Access to echocardiography facilitates informed management

Editor—Neil D Gillespie and colleagues found that clinical assessment detected left ventricular systolic function (sensitivity 81%) and that chest radiography improved specificity from 47% to 95%.1 The authors therefore concluded that echocardiography is not essential for patients with acute dyspnoea and clear evidence of heart failure but no murmur. They are right, however, to be cautious in extrapolating their findings to other clinical settings. Patients with important respiratory disease were excluded (they were admitted to a separate chest unit), and their subjects were the younger patients, often with overt cardiac disease or disease of a single system, referred to an acute medical admissions unit. The incidence of heart failure increases with age, and the high prevalence of diastolic dysfunction2 and comorbidity presents difficulties for accurate diagnosis in elderly patients with heart failure.

We determined the validity of a clinical diagnosis of systolic dysfunction and assessed the contribution made by echocardiography to patient management in a prospective study of consecutive patients with decompensated heart failure admitted to a geriatric assessment unit. For 61 patients (15 men; age 71-96 (mean 82)) with heart failure (two major or one major and two minor Framingham criteria) a consultant indicated proposed cardiac diagnosis—systolic heart failure, diastolic dysfunction, cor pulmonale, aortic/mitral valve disease—and management based on the patient's history, and clinical and radiographic findings.

After echocardiography the main cardiac diagnoses were systolic dysfunction (n=42), mitral stenosis (6), diastolic dysfunction (5), cor pulmonale (3), aortic stenosis (1), constrictive pericarditis (1), and normal cardiac function (3). In identifying systolic dysfunction clinical diagnosis had a sensitivity of 93% and specificity of 32% (positive predictive value 0.75, negative predictive value 0.66); radiological features of pulmonary congestion or oedema had a sensitivity of 76% and a specificity of 42% (0.74, 0.44); a clinical or radiological diagnosis had a sensitivity …