A systematic review 1 included 25 studies assessing the independent significance of cardiac findings by multivariate analysis, and 9 additional studies on the differentiation of systolic and diastolic dysfunction.
Only radiographic redistribution and jugular venous distension were very helpful in the detection of increased filling pressure. The pooled results of ten studies of multiple clinical findings in combination, or the overall clinical examination demonstrated that they could not reliably confirm or exclude increased filling pressure (overall sensitivity 62%, specificity 76%, positive likelihood ratio 2.6, negative likelihood ratio 0.5).
Radiographic cardiomegaly or redistribution, anterior q-waves, left bundle branch block or abnormal atypical impulse were very helpful findings in detecting decreased ejection fraction. The pooled sensitivity and specificity of overall clinical examination were 85% and 66%, the positive likelihood ratio was 2.5, negative likelihood ratio 0.2. Patients with no abnormal findings had a low probability of having systolic dysfunction, patients with 1 to 2 abnormal findings had intermediate probability, and patients with at least 3 abnormal findings had a high probability of systolic dysfunction.
Only the presence of current hypertension was very helpful in distinguishing diastolic from systolic dysfunction. Obesity, tachycardia, elderly age, and the absence of smoking and coronary disease were ´somewhat helpful´ findings. According to one study, overall clinical examination for diagnosing diastolic versus systolic dysfunction, multiple findings in combination had 76% accuracy.
A systematic review 1 including 22 studies was abstracted in DARE. The overall clinical examination by the emergency department physician had a high positive LR (4.4, 95% CI: 1.8 to 10.0) for a final diagnosis of heart failure. The most useful features in confirming the presence of heart failure were a medical history of congestive heart failure (positive LR 5.8, 95% CI: 4.1 to 8.0) or myocardial infarction (positive LR 3.1, 95% CI: 2.0 to 5.9). The most useful symptoms in confirming the presence of heart failure were paroxysmal nocturnal dyspnoea (positive LR 2.6, 95% CI: 1.5 to 4.5), orthopnoea (positive LR 2.2, 95% CI: 1.2 to 3.9). The most useful physical examination features in confirming the presence of heart failure were the presence of a third heart sound (positive LR 11, 95% CI: 4.9 to 25.0), jugular venous distension (positive LR 5.1, 95% CI: 3.2 to 7.9), pulmonary rales (positive LR 2.8, 95% CI: 1.9 to 4.1), any cardiac murmur (positive LR 2.6, 95% CI: 1.7 to 4.1) or leg oedema (positive LR 2.3, 95% CI: 1.5 to 3.7). The most useful chest radiographic features in confirming the presence of heart failure were pulmonary venous congestion (positive LR 12, 95% CI: 6.8 to 21.0), cardiomegaly (positive LR 3.3, 95% CI: 2.4 to 4.7) or interstitial oedema (positive LR 12.0, 95% CI: 5.2 to 27.0). Patients without cardiomegaly (negative LR 0.33, 95% CI: 0.23 to 0.48) or pulmonary venous congestion (negative LR 0.48, 95% CI: 0.28 to 0.83) were less likely to have heart failure. The most useful ECG features in confirming the presence of heart failure were atrial fibrillation (positive LR 3.8, 95% CI: 1.7 to 8.8), new T-wave changes (positive LR 3.0, 95% CI: 1.7 to 5.3) or abnormal ECG findings (positive LR 2.2, 95% CI: 1.6 to 3.1). Patients with a completely normal ECG (negative LR 0.64, 95% CI: 0.47 to 0.88) were less likely to have heart failure. A low serum BNP (less than 100 pg/mL) was the most useful test for excluding the presence of heart failure (negative LR 0.11, 95% CI: 0.07 to 0.16). However, BNP levels should be interpreted differently for patients with renal insufficiency.
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