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. 2000 Jan;50(450):50–54.

Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination, and investigations.

K Khunti 1, R Baker 1, G Grimshaw 1
PMCID: PMC1313613  PMID: 10695070

Abstract

Chronic heart failure is a common clinical syndrome that may have different causes. Its incidence and prevalence are predicted to rise substantially over the next 10 years. There are therefore major consequences for resource provision, especially in primary care, where most patients are managed. Chronic heart failure is a serious condition with high morbidity and mortality. There is good evidence to show that treatment with angiotensin-converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction improves symptoms and signs, slows progression of heart failure, reduces hospitalisation rates, and improves survival. Despite this evidence, primary care studies show that patients with heart failure are incorrectly diagnosed and inadequately treated. Most patients present in general practice, and because effective treatment relies on a correct diagnosis, this is a key step in the appropriate management of heart failure. The aim of this paper is to review the evidence about the usefulness of signs, symptoms, and investigations in diagnosing heart failure in primary care. To identify relevant studies for this review, four strategies were used: a MEDLINE search from 1993 to January 1998 using the diagnosis search filter; a MEDLINE search from 1993 to January 1998 using the guideline search filter to locate published heart failure guidelines; a search for review articles in the Cochrane Library; and a check of references in the studies identified. The search terms included MeSH terms and the keywords 'heart failure' and 'diagnosis'. All searches were limited to humans and English language articles. Studies were included in this review on the basis of quality and relevance to primary care. The review shows that symptoms and signs are important because they alert clinicians to the possibility of heart failure as a diagnosis. However, they are not sufficiently specific for confirming left ventricular systolic dysfunction. From the evidence available, a patient with suspected heart failure must have objective tests to confirm the diagnosis. These should include an electrocardiogram and, ideally, an echocardiogram. Further research is also needed on the usefulness of signs and symptoms in primary care, as most studies of heart failure have been conducted in secondary care.

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Selected References

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  1. Alam M., Rosenhamer G., Höglund C. Comparability of echocardiography and chest X-ray following myocardial infarction. J Intern Med. 1989 Sep;226(3):171–175. doi: 10.1111/j.1365-2796.1989.tb01375.x. [DOI] [PubMed] [Google Scholar]
  2. Andrews R., Cowley A. J. Clinical and economic factors in the treatment of congestive heart failure. Pharmacoeconomics. 1995 Feb;7(2):119–127. doi: 10.2165/00019053-199507020-00004. [DOI] [PubMed] [Google Scholar]
  3. Badgett R. G., Lucey C. R., Mulrow C. D. Can the clinical examination diagnose left-sided heart failure in adults? JAMA. 1997 Jun 4;277(21):1712–1719. [PubMed] [Google Scholar]
  4. Badgett R. G., Mulrow C. D., Otto P. M., Ramírez G. How well can the chest radiograph diagnose left ventricular dysfunction? J Gen Intern Med. 1996 Oct;11(10):625–634. doi: 10.1007/BF02599031. [DOI] [PubMed] [Google Scholar]
  5. Bittner V., Weiner D. H., Yusuf S., Rogers W. J., McIntyre K. M., Bangdiwala S. I., Kronenberg M. W., Kostis J. B., Kohn R. M., Guillotte M. Prediction of mortality and morbidity with a 6-minute walk test in patients with left ventricular dysfunction. SOLVD Investigators. JAMA. 1993 Oct 13;270(14):1702–1707. [PubMed] [Google Scholar]
  6. Bonneux L., Barendregt J. J., Meeter K., Bonsel G. J., van der Maas P. J. Estimating clinical morbidity due to ischemic heart disease and congestive heart failure: the future rise of heart failure. Am J Public Health. 1994 Jan;84(1):20–28. doi: 10.2105/ajph.84.1.20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Carlson K. J., Lee D. C., Goroll A. H., Leahy M., Johnson R. A. An analysis of physicians' reasons for prescribing long-term digitalis therapy in outpatients. J Chronic Dis. 1985;38(9):733–739. doi: 10.1016/0021-9681(85)90115-8. [DOI] [PubMed] [Google Scholar]
  8. Clark A. L., Coats A. J. Severity of heart failure and dosage of angiotensin converting enzyme inhibitors. BMJ. 1995 Apr 15;310(6985):973–974. doi: 10.1136/bmj.310.6985.973. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Clarke K. W., Gray D., Hampton J. R. Evidence of inadequate investigation and treatment of patients with heart failure. Br Heart J. 1994 Jun;71(6):584–587. doi: 10.1136/hrt.71.6.584. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Cohn J. N., Johnson G., Ziesche S., Cobb F., Francis G., Tristani F., Smith R., Dunkman W. B., Loeb H., Wong M. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med. 1991 Aug 1;325(5):303–310. doi: 10.1056/NEJM199108013250502. [DOI] [PubMed] [Google Scholar]
  11. Colquhoun M. C., Waine C., Monaghan M. J., Struthers A. D., Mills P. G. Investigation in general practice of patients with suspected heart failure: how should the essential echocardiographic service be delivered? Br J Gen Pract. 1995 Oct;45(399):517–519. [PMC free article] [PubMed] [Google Scholar]
  12. Cowie M. R., Struthers A. D., Wood D. A., Coats A. J., Thompson S. G., Poole-Wilson P. A., Sutton G. C. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care. Lancet. 1997 Nov 8;350(9088):1349–1353. doi: 10.1016/S0140-6736(97)06031-5. [DOI] [PubMed] [Google Scholar]
  13. Dargie H. J., McMurray J. J. Diagnosis and management of heart failure. BMJ. 1994 Jan 29;308(6924):321–328. doi: 10.1136/bmj.308.6924.321. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Davie A. P., Francis C. M., Caruana L., Sutherland G. R., McMurray J. J. Assessing diagnosis in heart failure: which features are any use? QJM. 1997 May;90(5):335–339. doi: 10.1093/qjmed/90.5.335. [DOI] [PubMed] [Google Scholar]
  15. Davie A. P., Francis C. M., Love M. P., Caruana L., Starkey I. R., Shaw T. R., Sutherland G. R., McMurray J. J. Value of the electrocardiogram in identifying heart failure due to left ventricular systolic dysfunction. BMJ. 1996 Jan 27;312(7025):222–222. doi: 10.1136/bmj.312.7025.222. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Echeverria H. H., Bilsker M. S., Myerburg R. J., Kessler K. M. Congestive heart failure: echocardiographic insights. Am J Med. 1983 Nov;75(5):750–755. doi: 10.1016/0002-9343(83)90403-5. [DOI] [PubMed] [Google Scholar]
  17. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl J Med. 1991 Aug 1;325(5):293–302. doi: 10.1056/NEJM199108013250501. [DOI] [PubMed] [Google Scholar]
  18. Etchells E., Bell C., Robb K. Does this patient have an abnormal systolic murmur? JAMA. 1997 Feb 19;277(7):564–571. [PubMed] [Google Scholar]
  19. Folland E. D., Kriegel B. J., Henderson W. G., Hammermeister K. E., Sethi G. K. Implications of third heart sounds in patients with valvular heart disease. The Veterans Affairs Cooperative Study on Valvular Heart Disease. N Engl J Med. 1992 Aug 13;327(7):458–462. doi: 10.1056/NEJM199208133270703. [DOI] [PubMed] [Google Scholar]
  20. Fowler P. B. Evidence-based diagnosis. J Eval Clin Pract. 1997 Apr;3(2):153–159. doi: 10.1046/j.1365-2753.1997.00098.x. [DOI] [PubMed] [Google Scholar]
  21. Francis C. M., Caruana L., Kearney P., Love M., Sutherland G. R., Starkey I. R., Shaw T. R., McMurray J. J. Open access echocardiography in management of heart failure in the community. BMJ. 1995 Mar 11;310(6980):634–636. doi: 10.1136/bmj.310.6980.634. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Gadsbøll N., Høilund-Carlsen P. F., Nielsen G. G., Berning J., Brunn N. E., Stage P., Hein E., Marving J., Løngborg-Jensen H., Jensen B. H. Symptoms and signs of heart failure in patients with myocardial infarction: reproducibility and relationship to chest X-ray, radionuclide ventriculography and right heart catheterization. Eur Heart J. 1989 Nov;10(11):1017–1028. doi: 10.1093/oxfordjournals.eurheartj.a059414. [DOI] [PubMed] [Google Scholar]
  23. Gillespie N. D., McNeill G., Pringle T., Ogston S., Struthers A. D., Pringle S. D. Cross sectional study of contribution of clinical assessment and simple cardiac investigations to diagnosis of left ventricular systolic dysfunction in patients admitted with acute dyspnoea. BMJ. 1997 Mar 29;314(7085):936–940. doi: 10.1136/bmj.314.7085.936. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Harlan W. R., oberman A., Grimm R., Rosati R. A. Chronic congestive heart failure in coronary artery disease: clinical criteria. Ann Intern Med. 1977 Feb;86(2):133–138. doi: 10.7326/0003-4819-86-2-133. [DOI] [PubMed] [Google Scholar]
  25. Hlatky M. A., Fleg J. L., Hinton P. C., Lakatta E. G., Marcus F. I., Smith T. W., Strauss H. C. Physician practice in the management of congestive heart failure. J Am Coll Cardiol. 1986 Oct;8(4):966–970. doi: 10.1016/s0735-1097(86)80442-9. [DOI] [PubMed] [Google Scholar]
  26. Ho K. K., Anderson K. M., Kannel W. B., Grossman W., Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation. 1993 Jul;88(1):107–115. doi: 10.1161/01.cir.88.1.107. [DOI] [PubMed] [Google Scholar]
  27. Houghton A. R., Sparrow N. J., Toms E., Cowley A. J. Should general practitioners use the electrocardiogram to select patients with suspected heart failure for echocardiography? Int J Cardiol. 1997 Oct 31;62(1):31–36. doi: 10.1016/s0167-5273(97)00181-2. [DOI] [PubMed] [Google Scholar]
  28. Ishmail A. A., Wing S., Ferguson J., Hutchinson T. A., Magder S., Flegel K. M. Interobserver agreement by auscultation in the presence of a third heart sound in patients with congestive heart failure. Chest. 1987 Jun;91(6):870–873. doi: 10.1378/chest.91.6.870. [DOI] [PubMed] [Google Scholar]
  29. Johnstone D. E., Abdulla A., Arnold J. M., Bernstein V., Bourassa M., Brophy J., Davies R., Gardner M., Hoeschen R., Mickleborough L. Diagnosis and management of heart failure. Canadian Cardiovascular Society. Can J Cardiol. 1994 Jul-Aug;10(6):613-31, 635-54. [PubMed] [Google Scholar]
  30. Kleber F. X., Niemöller L., Doering W. Impact of converting enzyme inhibition on progression of chronic heart failure: results of the Munich Mild Heart Failure Trial. Br Heart J. 1992 Apr;67(4):289–296. doi: 10.1136/hrt.67.4.289. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Kono T., Suwa M., Hanada H., Hirota Y., Kawamura K. Clinical significance of normal cardiac silhouette in dilated cardiomyopathy--evaluation based upon echocardiography and magnetic resonance imaging. Jpn Circ J. 1992 Apr;56(4):359–365. doi: 10.1253/jcj.56.359. [DOI] [PubMed] [Google Scholar]
  32. Macallan D. C., Bell J. A., Braddick M., Endersby K., Rizzo-Naudi J. The electrocardiogram in general practice: its use and its interpretation. J R Soc Med. 1990 Sep;83(9):559–562. doi: 10.1177/014107689008300909. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Madsen E. B., Gilpin E., Slutsky R. A., Ahnve S., Henning H., Ross J., Jr Usefulness of the chest x-ray for predicting abnormal left ventricular function after acute myocardial infarction. Am Heart J. 1984 Dec;108(6):1431–1436. doi: 10.1016/0002-8703(84)90688-4. [DOI] [PubMed] [Google Scholar]
  34. Mair F. S., Crowley T. S., Bundred P. E. Prevalence, aetiology and management of heart failure in general practice. Br J Gen Pract. 1996 Feb;46(403):77–79. [PMC free article] [PubMed] [Google Scholar]
  35. Mangione S., Nieman L. Z., Gracely E., Kaye D. The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey. Ann Intern Med. 1993 Jul 1;119(1):47–54. doi: 10.7326/0003-4819-119-1-199307010-00009. [DOI] [PubMed] [Google Scholar]
  36. Marantz P. R., Alderman M. H., Tobin J. N. Diagnostic heterogeneity in clinical trials for congestive heart failure. Ann Intern Med. 1988 Jul 1;109(1):55–61. doi: 10.7326/0003-4819-109-1-55. [DOI] [PubMed] [Google Scholar]
  37. Marantz P. R., Tobin J. N., Wassertheil-Smoller S., Steingart R. M., Wexler J. P., Budner N., Lense L., Wachspress J. The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria. Circulation. 1988 Mar;77(3):607–612. doi: 10.1161/01.cir.77.3.607. [DOI] [PubMed] [Google Scholar]
  38. McDonagh T. A., Morrison C. E., Lawrence A., Ford I., Tunstall-Pedoe H., McMurray J. J., Dargie H. J. Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population. Lancet. 1997 Sep 20;350(9081):829–833. doi: 10.1016/S0140-6736(97)03033-X. [DOI] [PubMed] [Google Scholar]
  39. McKee P. A., Castelli W. P., McNamara P. M., Kannel W. B. The natural history of congestive heart failure: the Framingham study. N Engl J Med. 1971 Dec 23;285(26):1441–1446. doi: 10.1056/NEJM197112232852601. [DOI] [PubMed] [Google Scholar]
  40. McMurray J., McDonagh T., Morrison C. E., Dargie H. J. Trends in hospitalization for heart failure in Scotland 1980-1990. Eur Heart J. 1993 Sep;14(9):1158–1162. doi: 10.1093/eurheartj/14.9.1158. [DOI] [PubMed] [Google Scholar]
  41. McNamara R. F., Carleen E., Moss A. J. Estimating left ventricular ejection fraction after myocardial infarction by various clinical parameters. Am J Cardiol. 1988 Aug 1;62(4):192–196. doi: 10.1016/0002-9149(88)90210-x. [DOI] [PubMed] [Google Scholar]
  42. Mulrow C. D., Lucey C. R., Farnett L. E. Discriminating causes of dyspnea through clinical examination. J Gen Intern Med. 1993 Jul;8(7):383–392. doi: 10.1007/BF02600079. [DOI] [PubMed] [Google Scholar]
  43. Murphy J. J., Frain J. P., Ramesh P., Siddiqui R. N., Bossingham C. M. Open-access echocardiography to general practitioners for suspected heart failure. Br J Gen Pract. 1996 Aug;46(409):475–476. [PMC free article] [PubMed] [Google Scholar]
  44. Ostojic M. C., Young J. B., Hess K. R. Prediction of left ventricular ejection fraction using a unique method of chest x-ray and ECG analysis: a noninvasive index of cardiac performance based on the concept of heart volume and mass interrelationship. Am Heart J. 1989 Mar;117(3):590–598. doi: 10.1016/0002-8703(89)90733-3. [DOI] [PubMed] [Google Scholar]
  45. Parameshwar J., Shackell M. M., Richardson A., Poole-Wilson P. A., Sutton G. C. Prevalence of heart failure in three general practices in north west London. Br J Gen Pract. 1992 Jul;42(360):287–289. [PMC free article] [PubMed] [Google Scholar]
  46. Patel R., Bushnell D. L., Sobotka P. A. Implications of an audible third heart sound in evaluating cardiac function. West J Med. 1993 Jun;158(6):606–609. [PMC free article] [PubMed] [Google Scholar]
  47. Remes J., Länsimies E., Pyörälä K. Usefulness of M-mode echocardiography in the diagnosis of heart failure. Cardiology. 1991;78(3):267–277. doi: 10.1159/000174793. [DOI] [PubMed] [Google Scholar]
  48. Remes J., Miettinen H., Reunanen A., Pyörälä K. Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J. 1991 Mar;12(3):315–321. doi: 10.1093/oxfordjournals.eurheartj.a059896. [DOI] [PubMed] [Google Scholar]
  49. Remes J., Reunanen A., Aromaa A., Pyörälä K. Incidence of heart failure in eastern Finland: a population-based surveillance study. Eur Heart J. 1992 May;13(5):588–593. doi: 10.1093/oxfordjournals.eurheartj.a060220. [DOI] [PubMed] [Google Scholar]
  50. Sackett D. L. The rational clinical examination. A primer on the precision and accuracy of the clinical examination. JAMA. 1992 May 20;267(19):2638–2644. [PubMed] [Google Scholar]
  51. Shiels P., MacDonald T. M. Isolated diastolic heart failure--what is it? Postgrad Med J. 1998 Aug;74(874):451–454. doi: 10.1136/pgmj.74.874.451. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Siefkin A. D. Dyspnea in the elderly: cardiac or pulmonary? Geriatrics. 1985 May;40(5):63-5, 68-70, 73. [PubMed] [Google Scholar]
  53. Spiteri M. A., Cook D. G., Clarke S. W. Reliability of eliciting physical signs in examination of the chest. Lancet. 1988 Apr 16;1(8590):873–875. doi: 10.1016/s0140-6736(88)91613-3. [DOI] [PubMed] [Google Scholar]
  54. Stevenson L. W., Perloff J. K. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA. 1989 Feb 10;261(6):884–888. [PubMed] [Google Scholar]
  55. Stewart A. L., Greenfield S., Hays R. D., Wells K., Rogers W. H., Berry S. D., McGlynn E. A., Ware J. E., Jr Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study. JAMA. 1989 Aug 18;262(7):907–913. [PubMed] [Google Scholar]
  56. Sutton G. C. Epidemiologic aspects of heart failure. Am Heart J. 1990 Dec;120(6 Pt 2):1538–1540. doi: 10.1016/0002-8703(90)90055-3. [DOI] [PubMed] [Google Scholar]
  57. Walker-Dilks C. J., McKibbon K. A., Haynes R. B. Beyond ACP Journal Club: how to harness MEDLINE for etiology problems. ACP J Club. 1994 Nov-Dec;121(3):A10–A11. [PubMed] [Google Scholar]
  58. Westman E. C., Matchar D. B., Samsa G. P., Mulrow C. D., Waugh R. A., Feussner J. R. Accuracy and reliability of apical S3 gallop detection. J Gen Intern Med. 1995 Aug;10(8):455–457. doi: 10.1007/BF02599919. [DOI] [PubMed] [Google Scholar]
  59. Wheeldon N. M., MacDonald T. M., Flucker C. J., McKendrick A. D., McDevitt D. G., Struthers A. D. Echocardiography in chronic heart failure in the community. Q J Med. 1993 Jan;86(1):17–23. [PubMed] [Google Scholar]

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