BMJ  2005;331:1379 (10 December), doi:10.1136/bmj.38664.661181.55 (published 1 December 2005)

Primary care

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

Frans H Rutten, general practitioner1, Karel G M Moons, professor of clinical epidemiology1, Maarten-Jan M Cramer, cardiologist2, Diederick E Grobbee, professor of clinical epidemiology1, Nicolaas P A Zuithoff, statistician1, Jan-Willem J Lammers, professor of pulmonology3, Arno W Hoes, professor of clinical epidemiology and general practice1

1 Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, 3508AB Netherlands, 2 Heart Lung Centre Utrecht, Department of Cardiology, University Medical Centre, Utrecht, 3 Heart Lung Centre Utrecht, Department of Pulmonary Diseases, University Medical Centre, Utrecht

Correspondence to: F H Rutten F.H.Rutten{at}umcutrecht.nl

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.


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Advice needed on treatment especially B blockers
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