Does this dyspneic patient in the emergency department have congestive heart failure?
Does this dyspneic patient in the emergency department have congestive heart failure?
复制标题
DOI：
10.1001/jama.294.15.1944
复制
发表时间：
2005-10-19
影响因子：
120.7
通讯作者：
Ayas, NT
中科院分区：
文献类型：
--
作者：
Wang, CS;FitzGerald, JM;Ayas, NT
背景：呼吸困难是急诊科常见的主诉，医生必须准确快速地做出诊断。目的评估病史、症状和体征以及常规诊断检查（胸片、心电图和血清b型利钠肽[BNP]）在急诊科区分心力衰竭与其他原因的呼吸困难的价值。我们检索MEDLINE（1966- 2005年7月），检索到的文献、既往综述和体检教科书中的参考文献列表。研究选择我们保留了22项研究的各种结果，用于诊断急诊出现呼吸困难的成年患者的心力衰竭。两位作者独立提取数据（敏感性、特异性和似然比[LRs]）并评估方法学质量。许多特征增加了心力衰竭的概率，每个类别的最佳特征是存在：(1)既往心力衰竭史(正LR=5.8； 95%置信区间[01,4.1-8.0]；(2)阵发性夜间呼吸困难症状（阳性LR=2.6; 95% Cl, 1.5 ~ 4.5）；(3)第三心音（S-3）疾驰征象（阳性LR = 11, 95% Cl, 4.9 ~ 25.0）；(4)胸片示肺静脉充血（阳性LR = 12.0, 95% Cl, 6.8 ~ 21.0）；(5)心电图示房颤（阳性LR=3.8; 95% Cl, 1.7 ~ 8.8）。最能降低心力衰竭发生概率的特征是无：(1)既往心力衰竭史（负LR= 0.45;95% Cl, 0.38-0.53）；(2)用力时出现呼吸困难症状（负LR=0.48; 95% Cl, 0.35 ~ 0.67）；(3) rales（负LR=0.51; 95% Cl, 0.37 ~ 0.70）；(4)胸片示心脏增大（阴性LR=0.33 95% Cl, 0.23-0.48）；(5)心电图异常（负LR=0.64; 9% cl, 0.47-0.88）。低血清BNP被证明是最有用的测试（血清b型利钠肽）
Context Dyspnea is a common complaint in the emergency department where physicians must accurately make a rapid diagnosis.Objective To assess the usefulness of history, symptoms, and signs along with routine diagnostic studies (chest radiograph, electrocardiogram, and serum B-type natriuretic peptide [BNP]) that differentiate heart failure from other causes of dyspnea in the emergency department.Data Sources We searched MEDLINE (1966-July 2005) and the reference lists from retrieved articles, previous reviews, and physical examination textbooks.Study Selection We retained 22 studies of various findings for diagnosing heart failure in adult patients presenting with dyspnea to the emergency department.Data Extraction Two authors independently abstracted data (sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality.Data Synthesis Many features increased the probability of heart failure, with the best feature for each category being the presence of (1) past history of heart failure (positive LR=5.8; 95% confidence interval [01, 4.1-8.0); (2) the symptom of paroxysmal nocturnal dyspnea (positive LR=2.6; 95% Cl, 1.5-4.5); (3) the sign of the third heart sound (S-3) gallop (positive LR = 11; 95% Cl, 4.9-25.0); (4) the chest radiograph showing pulmonary venous congestion (positive LR = 12.0; 95 % Cl, 6.8-21.0); and (5) electrocardiogram showing atrial fibrillation (positive LR=3.8; 95% Cl, 1.7-8.8). The features that best decreased the probability of heart failure were the absence of (1) past history of heart failure (negative LR=0,45;95% Cl, 0.38-0.53); (2) the symptom of dyspnea on exertion (negative LR=0.48; 95% Cl, 0.35-0.67); (3) rales (negative LR=0.51; 95% Cl, 0.37-0.70); (4) the chest radiograph showing cardiomegaly (negative LR=0.33 95% Cl, 0.23-0.48); and (5) any electrocardiogram abnormality (negative LR=0.64; 9 % cl, 0.47-0.88). A low serum BNP proved to be the most useful test (serum B-type natriuretic peptide