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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

The accuracy of symptoms, signs and diagnostic tests in the diagnosis of left ventricular dysfunction in primary care: a diagnostic accuracy systematic review

V Madhok, G Falk, A Rogers, AD Struthers, FM Sullivan, and T Fahey.

Review published: 2008.

CRD summary

This generally well-conducted review concluded that clinical history and examination were insufficient to rule in or rule out diagnosis of left ventricular systolic dysfunction (LVSD); brain natriuretic peptides and electrocardiogram may be most useful for ruling out LVSD when probability is in the intermediate range. The conclusions may be compromised by the apparent poor quality of the included studies.

Authors' objectives

To assess the accuracy of clinical history, signs, symptoms, electrocardiogram (ECG), chest X-ray and natriuretic peptides for the diagnosis of left ventricular systolic dysfunction (LVSD).

Searching

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and Zetoc were searched without language restrictions to March 2008; the search strategy was available online. Bibliographies of relevant papers were scanned.

Study selection

Cross-sectional studies that evaluated the accuracy of clinical history, signs, symptoms, ECG, chest X-ray and/or natriuretic peptides compared to echocardiography in patients from a community or primary care setting presenting with symptoms of LVSD were eligible for inclusion. Screening and case-control studies were excluded. The median prevalence of LVSD in the included studies was 30% (interquartile range 14% to 37%). The definitions used for the predictors of LVSD, cut-offs for the natriuretic peptide test and ejection fraction when used as a measure of of cardiac function varied across studies. Where studies explicitly used ejection fraction as a measure of cardiac function, cut-offs ranged from 35% to 50%.

Three reviewers independently applied the inclusion criteria; disagreements were resolved by discussion or recourse to a fourth reviewer.

Assessment of study quality

Two independent reviewers assessed study quality using modified QUADAS criteria and a tool for clinical prediction rules. Each study was allocated a composite score up to a maximum of 7 points). Disagreements were resolved by discussion or recourse to a third reviewer.

Data extraction

Data required to construct 2x2 tables were extracted by two independent reviewers, from which positive and negative likelihood ratios (LR+/-) were calculated. Disagreements were resolved by discussion or recourse to a third reviewer.

Methods of synthesis

Pooled estimates of positive and negative likelihood ratios were calculated using a random-effects model in the absence of heterogeneity (I2<50%). Where heterogeneity was observed (I2>50%), studies were combined in a narrative synthesis and ranges of positive and negative likelihood ratios were provided.

Results of the review

Twenty four studies met the inclusion criteria (n=10,710). Eleven studies had all the important predictors present in a significant proportion of the participants and 11 reported blinding of the interpreters of tests; only one was considered to have recruited an adequate sample size.

None of the items that related to clinical history could be relied upon to rule in or rule out LVSD: myocardial infarction (six studies, n=1,946); diabetes (two studies, n=717); hypertension (two studies, n=717); and male gender (two studies, n=1,471).

None of the items that related to symptoms could be relied upon to rule in or rule out LVSD: fatigue (two studies, n=1,079); dyspnoea (three studies, n=1,338); orthopnoea (three studies, n=1,338); and paroxysmal nocturnal dyspnoea (three studies, n=1,338).

Clinical signs:

Pooled positive likelihood ratio estimates for raised jugular venous pulsation (4.36, range 2.66 to 7.44; three studies), displaced apex beat (15.96, 95% CI 8.24 to 30.93; two studies) and a third heart sound (7.43, range 1.56 to 32.37; three studies) showed better diagnostic performance than other measures, but the numbers of studies in the analyses were small.

Pooled negative likelihood ratios were 0.88 (95% CI 0.83 to 0.91) for raised jugular venous pulsation, 0.58 (range 0.35 to 0.93) for displaced apex beat and 0.92 (range 0.77 to 0.96) for a third heart sound.

ECG was the most commonly evaluated diagnostic test (11 studies, n=3,570). The pooled positive likelihood ratio was 2.13 (95% CI 1.95 to 2.33) and negative likelihood ratio was 0.27 (range 0.06 to 0.76).

Brain natriuretic peptides (BNP) (nine studies) produced a pooled positive likelihood ratio of 1.90 (range 1.26 to 6.20) and negative likelihood ratio of 0.30 (range 0.02 to 0.80) when the cut-off nearest to 15pmol/L was used; there was significant heterogeneity between studies.

For clinical history, positive likelihood ratio ranged from 0.58 to 2.86 and negative likelihood ratio ranged from 0.68 to 1.30.

For symptoms, positive likelihood ratio ranged from 1.03 to 1.71 and negative likelihood ratio ranged from 0.50 to 0.98.

Most results were available in supplementary files available online (see URL For Additional Data; URLs accessed 31 July 2009).

Authors' conclusions

Findings for clinical history and examination were insufficient to rule in or rule out a diagnosis of LVSD. BNP and ECG appeared to have similar diagnostic utility and were most useful for ruling out LVSD when the probability of LVSD was in the intermediate range.

CRD commentary

The authors addressed a clear review question supported by appropriate inclusion criteria. Several relevant sources, including conference proceedings, were searched without language restrictions, which reduced the potential for publication and language bias. Each stage of the review was conducted in duplicate, which reduced the potential for error and bias. The quality of included studies was assessed using appropriate criteria and results were presented for each study. Most of the studies performed poorly on the quality assessment. Few details and results were reported in the paper; much of the detail was in supplementary files available only online. Several of the pooled results were subject to significant between-study heterogeneity, which made the reliability of these estimates uncertain. This was a generally well-conducted review, but the reliability of the conclusions may be compromised by the apparent poor quality of a number of the included studies and the small number of studies available for some of the comparisons.

Implications of the review for practice and research

Practice: Where prior prevalence of LVSD was 30%, a negative ECG or BNP lowered the post-test probability of LVSD to 10%. Pursuit of alternative diagnosis or a watchful waiting strategy seemed to be a cost effective and clinically appropriate approach (the authors did not evaluate cost-effectiveness). The authors also stated that their findings supported the sequential diagnostic algorithm recommended in clinical guidelines for heart failure.

Research: The authors stated that future studies needed to address the incremental value of combined findings from the clinical history and examination, and should incorporate cost-effectiveness data in relation to alternative diagnostic testing (particularly in relation to determining structural abnormalities such as valvular disease and left ventricular hypertrophy). Future studies may want to consider the use of supplementary or alternative reference standards in conjunction with echocardiography and assess long-term outcomes.

Funding

Individual authors were funded by: Irish College of General Practitioners; HRB Centre for Primary Care Research; and NHS Education for Scotland as an Academic General Practitioner Registrar.

Bibliographic details

Madhok V, Falk G, Rogers A, Struthers AD, Sullivan FM, Fahey T. The accuracy of symptoms, signs and diagnostic tests in the diagnosis of left ventricular dysfunction in primary care: a diagnostic accuracy systematic review. BMC Family Practice 2008; 9:56. [PMC free article: PMC2569936] [PubMed: 18842141]

Indexing Status

Subject indexing assigned by NLM

MeSH

Bias (Epidemiology); Diagnostic Techniques and Procedures /standards; Humans; Patient Selection; Primary Health Care /methods /standards; Quality Control; Ventricular Dysfunction, Left /diagnosis

AccessionNumber

12009100439

Database entry date

25/11/2009

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18842141

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