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Optimising direct access ECHO referral in suspected heart failure
M M Lindsay1, N E Goodfield, K J Hogg
1Cardiology Department, Stobhill NHS Trust, Glasgow.
Insights
A normal ECG combined with no history of myocardial infarction accurately predicts normal left ventricular function, improving heart failure diagnosis in primary care.
Area of Science:
- Cardiology
- Diagnostic Medicine
Background:
- Left ventricular systolic dysfunction (LVSD) diagnosis is crucial for heart failure management.
- Current diagnostic methods for LVSD can be resource-intensive, leading to suboptimal community-level diagnosis and treatment.
Purpose of the Study:
- To prospectively validate a combined approach using electrocardiogram (ECG) and clinical history to improve the accuracy of excluding left ventricular systolic dysfunction.
- To assess the sensitivity, specificity, and negative predictive value of this combined method.
Main Methods:
- A three-year prospective study involving 416 patients referred for echocardiography (ECHO) to assess left ventricular (LV) function.
- ECG interpretation was performed blind to ECHO results and patient history of myocardial infarction (MI).
Main Results:
- A normal ECG and a negative history of MI demonstrated 98% sensitivity and 99% negative predictive value for normal LV function.
- This combination significantly improved diagnostic accuracy compared to ECG alone.
- 73% of patients treated for suspected LVSD prior to referral were inappropriately treated, highlighting diagnostic challenges.
Conclusions:
- The combination of a normal ECG and no prior MI history is a highly sensitive and accurate predictor of normal LV function.
- Adoption of this method by general practitioners could optimize echocardiography use and improve heart failure diagnosis and management in the community.
Abstract:
The objective was to prospectively validate a method of increasing the sensitivity, specificity and negative predictive value of a normal ECG in the exclusion of left ventricular systolic dysfunction by the addition of clinical history. We performed a prospective three year study of all referrals to our direct access ECHO service for assessment of LV function. The ECG was reported blind of the result of the ECHO, history of MI or not was noted, and result of the ECHO predicted. Over three years 416 patients were assessed for the presence or absence of left ventricular systolic dysfunction and consequent changes in clinical management. A total of 320(77%) of patients referred with suspected left ventricular dysfunction were found to have normal left ventricular function. Of the 250(60%) patients treated prior to referral for assessment, 183(73%) were treated inappropriately. The combination of a normal ECG and a negative history of myocardial infarction had a sensitivity of 98% and a negative predictive value of 99% in the assessment of LV function. This was an improvement over a normal ECG alone. Our study shows that diagnosis and treatment of heart failure in the community remains sub-optimal. The combination of a normal ECG and no previous history of myocardial infarction is shown to be a sensitive and accurate predictor of normal left ventricular function. If adopted by general practitioners this would be a valuable method of optimising the use of echocardiography in patients with suspected left ventricular dysfunction.