Physician Assistant Board Review Questions of the Week – Congestive Heart Failure

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This week’s case-based question:


A 56-year-old-man with chronic obstructive pulmonary disease (COPD), type 2 diabetes, and well-controlled hypertension presents with fatigue, weakness, shortness of breath, and increasing lower extremity edema over the past 2 weeks.

On physical examination, temperature is 37 °C (98 °F), blood pressure is 122/75 mm Hg, heart rate 88 beats/min, respiration rate is 18 breaths/min, and oxygen saturation is 90% on room air.

A chest X-ray is shown below:

Which if the following has the highest sensitivity for obtaining the correct diagnosis?

Answer Options

chest X-ray
exam revealing an S3 gallop
ECG
brain natriuretic peptide (BNP)

And the answer is …


Correct Answer:

brain natriuretic peptide (BNP)

Educational Objective:

Diagnose new onset congestive heart failure, and understand the most appropriate tests in the work up for heart failure.

Key Point:

While heart failure is a clinical diagnosis, the most sensitive test (that is the best test to rule out other diseases) is a brain natriuretic peptide.

Explanation:

This patient’s diagnosis is congestive heart failure (CHF) and he presents with the classic symptoms of fatigue, weakness, dyspnea and edema (other symptoms include paroxysmal nocturnal dyspnea and orthopnea). Classic physical examination findings in CHF are jugular venous distention, an S3 heart sound, displaced apical impulse, and rales or wheezing on auscultation.

This patient’s x-ray reveals cardiomegaly (width of the heart is more than half of the total width of the chest) and congested pulmonary vascular which are both common radiographic findings in heart failure.

Heart failure is a clinical diagnosis, but various lab tests and other studies are helpful in the initial diagnosis. Of the options noted above, the study with the highest sensitivity (the ability of a study to correctly identify those with the disease) is a brain natriuretic peptide (BNP), which has a sensitivity of 93%. A BNP is particularly useful to differentiate the etiology of shortness of breath from other etiologies such as chronic obstructive pulmonary disease. The specificity (ability of test to identify those without the disease) of BNP in heart failure is only about 74% however; a chest x-ray is slightly less sensitive than a BNP at 83%. It also has a fairly low specificity of 68%, and is most helpful in patients who present with shortness of breath, in order to evaluate for any possible pulmonary disease. The physical examination finding of an S3 gallop has a very low sensitivity (4-7%) but a very high specificity. Also, the detection of an S3 gallop is highly variable and subjective between clinicians.

In the diagnosis of CHF, an EKG is a useful test to assess for the specific causes of heart failure (most commonly prior myocardial infarction or acute ischemia). However, both the sensitivity and specificity of an ECG is lower than that for a BNP (89% and 56% respectively) for diagnosing CHF. Of note, when a BNP is available, neither an EKG nor a chest x-ray will likely improve the accuracy of correctly diagnosing CHF.

References:

Ponikowoski P, Voors AA, Anker SD et al.; Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure from the European Society of Cardiology (ESC). 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. European Journal of Heart Failure. 2016;18(8):891-975.

Kelder JC, Cramer MJ, Van Wijngaarden J, et al. The diagnostic value of physical examination and additional testing in primary care patients with suspected heart failure. Circulation 2011; 124:2865.

Mant J, Doust J, Roalfe A, et al. Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. Health Technology Assessment 2009; 13:1.

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