may differ in the two groups <strong>of</strong> patients. We<br />
also excluded patients in whom left ventricular function<br />
was not measured, which may have introduced bias.<br />
However, only 15% <strong>of</strong> admitted patients were excluded<br />
for this reason. In addition, ejection fraction was determined<br />
by visual estimation <strong>of</strong> ECGs. Interobserver <strong>and</strong><br />
intraobserver variability <strong>of</strong> estimates <strong>of</strong> ejection fractions<br />
were not calculated, but this method correlates well with<br />
radionuclide angiography (r 0.88), with low interobserver<br />
variability (r 0.88) in patients with adequate images<br />
(31). Although the data were collected prospectively,<br />
some physicians may have known the ejection fractions<br />
<strong>of</strong> their patients when they recorded their admission<br />
notes. In addition, this study was performed in an innercity<br />
hospital that had patients with a high prevalence <strong>of</strong><br />
hypertension, <strong>and</strong> these results may not apply to other<br />
groups <strong>of</strong> patients. Nevertheless, the prevalence <strong>of</strong> diastolic<br />
dysfunction was similar to that reported in other<br />
studies (11,32).<br />
The etiology <strong>and</strong> prognosis <strong>of</strong> heart failure may be different<br />
in patients with normal or decreased systolic function<br />
(1,5). The treatment <strong>of</strong> diastolic dysfunction is not<br />
well defined; if future trials find that st<strong>and</strong>ard therapies<br />
for systolic dysfunction are equally effective in patients<br />
with diastolic dysfunction, recommendations to determine<br />
left ventricular function in patients with heart failure<br />
may need to be reassessed. However, our results indicate<br />
that differences in clinical parameters are not <strong>of</strong> sufficient<br />
magnitude to allow systolic function to be<br />
predicted reliably in a patient with heart failure, <strong>and</strong> support<br />
the recommendations <strong>of</strong> the American College <strong>of</strong><br />
Cardiology/American Heart Association (5) <strong>and</strong> the<br />
Agency for Health Care Policy <strong>and</strong> Research (33) that all<br />
patients with heart failure should undergo echocardiography<br />
or radionuclide ventriculography to measure left<br />
ventricular function.<br />
REFERENCES<br />
1. Packer M, Cohn JN, on behalf <strong>of</strong> the Steering Committee <strong>and</strong><br />
Membership <strong>of</strong> the Advisory Council to Improve Outcomes Nationwide<br />
in Heart Failure. Consensus recommendations for the<br />
management <strong>of</strong> chronic heart failure. Am J Cardiol. 1999;83:1A–<br />
38A.<br />
2. Senni M, Tribouilloy CM, Rodeheffer RJ, et al. Congestive heart<br />
failure in the community. A study <strong>of</strong> all incident cases in Olmstead<br />
County, Minnesota, in 1991. Circulation. 1998;98:2282–2289.<br />
3. Soufer R, Wohlgelernter D, Vita NA, et al. Intact systolic left ventricular<br />
function in clinical congestive heart failure. Am J Cardiol.<br />
1985;55:1032–1036.<br />
4. McDermott MM, Feinglass J, Lee PI, et al. Systolic function, readmission<br />
rates, <strong>and</strong> survival among consecutively hospitalized patients<br />
with congestive heart failure. Am Heart J. 1997;134:728 –736.<br />
5. Report <strong>of</strong> the American College <strong>of</strong> Cardiology/American Heart Association<br />
Task Force on Practice Guidelines (Committee on Eval-<br />
Clinical Findings in Heart Failure/Thomas et al<br />
444 April 15, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 112<br />
uation <strong>and</strong> Management <strong>of</strong> Heart Failure). Guidelines for evaluation<br />
<strong>and</strong> management <strong>of</strong> heart failure. Circulation. 1995;92:2764 –<br />
2784.<br />
6. Cohn JN, Johnson G, <strong>and</strong> the VA Cooperative Study Group. Heart<br />
failure with normal ejection fraction: the V-HeFT study. Circulation.<br />
1990;81(Suppl 2):III-48 –III-53.<br />
7. Dougherty AH, Naccarelli GV, Gray EL, et al. Congestive heart<br />
failure with normal systolic function. Am J Cardiol. 1984;54:778 –<br />
782.<br />
8. Wong WF, Gold S, Fukuyama O, Blanchette PL. Diastolic dysfunction<br />
in elderly patients with congestive heart failure. Am J Cardiol.<br />
1989;63:1526 –1528.<br />
9. Ghali JK, Kadadia S, Cooper RS, Liao Y. Bedside diagnosis <strong>of</strong> preserved<br />
versus impaired left ventricular systolic function in heart<br />
failure. Am J Cardiol. 1991;67:1002–1006.<br />
10. Stone GW, Griffin B, Shah PK, et al. Prevalence <strong>of</strong> unsuspected<br />
mitral regurgitation <strong>and</strong> left ventricular diastolic dysfunction in<br />
patients with coronary artery disease <strong>and</strong> acute pulmonary edema<br />
associated with normal or depressed left ventricular systolic function.<br />
Am J Cardiol. 1991;67:37–41.<br />
11. Aronow WS, Ahn C, Kronzon I. Prognosis <strong>of</strong> congestive heart failure<br />
in elderly patients with normal versus abnormal left ventricular<br />
systolic function associated with coronary artery disease. Am J Cardiol.<br />
1990;66:1257–1259.<br />
12. Aguirre FV, Pearson AC, Lewen MK, et al. Usefulness <strong>of</strong> Doppler<br />
echocardiography in the diagnosis <strong>of</strong> congestive heart failure. Am J<br />
Cardiol. 1989;63:1098 –1102.<br />
13. Cocchi A, Zuccala G, Del Sindaco D, et al. Cross-sectional<br />
echocardiography: a window on congestive heart failure in the elderly.<br />
Aging (Milano). 1991;3:257–262.<br />
14. Warnowicz MA, Parker H, Cheitlin MD. Prognosis <strong>of</strong> patients with<br />
acute pulmonary edema <strong>and</strong> normal ejection fraction after acute<br />
myocardial infarction. Circulation. 1983;67:330 –334.<br />
15. Bier AJ, Eichacker PQ, Sinoway LI, et al. Acute pulmonary edema:<br />
clinical <strong>and</strong> noninvasive evaluation. Angiology. 1988;39:211–218.<br />
16. Kinney EL, Wright RJ. Survival in patients with heart failure <strong>and</strong><br />
normal basal systolic wall motion. Angiology. 1989;40:1025–1029.<br />
17. Ho KKL, Anderson KM, Kannel WB, et al. Survival after the onset<br />
<strong>of</strong> congestive heart failure in Framingham Heart Study subjects.<br />
Circulation. 1993;88:107–115.<br />
18. Sgarbossa EB, Wagner GS. Electrocardiography. In: Topol EJ, ed.<br />
Textbook <strong>of</strong> Cardiovascular Medicine. Philadelphia: Lippincott-<br />
Raven; 1998:1545–1589.<br />
19. Chou T-C. Atrial abnormalities. Electrocardiography in Clinical<br />
Practice. 3rd ed. Philadelphia: W. B. Saunders; 1991:23–35.<br />
20. European Study Group on Diastolic Heart Failure. How to diagnose<br />
diastolic heart failure. Eur Heart J. 1998;19:990 –1003.<br />
21. Judge KW, Pawitan Y, Caldwell J, et al. Congestive heart failure<br />
symptoms in patients with preserved left ventricular systolic<br />
function: analysis <strong>of</strong> the CASS registry. J Am Coll Cardiol. 1991;18:<br />
377–382.<br />
22. Cregler LL, Georgiou D, Sosa I. Left ventricular diastolic dysfunction<br />
in patients with congestive heart failure. J Nat Med Assoc. 1991;<br />
83:49 –52.<br />
23. Marantz PR, Tobin JN, Wassertheil-Smoller S, et al. The relationship<br />
between left ventricular systolic function <strong>and</strong> congestive heart<br />
failure diagnosed by clinical criteria. Circulation. 1988;77:607–612.<br />
24. Echeverria HH, Bilsker MS, Myerburg RJ, Kessler KM. Congestive<br />
heart failure: echocardiographic insights. Am J Med. 1983;75:750 –<br />
755.<br />
25. Iriarte M, Murga N, Sagastagoitia D, et al. Congestive heart failure<br />
from left ventricular dysfunction in systemic hypertension. Am J<br />
Cardiol. 1993;71:308 –312.