Paucis Verbis: CHF likelihood ratios


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 
Thanks to Dr. Daniel Kievlan (UCSF-SFGH resident) for the idea for this PV card.





Feel free to download this card and print on a 4'' x 6'' index card.

See other Paucis Verbis cards.


References

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 . 


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