Recognising heart failure in elderly patients with stable chronic obstructive pulmonary disease in primary care: cross sectional diagnostic study

• Published in: BMJ Vol. 331; no. 7529; pp. 1379 - 1382
• Main Authors: Rutten, Frans H, Moons, Karel G M, Cramer, Maarten-Jan M, Grobbee, Diederick E, Zuithoff, Nicolaas P A, Lammers, an-Willem J, Hoes, Arno W
• Format: Journal Article
• Language: English
• Published: London British Medical Journal Publishing Group 10.12.2005; British Medical Association; BMJ Publishing Group LTD; BMJ Publishing Group; BMJ Publishing Group Ltd
• Edition: International edition
• Subjects: Aged; Ambulatory Care; Biological and medical sciences; Body mass index; Cardiology. Vascular system; Cardiovascular disease; Chronic obstructive pulmonary disease; Chronic obstructive pulmonary disease, asthma; Cross-Sectional Studies; Disease models; Echocardiography; Electrocardiography; Family Practice; Female; General aspects; Heart; Heart attacks; Heart failure; Heart Failure - complications; Heart Failure - diagnosis; Heart failure, cardiogenic pulmonary edema, cardiac enlargement; Humans; Male; Medical research; Medical sciences; Modeling; Natriuretic Peptide, Brain - blood; Natriuretic peptides; Odds Ratio; Older people; Patient medical history; Patients; Peptide Fragments - blood; Peptides; Physical examinations; Pneumology; Primary Care; Primary health care; Pulmonary Disease, Chronic Obstructive - complications; Radiography; Studies; Ultrasonic imaging; Human; Heart failure; Lung disease; Respiratory disease; Primary health care; Chronic disease; Cardiovascular disease; Patient; Medicine; Chronic; Heart disease; Cross sectional study; Bronchus disease; Obstructive pulmonary disease; Diagnosis; Elderly
• ISSN: 0959-8138; 0959-8146; 1468-5833; 1756-1833
• DOI: 10.1136/bmj.38664.661181.55

Abstract Objective To determine which clinical variables provide diagnostic information in recognising heart failure in primary care patients with stable chronic obstructive pulmonary disease (COPD) and whether easily available tests provide added diagnostic information. Design Cross sectional diagnostic study. Setting 51 primary care practices. Participants 1186 patients aged  65 years with COPD diagnosed by their general practitioner who did not have a diagnosis of heart failure confirmed by a cardiologist. Main outcome measures Independent diagnostic variables for concomitant heart failure in primary care patients with stable COPD. Results 405 patients (34% of eligible patients) underwent a systematic diagnostic investigation, which resulted in 83 (20.5%) receiving a new diagnosis of concomitant heart failure. Independent clinical variables for concomitant heart failure were a history of ischaemic heart disease, high body mass index, laterally displaced apex beat, and raised heart rate (area under the receiver operating characteristic curve (ROC area) 0.70, 95% confidence interval 0.64 to 0.76). Addition of measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) to the reduced “clinical model” had the largest added diagnostic value, with a significant increase of the ROC area to 0.77 (0.71 to 0.83), followed by electrocardiography (0.75, 0.69 to 0.81). C reactive protein and chest radiography had limited added value. A simplified diagnostic model consisting of the four independent clinical variables plus NT-proBNP and electrocardiography was developed. Conclusions A limited number of items easily available from history and physical examination, with addition of NT-proBNP and electrocardiography, can help general practitioners to identify concomitant heart failure in individual patients with stable COPD.