Prevalence of Negative Chest Radiography Results in the Emergency Department Patient With Decompensated Heart Failure

The Ohio State University, Columbus, Ohio, United States
Annals of emergency medicine (Impact Factor: 4.68). 02/2006; 47(1):13-8. DOI: 10.1016/j.annemergmed.2005.04.003
Source: PubMed


Although chest radiography is quick and inexpensive, previous research suggests that it is often misleading in emergency department (ED) patients with decompensated heart failure, resulting in misdiagnosis and inappropriate treatment. This study determines the rate of negative chest radiography results in patients found to have disease and the potential contribution of negative findings to a diagnosis discordant with heart failure by an emergency physician.
We used data from the Acute Decompensated Heart Failure National Registry (ADHERE), a registry of patients with a primary hospital discharge diagnosis of heart failure. We compared initial ED admitting diagnosis to the criterion standard of a hospital discharge diagnosis of heart failure and related these to radiographic findings of heart failure (interstitial edema, pulmonary edema, or vascular congestion, as determined by a staff radiologist) for patients first treated in the ED. The proportion of patients with a non-heart failure ED diagnosis and the diagnostic sensitivity of radiographic findings of heart failure are calculated.
There were 85,376 patients with chest radiograph results and an ED admitting diagnosis. Overall, there were 15,937 patients with no signs of congestion on ED chest radiography, giving a negative rate of 18.7% (95% confidence interval [CI] 18.4% to 18.9%). The proportion of patients with an ED non-heart failure admitting diagnosis was higher in patients with a negative chest radiograph result (23.3%; 95% CI 22.6% to 23.9%) than in patients with a positive chest radiograph result (13.0%; 95% CI 12.7% to 13.2%).
Approximately 1 of every 5 patients admitted from the ED with acute decompensated heart failure had no signs of congestion on chest radiography. Patients lacking signs of congestion on ED chest radiography were more likely to have an ED non-heart failure diagnosis than patients with signs of congestion. Clinicians should not rule out heart failure in patients with no radiographic signs of congestion.

11 Reads
  • Source
    • "Moreover, most of the times it is impossible to acquire posteroanterior and lateral projection in supine patients in the emergency setting; furthermore, ionizing radiation can cause damage to pregnant women. Finally, the report is not immediately available, and, above all, it has limited accuracy in detecting some diseases [4]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Dyspnea is one of the most frequent complaints in the Emergency Department. Thoracic ultrasound should help to differentiate cardiogenic from non-cardiogenic causes of dyspnea. We evaluated whether the diagnostic accuracy can be improved by adding a point-of-care-ultrasonography (POC-US) to routine exams and if an early use of this technique produces any advantage. Methods One hundred sixty-eight patients were enrolled and randomized in two groups: Group 1 received an immediate POC-US in addition to routine laboratory and instrumental tests; group 2 received an ultrasound scan within 1 h from the admission to the Emergency Department. The concordance between initial and final diagnosis and the percentage of wrong diagnosis in the two groups were evaluated. Mortality, days of hospitalization in Emergency Medicine department and transfers to other wards were compared. Sensitivity and specificity of the routine protocol and the one including ultrasonography for the diagnosis of the causes of dyspnea were also analyzed. Results Eighty-eight patients were randomized in group 1 and 80 in group 2. The concordance rate between initial and final diagnoses was significantly different (0.94 in group 1 vs. 0.22 in group 2, p < 0.005). The percentage of wrong initial diagnosis was 5% in group 1 and 50% in group 2 (p < 0.0001). Conclusions Adding POC-US to routine exams improves the diagnostic accuracy of dyspnea and reduces errors in the Emergency Department.
    Critical ultrasound journal 04/2014; 6(1):5. DOI:10.1186/2036-7902-6-5
  • Source
    • "This method, in an acute setting, is at times difficult to interpret and has a certain inter-observer variability [15]. Moreover, increased values of pulmonary capillary wedge pressure (PCWP) do not necessarily produce radiographic data indicative of APE [16]. The gold standard for evidencing pulmonary congestion is the measuring of PCWP by catheterization, a procedure not carried out routinely in respiratory units, even intensive ones. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Chest ultrasonography can be a useful diagnostic tool for respiratory physicians. It can be used to complete and widen the general objective examination also in emergency situations, at the patient’s bedside. The aim of this document is to promote better knowledge and more widespread use of thoracic ultrasound among respiratory physicians in Italy. This document II is focused on advanced approaches to chest ultrasonography especially in diagnosing sonographic interstitial syndrome with physical hypotheses about the genesis of vertical artifacts, differential diagnosis of cardiogenic pulmonary edema and non-cardiogenic pulmonary edema, raising diagnostic suspicion of pulmonary embolism, ultrasound characterization of lung consolidations and the use of ultrasonography to guide procedural interventions in pulmonology. Finally, document II focuses on chest ultrasonography as useful diagnostic tool in neonatal and pediatric care.
    Multidisciplinary respiratory medicine 08/2013; 8(1):55. DOI:10.1186/2049-6958-8-55 · 0.15 Impact Factor
  • Source
    • "The methods currently used for measuring EVLW are either inaccurate, e.g., chest X-ray (Collins et al., 2006; Halperin et al., 1985; Lichtenstein et al., 2004; Mant et al., 2009; Sivak et al., 1983), or invasive, e.g., thermo-dilution methods (Isakow and Schuster, 2006). Thus, new techniques able to quantify EVLW non-invasively and in real time are warranted. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Lung ultrasonography (LUS) and computed tomography (CT) were compared for quantitative assessment of extravascular lung water (EVLW) in 10 isolated bovine lung lobes. LUS and CT were obtained at different inflation pressures before and after instillation with known amounts of hypotonic saline. A video-based quantitative LUS analysis was superior to both single-frame quantitative analysis and visual scoring in the assessment of EVLW. Video-based mean LUS intensity was strongly correlated with EVLW density (r(2)=0.87) but weakly correlated with mean CT attenuation (r(2)=0.49) and physical density (r(2)=0.49). Mean CT attenuation was weakly correlated with EVLW density (r(2)=0.62) but strongly correlated with physical density (r(2)=0.99). When the effect of physical density was removed by partial correlation analysis, EVLW density was significantly correlated with video-based LUS intensity (r(2)=0.75) but not mean CT attenuation (r(2)=0.007). In conclusion, these findings suggest that quantitative LUS by video grey-scale analysis can assess EVLW more reliably than LUS visual scoring or quantitative CT.
    Respiratory Physiology & Neurobiology 04/2013; 187(3). DOI:10.1016/j.resp.2013.04.002 · 1.97 Impact Factor
Show more


11 Reads
Available from