A 50 y/o man with a history of CHF and COPD is brought in by ambulance in severe respiratory distress. He is sitting upright with a RR 30 and O2 saturation of 79% on room air.
Is this a CHF or COPD exacerbation?
This is a common dilemma faced in the ED. Fortunately there are likelihood ratios to help you risk stratify using a Bayes nomogram.
Note that the first table below (McCullough et al) enrolled ED patients WITH a known history of asthma or COPD. For the second table from JAMA (Wang et al), summative LRs for BNP are provided in ED patients with or without a history of asthma/COPD.
In the end, the most helpful positive findings which help you predict a CHF exacerbation causing dyspnea are (in descending order of LR):
- Exam: S3 heart sound
- CXR: Pulmonary edema
- Initial clinical judgment
- CXR: Cardiomegaly
- EKG: atrial fibrillation
- CXR: Pleural effusion
- EKG: Ischemic ST-T changes
- Exam: Jugular venous distension (JVD)
- History of atrial fibrillation
- Lab: BNP ≥ 100 pg/mL
- EKG: Q waves
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McCullough PA, Hollander JE, Nowak RM, et al; BNP Multinational Study Investigators. Uncovering heart failure in patients with a history of pulmonary disease: rationale for the early use of B-type natriuretic peptide in the emergency department. Acad Emerg Med. 2003 Mar;10(3):198-204. PubMed PMID: 12615582. Pubmed .
Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005 Oct 19;294(15):1944-56. PMID: 16234501. Pubmed .