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Abraham RA, Brinker SK. Chronic Obstructive Pulmonary Disease and the Physical Examination. Med Clin North Am 2022; 106:423-435. [PMID: 35491063 DOI: 10.1016/j.mcna.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Performing a hypothesis-driven examination in patients with possible chronic obstructive pulmonary disease (COPD) is an important component of increasing the recognition and diagnosis of this avoidable and costly medical condition. Using known likelihood ratios for various physical examination maneuvers can be combined with known individual risk factors and symptoms to adjust a patient's post-test probability of having COPD and inform appropriate diagnostic work-up. Equally important is intentionality in history-taking and physical examination procedures for patients with known COPD to mitigate the decreased quality of life and mortality and to monitor response to treatment.
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Affiliation(s)
- Reeni Ann Abraham
- Division of General Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Mail Code 9030, Dallas, TX 75390, USA.
| | - Stephanie Kaye Brinker
- Division of General Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Mail Code 9030, Dallas, TX 75390, USA
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Baldoumas G, Peschos D, Tatsis G, Chronopoulos SK, Christofilakis V, Kostarakis P, Varotsos P, Sarlis NV, Skordas ES, Bechlioulis A, Michalis LK, Naka KK. A Prototype Photoplethysmography Electronic Device that Distinguishes Congestive Heart Failure from Healthy Individuals by Applying Natural Time Analysis. Electronics 2019; 8:1288. [DOI: 10.3390/electronics8111288] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this paper, a prototype photoplethysmography (PPG) electronic device is presented for the distinction of individuals with congestive heart failure (CHF) from the healthy (H) by applying the concept of Natural Time Analysis (NTA). Data were collected simultaneously with a conventional three-electrode electrocardiography (ECG) system and our prototype PPG electronic device from H and CHF volunteers at the 2nd Department of Cardiology, Medical School of Ioannina, Greece. Statistical analysis of the results show a clear separation of CHF from H subjects by means of NTA for both the conventional ECG system and our PPG prototype system, with a clearly better distinction for the second one which additionally inherits the advantages of a low-cost portable device.
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Gallagher J, McCormack D, Zhou S, Ryan F, Watson C, McDonald K, Ledwidge MT. A systematic review of clinical prediction rules for the diagnosis of chronic heart failure. ESC Heart Fail 2019; 6:499-508. [PMID: 30854781 PMCID: PMC6487728 DOI: 10.1002/ehf2.12426] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 02/08/2019] [Indexed: 11/16/2022] Open
Abstract
Aims This study sought to review the literature for clinical prediction models for the diagnosis of patients with chronic heart failure in the community and to validate the models in a novel cohort of patients with a suspected diagnosis of chronic heart failure. Methods and results MEDLINE and Embase were searched from 1946 to Q4 2017. Studies were eligible if they contained at least one multivariable model for the diagnosis of chronic heart failure applicable to the primary care setting. The CHARMS checklist was used to evaluate models. We also validated models, where possible, in a novel cohort of patients with a suspected diagnosis of heart failure referred to a rapid access diagnostic clinic. In total, 5310 articles were identified with nine articles subsequently meeting the eligibility criteria. Three models had undergone internal validation, and four had undergone external validation. No clinical impact studies have been completed to date. Area under the curve (AUC) varied from 0.74 to 0.93 and from 0.60 to 0.65 in the novel cohort for clinical models alone with AUC up to 0.89 in combination with electrocardiogram and B‐type natriuretic peptide (BNP). The AUC for BNP was 0.86 (95% confidence interval 83.3–88.6%). Conclusions This review demonstrates that there are a number of clinical prediction rules relevant to the diagnosis of chronic heart failure in the literature. Clinical impact studies are required to compare the use of clinical prediction rules and biomarker strategies in this setting.
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Affiliation(s)
- Joe Gallagher
- School of Medicine & Medical Sciences, University College Dublin, Belfield, Dublin, 4, Ireland.,Irish College of General Practitioners, Lincoln Place, Dublin, Ireland
| | - Darren McCormack
- gHealth Research Group, University College Dublin, Belfield, Dublin, 4, Ireland
| | - Shuaiwei Zhou
- Heartbeat Trust, Crofton Terrace, Dun Laoghaire, Co Dublin, Ireland
| | - Fiona Ryan
- Heartbeat Trust, Crofton Terrace, Dun Laoghaire, Co Dublin, Ireland
| | - Chris Watson
- Centre for Experimental Medicine, Queens University, Belfast, Ireland
| | - Kenneth McDonald
- School of Medicine & Medical Sciences, University College Dublin, Belfield, Dublin, 4, Ireland
| | - Mark T Ledwidge
- School of Medicine & Medical Sciences, University College Dublin, Belfield, Dublin, 4, Ireland
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Kievit RF, Gohar A, Hoes AW, Bots ML, van Riet EES, van Mourik Y, Bertens LCM, Boonman-de Winter LJM, den Ruijter HM, Rutten FH. Efficient selective screening for heart failure in elderly men and women from the community: A diagnostic individual participant data meta-analysis. Eur J Prev Cardiol 2018; 25:437-446. [PMID: 29327942 PMCID: PMC5818024 DOI: 10.1177/2047487317749897] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/01/2017] [Indexed: 12/23/2022]
Abstract
Background Prevalence of undetected heart failure in older individuals is high in the community, with patients being at increased risk of morbidity and mortality due to the chronic and progressive nature of this complex syndrome. An essential, yet currently unavailable, strategy to pre-select candidates eligible for echocardiography to confirm or exclude heart failure would identify patients earlier, enable targeted interventions and prevent disease progression. The aim of this study was therefore to develop and validate such a model that can be implemented clinically. Methods and results Individual patient data from four primary care screening studies were analysed. From 1941 participants >60 years old, 462 were diagnosed with heart failure, according to criteria of the European Society of Cardiology heart failure guidelines. Prediction models were developed in each cohort followed by cross-validation, omitting each of the four cohorts in turn. The model consisted of five independent predictors; age, history of ischaemic heart disease, exercise-related shortness of breath, body mass index and a laterally displaced/broadened apex beat, with no significant interaction with sex. The c-statistic ranged from 0.70 (95% confidence interval (CI) 0.64-0.76) to 0.82 (95% CI 0.78-0.87) at cross-validation and the calibration was reasonable with Observed/Expected ratios ranging from 0.86 to 1.15. The clinical model improved with the addition of N-terminal pro B-type natriuretic peptide with the c-statistic increasing from 0.76 (95% CI 0.70-0.81) to 0.89 (95% CI 0.86-0.92) at cross-validation. Conclusion Easily obtainable patient characteristics can select older men and women from the community who are candidates for echocardiography to confirm or refute heart failure.
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Affiliation(s)
- Rogier F Kievit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Aisha Gohar
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
- Department of Experimental Cardiology, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Arno W Hoes
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Michiel L Bots
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Evelien ES van Riet
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Yvonne van Mourik
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Loes CM Bertens
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Leandra JM Boonman-de Winter
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
- Amphia Academy, Amphia, Breda, The Netherlands
| | - Hester M den Ruijter
- Department of Experimental Cardiology, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Frans H Rutten
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
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O’ Halloran L, McAdam B, Morgan K, Lewis C, Farrell D, Doherty S, Burke S, McGee H. Readmission rates among cardiology inpatients with echocardiography abnormalities associated with heart failure. Ir J Med Sci 2016; 185:717-722. [DOI: 10.1007/s11845-015-1353-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 08/30/2015] [Indexed: 11/25/2022]
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van Riet EES, Hoes AW, Limburg A, Landman MAJ, Kemperman H, Rutten FH. Extended prediction rule to optimise early detection of heart failure in older persons with non-acute shortness of breath: a cross-sectional study. BMJ Open 2016; 6:e008225. [PMID: 26880668 PMCID: PMC4762114 DOI: 10.1136/bmjopen-2015-008225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 11/23/2015] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES There is a need for a practical tool to aid general practitioners in early detection of heart failure in the elderly with shortness of breath. In this study, such a screening rule was developed based on an existing rule for detecting heart failure in older persons with a diagnosis of chronic obstructive pulmonary disease. The original rule included a history of ischaemic heart disease, body mass index, laterally displaced apex beat, heart rate, elevated N-terminal pro B-type natriuretic peptide and an abnormal ECG. DESIGN Cross-sectional data were used to validate, update and extend the original prediction rule according to a standardised state-of-the-art stepwise approach. SETTING Primary care with 30 participating general practices. PARTICIPANTS Community-dwelling people aged ≥ 65 years with shortness of breath on exertion. METHODS AND RESULTS Validation of the existing screening rule in our population showed satisfying discrimination with a concordance statistic of 0.84 (range 0.80-0.85), but poor calibration. Performance measures were most improved by adding the predictors age >75 years, peripheral oedema and systolic murmur, resulting in a concordance statistic of 0.88 (range 0.85-0.90) and a net reclassification improvement of 31%. A risk score was computed, which showed high accuracy with a negative predictive value of 87% and a positive predictive value of 73%. Evaluating the improved rule in the derivation set and an independent set of patients with type 2 diabetes aged 60 years or older showed satisfying generalisability of the rule. CONCLUSIONS Our rule resulted in excellent prediction of heart failure in the large domain of the elderly with shortness of breath, and would help general practitioners to select those needing echocardiography. TRIAL REGISTRATION NUMBER NCT01202006.
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Affiliation(s)
- Evelien E S van Riet
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Marcel A J Landman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hans Kemperman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Boonman-de Winter LJ, Rutten FH, Cramer MJ, Landman MJ, Zuithoff NP, Liem AH, Hoes AW. Efficiently screening heart failure in patients with type 2 diabetes. Eur J Heart Fail 2014; 17:187-95. [DOI: 10.1002/ejhf.216] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 10/30/2014] [Accepted: 11/07/2014] [Indexed: 11/10/2022] Open
Affiliation(s)
- Leandra J.M. Boonman-de Winter
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; The Netherlands
- Center for Diagnostic Support in Primary Care (SHL-Groep); Department of Scientific Research; Etten-Leur The Netherlands
| | - Frans H. Rutten
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; The Netherlands
| | - Maarten J. Cramer
- Department of Cardiology, Division of Heart and Lungs; University Medical Center Utrecht; The Netherlands
| | | | - Nicolaas P.A. Zuithoff
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; The Netherlands
| | - Anho H. Liem
- Department of Cardiology; Sint Franciscus Hospital; Rotterdam The Netherlands
| | - Arno W. Hoes
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; The Netherlands
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Assareh A, Haybar H, Yoosefi H, Bozorgmanesh M. Bedside-Friendly Prediction for Presence of Post-Myocardial lnfarction Systolic Dysfunction Using Multimarker Panel: Integrating Salivary Diagnostics into Clinical Practice. Korean Circ J 2013; 43:246-54. [PMID: 23682284 PMCID: PMC3654112 DOI: 10.4070/kcj.2013.43.4.246] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 02/18/2013] [Accepted: 03/08/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES We investigated if a combination of plasma or salivary interleukin-2 (IL-2), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), transforming growth factor-beta (TGF-β), and troponin can improve estimation of the pretest probability of the left ventricular systolic dysfunction (LVSD). SUBJECTS AND METHODS Eighty patients with newly-diagnosed myocardial infarction (MI) were echocardiographically examined for LVSD (ejection fraction ≤40%). Measurements included traditional MI risk factors, plasma and salivary concentrations of troponin, IL-2, IL-6, TNF-α, and TGF-β. With the LVSD as the outcome variable, we developed logistic regression models, starting with a basic model incorporating traditional risk factors and consecutively adding salivary and plasma biomarkers. Models were compared using several criteria, including (but not limited to) C statistic (discrimination) and net reclassification improvement index (NRI). RESULTS APART FROM TROPONIN, PLASMA, AND SALIVARY VALUES OF THE BIOMARKERS WERE CORRELATED: spearman's ρ was 0.19 (p=0.088) for troponin, 0.36 (p=0.001) for IL-2, 0.74 (p<0.001) for IL-6, 0.61 (p<0.001) for TNF-α, and 0.65 (p<0.001) for TGF-β. The predictive performances of the basic model for estimating the pretest probability of the presence of LVSD considerably improved when cytokines were added (salivary added: C-statistic from 0.77 to 0.82 and NRI 77%; plasma added: C-statistic to 0.80 and NRI 134%). CONCLUSION Multiple biomarkers added diagnostic value to the standard risk factors for predicting the presence of post-MI LVSD.
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Affiliation(s)
- Ahmadreza Assareh
- Cardiovascular Research Center, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran
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Tait L, Roalfe AK, Mant J, Cowie MR, Deeks JJ, Iles R, Barton PM, Taylor CJ, Derit M, Hobbs FDR. The REFER (REFer for EchocaRdiogram) protocol: a prospective validation of a clinical decision rule, NT-proBNP, or their combination, in the diagnosis of heart failure in primary care. Rationale and design. BMC Cardiovasc Disord 2012; 12:97. [PMID: 23110558 PMCID: PMC3519731 DOI: 10.1186/1471-2261-12-97] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 10/17/2012] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Heart failure is a major cause of mortality and morbidity. As mortality rates are high, it is important that patients seen by general practitioners with symptoms suggestive of heart failure are identified quickly and treated appropriately. Identifying patients with heart failure or deciding which patients need further tests is a challenge. All patients with suspected heart failure should be diagnosed using objective tests such as echocardiography, but it is expensive, often delayed, and limited by the significant skill shortage of trained echocardiographers. Alternative approaches for diagnosing heart failure are currently limited. Clinical decision tools that combine clinical signs, symptoms or patient characteristics are designed to be used to support clinical decision-making and validated according to strict methodological procedures. The REFER Study aims to determine the accuracy and cost-effectiveness of our previously derived novel, simple clinical decision rule, a natriuretic peptide assay, or their combination, in the triage for referral for echocardiography of symptomatic adult patients who present in general practice with symptoms suggestive of heart failure. METHODS/DESIGN This is a prospective, Phase II observational, diagnostic validation study of a clinical decision rule, natriuretic peptides or their combination, for diagnosing heart failure in primary care. Consecutive adult primary care patients 55 years of age or over presenting to their general practitioner with a chief complaint of recent new onset shortness of breath, lethargy or peripheral ankle oedema of over 48 hours duration, with no obvious recurrent, acute or self-limiting cause will be enrolled. Our reference standard is based upon a three step expert specialist consensus using echocardiography and clinical variables and tests. DISCUSSION Our clinical decision rule offers a potential solution to the diagnostic challenge of providing a timely and accurate diagnosis of heart failure in primary care. Study results will provide an evidence-base from which to develop heart failure care pathway recommendations and may be useful in standardising care. If demonstrated to be effective, the clinical decision rule will be of interest to researchers, policy makers and general practitioners worldwide. TRIAL REGISTRATION ISRCTN17635379.
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Affiliation(s)
- Lynda Tait
- Primary Care Clinical Sciences, Primary Care Clinical Sciences Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Andrea K Roalfe
- Primary Care Clinical Sciences, Primary Care Clinical Sciences Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Jonathan Mant
- General Practice & Primary Care Research Unit, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 OSR, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, SW3 6LY, UK
| | - Jonathan J Deeks
- Public Health, Epidemiology and Biostatistics, Public Health Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Rachel Iles
- Primary Care Clinical Sciences, Primary Care Clinical Sciences Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Pelham M Barton
- Health Economics Unit, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Clare J Taylor
- Primary Care Clinical Sciences, Primary Care Clinical Sciences Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Marites Derit
- Primary Care Clinical Sciences, Primary Care Clinical Sciences Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - FD Richard Hobbs
- Department of General Practice, University of Oxford, 23-38 Hythe Bridge Street, Oxford, OX1 2ET, UK
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Madhok V, Falk G, Rogers A, Struthers AD, Sullivan FM, Fahey T. The accuracy of symptoms, signs and diagnostic tests in the diagnosis of left ventricular dysfunction in primary care: a diagnostic accuracy systematic review. BMC Fam Pract 2008; 9:56. [PMID: 18842141 DOI: 10.1186/1471-2296-9-56] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Accepted: 10/08/2008] [Indexed: 11/10/2022]
Abstract
BACKGROUND To assess the accuracy of findings from the clinical history, symptoms, signs and diagnostic tests (ECG, CXR and natriuretic peptides) in relation to the diagnosis of left ventricular systolic dysfunction (LVSD) in a primary care setting. METHODS Diagnostic accuracy systematic review, we searched Medline (1966 to March 2008), EMBASE (1988 to March 2008), Central, Cochrane and ZETOC using a diagnostic accuracy search filter. We included cross-sectional or cohort studies that assess the diagnostic utility of clinical history, symptoms, signs and diagnostic tests, against a reference standard of echocardiography. We calculated pooled positive and negative likelihood ratios and assessed heterogeneity using the I2 index. RESULTS 24 studies incorporating 10,710 patients were included. The median prevalence of LVSD was 29.9% (inter-quartile range 14% to 37%). No item from the clinical history or symptoms provided sufficient diagnostic information to "rule in" or "rule out" LVSD. Displaced apex beat shows a convincing diagnostic effect with a pooled positive likelihood ratio of 16.0 (8.2-30.9) but this finding occurs infrequently in patients. ECG was the most widely studied diagnostic test, the negative likelihood ratio ranging from 0.06 to 0.6. Natriuretic peptide results were strongly heterogeneous, with negative likelihood ratios ranging from 0.02 to 0.80. CONCLUSION Findings from the clinical history and examination are insufficient to "rule in" or "rule out" a diagnosis of LVSD in primary care settings. BNP and ECG measurement appear to have similar diagnostic utility and are most useful in "ruling out" LVSD with a normal test result when the probability of LVSD is in the intermediate range.
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