Can heart failure be diagnosed in primary care?

BMJ 2000; 321 doi: http://dx.doi.org/10.1136/bmj.321.7255.188 (Published 22 July 2000) Cite this as: BMJ 2000;321:188

Use of chest x-ray in diagnosing heart failure

In an otherwise excellent commentary[1] (Can heart
failure be diagnosed in primary care? ) on the article by
Lyn Caruana and colleagues[2] , Prof. Richard Hobbs
fails to mention the value of the chest X-ray. As every
medical student knows the chest X-ray provides
information on cardiac size and the major cardiac
structures, and more fundamentally on any respiratory
cause of breathlessness. It is even more extraordinary
that in the article by Caruana et al, no mention of the
chest X-ray in the diagnostic process is made in a
study which was especially focussing on excluding
other causes of the patients symptoms.

The current obsession with open-access
echocardiography is tending to unnerve GP’s who feel
that they cannot now make the diagnosis of heart
failure without demonstrating abnormal left ventricular
function. In fact the vast majority of patients can be
diagnosed and treated with a knowledge of the past
history, clinical findings, chest X-ray and ECG[3] .

Our own experience of open-access echocardiography
over a two year period was that it added very little to the
diagnostic process for those in primary care, except in
the presence of a heart murmur[4] . Given the rising
demands for specialist technician and medical time, it
is neither realistic nor desirable to use
echocardiography as a screening test for heart failure.
BNP may prove better [3], but surely the first test in
primary care for a breathless patient should be a chest

Yours faithfully

Dr Chris Davidson


Sussex Cardiac Centre,
Royal Sussex County Hospital
Brighton BN2 5BE

1. Hobbs R, Can heart failure be diagnosed in primary
care? BMJ 2000 321 188-9

2. Caruana L, Petrie MC, Davie AP, McMurray JJV. Do
patients with suspected heart failure and preserved left
ventricular function suffer from "diastolic heart failure" or
from misdiagnosis? BMJ 2000 321 215-8

3. Landray MJ, Lehman R, Arnold I. Measuring brain
naturetic peptide in suspected left ventricular systolic
function in general practice. BMJ 2000 320 985-6

4. Wong PS, Doshi S, Open access echocardiography.
Service is valuable for cardiac murmurs. BMJ 1995 311

Competing interests: No competing interests

07 August 2000
Christopher Davidson
Royal Sussex County Hospital, Brighton
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