CARDIOLOGY/BRIEF RESEARCH REPORT
Prevalence of Negative Chest Radiography Results in the
Emergency Department Patient With Decompensated
Sean P. Collins, MD*
Christopher J. Lindsell, PhD
Alan B. Storrow, MD
William T. Abraham, MD
On behalf of the ADHERE
and Study Group*
From the University of Cincinnati, Department of Emergency Medicine (Collins, Storrow) and
the Institute for the Study of Health (Lindsell), Cincinnati, OH; and the Division of Cardiology,
The Ohio State University, Columbus, OH (Abraham).
Study objective: 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.
Methods: 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.
Results: 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%).
Conclusion: 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. [Ann Emerg Med. 2006;47:13-18.]
0196-0644/$-see front matter
Copyright ª 2006 by the American College of Emergency Physicians.
SEE EDITORIAL, P. 19.
Emergency department (ED) presentations for decompen-
sated heart failure account for the majority of the 995,000
annual hospital admissions for this disease process.1To facilitate
efficient, effective care for these patients, rapid and accurate
detection of acute decompensated heart failure must be
accomplished. Unfortunately, the dyspneic ED patient often
presents a diagnostic dilemma. Misdiagnosis of heart failure can
result in significant morbidity and mortality.2Treatment
interventions for patients with similar conditions that present
with dyspnea, such as pneumonia and chronic obstructive
*Members of the ADHERE SAC and Study Group are listed in the
Volume 47, no. 1 : January 2006
Annals of Emergency Medicine 13
in data interpretation and manuscript preparation. SPC takes
responsibility for the paper as a whole.
Funding and support: The authors report this study did not
receive any outside funding or support but did have database
support from ADHERE.
Publication dates: Received for publication August 18, 2004.
Revisions received November 16, 2004, January 28, 2005, and
March 3, 2005. Accepted for publication April 5, 2005.
Available online June 20, 2005.
Address for reprints: Sean P. Collins, MD, University of
Cincinnati, Department of Emergency Medicine, 231 Albert
Sabin Way, Cincinnati, OH 45267; 513-558-8079,
fax 513-558-5791; E-mail email@example.com.
1. Graff L, Orledge J, Radford MJ, et al. Correlation of the Agency
for Health Care Policy and Research congestive heart failure
admission guideline with mortality: peer review organization
voluntary hospital association initiative to decrease events
(PROVIDE) for congestive heart failure. Ann Emerg Med. 1999;
2. Bales AC, Sorrentino MJ. Causes of congestive heart failure:
prompt diagnosis may affect prognosis. Postgrad Med. 1997;101:
3. Stevenson LW, Perloff JK. The limited reliability of physical signs for
estimating hemodynamics in chronic heart failure. JAMA. 1989;
4. Kono T, Suwa M, Hanada H, et al. Clinical significance of normal
cardiac silhouette in dilated cardiomyopathy: evaluation based
upon echocardiography and magnetic resonance imaging. Jpn Circ
5. Mahdyoon H, Klein R, Eyler W, et al. Radiographic pulmonary
congestion in end-stage congestive heart failure. Am J Cardiol.
6. Adams KF, Fonarow GC, Emerman CL, et al. Characteristics and
outcomes of patients hospitalized for heart failure in the United
States: rationale, design, and preliminary observations from the
first 100,000 cases in the Acute Decompensated Heart Failure
National Registry (ADHERE). Am Heart J. 2005;149:209-216.
7. Newcombe R. Two-sided confidence intervals for the single
proportion: comparison of seven methods. Stat Med. 1998;17:
8. Knudsen CW, Omland T, Clopton P, et al. Diagnostic value of B-type
natriuretic peptide and chest radiographic findings in patients with
acute dyspnea. Am J Med. 2004;116:363-368.
9. Davie AP, Francis CM, Caruana L, et al. Assessing diagnosis in
heart failure: which features are any use? QJM. 1997;90:335-339.
10. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement
of B-type natriuretic peptide in the emergency diagnosis of heart
failure. N Engl J Med. 2002;347:161-167.
Appendix. The ADHERE Registry Scientific Advisory Committee
William T. Abraham, MD, FACP, FACC, The Ohio State
University Heart Center, Columbus, OH; Kirkwood F. Adams,
Jr, MD, University of North Carolina, Chapel Hill, NC;
Robert L. Berkowitz, MD, PhD, Hackensack University
Hospital, Hackensack, NJ; Maria Rosa Costanzo, MD,
Midwest Heart Specialists, Naperville, IL; Teresa De Marco,
MD, University of California, San Francisco, CA; Charles L.
Emerman, MD, FACEP, Cleveland Clinic Foundation,
Cleveland, OH; Gregg C. Fonarow, MD, Ahmanson–UCLA
Cardiomyopathy Center, Los Angeles, CA; Marie Galvao,
MSN, ANP-C, Montefiore Medical Center, Bronx, NY; J.
Thomas Heywood, MD, FACC, Loma Linda University
Medical Center, Loma Linda, CA; Thierry H. LeJemtel, MD,
Albert Einstein Hospital, Bronx, NY; Lynne Warner Stevenson,
MD, Brigham and Women’s Hospital, Boston, MA; and Clyde
W. Yancy, MD, FACC, University of Texas, Southwestern
Medical Center Medical Center, Dallas, TX.
The ADHERE Registry Study Group
Sharon Tellyer, DVM, ELS, Department of Clinical
Registries, Scios Inc., Fremont, CA; and Janet Wynne, MS,
Department of Biostatistics, Scios Inc., Fremont, CA.
Negative Chest Radiography Results in Patients With Decompensated Heart Failure
Collins et al
18 Annals of Emergency MedicineVolume 47, no. 1 : January 2006