Category Archives: Acute Dyspnea

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Conclusion

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: ConclusionThe differential diagnosis of the patient with acute shortness of breath remains a fundamental clinical challenge for the practitioner. This task is not guided by clear criteria for distinguishing cardiac from pulmonary causes of dyspnea because none exist. Many noninvasive and invasive tests, such as pulmonary function testing, radionuclide angiography, and catheterization procedures, can be helpful in making this distinction. However, these procedures are most often employed in the long-term management of patients rather than in the acute setting, and none is performed at the bedside. buy levaquin online Continue reading

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Discussion (Part 6)

To evaluate this possibility, we examined the relation between the response to maneuvers and the presence of an S3 gallop. The S3 was chosen because it has the highest point count of any physical finding in this scale, as well as for its well-documented interobserver and intraobserver variability. In all, there were 12 patients with an S3. Continue reading

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Discussion (Part 5)

Our criteria were also dependent on the chest x-ray film, which was not obtained in every case. Fifteen subjects did not have a chest roentgenogram obtained, none of whom met criteria for congestive heart failure. Therefore, it is likely that the absence of a chest x-ray film led to an underestimate of subjects actually meeting criteria for congestive heart failure. However, only one of these 15 subjects had an S3 gallop; this subject had seven points on the congestive heart failure score without the chest x-ray film, and quite probably should have been diagnosed as having congestive heart failure (although this patient denied a history of congestive heart failure and had neither a primary nor secondary emergency room diagnosis of congestive heart failure). Continue reading

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Discussion (Part 4)

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Discussion (Part 4)There are several limitations of our study. The first, and most significant, is the lack of an incontrovertible “gold standard” or uniformly accepted criteria, for the diagnosis of congestive heart failure. It may be argued, for instance, that the “false-positive” Valsalva responses are actually “false-negatives” of the criteria used. However, the predetermined clinical criteria we elected to use were developed and validated against invasive hemodynamic measures by another research group, and we have also previously validated these criteria against radionuclide determination of LVEF. Further, since congestive heart failure is a clinical syndrome, we believe a clinical definition is appropriate, especially in light of the well-knowii limitations of such noninvasive “gold” standards as LVEF. Indeed, we have recently reported that the clinical diagnosis of congestive heart failure by these criteria is even a better predictor of survival than the LVEF. buy asthma inhalers Continue reading

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Discussion (Part 3)

The Valsalva maneuver was first described in 1704 in order to expel pus from the middle ear; it has since found widespread use in the bedside evaluation of heart murmurs as well as left ventricular and autonomic function. The response to this maneuver has been found to correlate well with left ventricular ejection fraction in a population of dyspneic patients with chronic obstructive pulmonary disease. In this study, 20 of 37 patients had a normal, sinusoidal response to Valsalva (mean LVEF 0.64 ±0.13), eight had an absent overshoot response (mean LVEF 0.42 ±0.20), and nine had a square wave response (mean LVEF 0.19 ±0.05). Our data confirm that an abnormal response to the Valsalva maneuver is a valid indicator of congestive heart failure in dyspneic patients; howev er, of 17 abnormal responses in our study, only two had the square wave response. This may reflect differences in technique and interpretation, inability of acutely ill patients to perform an optimal maneuver, or a lower prevalence of severely impaired ventricular function. buy flovent inhaler Continue reading

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Discussion (Part 2)

Since the concordance between the emergency room diagnosis and the criteria was only fair, it is possible that disagreement was greatest in the “marginal” diagnosis. However, regardless of the diagnosis or its agreement with preestablished criteria for congestive heart failure, the emergency room physicians had a high degree of certainty in their diagnoses. In all 12 patients diagnosed by the emergency room physician as having congestive heart failure, the degree of certainty was available. For those who met criteria, the DOC was 0.88; for those who did not, it was 0.89. For the 39 patients not diagnosed by the emergency room physician as having congestive heart failure, DOC was available in 32. The DOC in those not meeting criteria was 0.88; for those meeting criteria for congestive heart failure, the DOC was 0.83. buy ortho tri-cyclen online Continue reading

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Discussion (Part 1)

We found that the diagnosis of congestive heart failure is frequently missed in the emergency room assessment of the acutely dyspneic patient. Further, our data indicate that simple, bedside clinical maneuvers are valid in the assessment of acute shortness of breath in the emergency room and may be helpful in making the diagnosis of congestive heart failure. Continue reading

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Results (Part 3)

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Results (Part 3)No subject had a PPP of less than 0.25; however, two subjects had a PPP = 0.25, which would just meet the cutoff for abnormal PPP previously established. Both of these subjects had congestive heart failure by criteria. Further, we noted a statistically significant association between PPP and the diagnosis of congestive heart failure: those who met criteria had a mean PPP of 0.3725 ±0.063 (range 0.25 to 0.46), vs 0.4225 ±0.094 (range 0.27 to 0.67) in those who did not meet criteria (p = 0.044 by Student’s Mest). However, the range of values observed both with and without congestive heart failure was extensive (Fig 1); setting a cutoff of 0.40 yielded an association short of statistical significance (p = 0.059 by Fisher’s exact test). Continue reading

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Results (Part 2)

The response to the various physical examination maneuvers was compared with the clinical diagnosis of congestive heart failure, both by criteria (Table 3) and by the emergency room physician (Table 4). The hepatojugular reflux test was usually evaluable (assessed in 48, or 94 percent), but was rarely present (positive in six, or 13 percent). Conversely; the Valsalva maneuver was often uninterpretable (assessed in 32, or 63 percent), but was more likely to be abnormal if assessed (positive in 17, or 53 percent). Continue reading

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Results (Part 1)

One hundred and three patients were considered for entry in this study. Of these, 52 were excluded (21 non-English speaking, two felt to be too unstable clinically, six disoriented, four left the emergency room before a physical examination could be performed, and 19 refused to participate), leaving 51 subjects. Those excluded were similar to those included with regard to age (mean age 68 in those excluded vs 64 in the study population), emergency room diagnosis of congestive heart failure (eight vs 12 patients), and admission rates (22 vs 26 admitted). Continue reading

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