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

doi:10.1136/bmj.38664.661181.55

BMJ, 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 ¹^*, Karel G M Moons ¹, Maarten-Jan M Cramer ², Diederick E Grobbee ¹, Nicolaas P A Zuithoff ¹, Jan-Willem J Lammers ³, Arno W Hoes ¹

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{at}umcutrecht.nl.

Objective To determine which clinical variables provide diagnosticinformation in recognising heart failure in primary care patientswith stable chronic obstructive pulmonary disease (COPD) andwhether easily available tests provide added diagnostic information.

DesignCross sectional diagnostic study.

Setting 51 primary care practices.

Participants1186 patients aged $≥$ 65 years with COPD diagnosed by their generalpractitioner who did not have a diagnosis of heart failure confirmedby a cardiologist.

Main outcome measures Independent diagnosticvariables for concomitant heart failure in primary care patientswith stable COPD.

Results 405 patients (34% of eligible patients)underwent a systematic diagnostic investigation, which resultedin 83 (20.5%) receiving a new diagnosis of concomitant heartfailure. Independent clinical variables for concomitant heartfailure were a history of ischaemic heart disease, high bodymass index, laterally displaced apex beat, and raised heartrate (area under the receiver operating characteristic curve(ROC area) 0.70, 95% confidence interval 0.64 to 0.76). Additionof measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP)to the reduced "clinical model" had the largest added diagnosticvalue, with a significant increase of the ROC area to 0.77 (0.71to 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 independentclinical variables plus NT-proBNP and electrocardiography wasdeveloped.

Conclusions A limited number of items easily availablefrom history and physical examination, with addition of NT-proBNPand electrocardiography, can help general practitioners to identifyconcomitant heart failure in individual patients with stableCOPD.

(Accepted 31 October 2005)

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