Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute DyspneaIn patients with acute shortness of breath, the diagnosis of the cause is often difficult, particularly the differentiation between cardiac and pulmonary disease. Previous investigators have shown a high degree of diagnostic uncertainty in patients hospitalized for dyspnea; others have shown that the medical history is often of paramount importance in determining the diagnosis.
The value of the physical examination in assessing such patients has not been adequately studied. However, there have been reports indicating that various maneuvers performed during the physical examination of chronically ill patients may facilitate the clinical diagnosis of congestive heart failure. The presence of hepatojugular reflux on physical examination is known to relate to invasive measures of central venous and pulmonary wedge pressure*’ in selected patients. In addition, the response of the blood pressure during and after the Valsalva maneuver is classically described as relating to ventricular function, and has been shown to correlate well with left ventricular ejection fraction in patients with chronic obstructive pulmonary disease. Although assessment of proportional pulse pressure (PPP) was not included in our original study design, a recent report indicated a correlation between the PPP ([systolic BP – diastolic BP] / systolic BP) and hemodynamic measurements in patients with congestive heart failure, with a PPP of less than 0.25 significantly predicting abnormal cardiac index at catheterization.
To determine the value of these clinical maneuvers in patients with acute dyspnea, we studied patients presenting to the emergency room with the chief complaint of shortness of breath. The diagnosis of congestive heart failure was made two ways as follow: clinically by the emergency room physician, and by the investigators blindly applying predetermined and previously validated clinicoradiographic criteria for the diagnosis. These diagnoses were then compared and related to the patients’ response to the clinical maneuvers. asthma inhalers


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