Heart Failure - initial

IncidenceNumbers (% or LR)
1. General population <75 years old annual incidence 0.2 % [1-3]
2. Primary care 75-85 years old 1% [1-3]
3. >85 years old 2% [1-3]
Risk Factor
1. Prior heart failure LR 5.8 [4]
2. Prior myocardial infarction or coronary artery disease LR 2.5 [4]
3. DiabetesLR 1.7 [4]
4. HypertensionLR 1.4 [4]
5. COPD LR 0.8
Symptoms/Syndrome
1. Shortness of breath awakening the patient at night (PND) LR 2.6 [4]
2. Breathless when lying down (orthopnea)LR 2.2 [4]
3. Leg swellingLR 1.6 [4]
4. Difficulty breathing with exertion LR 1.3 [4]
5. No other clinical symptoms or syndrome LR 0.8 [4]
TestClinical sensitivityClinical specificity
1. BNP >10090% [5-8] 76% [5-8]
2. BNP >40062% [5-8] 93% [5-8]
Other
Explanation for + test without disease:
BNP elevated in women, renal failure, age [5]
Explanation for - test without disease:
BNP falsely low in obesity [5]
Example of high value use:
Testing in patients with signs/symptoms of heart failure
Example of low value use:
Trending BNP during heart failure exacerbation

Discussion

Incidence and risk factors:

Incidence of heart failure varies greatly by age.[9] Population based studies of those under age 75 identified rates of approximately 12-20/1000 people or 0.12-0.2% annual incidence.[1,2] Incidence was higher if elderly.[1,2]

Risk factors for heart failure primarily relate to past heart failure or coronary artery disease.[4] More general risk factors such as diabetes have less impact. Presence of COPD had a negative predictive impact on the patient having a diagnosis of heart failure as an explanation of clinical symptoms (LR 0.8).[4]

Symptoms/Syndromes:

Symptoms of heart failure that were most predictive include paroxysmal nocturnal dyspnea (PND) or shortness of breath when reclining (orthopnea).[4] Other predictors include leg swelling or difficult breathing with exertion.[4]

Test sensitivity & specificity

The primary diagnostic test for heart failure is BNP or N-terminal pro-BNP (most health systems use one or the other).[5] The mean BNP has been interpreted based on different cutoff values to maximize either sensitivity or specificity since early descriptions of BNP clinical testing.[6] Best estimates of the clinical sensitivity or specificity of BNP were found for cutoffs of greater than 100 or greater than 400.

The sensitivity and specificity of BNP were evaluated in adults presenting to emergency care settings with shortness of breath as their predominant symptom.[6] Using a cutoff of > 100 pg/ml, the sensitivity was 90% and specificity was 76%.[6,7] Additional analysis of the results from this study also showed that using a cutoff of> 400 pg/ml resulted in a sensitivity of 62% and specificity of 93% (in individuals without atrial fibrillation).[8] Since most individuals with acute heart failure have BNP levels over 400 pg/ml, this has been proposed as the ideal cutoff for “ruling in” heart failure.[7] Results in the 100-400 pg/ml range are described as intermediate and necessitating further clinical judgment.[6]

References

  1.  Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart. 2007;93(9):1137-1146. doi:10.1136/hrt.2003.025270

  2. Mant J, Doust J, Roalfe A, et al. Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. Health Technol Assess. 2009;13(32):1-232. doi:10.3310/hta13320

  3. Borlaug BA. Heart failure with preserved ejection fraction: Clinical manifestations and diagnosis - UpToDate. UpToDate. Accessed November 3, 2021. https://www.uptodate.com/contents/heart-failure-with-preserved-ejection-fraction-clinical-manifestations-and-diagnosis

  4. Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? JAMA. 2005;294(15):1944-1956. doi:10.1001/jama.294.15.1944

  5. Colucci WS, Chen HH. Natriuretic peptide measurement in heart failure - UpToDate. UpToDate. Accessed November 3, 2021. https://www.uptodate.com/contents/natriuretic-peptide-measurement-in-heart-failure?search=heart%20failure&topicRef=113235&source=see_link#H3612693290

  6. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid Measurement of B-Type Natriuretic Peptide in the Emergency Diagnosis of Heart Failure. N Engl J Med. 2002;347(3):161-167. doi:10.1056/NEJMoa020233

  7. Maisel A. B-Type Natriuretic Peptide Levels: Diagnostic and Prognostic in Congestive Heart Failure. Circulation. 2002;105(20):2328-2331. doi:10.1161/01.CIR.0000019121.91548.C2

  8. Knudsen CW, Omland T, Clopton P, et al. Impact of Atrial Fibrillation on the Diagnostic Performance of B-Type Natriuretic Peptide Concentration in Dyspneic Patients: An Analysis From the Breathing Not Properly Multinational Study. J Am Coll Cardiol. 2005;46(5):838-844. doi:10.1016/j.jacc.2005.05.057

  9. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online October 28, 2021:CIR.0000000000001029. doi:10.1161/CIR.0000000000001029 

Authors: Eric Schultz, Brendan Day, Daniel Morgan, Deborah Korenstein, Sanket Dhruva