Tips on diagnosing heart failure in a patient with COPD using an Evidence-based approach

1. DIAGNOSING HEART FAILURE IN
PATIENTS WITH & WITHOUT
COPD/ASTHMA

2.  A 54 year old male patient with a past history of
CCF….
 C/O: Breathlessness on exertion, Orthopnea
 O/E: Dyspnoeic, raised JVP, Third heart sound,
bibasal crackles, LL edema
 Diagnosis: ?Congestive Cardiac Failure
 Tests: CXR Pulmonary Edema
Brain Natriuretic Peptide 127 pg/ml
A Case Scenario

3. TESTS IN ER FOR DYSPNOEIC PATIENTS
Pulse Oximetry Assess Severity
ABG Assess Severity
Identify Cause:
Acidosis, High
PaCO2 suggests
COPD

4. TESTS IN ER FOR DYSPNOEIC PATIENTS
Chest X-ray Identify Cause
 Consolidation (seen in
pneumonia)
 Hyperexpansion of the lungs
which is seen in asthma and
COPD
 Interstitial oedema (acute
pulmonary oedema and ARDS)
 Pneumothorax
 Rib fractures and lung
contusions following a traumatic
chest injury
 Pleural effusions
 Pulmonary embolism e.g. wedge
consolidation, hypoperfused
areas

5. TESTS IN ER FOR DYSPNOEIC PATIENTS
Lung Ultrasound  Pneumothorax - the
sensitivity and specificity for
pneumothorax using this test
is much better than chest x-
ray. The findings include loss
of lung sliding and the
absence of the seashore
pattern in B mode ultrasound.
 Pulmonary oedema - the
presence of multiple lung
rockets and pleural effusions
are highly suggestive of
congestive cardiac failure.

6. TESTS IN ER FOR DYSPNOEIC PATIENTS
Echocardiography  Dilated RA/RV with
right heart strain
suggestive of
pulmonary embolism;
pericardial effusion
suggestive of
pericardial
tamponade; basic
contractility of the
heart - useful in the
diagnosis of heart
failure.

7. TESTS IN ER FOR DYSPNOEIC PATIENTS
Complete blood count Anemia
C-Reactive Protein Infection/Inflammation/Infarction
Urea, Creatinine, Glucose,
Bicarbonate
Renal Asthma, Diabetic/Metabolic
Acidosis
D-dimer Useful if negative to exclude Pulmonary
Embolism in those with low pre-test
probability
Troponin Acute coronary syndrome.
ECG Acute Coronary Syndrome, Arrhythmia
CT Pulmonary Angiogram (CTPA) Indications are in patients who are low
and intermediate risk with a positive d-
dimer or in high risk patients.
Ultrasound Doppler Legs If CTPA is not available and Pulmonary
embolism is highly suspected.

8. APPLYING SENSITIVITY & SPECIFICITY
A screening test that is used to ‘rule out’ a diagnosis
should have a high degree of sensitivity.
A confirmatory test that is used to ‘rule in’ a diagnosis
should have a high degree of specificity.

9. Likelihood Ratio
• Sensitivity and specificity are combined into an overall
measure of the efficacy of a diagnostic test called the
likelihood ratio
• Likelihood ratio: the likelihood that a given test
result would be expected in a patient with the target
disorder compared to the likelihood that the same result
would be expected in a patient without that disorder.

10. Likelihood Ratio + = sens/1-spec
 It is the power of a +ve test to rule in a
diagnosis
 It is the likelihood of having the disease
if the test is +VE
 The increase in the odds of
having the disease after a
positive test result
Likelihood Ratio

11. Likelihood Ratio - = 1-sens/spec
 It is the power of a –ve test to rule out
a diagnosis
 It is the likelihood of not having the
disease if the test is –VE
 The decrease in the odds of
having the disease after a
negative test result
Likelihood Ratio

12. INTERPRETING LIKELIHOOD RATIOS
LR + LR - Effect on Post-test
Probability
>10 <0.1 Large, often conclusive
4-10 0.1-0.3 Moderate
2-4 0.3-0.5 Small, occ. important
1-2 0.5-1 Small, rarely important
• LR+ are always greater than 1.0; the larger the number, the more likely is the
patient to have the disease after a positive test result.
•LR- are always less than 1.0, with the smaller numbers signifying a lower risk for
disease than pretest estimates.

14. Does this Patient have CCF? H & P

15. BEST DIAGNOSTIC PREDICTORS IN HEART
FAILURE: THE GREENS WITH LR MORE THAN 5
Item Sensitivity Specificity LR+ LR-
PH Heart
Failure
0.6 0.9 5.8 0.45
Dyspnea on
Exertion
0.84 0.34 1.3 0.48
Orthopnea 0.50 0.77 2.2 0.65
3rd Heart
Sound
0.13 0.99 11 0.88
Raised JVP 0.39 0.92 5.1 0.66
BNP more
than
100pg/ml
0.93 0.66 2.7 0.11

16. Does this Patient have CCF?
CXR & ECG : Of Diagnostic Value

17. IN THE EMERGENCY ROOM: YOUR GUIDE

18. HEART FAILURE DIAGNOSIS IN PATIENTS WITH
DYSPNEA
 Clinical Picture as above
 BNP/NT pro-BNP
 Prediction Rule
 Mean Platelet Volume
 Bedside Ultrasound
As with any test, the pretest probability is
important and the result must be
interpreted in the clinical context.

19. BNP/NT PRO-BNP
 A Low or Normal BNP/NT-Pro BNP in the non-
obese excludes Heart Failure
 A relatively high BNP/NT-pro-BNP suggests a
diagnosis of heart failure if other data are
supportive e.g. History, Physical Examination,
Chest x-ray, Echo etc.
The diagnostic accuracy of the natriuretic peptides in heart failure: systematic review and
diagnostic meta-analysis in the acute care setting
BMJ 2015; 350 doi:http://dx.doi.org/10.1136/bmj.h910 (Published 04 March 2015)Cite this
as: BMJ 2015;350:h910

20. BNP/NT PRO-BNP: BOTH ARE EQUIVALENT IN
THEIR DIAGNOSTIC VALUE
Natriuretic peptide
(threshold)
Sensitivity % Specificity %
B type natriuretic
peptide:
≤100 ng/L 0.95 0.63
100-500 ng/L 0.85 0.86
≥500 ng/L 0.35 0.78
N terminal pro-brain
natriuretic peptide:
≤300 ng/L 0.99 0.43
300-1800 ng/L 0.90 0.76
≥1800 ng/L 0.67 0.72

21. HEART FAILURE PREDICTION RULE
BMJ Open. 2016 Feb 15;6(2):e008225. doi: 10.1136/bmjopen-2015-
008225.Extended prediction rule to optimize early detection of heart failure in older persons with non-
acute shortness of breath: a cross-sectional study. van Riet EE

22.  A score of more than 22 confirms the Diagnosis of Heart
Failure as a cause of dyspnea.
Score Sensitivity Specificity +ve LR -ve LR
9 or less No Heart Failure
10-15 0.95 0.54 2 0.09
16-21 0.84 0.78 3.8 0.2
22-30 0.30 0.98 15 0.7

23. BEDSIDE ULTRASOUND: MORE SENSITIVE THAN
CHEST X-RAY
 Pleural effusions especially if bilateral
 Kerley B Lines
Curr Cardiol Rev. 2012 May; 8(2): 123–136. Lung Ultrasound in the Management of Acute Decompensated Heart
Failure. Shiang-Hu Ang and Phillip Andrus

24. MEAN PLATELET VOLUME: HIGH(MORE THAN 10.5)
SUGGEST HEART FAILURE IN COPD PATIENTS
Utility of N-terminal pro B-type natriuretic peptide and mean platelet volume in differentiating
congestive heart failure from chronic obstructive pulmonary disease. Wang R. Int J Cardiol. 2013.