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Integrated Evidence-Based Approach

Heart Failure (see  Chap. 26)

History

Both exertional and resting symptoms should be explored. Common symptoms include dyspnea, fatigue, exercise limitation, orthopnea, and edema. In a review of 22 studies of adult patients presenting to an emergency room with dyspnea, the probability of heart failure was best predicted by a past history of heart failure (LR, 5.8; 95% CI, 4.1 to 8.0), paroxysmal nocturnal dyspnea (PND) (LR, 2.6; 95% CI, 1.5 to 4.5), a third heart sound (LR, 11; 95% CI, 4.9 to 25.0), or atrial fibrillation (LR, 3.8; 95% CI, 1.7 to 8.8).[34] An initial clinical impression of heart failure by the physician was one of the stronger clinical predictors of this diagnosis (LR, 4.4; 95% CI, 1.8 to 10.0). With the exception of PND, these same features were also predictive of heart failure when there was concomitant pulmonary disease.[34]

Severe and sudden-onset dyspnea indicates acute pulmonary edema, typically precipitated by ischemia, arrhythmia, …