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
The clinical utility of the hepatojugular reflux maneuver is limited by its poor sensitivity. Therefore, although its presence is a rather specific indicator of congestive heart failure, its absence can not be taken as evidence against the diagnosis. The major limitation of the Valsalva maneuver is that it is dependent on patient effort, so it is not surprising that it was often not obtained in this study. In fact, considering that all of our patients were acutely short of breath, it is striking that almost two thirds did have an evaluable Valsalva response.
Our findings are consistent with work of previous authors showing the validity of the hepatojugular reflux, or abdominojugular test,6 as a clinical sign of congestive heart failure. These studies were primarily designed to elucidate the mechanism of the response to this classic physical maneuver, which was first described in 1885. To our knowledge, this is the first study to demonstrate the clinical utility of this maneuver in a population of acutely symptomatic patients.

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