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Rapid Responses: Rapid Responses published:
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Reference test for heart failure
- Malcolm S McLean (9 December 2005)
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Recognising heart failure in patients with COPD
- Elliot F Epstein (12 December 2005)
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Advice needed on treatment especially B blockers
- john sharvill (16 December 2005)
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Breathlessness: Cardiac or Pulmonary?
- Tsung O. Cheng (1 January 2006)
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Authors' reply
- Frans H. Rutten, Prof. A.W. Hoes, MD, PhD (18 January 2006)
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Malcolm S McLean, GP Henfield Medical Centre, West Sussex, BN5 9JQ
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The authors do not have a reference test for heart failure. They choose not to use echocardiography both because it is imperfect, not a 'gold standard', and because it is not freely available in primary care. For their study, instead of a reference test, they use a panel of two cardiologists, a pulmonologist and a GP. This panel then decides on the diagnosis for each patient in the study using the variables measured as part of the study (apart from natriuretic peptide). I am concerned that this introduces a circularity into the study so that, in effect, they are merely reporting on what variables this panel believes constitute a diagnosis of heart failure. This could have been achieved without measuring any of the variables; just interviewing the panel. Competing interests: None declared |
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Elliot F Epstein, Consultant Physician Walsall Manor Hospital, WS2 9PS
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Rutten FH (1) et al have identified factors, such as ischaemic heart disease, that predict the presence of heart failure in patients with chronic obstructive pulmonary disease. However, important causes of heart failure, such as hypertension (2), were not included as confounding variables in the multivariable logistic regression analyses. I thus believe the conclusions reached by the authors are flawed. 1 Rutten F, Moons K, Cramer M, Grobbee D, et al. Recognising heart failure in elderly patients with stable chronic obstructive pulmonary disease in primary care: cross sectional diagnostic study. BMJ. 2005;331:1379 2 He J, Ogden L, Bazzano L, Vupputuri S, et al. Risk Factors for Congestive Heart Failure in US Men and Women: NHANES I Epidemiologic Follow-up Study. Arch Intern Med. 2001; 161: 996-1002. Competing interests: None declared |
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john sharvill, GP Deal England ct14 7au
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This article highlights that heart failure and COPD co-exist. The main questions though are can one use low dose heart failure b blockers in copd and do we need guidance of when? Also how can we tell class 3 or 4 failure that may benefit from spironolactone from breathlessness from copd which may be made worse by more poly-pharmacy? Competing interests: None declared |
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Tsung O. Cheng, Professor of Medicine George Washington University, Washington, D.C. 20037
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I read with interest the article by Rutten et al [1] in which they described four clinical parameters (history of ischemic heart disease, laterally displaced apex beat, high body mass index, and raised heart rate) and two laboratory tests (natriuretic peptide measurements and electrocardiography) that help to recognize congestive heart failure (CHF) in elderly patients with chronic obstructive pulmonary disease (COPD). I wish to point out that none of these are always reliable. As I indicated in my recent paper [2], weight gain usually indicates CHF, whereas weight loss usually is the case in COPD. However, as Coats [3] pointed out recently, weight loss is a common accompaniment of the progression of treated CHF. Although the recent introduction of B-type natriuretic peptide (BNP) measurement is helpful in CHF diagnosis [1] with a sensitivity of 90%, the spcificity of BNP is only 75% [4]. Finally, acute onset of dyspnea on exertion can be an angina equivalent [5,6]. This entity was accurately described by Louis Gallavardin in as early as 1924 [7]. In 1933 he coined the very descriptive, though somewhat awkward combination of Latin and Greek, “blockpnea” [8]. Strangely enough, this prominent equivalent of angina has gained little recognition in the English medical literature, although it is well accepted by the French cardiologists [9]. The importance of this symptom as an angina equivalent was recently emphasized by Abidov et al [10]. The distinguishing feature of blockpnea is its acute onset [6]. Tsung O. Cheng, M.D. Professor of Medicine George Washington University Washington, D.C. References 1. Rutten FH, Moons KGM, Cramer M-J M, et al: Recognising heart failure in elderly patients with stable chronic obstructive pulmonary disease in primary care: cross sectional diagnostic study. BMJ 2005;331:1379-1382. 2. Cheng TO: Shortness of breath: COPD or CHF? Int J Cardiol 2005;105:349 -350. 3. Coats AJS: Dyspnoea in CHF and COPD. Int J Cardiol 2005;105:351. 4. Knudsen CW, Omland T, Clopton P, et al: Diagnostic value of B-type natriuretic peptide and chest radiographic findings in patients with acute dyspnea. Am J Med 2004;116:363-368. 5. Cheng TO: Blockpnea as an angina equivalent. Am J Cardiol 1989;64:834. 6. Cheng TO: Acute dyspnea on exertion is an angina equivalwent. Int J Cardiol, in press. 7. Gallavardin L. Y a-t-il un équivalent non douloureux de l’angine de poitrine d’effort? Lyon Med 1924;134:345-358. 8. Gallavardin L. Les syndromes d’effort dans les affections cardioaortiques. J Med Lyon 1933;14:539-558. 9. Chevalier H: Blockpnea on effort in emphysematous patients – a diagnostic challenge. Am Heart J 1967;73:579-581. 10. Abidov A, Rozanski A, Hachamovitch R, et al: Prognostic significance of dyspnea in patients referred for cardiac stress testing. N Engl J Med 2005;353:1889-1898. Competing interests: None declared |
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Frans H. Rutten, General practitioner, MD, PhD Julius Centre UMC Utrecht, 3508 AB, Prof. A.W. Hoes, MD, PhD
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Re: Reference test for heart failure (Malcolm S McLean) Heart failure lacks a 'gold standard' and consensus diagnosis of an expert panel using all available diagnostic information, including echocardiography is regarded as the most optimal reference standard.1 In our study the diagnosis of heart failure was set by the presence of ventricular dysfunction on echocardiography in combination with symptoms (i.e. orthopnoea, paroxysmal nocturnal dyspnoea, fatigue, peripheral oedema, nocturia ¡Ý2 times a night, or any combination of these symptoms) and/or signs (i.e. peripheral or pulmonary fluid retention or raised jugular venous pressure) indicative of heart failure. Any incorporation bias is likely to be small because most diagnostic determinants we studied were not crucial in the panel decision process. Re: Recognising heart failure in patients with COPD (Elliot F Epstein); Advice needed on treatment especially beta-blockers (John Sharvill) Because we performed a diagnostic study we were not able to answer questions regarding treatment of heart failure, etiological factors or pathophysiological mechanisms. Since a diagnostic study differs from an etiological study, confounding was not an issue in our study. Re: Breathlessness cardiac or pulmonary (Tsung Cheng) The aspects about body weight and dyspnoea as 'anginal variant' as mentioned by Cheng are well known. However, these aspects have little to do with our study. Regarding the applicability of amino-terminal pro B type natriuretic peptide (NT-proBNP), it is important to notice that we studied NT-proBNP in a multivariable way and our results can therefore not be compared with studies assessing (NT-pro)BNP in a univariable way only. Frans H Rutten, MD, PhD, general practitioner
1. Moons KG, Grobbee DE. When should we remain blind and when should our eyes remain open in diagnostic studies? J Clin Epidemiol 2002;55:633- 6. Competing interests: None declared |
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