Diagnostic Methods Congestive Heart Failure

There is no uniformly accepted clinical definition for congestive heart failure (CHF), although criteria have been published by various groups. There is also no reference standard for CHF, although left ventricular ejection fraction (LVEF) gives a quantitative assessment of systolic function and is useful in predicting prognosis. To determine the relationship between LVEF and clinically diagnosed CHF, we compared resting LVEF determined by radionuclide ventriculography with diagnosis of CHF by clinical criteria in 407 patients, based on clinical data collected by a cardiology fellow. Of 153 patients with a low LVEF (s0.40), 30 (20%) met none of the criteria for CHF. Conversely, of 204 patients with normal LVEF (.0.50), 105 (51%) met at least one of the criteria. We conclude that different criteria for CHF will have varying utility depending on the population being examined, and that a combination of clinical features and an objective measure of cardiac performance is needed to diagnose CHF. Circulation 77, No. 3, 607-612, 1988. CONGESTIVE HEART FAILURE is among the most frequently encountered cardiac diagnoses. Prevalence of congestive heart failure is estimated to be 1% in the United States,1 and Framingham data gives an incidence rate of about 2 per 1000 persons per year.2 Only 50% of patients diagnosed as having congestive heart failure survive for 5 years.' It also has major impact in terms of morbidity and hospitalization; among elderly patients, it is the most common medical indication for hospitalization.3 Epidemiologic studies in congestive heart failure have been hampered by the lack of uniform diagnostic criteria, relying instead on physician diagnosis of the disease. The Framingham Study2 created clinical criteria for diagnosing congestive heart failure (table 1); however, these criteria have never been validated against a reference standard. A study performed at From the Department of Epidemiology and Social Medicine, Medicine and Nuclear Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY. Supported in part by grant number HS 04854 from the National Center for Health Services Research, OASH. Dr. Marantz was supported by NRSA training grant 5T32-HL07379-09. Address for correspondence: Paul Marantz, M.D., M.P.H., Department of Epidemiology and Social Medicine, Montefiore Medical Center, 111 East 210th St., Bronx, NY 10467. Received Sept. 28, 1987; revision accepted Dec. 10, 1987. Vol. 77, No. 3, March 1988 Duke4 derived another set of clinical criteria for congestive heart failure by a multivariate analysis of clinical variables against left ventricular end-diastolic pressure greater than 15 mg Hg in patients referred for cardiac catheterization with anatomically confirmed coronary artery disease. The criteria generated by this study were the presence of either an S3 on examination or cardiomegaly on the chest x-ray (cardiothoracic ratio > 0.48). A third group in Boston5 used clinical judgment to derive a set of diagnostic criteria (table 2), and then validated these against a pulmonary capillary wedge pressure greater than 12 mm Hg in patients undergoing nonemergency right heart catheterization. To determine the relationship between the clinical diagnosis of congestive heart failure and objective measurement of systolic cardiac function, we compared the diagnosis of congestive heart failure, as determined by applying three different rating scales, with resting left ventricular ejection fraction, as measured by radionuclide wall motion studies. Although not a reference standard for the diagnosis of congestive heart failure per se, resting left ventricular ejection fraction has clinical significance as the most important predictor of prognosis in patients with coronary heart disease.6 It also can identify the subgroup of patients 607 by gest on A ril 6, 2017 http://ciajournals.org/ D ow nladed from