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Interobserver agreement and accuracy of bedside estimation of right and left ventricular ejection fraction in acute
N Gadsbøll1, P F Høilund-Carlsen, G G Nielsen
1Department of Cardiology, Glostrup University Hospital, Denmark.
Insights
Clinicians
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Medicine
Background:
- Estimating left ventricular (LV) and right ventricular (RV) ejection fraction (EF) is crucial in acute myocardial infarction (AMI) management.
- Clinical assessment methods are often used to estimate EF, but their accuracy and inter-observer agreement require evaluation.
Purpose of the Study:
- To assess the accuracy and agreement of clinical estimations of left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) in patients with AMI.
- To identify clinical variables that best predict LVEF and RVEF in AMI patients.
Main Methods:
- Three clinicians independently estimated LVEF and RVEF in 98 AMI patients using clinical data and imaging.
- Ejection fractions were categorized as normal, mildly reduced, moderately reduced, or severely reduced.
- Radionuclide ventriculography (RNV) served as the reference standard for EF estimation.
Main Results:
- LVEF was correctly estimated in 43% of cases, with 45% deviating by one category and 12% by two categories.
- Clinician agreement on LVEF was low (32%).
- RVEF was correctly estimated in 67% of cases, but clinicians struggled to identify patients with reduced RVEF, showing significant disagreement.
Conclusions:
- Clinical estimation of LVEF in AMI patients has moderate accuracy and poor agreement among clinicians.
- Traditional clinical predictors of ventricular function were surprisingly poor indicators of LVEF and RVEF in this cohort.
- Further research into more reliable methods for EF assessment in AMI is warranted.
Abstract:
Ninety-eight patients with acute myocardial infarction were examined by 3 clinicians who, independently of each other, gave an estimate of left ventricular (LV) and right ventricular (RV) ejection fraction (EF) in each patient. Their estimates were based on physical examination, chest x-ray, electrocardiogram, patient history and clinical course during admission. Ejection fractions were estimated as belonging to 1 of 4 categories: normal (LVEF greater than or equal to 0.53, RVEF greater than or equal to 0.57), mildly reduced (LVEF 0.40 to 0.52, RVEF 0.45 to 0.56), moderately reduced (LVEF 0.30 to 0.39, RVEF 0.35 to 0.44) or severely reduced (LVEF less than 0.30, RVEF less than 0.35). Radionuclide ventriculography was carried out immediately after the physical examination. LVEF was correctly estimated in 43% of all examinations, deviated from radionuclide LVEF by 1 LVEF category in 45% and by 2 LVEF categories in 12%. The 3 clinicians agreed on estimated LVEF in only 32% of the patients. RVEF was correctly estimated in 67% of the examinations, but none of the clinicians identified greater than 43% of the relatively few patients with reduced radionuclide RVEF and they greatly disagreed as to who among the patients had a reduced RVEF. Previous myocardial infarction, electrocardiographic infarct location, Killip class, physical signs of left- and right-sided heart failure, radiographic pulmonary congestion and cardiomegaly were analyzed to determine which were the most helpful in predicting LVEF and RVEF. The results disclosed that several variables, traditionally believed to be reliable indexes of reduced ventricular function, were surprisingly poor predictors of LVEF and RVEF.