Impact of ejection fraction and "caval index" evaluation by emergency physician on clinical judgement for the diagnosis of acute heart failure

Acute dyspnea is among the most frequent reasons to apply to emergency service. Dyspnea may result from both cardiac-related situations such as acute coronary syndrome, heart failure, massive pericardial effusion, and extracardiac (pulmonary etc.) pathologies. Acute heart failure lists on top of these differential diagnoses. In all dyspnea cases, either cardiac or extracardiac origin, rapid diagnosis and early treatment are essential in order to reduce patient mortality and morbidity. Acute heart failure (AHF), which is one of dyspnea causing cardiac pathologies, can often be difficult to clinically evaluate in a group of patients. It is a progressive disease that can cause high mortality and morbidity. Due to its rapidly progressing nature, early detection and treatment is crucial to minimise mortality and morbidity. The aim of our study is to specify the clinical contribution, of FOCUS-determined ejection fraction and CI evaluation in emergency patients with complaints of dyspnea, to the diagnosis of acute heart failure. 18 years old or older patients whose primary complaint was dyspnea and whose triage group was 1-2-3, were included in this prospective, cross-sectional study. Patients who were pregnant, dispatched from other hospitals, already diagnosed ones, whom had penetrative and blunt thoracic trauma, and patients with acute myocard infarctus, asthma, pneumothorax, whose cause of dyspnea were obvious, were excluded from the study. Before the study, 10 research assistants received training on 1) mitral valve EPSS (E-Point to Septal Separation) method for Ejection Fraction (EF) evaluation, and 2) volume evaluation with "caval index" (CI) measurement. Before sonographic evaluation, patients‟ data were recorded by primary physician. Then, EF and CI measurements were performed and recorded by an independent researcher. After each step; 1) following primary examination, 2) following left ventricle EF and CI evaluation, primary physician checked one of 49 the boxes of "not acute heart failure", "not sure", and "acute heart failure". Records and forms of every included patient were reevaluated by an independent cardiologist and emergency specialist after case reception. In addition, patients were called 15 days after application, in order to record their final diagnosis. In our study, 213 patients were prospectively investigated. 26 of them were excluded, 91 of included patients were female, and overall average age was 69.36 (12.03 sd). EF evaluation of emergency physician, whose has a high agreement with cardiology consultant‟s EF evaluation (kappa: 0.845), was 0.809 sensitive, 0.781 specific for definitive diagnosis of acute heart failure. PLR and NLR values were determined as 3.694 and 0.244 respectively. These values for CI evaluation by emergency physician were as follows: 0.811 sensitivity, 0.32 specificity, 0.425 NLR, and 1.192 PLR. For diagnosing acute heart failure, decision following sonographic evaluation was found to be more confident, compared to before sonographic evaluation (sensitivity: 0.558-0.776, specificity: 0.845-0.835, NLR: 0.487-0.268 and PLR: 3.743-4.703 respectively). In light of our data, we think that EF and CI evaluations performed with the EPSS method will, for the ultimate purpose of differentially diagnosing dyspnea patients with acute heart failure, contribute to clinical judgement generated by first examination which contains history, physical examination, EKG, and chest xray.