16
Dyspnea: How to Differentiate Between
Acute Heart Failure Syndrome and
Other Diseases
Clément R. Picard and Abdellatif Tazi
Patient present with acute dyspnea every day
in emergency departments (EDs) and intensive
care units (ICUs). Acute dyspnea is mostly due to
potentially life-threatening cardiac or respiratory
conditions, and treating it promptly requires
understanding of the underlying mechanisms. A
number of disorders cause dyspnea, including
acute heart failure syndrome (AHFS), chronic
obstructive pulmonary disease (COPD), asthma,
pulmonary embolism, pneumonia, metabolic aci-
dosis, neuromuscular weakness, and others.
Although the clinical diagnosis of typical acute
pulmonary edema or acute severe asthma is readily
made, the presentation is less typical in a number
of cases, for which consultation among ED physi-
cians and respiratory and cardiology consultants is
needed. Because of the prevalence of chronic heart
failure (CHF), COPD, and asthma in the general
population (2%, 5% to 10%, and 5%, respectively),
differentiation among these three disorders is fre-
quently needed1–3. Indeed, acute dyspnea in these
patients is not necessarily due to an exacerbation of
their underlying chronic condition and may have
another cause (e.g., pneumothorax in an asthmatic
patient). Furthermore, combined cardiopulmo-
nary dysfunction may present with complex or
atypical symptoms (e.g., pulmonary edema in a
COPD patient). Finally, the differences in the treat-
ment strategies in pulmonary and cardiac diseases
and the probability of worsening of the primary
disease with the incorrect treatment modality
necessitates early and accurate diagnosis.
Depending on the hospital setting, AHFS
accounts for 30% to 70% of acute dyspnea in the
ED4. Quick identification of AHFS remains crucial
and lifesaving, and may lead to prompt admission
of the patient in a specialized cardiovascular ICU.
An early diagnosis of AHFS was also proven to be
cost-effective and to reduce the hospital length of
stay5,6. Thus, a simple and quick way of differen-
tiating cardiac and pulmonary causes of dyspnea
is essential in patients admitted to the ED and
should be based on routine procedures. In prac-
tice, medical history, symptoms, physical exami-
nation, chest x-ray (CXR), electrocardiogram
(ECG), and, more recently, blood B-type natri-
uretic peptide (BNP) values are sufficient to
recognize AHFS in most patients presenting with
acute dyspnea. Other investigations (echocar-
diography, nuclear scans, or cardiac catheteriza-
tion) require time and expertise and thus cannot
be used as a screening procedure.
Does the Dyspneic Patient have a
High Probability of Acute Heart
Failure Syndrome?
To address this question, one has to identify
among the clinical examination and routine inves-
tigations the features that have the highest speci-
ficity and the highest positive likelihood ratio
(LR) for the diagnosis of AHFS. Few studies have
investigated the performance of clinical examina-
tion, CXR, and ECG in distinguishing cardiac and
noncardiac causes in order to design an evidence-
based approach of acute dyspnea in this setting.
Since the routine use of blood BNP levels, this
question has been revisited, leading to significant
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progress in the rationale for the diagnosis of
dyspnea in ED.
Badgett et al.7 reviewed the literature to ascer-
tain whether history, physical examination, CXR,
and ECG can reliably diagnose left heart failure,
that is, decreased left ventricular ejection fraction
or increased filling pressure. The overall clinical
examination did not yield predictive values that
reliably confirmed or excluded an increased filling
pressure in typical patients in the ED. Much vari-
ability existed in the precision of clinical findings,
which was partly attributable to subspecialty
training or examiner experience. Nevertheless,
the best findings for detecting increased left
ventricular filling pressure were jugular venous
distention and radiographic vascular redistribu-
tion. These results, however, were in patients
referred for consideration of cardiac transplant
with known severe systolic dysfunction. In patients
with less severe systolic dysfunction, these find-
ings may not be useful and their absence cannot
exclude the diagnosis. Dependent edema was
helpful when present but had a poor sensitivity.
The best findings for detecting systolic dysfunc-
tion were abnormal apical impulse, radiographic
cardiomegaly, and Q waves or left bundle branch
block on an ECG. The predictive value of these
signs depends on the probability and the severity
of left heart dysfunction. Findings that were not
significant in a majority of studies to detect
decreased ejection fraction were age, orthopnea,
left ventricular hypertrophy on ECG, history of
hypertension, or congestive heart failure.
In another study on almost 2500 patients with
severe heart failure due to systolic dysfunction, an
elevated jugular venous pressure and a third heart
sound (S3) were found to be diagnostic of AHFS
but were present in only 24% and 11%, respec-
tively, of the patients8. The use of computerized
TABLE 16.1. Accuracy of most suggestive features for the diagnosis of AHFS in dyspneic
patient presenting to the emergency department
Finding
Past history of AHFS
Paroxysmal nocturnal dyspnea
Third heart sound gallop
Pulmonary venous congestion on
CXR
Atrial fibrillation on ECG
CXR, chest x-ray; ECG, electrocardiogram; LR, likelihood ratio.
Source: Based on date from Wang et al.4
C.R. Picard and A. Tazi
detection of S3 (Audicor algorithm) improved
sensitivity when compared to heart auscultation
(41% vs. 18%, respectively) but decreased speci-
ficity (87% vs. 98%, respectively) in another
study9. A small case-control study of eight patients
suggested that ultrasonographic examination of
the internal jugular vein performed by an ED phy-
sician in patients without clinical jugular venous
distention could be more sensitive10.
The clinical focus on dyspneic patients, however,
is more useful because not every patient with left
ventricular dysfunction or high filling pressures
on objective cardiac testing will be subjectively
dyspneic, and patients with a reduced ejection
fraction may be dyspneic from causes other than
heart failure. More recently, Wang et al.4 selected
22 studies of adult patients presenting with
dyspnea at the ED to assess the usefulness of
history, symptoms, and signs along with routine
diagnostic studies (CXR, ECG, serum BNP) that
differentiate heart failure from other causes of
dyspnea. Among the features that increased the
probability of heart failure, the best feature for
each category were a past history of heart failure,
the symptoms of paroxysmal nocturnal dyspnea,
the sign of the third heart sound (S3) gallop, CXR
showing pulmonary venous congestion, and ECG
showing atrial fibrillation. The sensitivity, speci-
ficity, and positive and negative LRs of these
findings for the diagnosis of AHFS are shown in
Table 16.1. The presence of new T-wave changes
or abnormal ECG findings increased the LR of
heart failure but was evaluated in fewer studies.
The overall clinical impression of the physician
initially treating the patient in the ED was also
important to consider and had a high positive LR
for the diagnosis of AHFS.
Other tests have been evaluated for the distinc-
tion between cardiac and noncardiac causes of
Sensitivity Specificity Positive LR Negative LR
0.6 0.9 5.8 0.45
0.41 0.84 2.6 0.7
0.13 0.99 11 0.88
0.54 0.96 12 0.48
0.26 0.93 3.8 0.79